Ambulatory Care Test Ambulatory Care Patient Assessment and Triage 5 — Questions and Answers
Question 1: A patient presents with a suspected urinary tract infection. Which additional history finding would MOST indicate the need for urgent evaluation rather than empiric antibiotic treatment?
- Burning with urination for 2 days
- Flank pain, fever of 102.5°F, and rigors (Correct answer)
- Increased urinary frequency without systemic symptoms
- Mild suprapubic discomfort with no fever
Correct answer: Flank pain, fever of 102.5°F, and rigors
Flank pain, high fever, and rigors suggest pyelonephritis or urosepsis, requiring urgent evaluation and potentially IV antibiotics.
Question 2: When triaging a patient who speaks limited English, the BEST practice for obtaining an accurate patient history is:
- Ask a family member present to translate the patient's responses
- Use a qualified medical interpreter, either in-person or via phone/video (Correct answer)
- Use simple English words and gestures to communicate
- Defer to the provider to conduct the history without nursing assessment
Correct answer: Use a qualified medical interpreter, either in-person or via phone/video
Qualified medical interpreters ensure accurate, confidential communication and are legally required under Title VI of the Civil Rights Act.
Question 3: During triage, a 32-year-old female reports her last menstrual period was 8 weeks ago, she has a positive home pregnancy test, and is now experiencing sharp unilateral pelvic pain and light vaginal bleeding. The nurse should suspect:
- Threatened abortion with expectant management
- Ectopic pregnancy requiring urgent evaluation (Correct answer)
- Normal implantation bleeding in early pregnancy
- Ovarian cyst rupture unrelated to pregnancy
Correct answer: Ectopic pregnancy requiring urgent evaluation
Unilateral pelvic pain with vaginal bleeding in early pregnancy is a classic presentation of ectopic pregnancy, a surgical emergency.
Question 4: The SBAR (Situation, Background, Assessment, Recommendation) framework is PRIMARILY used in ambulatory care to:
- Document the patient's chief complaint in the medical record
- Communicate critical patient information to providers in a structured format (Correct answer)
- Educate patients on managing chronic conditions at home
- Conduct a systematic head-to-toe physical assessment
Correct answer: Communicate critical patient information to providers in a structured format
SBAR is a standardized communication tool that ensures clear, concise, and complete handoff or escalation communication between clinicians.
Question 5: A patient with chronic obstructive pulmonary disease (COPD) calls reporting increased dyspnea and a change in sputum color from white to yellow-green. The nurse should triage this as:
- Routine — schedule a follow-up visit within 2 weeks
- Non-urgent — advise the patient to increase fluid intake and monitor
- Urgent — assess further and facilitate same-day evaluation for a possible COPD exacerbation (Correct answer)
- Emergency — call 911 immediately without further assessment
Correct answer: Urgent — assess further and facilitate same-day evaluation for a possible COPD exacerbation
Increased dyspnea and purulent sputum in a COPD patient are hallmark signs of an acute exacerbation requiring prompt same-day evaluation and treatment.
Question 6: Which of the following is an example of a subjective finding during a patient assessment?
- Blood pressure of 140/90 mmHg measured by the nurse
- Crackles heard on auscultation of the lung bases
- Patient reports feeling 'short of breath when climbing stairs' (Correct answer)
- Oxygen saturation reading of 94% on pulse oximetry
Correct answer: Patient reports feeling 'short of breath when climbing stairs'
Subjective data is information reported by the patient that cannot be directly measured or observed by the clinician.
Question 7: A nurse is reviewing a patient's medication list and notes the patient is taking St. John's Wort along with a prescribed SSRI antidepressant. The PRIORITY concern is:
- The combination will reduce the effectiveness of the SSRI requiring dose adjustment
- Risk of serotonin syndrome due to additive serotonergic effects (Correct answer)
- St. John's Wort will cause excessive sedation when combined with SSRIs
- There is no significant interaction between herbal supplements and SSRIs
Correct answer: Risk of serotonin syndrome due to additive serotonergic effects
St. John's Wort has serotonergic activity; combining it with an SSRI can precipitate serotonin syndrome, a potentially life-threatening condition.
Ambulatory Care Test Ambulatory Care Patient Assessment and Triage 5
A patient presents with a suspected urinary tract infection.
Which additional history finding would MOST indicate the need for urgent evaluation rather than empiric antibiotic treatment?