Ambulatory Care Patient Assessment and Triage Flashcards
7 cards from real Ambulatory Care Test practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Ambulatory Care Patient Assessment and Triage flashcards as text
A patient presents with a deep laceration on the forearm with active bleeding that soaks through a cloth in under 2 minutes. The nurse should:
Answer: Apply direct pressure and arrange immediate transfer to the emergency department
Rapid blood-soaking through a cloth indicates significant hemorrhage requiring emergency intervention beyond ambulatory scope.
Which finding during a respiratory assessment warrants IMMEDIATE escalation in the ambulatory care setting?
Answer: Accessory muscle use with an O2 saturation of 88%
Accessory muscle use combined with hypoxia (O2 sat <90%) indicates severe respiratory distress requiring emergency intervention.
A 68-year-old diabetic patient reports increased thirst, frequent urination, and blurry vision for the past 3 days. Which assessment finding would MOST indicate a hyperglycemic crisis?
Answer: Blood glucose of 480 mg/dL with fruity breath odor and Kussmaul breathing
A blood glucose of 480 mg/dL with fruity breath and Kussmaul breathing are hallmarks of diabetic ketoacidosis (DKA).
During a well-child visit, a 4-year-old's developmental screening shows failure to draw simple shapes, use 4-word sentences, or follow 3-step instructions. The nurse's BEST next action is:
Answer: Refer for comprehensive developmental evaluation
Significant delays across multiple developmental domains at age 4 require prompt referral for comprehensive evaluation and early intervention.
A patient on warfarin therapy reports a new nosebleed that lasted 25 minutes before stopping. The nurse should FIRST:
Answer: Check the most recent INR and assess for other bleeding signs
Prolonged bleeding in a patient on warfarin requires checking the INR to assess anticoagulation status and identifying potential supratherapeutic levels.
Which of the following BEST describes the concept of 'red flag' symptoms in ambulatory triage?
Answer: Indicators that suggest a potentially serious or life-threatening condition requiring urgent evaluation
Red flag symptoms are clinical warning signs that suggest serious pathology and require urgent or emergent evaluation.
A patient presents for a follow-up stating they stopped taking their antihypertensive medication because it 'was too expensive.' The MOST appropriate nursing response is:
Answer: Assess blood pressure, explore barriers, and collaborate on a plan including cost-effective alternatives
A comprehensive approach addressing clinical status, social determinants, and collaborative problem-solving best supports medication adherence.