Next Assessment and Evaluation 3 — Questions and Answers
Question 1: A nurse is conducting a head-to-toe assessment and auscultates crackles in the lung bases bilaterally. This finding is MOST consistent with which condition?
- Pneumothorax
- Pulmonary edema or fluid accumulation (Correct answer)
- Asthma exacerbation
- Pleural effusion on one side only
Correct answer: Pulmonary edema or fluid accumulation
Bilateral basilar crackles are a classic sign of fluid accumulation in the lungs, commonly seen in pulmonary edema or heart failure.
Question 2: When assessing a patient's abdomen, what is the correct order of techniques?
- Inspection, palpation, percussion, auscultation
- Auscultation, inspection, palpation, percussion
- Inspection, auscultation, percussion, palpation (Correct answer)
- Palpation, percussion, inspection, auscultation
Correct answer: Inspection, auscultation, percussion, palpation
For abdominal assessment, auscultation is performed before palpation and percussion to avoid altering bowel sounds.
Question 3: A nurse is reassessing a patient 1 hour after administering a diuretic for fluid overload. Which finding best indicates the intervention was effective?
- Blood pressure increased from 130/80 to 150/90 mmHg
- Urine output of 200 mL in the past hour (Correct answer)
- Respiratory rate increased from 16 to 22 breaths/min
- Bilateral pitting edema unchanged from baseline
Correct answer: Urine output of 200 mL in the past hour
Increased urine output after diuretic administration indicates the medication is effectively removing excess fluid.
Question 4: A nurse reviews a patient's chart before the shift assessment. This is an example of which type of data source?
- Primary source
- Secondary source (Correct answer)
- Tertiary source
- Real-time source
Correct answer: Secondary source
Secondary data sources include medical records, lab results, and reports from other healthcare providers, as opposed to primary data collected directly from the patient.
Question 5: During evaluation, a nurse determines that a patient's goal was NOT met. What is the most appropriate next action?
- Discharge the patient and document goal as met
- Revise the plan of care to address barriers to goal achievement (Correct answer)
- Continue the same interventions without modification
- Transfer the patient to a higher level of care immediately
Correct answer: Revise the plan of care to address barriers to goal achievement
When a goal is not met, the nurse must reassess and revise the plan of care to identify and address the reasons for failure.
Question 6: A nurse uses the CAGE questionnaire during a patient assessment. What is this tool designed to screen for?
- Fall risk
- Depression and suicidal ideation
- Alcohol use disorder (Correct answer)
- Nutritional deficits
Correct answer: Alcohol use disorder
The CAGE questionnaire is a validated four-question screening tool used to identify patients at risk for alcohol use disorder.
Question 7: A postoperative patient reports pain of 7/10 but is observed laughing and talking with family. How should the nurse respond?
- Disregard the pain report since the patient appears comfortable
- Document that pain appears well-controlled based on behavior
- Accept the patient's self-report as the primary indicator of pain (Correct answer)
- Withhold analgesics until behavior is consistent with pain report
Correct answer: Accept the patient's self-report as the primary indicator of pain
The patient's self-report is the most reliable indicator of pain; behavioral cues alone should not override subjective pain reports.
Next Assessment and Evaluation 3
A nurse is conducting a head-to-toe assessment and auscultates crackles in the lung bases bilaterally.
This finding is MOST consistent with which condition?