Disease Prevention

Which exercise is appropriate for the patient who has a Glasgow Coma Scale of 4?

Which patient requires the most immediate attention?

The patient tells the nurse “I drink three cups of black coffee a day. Is that okay?” Which response by the nurse is best?

Which complication is of greatest concern for the patient with nephrotic syndrome?

Which patient is at highest risk for thyroid disease?

The nurse is assisting with the development of a tool in the electronic medical record to prompt providers to screen appropriate individuals for hypothyroidism. The nurse provides which characteristics to the informatics team to include in the tool? Select all that apply.

The nurse is planning care for a patient returning from surgery for a colon resection and ileal pouch-anal anastomosis. Which interventions does the nurse employ to prevent surgical site infection? Select all that apply.

The urine output of a 40-year-old male patient with a urethral catheter has decreased from 80 mL/h to 15 mL/h. Which action should the nurse take first?

The full-term neonate is born via normal spontaneous vaginal delivery (NSVD). The neonate cries at the perineum and maintained flexion against gravity but is noted to be bluish gray. Which intervention is appropriate?

Place the nursing interventions for a 16-year-old patient in the hospital for severe malnutrition and depression with a history of falls in order from highest priority to lowest priority.

The emergency department nurse is assessing the unconscious patient following a fall from the ladder while he was doing home improvement work. Which assessment is performed first?

The nurse is the first responder to a motor vehicular accident involving the injury of a 40-year-old male. Which action is the highest priority?

The nurse is involved in a motor vehicular accident in which a minor injury from the seatbelt was sustained. Which action does the nurse take first in helping the other victims?

The patient from India tells the nurse that, in addition to his conventional medical treatment, he would also like to be treated according to the principles of Ayurvedic medicine. The nurse plans care based on which understanding of the focus of Ayurvedic medicine?

The patient with malignant hypertension has suffered from a transient ischemic attack. He asks the nurse if he can continue taking his St. John’s wort for depression. Which answer by the nurse is most appropriate?

The nurse is providing discharge instructions and education to a patient with stomach cancer who is interested in alternative/complementary medicine. Which low-risk therapies does the nurse include in the discussion? Select all that apply.

The patient reports an interest in using a herbal supplement to help with his depression. The nurse discusses herbal supplements with the patient based on which understanding of the nurse’s role in alternative and complementary medicine?

The nurse attempts, but is unable, to contact the provider to clarify a prescription that is much higher than the normal dosage. Which action by the nurse is appropriate?

The patient with cervical cancer has an implanted sealed internal radiation device. The nurse provides which instruction to the patient?

Which tool is most effective for promoting safety when ambulating an elderly patient who is a fall risk?

The provider orders physical restraints for a patient in alcohol withdrawal who is delirious, combative, and a fall risk. Which statement is true regarding use of physical restraints for this patient?

The nurse is the first responder to a 3-year-old male who is with his mother, having recently ingested a large quantity of household cleaner. The patient is unconscious but is hemodynamically stable and breathing. An ambulance has already been called. Which action by the nurse is appropriate?

The patient with neurosyphilis who has attempted to stab the nurse with scissors, pulled out several IVs, and is a fall risk is placed in wrist restraints per physician order. How frequently does the nurse assess the patient’s skin integrity?

The nurse is supervising the care of a patient with a wound infected with methicillin-resistant staphylococcus aureus (MRSA). Which action by the student nurse would prompt the nurse to intervene?

Which characteristic of a home is most effective at preventing falls in the elderly patient?

A unit has experienced a significant rise in the incidence of hospital-acquired urinary tract infections (UTIs). Which action item will be most effective to reduce the incidence of hospital-acquired UTIs?

The nurse is supervising the care of a diabetic patient with stomach cancer. After surgery, the patient is placed on total parenteral nutrition (TPN). Which information does the nurse provide the nursing student about the TPN?

The nurse is most vigilant for signs of which complication in a patient receiving total parenteral nutrition (TPN)?

The patient with tears of the right medial meniscus asks the nurse about the use of therapeutic massage. Which response by the nurse is appropriate?

Which patient is most at risk for developing a decubitus ulcer?

The nurse is providing dietary education for a patient with chronic alcoholism complicated by iron deficiency anemia and Wernicke encephalopathy. Which statement by the patient indicates a need for further teaching?

The nurse is teaching a nursing student about hand washing. Which statement by the nursing student indicates understanding of the teaching?

Which statement by the patient who has recently undergone a radical mastectomy indicates they understand teaching by the nurse?

Which nursing intervention will be most effective in preventing the spread of Clostridium difficile between patients?

Which patient is at the highest risk for falls?

A person in the hospital pulls out a firearm and starts shooting patients and staff at random in the emergency department. Which action by the nurse is most appropriate?

Which interventions does the nurse implement for the patient diagnosed with Clostridium difficile? Select all that apply.

The patient is diagnosed with new, rapid atrial fibrillation and thinks the problem has been going on for two weeks. Which statement by the patient indicates an understanding of teaching about the diagnosis?

The nurse is caring for a 62-year-old female who was recently diagnosed with glaucoma. The patient is given docusate. Which of the following is the primary reason for giving the patient a stool softener?

The 50-year-old patient receiving chemotherapy for breast cancer has developed a fungal bloodstream infection. Which intervention is the nurse’s first consideration?

The nurse is counseling the parents of a 7-year-old child who are concerned because of a strong family history of type 2 diabetes mellitus. The nurse instructs the parents that the initial screening for type 2 diabetes mellitus will occur at which time? 

The nurse instructs parents on which type of diet to decrease the risk for lead poisoning in their children? 

The patient who will be travelling out of the country soon is concerned about traveler's diarrhea. How does the nurse counsel the patient? 

The nurse uses which technique to counsel a patient with chronic obstructive pulmonary disorder (COPD) about quitting smoking? 

The nurse is preparing a 56-year-old male for a surgery that will take several hours. The nurse performs which intervention to decrease the patient's risk of pressure injury during the procedure?

Maternal infection with which organism(s) during pregnancy may lead to neonatal seizures? Select all that apply.

A new mother is discussing alcohol consumption while breastfeeding her baby. Which statement indicates a need for further teaching? 

The nurse is assigned to a patient with epilepsy. Which nursing intervention is most important for this patient? 

Following nephrectomy surgery, the patient is groggy and continuously pulls at the IV inserted in the right arm. Which intervention is most appropriate to protect the IV?

The nurse is providing discharge planning and education for a 72-year-old patient who is being discharged home after a diagnosis of atrial fibrillation. The nurse focuses education on which adverse event?