Deck 30: Bedside Assessment and Electronic Documentation

Question 1

The nurse has administered a pain medication to a patient by an IV infusion. When should the nurse reassess the patient's response to the medication?

A) Within 5 minutes
B) Within 15 minutes
C) Within 30 minutes
D) Within 60 minutes

Answer 1

Within 15 minutes

Question 2

What should the nurse assess before entering the patient's room on morning rounds?

A) Patient's general appearance
B) Presence of any visitors in the room
C) Posted conditions, such as isolation precautions
D) Patient's input and output chart from the previous shift

Answer 2

Posted conditions, such as isolation precautions

Question 3

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) Sudden restlessness
B) Temperature: 38.6 $\degree$ C
C) Oxygen saturation: 95%
D) Heart rate: 130 beats per minute
E) Systolic blood pressure: 150 mm Hg
F) Respiratory rate: 22 breaths per minute

Answer 3

Sudden restlessness
Temperature: 38.6 $\degree$ C
Heart rate: 130 beats per minute

Question 4

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) The IV site date is noted.
B) Capillary refill in the fingers is checked and noted.
C) Whether the patient is sufficiently voiding is noted.
D) Proper IV solution is infusing, according to the physician's orders.
E) The IV solution is infusing at the proper rate, according to physician's orders.
F) The infusion is proper, according to the nurse's assessment of the patient's needs.

Question 5

During a morning assessment, the nurse notices that a patient's urine output is below the expected amount. What should the nurse do next?

A) Perform a bladder scan test.
B) Refer the patient to an urologist.
C) Obtain an order for a Foley catheter.
D) Obtain an order for a straight catheter.

Question 6

When assessing a patient in the hospital setting, the nurse knows which statement to be true?

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.

Question 7

During an assessment, the nurse is unable to palpate pulses in the left lower leg. What should the nurse do next?

A) Reassess the pulses in 1 hour.
B) Document that the pulses are nonpalpable.
C) Use a Doppler device to assess the pulses.
D) Ask the patient turn to the side, and then palpate for the pulses again.

Question 8

When entering a patient's room for the first time, what should the nurse do first?

A) Offer the patient something to drink.
B) Check the infusion pump settings for accuracy.
C) Check the intravenous (IV) infusion site for swelling or redness.
D) Make eye contact with the patient, and introduce him or herself as the patient's nurse.

Question 9

Consider the below scenario phone conversation when answering the following three questions: "Dr. Jones, this is Mary Smith, RN, on the postsurgical unit at City Hospital. I'm calling about Tom King, your 46-year-old patient who had an inguinal hernia repair this morning. He has not voided since surgery, 8 hours ago. He has received 1900 mL Lactated Ringers IV and 720 mL oral fluids. He can't initiate a stream, but states that he "feels the need to urinate." His bladder is distended by palpation and shows a volume of 800 mL when scanned with the bladder scanner. We've tried standing him to void, providing privacy, and running water, but he is still unable to go. He appears to have urinary retention and I'd like to try using a straight catheter to relieve his retention, what do you think?"
In the above scenario, what part of the SBAR communication tool is the underlined information?

A) S
B) B
C) A
D) R

Question 10

When assessing the neurologic system of a hospitalized patient during morning rounds, what should the nurse include during the assessment?

A) Blood pressure
B) Patient's ability to communicate
C) Patient's personal hygiene level
D) Patient's rating of pain on a scale of 1 to 10

Question 11

During an assessment of a hospitalized patient, the nurse pinches a fold of skin under the clavicle and on the forearm. What is the nurse assessing?

A) Presence of edema
B) Mobility and turgor
C) Patient's response to pain
D) Percentage of the patient's fat-to-muscle ratio

Question 12

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 B portion of SBAR?

A) "We need an order for oxygen."
B) "He is 4 days postoperative, and his incision is open to air."
C) "I'm worried that his gastrointestinal bleeding is getting worse."
D) "My name is Ms. Smith, and I'm giving the report on Mrs. X in room 1104."