Chapter 29 Assessment of
Hospitalized Adult HA EXAM 4
Questions and Correct Answers.
focused assessments: - Answer - evaluate progress toward a goal later in the stay
- concentrates on assessing for anticipated problems that can result from hospitalization such
as: pneumonia, skin breakdown, falls, or infections, and those specific to the patient's problems
comprehensive assessment: - Answer - taken upon admission
- more detailed and complete
shift assessment: - Answer - performed at the beginning of the shift and includes: an
abbreviated examination, with emphasis on risk areas, such as auscultation of the lungs and
abdomen, and assessment of circulation and level of consciousness.
when there are signs of an emergent, acute, or urgent situation, the nurse performs: - Answer
immediate assessments and interventions with a team of providers.
Failure to recognize and respond to patient deterioration and escalate care has led to an: -
Answer increased risk of adverse events in hospitalized (may have been avoided if patient
deterioration had been recognized/responded to earlier)
Acute and urgent situations such as the following warrant immediate attention and
interventions: - Answer - RR lower than 8 or greater than 28 breaths/min
- change in oxygen saturation below 90% despite oxygen administration
- threatened airway
- change in systolic BP to less than 90
- increase in diastolic BP greater than 110
- change in heart rate to fewer than 50 or greater than 120 beats/min
- onset chest pain or signs of acute myocardial infarction
- acutely cold, cyanotic, or pulseless extremity
- confusion, agitation, or delirium
- acute altered mental status
, - uncontrolled pain
- acute change in urine output less than 50 ml over 4 hours
- acute bleeding
- sepsis
the Five Rights of Delegation: - Answer - the RIGHT task
- under the RIGHT circumstances
- to the RIGHT person
- w/ the RIGHT directions and communication
- under the RIGHT supervision and evaluation
the RN assesses the basic care activities before delegating to a UAP, including the following: -
Answer - activities of daily living (ADLs) + assistive devices
- nutrition/oral hydration
- elimination
- personal hygiene
- mobility/immobility
- rest and sleep
- non-pharmacological comfort interventions
adverse events related to the assessment process of patients include: - Answer - inaccurate or
inadequate monitoring
- delay in assessment and monitoring of patients
- delay in recognizing abnormal results of assessment,
- failure to communicate abnormal results to the provider
- delay in treatment and follow-up as examples.
these types of adverse events have been grouped into a concept called "failure to rescue"
Common Complications of the Hospitalized Patient: - Answer - object retained after surgery
- air embolism
- pressure ulcers
Hospitalized Adult HA EXAM 4
Questions and Correct Answers.
focused assessments: - Answer - evaluate progress toward a goal later in the stay
- concentrates on assessing for anticipated problems that can result from hospitalization such
as: pneumonia, skin breakdown, falls, or infections, and those specific to the patient's problems
comprehensive assessment: - Answer - taken upon admission
- more detailed and complete
shift assessment: - Answer - performed at the beginning of the shift and includes: an
abbreviated examination, with emphasis on risk areas, such as auscultation of the lungs and
abdomen, and assessment of circulation and level of consciousness.
when there are signs of an emergent, acute, or urgent situation, the nurse performs: - Answer
immediate assessments and interventions with a team of providers.
Failure to recognize and respond to patient deterioration and escalate care has led to an: -
Answer increased risk of adverse events in hospitalized (may have been avoided if patient
deterioration had been recognized/responded to earlier)
Acute and urgent situations such as the following warrant immediate attention and
interventions: - Answer - RR lower than 8 or greater than 28 breaths/min
- change in oxygen saturation below 90% despite oxygen administration
- threatened airway
- change in systolic BP to less than 90
- increase in diastolic BP greater than 110
- change in heart rate to fewer than 50 or greater than 120 beats/min
- onset chest pain or signs of acute myocardial infarction
- acutely cold, cyanotic, or pulseless extremity
- confusion, agitation, or delirium
- acute altered mental status
, - uncontrolled pain
- acute change in urine output less than 50 ml over 4 hours
- acute bleeding
- sepsis
the Five Rights of Delegation: - Answer - the RIGHT task
- under the RIGHT circumstances
- to the RIGHT person
- w/ the RIGHT directions and communication
- under the RIGHT supervision and evaluation
the RN assesses the basic care activities before delegating to a UAP, including the following: -
Answer - activities of daily living (ADLs) + assistive devices
- nutrition/oral hydration
- elimination
- personal hygiene
- mobility/immobility
- rest and sleep
- non-pharmacological comfort interventions
adverse events related to the assessment process of patients include: - Answer - inaccurate or
inadequate monitoring
- delay in assessment and monitoring of patients
- delay in recognizing abnormal results of assessment,
- failure to communicate abnormal results to the provider
- delay in treatment and follow-up as examples.
these types of adverse events have been grouped into a concept called "failure to rescue"
Common Complications of the Hospitalized Patient: - Answer - object retained after surgery
- air embolism
- pressure ulcers
