Chapter 30: Bedside Assessment and
Electronic Documentation
Physical Examination and Health Assessment, 8th Edition by
Carolyn Jarvis
MULTIPLE CHOICE
1. At the beginning of rounds when entering the room, what should the nurse do first?
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 him or herself as the patients
nurse.
d. Offer the patient something to drink.
ANS: C
When entering a patients room, the nurse should make direct eye contact, without
being distracted by IV pumps and other equipment, and introduce him or herself
as the patients nurse.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
2. During an assessment, the nurse is unable to palpate pulses in the left lower leg. What
should the nurse do next?
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 a Doppler device to assess the pulses.
ANS: D
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
3. During a morning assessment, the nurse notices that a patients urine output is below the
expected amount. What should the nurse do next?
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 an urologist.
, ANS: C
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
4. What should the nurse assess before entering the patients room on morning rounds?
a. Posted conditions, such as isolation precautions
b. Patients input and output chart from the previous shift
c. Patients general appearance
d. Presence of any visitors in the room
ANS: A
On the way to the patients 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
5. The nurse has administered a pain medication to a patient by an IV infusion. The nurse
should reassess the patients response to the pain medication within minutes.
a. 5
b. 15
c. 30
d. 60
ANS: B
If pain medication is given, then the nurse should reassess the patients response in
15 minutes for IV
administration or 1 hour for oral administration.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapies
6. During an assessment of a hospitalized patient, the nurse pinches a fold of skin under the
clavicle or on the forearm to test the:
a. Mobility and turgor.
b. Patients response to pain.
c. Percentage of the patients fat-to-muscle ratio.
d. Presence of edema.
ANS: A
Pinching a fold of skin under the clavicle or on the forearm is done by the nurse to
determine mobility and turgor.
Electronic Documentation
Physical Examination and Health Assessment, 8th Edition by
Carolyn Jarvis
MULTIPLE CHOICE
1. At the beginning of rounds when entering the room, what should the nurse do first?
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 him or herself as the patients
nurse.
d. Offer the patient something to drink.
ANS: C
When entering a patients room, the nurse should make direct eye contact, without
being distracted by IV pumps and other equipment, and introduce him or herself
as the patients nurse.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
2. During an assessment, the nurse is unable to palpate pulses in the left lower leg. What
should the nurse do next?
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 a Doppler device to assess the pulses.
ANS: D
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
3. During a morning assessment, the nurse notices that a patients urine output is below the
expected amount. What should the nurse do next?
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 an urologist.
, ANS: C
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
4. What should the nurse assess before entering the patients room on morning rounds?
a. Posted conditions, such as isolation precautions
b. Patients input and output chart from the previous shift
c. Patients general appearance
d. Presence of any visitors in the room
ANS: A
On the way to the patients 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
5. The nurse has administered a pain medication to a patient by an IV infusion. The nurse
should reassess the patients response to the pain medication within minutes.
a. 5
b. 15
c. 30
d. 60
ANS: B
If pain medication is given, then the nurse should reassess the patients response in
15 minutes for IV
administration or 1 hour for oral administration.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Physiologic Integrity: Pharmacologic and Parenteral
Therapies
6. During an assessment of a hospitalized patient, the nurse pinches a fold of skin under the
clavicle or on the forearm to test the:
a. Mobility and turgor.
b. Patients response to pain.
c. Percentage of the patients fat-to-muscle ratio.
d. Presence of edema.
ANS: A
Pinching a fold of skin under the clavicle or on the forearm is done by the nurse to
determine mobility and turgor.
