Deck 28: Reassessment of the Hospitalized Adult

Question 1

Which statement reflects the assessment of the patient in the hospital setting?
1)The patient will need a brief assessment at least every 4 hours.
2)The patient will need a consistent,specialized exam every 8 hours that focuses on certain parameters.
3)The patient will need a complete head-to-toe physical examination every 24 hours.
4)Most patients require a minimal examination each shift unless they are in critical condition.

Answer 1

2
In a hospital setting,the patient does not require a complete head-to-toe physical examination during every 24-hour stay.The patient does require a consistent specialized exam every 8 hours that focuses on certain parameters.

Question 2

During an assessment,the nurse is unable to palpate pulses in the left lower leg.The nurse should:
1)document that the pulses are not palpable.
2)reassess the pulses in 1 hour.
3)have the patient turn to the side and then palpate for the pulses again.
4)use a Doppler device to assess the pulses.

Answer 2

4
Be prepared to assess pulses in the lower extremities by Doppler measurement if they cannot be detected by palpation.

Question 3

During an assessment of a hospitalized patient,the nurse pinches a fold of skin under the clavicle or on the forearm to note:
1)mobility and turgor.
2)the patient's response to pain.
3)the percentage of the patient's fat-to-muscle ratio.
4)the presence of edema.

Answer 3

1
Pinch up a fold of skin under the clavicle or on the forearm to note mobility and turgor.

Question 4

When assessing the neurologic system of a hospitalized patient during morning rounds,the nurse will include which of the following?
1)Blood pressure
2)The patient's rating of pain on a 1 to 10 scale
3)The patient's ability to communicate
4)The patient's personal hygiene level

Question 5

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:
1)5 minutes.
2)15 minutes.
3)30 minutes.
4)60 minutes.

Question 6

The nurse is assessing the intravenous (IV)infusion at the beginning of the shift.Which of the following should be included in the assessment of the infusion? Select all that apply.
1)Proper IV solution is infusing according to physician's orders.
2)Infusing at the proper rate according to physician's orders.
3)Infusion proper according to the nurse's own assessment of the patient's needs.

Question 7

When assessing a patient's general appearance,the nurse will include which of the following?
1)Is the patient's muscle strength equal in both arms?
2)Is ptosis or facial droop present?
3)Does the patient respond appropriately to questions?
4)Are the pupils equal in reaction and size?

Question 8

At the beginning of rounds,when the nurse enters the room,what should be done first?
1)Check the intravenous infusion site for swelling or redness.
2)Check the infusion pump settings for accuracy.
3)Make eye contact with the patient and introduce himself or herself as the patient's nurse.
4)Offer the patient something to drink.

Question 9

What should the nurse assess before entering the patient's room on morning rounds?
1)Posted conditions,such as isolation precautions
2)The patient's input and output chart from the previous shift
3)The patient's general appearance
4)The presence of any visitors in the room