Chapter 29: Bedside Assessment of the Hospitalized Patient My Nursing Test Banks

Chapter 29: Bedside Assessment of the Hospitalized Patient

Jarvis: Physical Examination & Health Assessment, 7th Edition

MULTIPLE CHOICE

1. 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.

ANS: C

When entering a patients room, the nurse should make direct eye contact, without being distracted by IV pumps and other equipment, and introduce him or herself as the patients nurse.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 799

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

2. 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.

ANS: D

The nurse should be prepared to assess pulses in the lower extremities by Doppler measurement if they cannot be detected by palpation.

DIF: Cognitive Level: Applying (Application) REF: p. 802

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

3. 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.

ANS: C

If urine output is below the expected value, then the nurse should perform a bladder scan according to institutional policy to check for retention.

DIF: Cognitive Level: Applying (Application) REF: p. 803

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

4. 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

ANS: A

On the way to the patients room, the nurse should assess the presence of conditions such as isolation precautions, latex allergies, or fall precautions.

DIF: Cognitive Level: Applying (Application) REF: p. 799

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

5. 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

ANS: B

If pain medication is given, then the nurse should reassess the patients response in 15 minutes for IV administration or 1 hour for oral administration.

DIF: Cognitive Level: Applying (Application) REF: p. 800

MSC: Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

6. 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.

ANS: A

Pinching a fold of skin under the clavicle or on the forearm is done by the nurse to determine mobility and turgor.

DIF: Cognitive Level: Applying (Application) REF: p. 802

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

7. 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

ANS: C

Assessment of a patients ability to communicate is part of the neurologic assessment. Blood pressure and pain rating are measurements, and personal hygiene is assessed under general appearance.

DIF: Cognitive Level: Applying (Application) REF: p. 801

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

8. 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?

ANS: C

Assessing whether the patient appropriately responds to questions is a component of an assessment of the patients general appearance. The other answers reflect components of the neurologic examination.

DIF: Cognitive Level: Applying (Application) REF: p. 800

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

9. 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.

ANS: B

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

DIF: Cognitive Level: Applying (Application) REF: p. 799

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

10. 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.

ANS: D

During the Background portion, the nurse should state data pertinent to the moments problem such as the condition of the patients incision. During the Situation portion, the nurse provides his or her name and the patients name. During the Assessment portion, the nurse states what he or she thinks is happening (e.g., gastrointestinal bleeding). During the Recommendation portion, the nurse should offer probable solutions or orders that may be implemented.

DIF: Cognitive Level: Analyzing (Analysis) REF: pp. 804-805

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

MULTIPLE RESPONSE

1. 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.

ANS: A, B, C, E

The nurse should verify that the proper IV solution is hanging and is flowing at the proper rate according to the physicians orders and the nurses own assessment of the patients needs. In addition, the nurse should note the date of the IV site and surrounding skin condition. Checking capillary refill is part of the cardiovascular assessment; checking the patients voiding is part of the genitourinary assessment.

DIF: Cognitive Level: Applying (Application) REF: p. 799

MSC: Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

2. 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

ANS: A, D, F

The following examination findings require immediate attention:

High or low temperature: (36.1 C or 37.8 C)

High or low blood pressure: (systolic pressure 90 mm Hg or 160 mm Hg)

High or low number of respirations: (12 or 28 breaths per minute)

High or low heart rate: (60 or 90 beats per minute)

Oxygen saturation: 92%

Sudden restlessness or anxiety, altered level of consciousness, confusion, or difficulty in arousing

DIF: Cognitive Level: Applying (Application) REF: p. 803

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

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