Patient Assessment and Evaluation Flashcards

A patient with COPD has a resting oxygen saturation of 88%. The nurse aide should:

Answer: Report this finding to the nurse immediately

Although COPD patients may tolerate lower saturations, 88% at rest still requires prompt nursing evaluation to determine if intervention is needed.

Which patient statement best indicates the patient understands their discharge instructions after a fall assessment?

Answer: 'I will call for help before getting out of bed.'

Stating they will call for help before getting out of bed shows the patient understands fall prevention precautions.

During a skin assessment, a nurse aide finds a Stage 2 pressure injury on the coccyx. Stage 2 is characterized by:

Answer: Partial thickness skin loss with a shallow open wound

Stage 2 pressure injuries involve partial thickness skin loss, appearing as a shallow open wound or intact blister.

When assessing a patient's gait, which observation indicates an increased fall risk?

Answer: Shuffling steps with a wide base of support

Shuffling gait is associated with conditions like Parkinson's disease and greatly increases the risk of falls.

A patient reports feeling 'butterflies' in the chest and shortness of breath. These symptoms are most consistent with:

Answer: Anxiety or a cardiac dysrhythmia requiring evaluation

Palpitations and dyspnea together may indicate a cardiac dysrhythmia or anxiety and must be evaluated by the nurse.

The Braden Scale is used to assess a patient's risk for:

Answer: Pressure injuries

The Braden Scale evaluates six factors to estimate a patient's risk of developing pressure injuries.

A nurse aide notices that a patient's right hand is swollen, red, warm, and painful after IV placement. These findings most likely indicate:

Answer: Phlebitis or infiltration of the IV

Swelling, redness, warmth, and pain at an IV site are classic signs of phlebitis or infiltration requiring nursing intervention.