Chapter 30 Practice Questions - Bedside Assessment and Electronic Documentation Flashcards
At the beginning of rounds when entering the room, what should the nurse do first?
a. Check the intravenous (IV) infusion site for swelling or redness.
b. Check the infusion pump settings for accuracy.
c. Make eye contact with the patient, and introduce him or herself as the patients nurse.
d. Offer the patient something to drink.
c. Make eye contact with the patient, and introduce him or herself as the patients nurse.
During an assessment, the nurse is unable to palpate pulses in the left lower leg. What should the nurse do next?
a. Document that the pulses are nonpalpable.
b. Reassess the pulses in 1 hour.
c. Ask the patient turn to the side, and then palpate for the pulses again.
d. Use a Doppler device to assess the pulses.
d. Use a Doppler device to assess the pulses.
During a morning assessment, the nurse notices that a patients urine output is below the expected amount. What should the nurse do next?
a. Obtain an order for a Foley catheter.
b. Obtain an order for a straight catheter.
c. Perform a bladder scan test.
d. Refer the patient to an urologist.
c. Perform a bladder scan test.
What should the nurse assess before entering the patients room on morning rounds?
a. Posted conditions, such as isolation precautions
b. Patients input and output chart from the previous shift
c. Patients general appearance
d. Presence of any visitors in the room
a. Posted conditions, such as isolation precautions
The nurse has administered a pain medication to a patient by an IV infusion. The nurse should reassess the patients response to the pain medication within _____ minutes.
a. 5
b. 15
c. 30
d. 60
b. 15
During an assessment of a hospitalized patient, the nurse pinches a fold of skin under the clavicle or on the forearm to test the:
a. Mobility and turgor.
b. Patients response to pain.
c. Percentage of the patients fat-to-muscle ratio.
d. Presence of edema.
a. Mobility and turgor.
When assessing the neurologic system of a hospitalized patient during morning rounds, the nurse should include which of these during the assessment?
a. Blood pressure
b. Patients rating of pain on a scale of 1 to 10
c. Patients ability to communicate
d. Patients personal hygiene level
c. Patients ability to communicate
When assessing a patients general appearance, the nurse should include which question?
a. Is the patients muscle strength equal in both arms?
b. Is ptosis or facial droop present?
c. Does the patient appropriately respond to questions?
d. Are the pupils equal in reaction and size?
c. Does the patient appropriately respond to questions?
When assessing a patient in the hospital setting, the nurse knows which statement to betrue?
a. The patient will need a brief assessment at least every 4 hours.
b. The patient will need a consistent, specialized examination every 8 hours that focuses on certain parameters
c. The patient will need a complete head-to-toe physical examination every 24 hours.
d. Most patients require a minimal examination each shift unless they are in critical condition.
b. The patient will need a consistent, specialized examination every 8 hours that focuses on certain parameters
The nurse is giving report to the next shift and is using the situation, background, assessment, recommendation (SBAR) framework for communication. Which of these statements reflects the Background portion of the report?
a. Im worried that his gastrointestinal bleeding is getting worse.
b. We need an order for oxygen.
c. My name is Ms. Smith, and Im giving the report on Mrs. X in room 1104.
d. He is 4 days postoperative, and his incision is open to air.
d. He is 4 days postoperative, and his incision is open to air.
The nurse is assessing the IV infusion at the beginning of the shift. Which factors should be included in the assessment of the infusion? Select all that apply.
a. Proper IV solution is infusing, according to the physicians orders.
b. The IV solution is infusing at the proper rate, according to physicians orders.
c. The infusion is proper, according to the nurses assessment of the patients needs.
d. Capillary refill in the fingers is checked and noted.
e. The IV site date is noted.
f. Whether the patient is sufficiently voiding is noted.
a. Proper IV solution is infusing, according to the physicians orders.
b. The IV solution is infusing at the proper rate, according to physicians orders.
c. The infusion is proper, according to the nurses assessment of the patients needs.
e. The IV site date is noted.
The nurse is completing an assessment on a patient who was just admitted from the emergency department. Which assessment findings would require immediate attention? Select all that apply.
a. Temperature: 38.6 C
b. Systolic blood pressure: 150 mm Hg
c. Respiratory rate: 22 breaths per minute
d. Heart rate: 130 beats per minute
e. Oxygen saturation: 95%
f. Sudden restlessness
a. Temperature: 38.6 C
d. Heart rate: 130 beats per minute
f. Sudden restlessness
