Ambulatory Care Test Ambulatory Care Patient Assessment and Triage 3 — Questions and Answers
Question 1: 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:
- Apply a sterile dressing and schedule wound care for later in the day
- Apply direct pressure and arrange immediate transfer to the emergency department (Correct answer)
- Clean the wound thoroughly and apply skin closure strips
- Elevate the extremity and reassess in 30 minutes
Correct 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.
Question 2: Which finding during a respiratory assessment warrants IMMEDIATE escalation in the ambulatory care setting?
- Respiratory rate of 16 breaths per minute
- O2 saturation of 99% on room air
- Accessory muscle use with an O2 saturation of 88% (Correct answer)
- Mild expiratory wheezing with normal oxygen saturation
Correct 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.
Question 3: 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?
- Blood glucose of 130 mg/dL with mild fatigue
- Blood glucose of 480 mg/dL with fruity breath odor and Kussmaul breathing (Correct answer)
- Blood glucose of 180 mg/dL with mild headache
- Blood glucose of 200 mg/dL with normal respiratory pattern
Correct 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).
Question 4: 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:
- Reassure parents this is normal variation and rescreen at age 5
- Refer for comprehensive developmental evaluation (Correct answer)
- Provide educational handouts on home developmental activities
- Schedule a recheck in 6 months to see if the child catches up
Correct answer: Refer for comprehensive developmental evaluation
Significant delays across multiple developmental domains at age 4 require prompt referral for comprehensive evaluation and early intervention.
Question 5: A patient on warfarin therapy reports a new nosebleed that lasted 25 minutes before stopping. The nurse should FIRST:
- Reassure the patient that nosebleeds are a normal warfarin side effect
- Check the most recent INR and assess for other bleeding signs (Correct answer)
- Advise the patient to stop warfarin immediately
- Tell the patient to apply ice and monitor for reoccurrence
Correct 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.
Question 6: Which of the following BEST describes the concept of 'red flag' symptoms in ambulatory triage?
- Symptoms that are bothersome but have been present for years
- Indicators that suggest a potentially serious or life-threatening condition requiring urgent evaluation (Correct answer)
- Symptoms that require only a follow-up appointment within the month
- Chronic conditions that are stable and managed with current medications
Correct 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.
Question 7: 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:
- Document medication non-compliance and notify the provider
- Assess blood pressure, explore barriers, and collaborate on a plan including cost-effective alternatives (Correct answer)
- Advise the patient to restart the original medication as soon as possible without provider input
- Educate the patient on the dangers of stopping medication and move on to the next concern
Correct 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.
Ambulatory Care Test Ambulatory Care Patient Assessment and Triage 3
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: