NursingNursing PracticeHealth Assessment for Nursing PracticePractice Set 11
Questions Bank
Development of which complication is considered a never event?
Fever
Atelectasis
Pressure ulcer
Thrombophlebitis
For which patient does the nurse make assessment of the oral mucous membrane a priority?
The patient who has an arteriovenous (AV) fistula
The patient who has a gastrostomy tube
The patient who uses a Ventimask
The patient who has a colostomy
How does a nurse assess perfusion to the foot when a patient has a cast from the left middle calf to the toes?
Palpate the popliteal pulse of the left leg.
Palpate the posterior tibial pulse of the left leg.
Assess movement and sensation of the left toes.
Assess the capillary refill of the left toes.
A nurse uses the Glasgow Coma Scale to assess which patient?
The patient who has a new onset of quadriplegia
The patient who has tonic-clonic seizures
The patient who requires stimuli for responses
The patient who has dementia
During the assessment, the nurse determines that the patient's Glasgow Coma Scale score is 15. What is the meaning of this number for this patient?
This patient is fully conscious.
This patient has movement but does not open the eyes or speak.
This patient is unable to respond to any stimuli.
This patient opens the eyes but does not speak or move.