Deck 28: Bedside Assessment of the Hospitalized Adult

Question 1

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

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

Answer 1

Posted conditions, such as isolation precautions

Question 2

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) The patient's rating of pain on a 1 to 10 scale
C) The patient's ability to communicate
D) The patient's personal hygiene level

Answer 2

The patient's ability to communicate

Question 3

When assessing a patient's general appearance,the nurse should include which of these questions?

A) Is the patient's muscle strength equal in both arms?
B) Is ptosis or facial droop present?
C) Does the patient respond appropriately to questions?
D) Are the pupils equal in reaction and size?

Answer 3

Does the patient respond appropriately to questions?

Question 4

The nurse is assessing the intravenous (IV)infusion at the beginning of the shift.Which of these should be included in the assessment of the infusion? Select all that apply.

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

Question 5

At the beginning of rounds,when the nurse enters the room,what should the nurse do first?

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

Question 6

During an assessment of a hospitalized patient,the nurse pinches a fold of skin under the clavicle or on the forearm to test:

A) mobility and turgor.
B) the patient's response to pain.
C) the percentage of the patient's fat-to-muscle ratio.
D) the presence of edema.

Question 7

When assessing a patient in the hospital setting,the nurse knows that which statement is 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 8

The nurse is giving report to the next shift and is using the SBAR framework for communication.Which of these statements reflects the Background portion of the report?

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

Question 9

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 not palpable.
B) Reassess the pulses in 1 hour.
C) Have the patient turn to the side and then palpate for the pulses again.
D) Use a Doppler device to assess the pulses.

Question 10

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) 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 a urologist.

Question 11

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 is 101.4° F.
B) Systolic blood pressure is 150 mm Hg.
C) Respiratory rate is 22 breaths per minute.
D) Heart rate is 130 beats per minute.
E) Oxygen saturation is 95%.
F) Patient exhibits sudden restlessness.

Question 12

The nurse has administered a pain medication to a patient by an intravenous infusion.The nurse should reassess the patient's response to the pain medication within _____ minutes.

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