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A series of questions and answers related to bedside assessment in nursing. It covers various aspects of patient assessment, including vital signs, physical examination, laboratory values, and documentation. Designed to help nursing students prepare for exams and gain a better understanding of bedside assessment procedures.
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what are the three different types of assessments correct answer: basic, comprehensive, focused what is a basic assessment correct answer: head to toe what is a focused assessment correct answer: in addition to the basics, centralized around one issue how should you begin your shift correct answer: assessment of EHR data what should you review in EHR before entering the pts room correct answer: admitting dx, past medical hx, allergies, MAR, abn and pertinent normal labs, baseline vitals what is MAR correct answer: medication administration record why is documenting and knowing a pt's I/O important correct answer: to make sure the kidneys are functioning why is it important to get pt's their medications on time correct answer: the longer pain goes the more difficult it is to control why do nurses have to label patients based on priority level correct answer: so they can decide who needs to be seen first
what is a first level priority correct answer: emergent, life threatening, and immediate examples of first level priority correct answer: decreased O sats, chest pain , 3Ds what is a second level priority correct answer: next in urgency, requiring attention so as to avoid further deterioration example of second level priority correct answer: mental status changes, abnormal values, untreated pain what is a third level priority correct answer: important to pts health but can be addressed after more urgent problems are addressed what are collaborative problems correct answer: approach to treatment involves multiple disciplines what should you always do BEFORE going into the pts room correct answer: gather appropriate equipment and PPE how should you introduce yourself correct answer: as the student nurse and just your first name why do we write our names on the whiteboard in a pts room correct answer: they have the right to know who is caring for them order of assessing the pt correct answer: start with VS, then a basic head to toe, and then focused based on dx
what should be assessed in a surgical assessment correct answer: wounds, incisions, drainage bedside assessment includes assessment of everything including correct answer: whats attached to the pt, whos affiliated with pt, and the belongings of the pt what should be included when describing drains on pts correct answer: type, location, content, amount what should be included when describing ivs on pts correct answer: location, type of fluid, rate of infusion, amount left what is considered renal insufficiency correct answer: <30 ml how much fluid should the kidneys be getting rid of correct answer: >30 mL why is post op n/v concerning correct answer: could rip sutures or risk for aspiration if a pt starts saying they are gonna die why should we take them seriously correct answer: this is a built in defense mechanism and usually bad things happen when pts start to say this what does SBAR stand for correct answer: situation, background, assessment, recommendation what is situation in SBAR correct answer: what happening now? introduce pt and briefly explain the problem
what is background in SBAR correct answer: explain hx or whats going on, vs what is assessment in SBAR correct answer: details of when problem started occurring and as a whole what is recommendation in SBAR correct answer: what you want the provider to do what is the purpose of SBAR correct answer: helps organize and standardize shift report and communication to provider or another department, improves communication, reduces medical error what are the advantages of EHR correct answer: current info, portable, immediate access, quicker decisions, safer, safety checks what does POE stand for correct answer: provider order entry what is POE correct answer: provider enter their stuff directly into the system so nurses don't have to decipher their handwriting