NSG 521 Module 12 Assessment of the Hospitalized Client Questions and Correct Answers the Latest Update
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Course
NSG 521
Institution
NSG 521
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...
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
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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