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NURS 247 Exam 4 Bedside Assessment Questions
With Complete Solutions
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
