Trivium Patient Assessment and Evaluation 4

Question 1

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

Accepted Answer

Report this finding to the nurse immediately

Answer

Consider this normal for a COPD patient and continue routine care

Answer

Encourage the patient to take deep breaths and recheck in an hour

Answer

Document it at the end of the shift

Question 2

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

Accepted Answer

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

Answer

'I can get up on my own as long as I feel okay.'

Answer

'I only need help when it's dark outside.'

Answer

'My family will remind me when I forget.'

Question 3

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

Accepted Answer

Partial thickness skin loss with a shallow open wound

Answer

Intact skin with non-blanchable redness

Answer

Full thickness skin loss exposing subcutaneous tissue

Answer

Full thickness tissue loss with exposed bone or tendon

Question 4

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

Accepted Answer

Shuffling steps with a wide base of support

Answer

A smooth, steady stride with arms swinging evenly

Answer

Upright posture with confident foot placement

Answer

Normal speed of ambulation for the patient's age

Question 5

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

Accepted Answer

Anxiety or a cardiac dysrhythmia requiring evaluation

Answer

Normal digestion after a large meal

Answer

A musculoskeletal complaint from recent exercise

Answer

Hunger and need for a snack

Question 6

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

Accepted Answer

Pressure injuries

Answer

Falls

Answer

Malnutrition

Answer

Cognitive decline

Question 7

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

Accepted Answer

Phlebitis or infiltration of the IV

Answer

Normal healing at the IV site

Answer

Allergic reaction to the IV tubing

Answer

Bruising from a blood draw