Ambulatory Care Test Ambulatory Care Patient Assessment and Triage 3

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:

Accepted Answer

Apply direct pressure and arrange immediate transfer to the emergency department

Answer

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?

Accepted Answer

Accessory muscle use with an O2 saturation of 88%

Answer

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?

Accepted Answer

Blood glucose of 480 mg/dL with fruity breath odor and Kussmaul breathing

Answer

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:

Accepted Answer

Refer for comprehensive developmental evaluation

Answer

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:

Accepted Answer

Check the most recent INR and assess for other bleeding signs

Answer

Prolonged bleeding in a patient on warfarin requires checking the INR to assess anticoagulation status and identifying potential supratherapeutic levels.

Ambulatory Care Test Practice Test

Ambulatory Care Test Practice Test

Ambulatory Care Test Ambulatory Care Patient Assessment and Triage 3