Next Assessment and Evaluation 2 — Questions and Answers
Question 1: A nurse notes that a patient's wound edges are red, warm, and have purulent drainage 3 days post-op. Which type of assessment data is this?
- Subjective data reported by the patient
- Objective data observed by the nurse (Correct answer)
- Historical data from the medical record
- Diagnostic data from laboratory results
Correct answer: Objective data observed by the nurse
Objective data is information the nurse observes, measures, or detects through physical examination, such as wound appearance and drainage.
Question 2: When evaluating the effectiveness of a pain management intervention, which outcome best indicates goal achievement?
- Patient states understanding of the pain scale
- Patient's pain rating decreases from 8/10 to 3/10 after medication (Correct answer)
- Nurse documents the medication was administered on time
- Patient requests additional pain medication after 2 hours
Correct answer: Patient's pain rating decreases from 8/10 to 3/10 after medication
A measurable decrease in the patient's self-reported pain score directly demonstrates the effectiveness of the pain management intervention.
Question 3: A nurse is performing a focused assessment on a patient with chest pain. Which action should the nurse prioritize FIRST?
- Review the patient's past medical history
- Obtain a 12-lead ECG
- Assess airway, breathing, and circulation (Correct answer)
- Administer prescribed nitroglycerin
Correct answer: Assess airway, breathing, and circulation
Assessing airway, breathing, and circulation (ABCs) is always the first priority to identify life-threatening conditions.
Question 4: Which finding during a neurological assessment would require the nurse to notify the provider immediately?
- Pupils equal and reactive to light bilaterally
- Glasgow Coma Scale score of 15
- Unilateral pupil dilation and sluggish response (Correct answer)
- Patient alert and oriented to person, place, and time
Correct answer: Unilateral pupil dilation and sluggish response
Unilateral pupil dilation with sluggish response is a sign of increased intracranial pressure and requires immediate provider notification.
Question 5: A nurse is evaluating a patient's plan of care. Which step in the nursing process does this represent?
- Assessment
- Diagnosis
- Planning
- Evaluation (Correct answer)
Correct answer: Evaluation
Evaluation is the step in the nursing process where the nurse determines whether patient outcomes and goals have been met.
Question 6: A patient with COPD has an SpO2 of 88% on room air. How should the nurse interpret this finding?
- Normal for a patient with COPD; no action needed
- Slightly below normal but not significant
- Critically low; prepare for immediate intubation
- Below the acceptable range; notify the provider and apply supplemental oxygen (Correct answer)
Correct answer: Below the acceptable range; notify the provider and apply supplemental oxygen
SpO2 of 88% is below the acceptable threshold and requires supplemental oxygen and provider notification, though COPD patients may tolerate slightly lower levels than others.
Question 7: Which data collection method would best help the nurse assess a patient's skin turgor?
- Auscultation over the abdomen
- Palpation by gently pinching the skin on the forearm (Correct answer)
- Inspection of mucous membrane color
- Percussion over the thoracic cavity
Correct answer: Palpation by gently pinching the skin on the forearm
Skin turgor is assessed by gently pinching the skin; slow return to normal position indicates decreased turgor and possible dehydration.
Next Assessment and Evaluation 2
A nurse notes that a patient's wound edges are red, warm, and have purulent drainage 3 days post-op.
Which type of assessment data is this?