Chapter 30: Bedside Assessment and Electronic Documentation

Jarvis: Physical Examination and Health Assessment, 8th Edition

Multiple Choice

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

a. Offer the patient something to drink.

b. Check the infusion pump settings for accuracy.

c. Check the intravenous (IV) infusion site for swelling or redness.

d. Make eye contact with the patient, and introduce him or herself as the patient’s nurse.

ANS: D

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

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care a. Reassess the pulses in 1 hour. b. Document that the pulses are nonpalpable. c. Use a Doppler device to assess the pulses. d. Ask the patient turn to the side, and then palpate for the pulses again.

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

ANS: C

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)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care a. Perform a bladder scan test. b. Refer the patient to an urologist. c. Obtain an order for a Foley catheter. d. Obtain an order for a straight catheter.

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

ANS: A

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)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care a. Patient’s general appearance b. Presence of any visitors in the room c. Posted conditions, such as isolation precautions d. Patient’s input and output chart from the previous shift

4. What should the nurse assess before entering the patient’s room on morning rounds?

ANS: C

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

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control a. Within 5 minutes b. Within 15 minutes c. Within 30 minutes d. Within 60 minutes

5. 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?

ANS: B

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

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Physiological Integrity: Pharmacologic and Parenteral Therapies a. Presence of edema b. Mobility and turgor c. Patient’s response to pain d. Percentage of the patient’s fat-to-muscle ratio

6. 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?

ANS: B

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: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance a. Blood pressure b. Patient’s ability to communicate c. Patient’s personal hygiene level d. Patient’s rating of pain on a scale of 1 to 10

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

ANS: B

Assessment of a patient’s 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)

MSC: Client Needs: Health Promotion and Maintenance 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.

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

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: Understanding (Comprehension)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care a. “We need an order for oxygen.” b. “He is 4 days postoperative, and his incision is open to air.” c. “I’m worried that his gastrointestinal bleeding is getting worse.” d. “My name is Ms. Smith, and I’m giving the report on Mrs. X in room 1104.”

9. 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?

ANS: B

During the Background portion, the nurse should state data pertinent to the moment’s problem such as the condition of the patient’s incision. During the Situation portion, the nurse provides his or her name and the patient’s 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: Applying (Application)

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

10. 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?

ANS: D

R stands for recommendation: What do you want the provider to do to improve the patient’s situation? Here you offer probably solutions (order more pain medication; come and assess the patient, etc.). S stands for situation: What is happening right now? Why are you calling? State your name, your unit, patient’s name, room number, patient’s problem, when it happened or when it started, and how severe. B stands for background: Do not recite the patient’s full history since admission. Do state the data pertinent to this moment’s problem (admitting diagnosis, when admitted, and appropriate immediate assessment data). A stands for assessment: What do you think is happening in regard to the current problem? If you do not know, at least state which body system you think is involved; how severe is the problem.

DIF: Cognitive Level: Applying (Application)

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

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. The IV site date is noted.

b. Capillary refill in the fingers is checked and noted.

c. Whether the patient is sufficiently voiding is noted.

d. Proper IV solution is infusing, according to the physician’s orders.

e. The IV solution is infusing at the proper rate, according to physician’s orders.

f. The infusion is proper, according to the nurse’s assessment of the patient’s needs.

ANS: A, D, E, F

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

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Physiological Integrity: Pharmacologic and Parenteral Therapies a. Sudden restlessness b. Temperature: 38.6°C c. Oxygen saturation: 95% d. Heart rate: 130 beats per minute e. Systolic blood pressure: 150 mm Hg f. Respiratory rate: 22 breaths per minute

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.)

ANS: A, B, D

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)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation