Exam 30: Bedside Assessment and Electronic Documentation

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.)

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?

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?

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?

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

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

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

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

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.)

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

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?

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