Question 1

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

Accepted Answer

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

Question 2

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

Accepted Answer

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 himself or herself as the patient's nurse 
D) Offer the patient something to drink 
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 himself or herself as the patient's nurse 
D) Offer the patient something to drink C

Question 3

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

Accepted Answer

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

Question 4

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

Accepted Answer

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, focusing 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. 
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, focusing 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 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?

Accepted Answer

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 
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 6

When assessing the neurological system of a hospitalized patient during morning rounds, the nurse should include which of these during the assessment?

Accepted Answer

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

Question 7

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?

Accepted Answer

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 the report on Mrs.X in room 1104." 
D) "He is 4 days postoperative, and his incision is open to air." 
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 the report on Mrs.X in room 1104." 
D) "He is 4 days postoperative, and his incision is open to air."

Question 8

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

Accepted Answer

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

Question 9

With the implementation of the electronic health record (EHR), the nurse can use it to:

Accepted Answer

A) Review patient orders 
B) Document findings from a complete head-to-toe examination 
C) Document the frequency of alarms 
D) Document administration of medications 
E) Document patient care provided
F)Retrieve necessary patient information 
A) Review patient orders 
B) Document findings from a complete head-to-toe examination 
C) Document the frequency of alarms 
D) Document administration of medications 
E) Document patient care provided
F)Retrieve necessary patient information

Question 10

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

Accepted Answer

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 the Doppler device to assess the pulses 
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 the Doppler device to assess the pulses

Question 11

When assessing a patient's general appearance, the nurse should include which question?

Accepted Answer

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? 
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?

Exam 29: Bedside Assessment of the Hospitalized Patient

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

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

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

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

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 assessing the neurological system of a hospitalized patient during morning rounds, the nurse should include which of these during the assessment?

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?

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

With the implementation of the electronic health record (EHR), the nurse can use it to:

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

When assessing a patient's general appearance, the nurse should include which question?

Evidence-Based Assessment

Health Promotion in the Context of Health Assessment

Cultural Competence: Cultural Care

The Interview

The Complete Health History

Mental Health Assessment

Substance Use and Health Assessment

Interpersonal Violence Assessments

Assessment Techniques and the Clinical Setting

General Survey, Measurement, Vital Signs

Pain Assessment

Nutritional Assessment

Skin, Hair, and Nails

Head, Face, and Neck, Including Regional Lymphatics

Eyes

Ears

Nose, Mouth, and Throat

Breasts and Regional Lymphatics

Thorax and Lungs

Heart and Neck Vessels

Peripheral Vascular System and Lymphatic System

Abdomen

Anus, Rectum, and Prostate

Musculoskeletal System

Neurological System

Male Genitourinary System

Female Genitourinary System

The Complete Health Assessment: Adult, Infant, Child, and Adolescent

The Pregnant Woman

Functional Assessment of the Older Adult

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