INACE Patient Assessment and Evaluation 2 — Questions and Answers
Question 1: A nursing assistant notices a resident's skin is pale, cool, and clammy. What should be done first?
- Apply a warm blanket and continue routine care
- Report these findings to the nurse immediately (Correct answer)
- Offer the resident a warm beverage
- Document the observation at the end of the shift
Correct answer: Report these findings to the nurse immediately
Pale, cool, clammy skin can indicate shock or circulatory problems and must be reported to the nurse immediately.
Question 2: When counting a patient's pulse, the nursing assistant notes it is irregular. What is the correct action?
- Record only the rate and do not mention the rhythm
- Count for exactly 15 seconds and multiply by four
- Count for a full 60 seconds and report the irregularity to the nurse (Correct answer)
- Ask the patient if they feel any pain
Correct answer: Count for a full 60 seconds and report the irregularity to the nurse
An irregular pulse should be counted for a full 60 seconds and the irregularity reported to the nurse for further evaluation.
Question 3: Which observation about urine output should be reported to the nurse?
- Urine is pale yellow and clear
- Patient voided 300 mL over 8 hours
- Urine appears dark amber and has a strong odor (Correct answer)
- Patient voided once in the morning
Correct answer: Urine appears dark amber and has a strong odor
Dark amber urine with a strong odor may indicate dehydration or infection and must be reported to the nurse.
Question 4: A resident reports feeling dizzy when standing up from a chair. This symptom is MOST associated with:
- Hypertension
- Orthostatic hypotension (Correct answer)
- Hyperglycemia
- Peripheral edema
Correct answer: Orthostatic hypotension
Dizziness upon standing is a classic sign of orthostatic hypotension, a drop in blood pressure when changing positions.
Question 5: When assessing a patient's level of consciousness, which response indicates the LOWEST level of responsiveness?
- Patient responds to verbal commands
- Patient responds only to pain (Correct answer)
- Patient is drowsy but arousable
- Patient is confused but oriented to name
Correct answer: Patient responds only to pain
Responding only to painful stimuli indicates a severely decreased level of consciousness.
Question 6: A nursing assistant is observing a patient's respirations. Which finding requires immediate reporting?
- Rate of 16 breaths per minute
- Regular rhythm with equal depth
- Respirations of 8 per minute with periods of no breathing (Correct answer)
- Slight variation in depth between breaths
Correct answer: Respirations of 8 per minute with periods of no breathing
A rate of 8 breaths per minute with apnea periods is dangerously low and requires immediate reporting.
Question 7: Which action BEST helps a nursing assistant accurately measure a patient's blood pressure?
- Have the patient cross their legs during measurement
- Place the cuff over thick clothing for comfort
- Allow the patient to rest quietly for at least 5 minutes before measurement (Correct answer)
- Take the measurement while the patient is walking
Correct answer: Allow the patient to rest quietly for at least 5 minutes before measurement
Allowing the patient to rest 5 minutes before measurement ensures a more accurate baseline blood pressure reading.
INACE Patient Assessment and Evaluation 2
A nursing assistant notices a resident's skin is pale, cool, and clammy.
What should be done first?