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

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

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

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

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

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

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

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

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

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

(Trivium) Trivium Health Care Exam Practice Test