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NSG 521 Module 12 Assessment of the Hospitalized Client Questions and Correct Answers the Latest Update $15.49
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NSG 521 Module 12 Assessment of the Hospitalized Client Questions and Correct Answers the Latest Update
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As a nurse, you are continuously assessing patients. When there are signs of an emergent, acute, or urgent situation, you perform immediate assessments and interventions with a team of providers. True Acute and urgent situations such as the following warrant immediate attention and interve...

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  • November 7, 2024
  • 59
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

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  • nsg 521 module 12 assessment of the hospitalized

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  • NSG 521
  • NSG 521

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NSG 521 Module 12 Assessment of the
Hospitalized Client Questions and
Correct Answers the Latest Update
As a nurse, you are continuously assessing patients. When there are signs of an

emergent, acute, or urgent situation, you perform immediate assessments and

interventions with a team of providers.


✓ True



Acute and urgent situations such as the following warrant immediate attention

and interventions:

A respiratory rate lower than 8 or greater than 28 breaths/min

An acute change in oxygen saturation below 90% despite oxygen administration

A threatened airway

Acute change in systolic BP to less than 90 mm Hg or a sustained increase in

diastolic BP greater than 110 mm Hg

Acute change in heart rate to fewer than 50 or greater than 120 beats/min

New-onset chest pain or signs of acute myocardial infarction

An acutely cold, cyanotic, or pulseless extremity

Confusion, agitation, or delirium

Unexplained lethargy or acute altered mental status



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Difficulty speaking or signs of acute stroke

Acute change in pupillary response

New seizure

Temperature greater than 39.0°C (102.2°F)

Uncontrolled pain

Acute change in urine output less than 50 ml (about 1¾ oz) over 4 hours

Acute bleeding

Suspected severe sepsis (AHRQ, 2013a)


✓ True



An urgent assessment is warranted for an acute change in heart rate to fewer

than 50 beats/minute.


✓ True



An urgent assessment is warranted when there is an acute change in pupillary

response.


✓ True



An urgent assessment is warranted for an acute change in heart rate to greater

than 120 beats/minute.


✓ True



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An urgent assessment is warranted when acute altered mental status occurs.


✓ True



An urgent assessment is warranted when an extremity becomes acutely cold.


✓ True



An urgent assessment is warranted in the presence of confusion, agitation, or

delirium.


✓ True



Perform a safety inspection of the hospitalized patient and environment,

including equipment. You will often perform this assessment during the change-

of-shift rounding or handoff procedure. The purpose is to assess the patient's

immediate medical condition as well as potential hazards such as falls, impaired

breathing, malfunctioning equipment or complications from IV lines, and

intubation.


✓ True



The initial safety inspection includes the following steps:

Directly observe the patient for breathing, airway, skin color, signs of dyspnea,

and airway secretions.

If the patient is awake, briefly introduce yourself and provide your name and

contact information.


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Check that the patient's identification band includes two patient identifiers.

Observe the patient while he or she is lying in bed, sitting in a chair, moving in

the room, and fall risk.

Check that the lighting and call bell are within reach.

Observe for cues of recent events (e.g., suctioning equipment, meals).

Trace tubes to insertion site and check solutions and rates. Check IV fluids and

tube feeding for accurate infusion. Check urinary catheter positioning.

Check that equipment is working properly, alarms are on, bed alarms are on,

and restraints are in place, as necessary.


✓ True



In addition to verbal notification of a deteriorating patient to the provider, most

facilities have escalation protocols. Patients whose condition deteriorates

acutely while hospitalized often exhibit warning signs in the hours before

experiencing adverse clinical outcomes. Rapid response teams are designed to

intervene during this critical period, usually on general medical or surgical wards


✓ True



After any urgent needs have been addressed, you may then perform the initial

comprehensive hospital assessment (Box 29.3). The admission assessment

includes assessment of the physical, emotional, and mental aspects of all body

systems as well as the environment, cultural, and social issues affecting the

patient. This includes the collection of both subjective and objective data.

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