INACE Patient Assessment and Evaluation 2

Question 1

A nursing assistant notices a resident's skin is pale, cool, and clammy. What should be done first?

Accepted Answer

Report these findings to the nurse immediately

Answer

Apply a warm blanket and continue routine care

Answer

Offer the resident a warm beverage

Answer

Document the observation at the end of the shift

Question 2

When counting a patient's pulse, the nursing assistant notes it is irregular. What is the correct action?

Accepted Answer

Count for a full 60 seconds and report the irregularity to the nurse

Answer

Record only the rate and do not mention the rhythm

Answer

Count for exactly 15 seconds and multiply by four

Answer

Ask the patient if they feel any pain

Question 3

Which observation about urine output should be reported to the nurse?

Accepted Answer

Urine appears dark amber and has a strong odor

Answer

Urine is pale yellow and clear

Answer

Patient voided 300 mL over 8 hours

Answer

Patient voided once in the morning

Question 4

A resident reports feeling dizzy when standing up from a chair. This symptom is MOST associated with:

Accepted Answer

Orthostatic hypotension

Answer

Hypertension

Answer

Hyperglycemia

Answer

Peripheral edema

Question 5

When assessing a patient's level of consciousness, which response indicates the LOWEST level of responsiveness?

Accepted Answer

Patient responds only to pain

Answer

Patient responds to verbal commands

Answer

Patient is drowsy but arousable

Answer

Patient is confused but oriented to name

Question 6

A nursing assistant is observing a patient's respirations. Which finding requires immediate reporting?

Accepted Answer

Respirations of 8 per minute with periods of no breathing

Answer

Rate of 16 breaths per minute

Answer

Regular rhythm with equal depth

Answer

Slight variation in depth between breaths

Question 7

Which action BEST helps a nursing assistant accurately measure a patient's blood pressure?

Accepted Answer

Allow the patient to rest quietly for at least 5 minutes before measurement

Answer

Have the patient cross their legs during measurement

Answer

Place the cuff over thick clothing for comfort

Answer

Take the measurement while the patient is walking