Disease Prevention

The nurse is assigned to a 52-year-old patient who is admitted for elective cholecystectomy. While undergoing preoperative evaluation, the patient mentions to the nurse an allergy that is not documented in the health record. Which action by the nurse is most appropriate?

The 17-year-old pregnant female patient presents for her first prenatal visit. The nurse plans care based on which understanding of recommended screening?

The nurse learns the patient uses nasal irrigation to help prevent sickness during flu season. Which statement by the nurse is the most important?

Which statement by the patient with type 2 diabetes mellitus who has received education about foot care indicates a need for further teaching?

The patient with major depressive disorder who has been off medication for a couple of years has been prescribed fluoxetine (Zoloft) again. The patient states, "I'm concerned about starting this medication again. I'm a taxi driver and it always used to make me so sleepy." Which instruction from the nurse is appropriate?

Which infection control practice is most appropriate?

How frequently does the nurse clean the toys of a pediatric patient with measles?

The elderly patient is at risk for falls related to urinary incontinence. Which intervention is appropriate?

The 85-year-old patient fell in the bathroom. Which score will most accurately predict the adverse effects the patient will experience from the fall?

Which intervention does the nurse utilize first to decrease the risk for fall in the patient who is confused and agitated?

The nurse caring for the patient with pulmonary tuberculosis requests which personal protective equipment?

A 30-year-old female presents in the emergency room with symptoms of a lower respiratory infection with a productive cough, but there are no N95 respirators for the staff to utilize. Which action by the nurse is appropriate?

The nurse is participating in a project to reduce infection of multidrug resistant organisms (MDRO). Which type of surveillance will assist in this endeavor?

Which error in the use of a child's car seat occurs most frequently?

Which personal hygiene interventions will increase the patient’s risk for infection? Select all that apply.

A 23-year-old pregnant woman presents to the clinic stating, “I am a teacher and have heard there is a measles outbreak in my community. I want to get the measles vaccine to protect my baby and myself. Which response by the nurse is most appropriate?

The patient has a peripherally inserted central catheter (PICC) for the long-term administration of parenteral nutrition, oxacillin, and gentamicin. Which assessment findings, if present in the patient, indicate the patient is experiencing a complication of the PICC line? Select all that apply.

The nurse is providing discharge teaching to the patient who has experienced episodes of atrioventricular nodal reentry tachycardia (AVNRT). Which patient drink selection(s), if chosen by the patient, indicate a need for further teaching? Select all that apply.

The patient who experiences frequent episodes of atrioventricular nodal reentry tachycardia (AVNRT) that do not cause hemodynamic compromise is being discharged. The nurse is supervising the student nurse providing discharge teaching to the patient. Which method for self-treatment of AVNRT, if taught by the student nurse, would prompt the nurse to intervene immediately?

The patient with severe abdominal pain and distention, elevated white blood cell count, fever, and disorientation is diagnosed with toxic megacolon due to Clostridium difficile infection. Which order for this patient does the nurse question?

The unvaccinated child presents to the emergency department with a fever lasting 6 days, malaise, and a new, diffuse, maculopapular rash that started on the face and has spread to the chest and arms. Prior to entering the room to assess the patient, the nurse dons which personal protective equipment (PPE)? Select all that apply.

The school nurse who works in an area with poor vaccination compliance learns a child has developed measles after being in class for the past week. Twenty other children in the class have not received the measles vaccine. The nurse anticipates how many of these children will contract measles?

A patient who was admitted with measles infection spent 4 hours in the busy emergency department. Each hour the patient was in the emergency department, 10 new patients entered the room. This trend continued for six hours after the patient was admitted to a room. How many patients are at risk for contracting the measles virus?

Which neonate must be most closely monitored for signs of Hirschsprung disease?

The patient in the intensive care unit who is intubated and mechanically ventilated abruptly requires a drastically increased fraction of inspired oxygen (FiO2) and is hypoxic, hypotensive, and tachycardic. Which intervention does the nurse perform first?

The intubated patient is receiving bolus enteral nutrition. In which position does the nurse place the patient to prevent aspiration?

The nurse is creating a tool to automatically screen for patients who are at an increased risk for aspiration pneumonia. Which patient conditions or medical histories does the nurse include in the screening tool? Select all that apply.

The 82-year-old patient from the long-term care facility is brought to the emergency department with wet-sounding cough and increased work of breathing. Vital signs are normal with the exception of tachypnea and an oxygen saturation of 91% on room air. Upon auscultation, the nurse notes diminished breath sounds over the right upper lobe. Chest radiograph indicates consolidation in the right upper lobe of the lung. The nurse prepares the patient for which test?

The nurse is teaching the nursing student the care of a patient with a tracheostomy. Which action by the nursing student when preparing to change the tracheostomy tube would prompt the nurse to intervene immediately?

The nurse is vigilant for which signs of complications in the patient with Zenker diverticulum?

The mechanically ventilated patient has a chest tube in place for the treatment of a tension pneumothorax. Which safety supplies does the nurse ensure are at bedside to prevent complications of an accidentally-removed chest tube? Select all that apply.

A nurse is teaching a student about Good Samaritan laws. Which statement is correct?

In the weeks after a stroke, which patient problem is of the highest priority?

A nurse is preparing discharge plans. Which patient is most likely to need home health care services?

The nurse provides care for the client diagnosed with Barrett's esophagus. Which goals does the nurse establish in the plan of care? Select all that apply.

The family practice nurse is reviewing telephone messages from patients. Which call is to be returned first?

The nurse is creating a tool to screen patients for depression and includes questions about which symptoms in the tool? Select all that apply.

The nurse is planning care for the patient with severe liver disease who has substantial ascites and peripheral edema. Which interventions are included in the care plan? 

The nurse is instructing the student nurse on proper sterile technique. Which statements are included in the teaching? Select all that apply.

The patient has undergone cataract surgery and is preparing for discharge. Which statement by the patient indicates an understanding of discharge teaching?

The nurse is reviewing the chart of the patient scheduled for a cardiac catheterization. Which characteristics, if present in the patient's chart, alert the nurse to an increased risk for cerebrovascular complications due to the procedure? Select all that apply. 

The nurse is instructing the unlicensed assistive personnel (UAP) on the proper care of dentures. Which actions by the UAP indicate an understanding of the teaching? Select all that apply.

The nurse is caring for the 3.7 kg neonate who was born at 38 weeks gestation after an uncomplicated pregnancy and delivery in the newborn nursery. Which immunization does the nurse administer to the patient prior to discharge from the hospital?

The home health nurse is working with a patient who is a fall risk. During a home visit, the nurse sees the patient repeatedly using a step stool. Which intervention is the most appropriate?

The nurse is helping a woman who is 12 weeks pregnant develop a diet plan. Which initial action by the nurse is appropriate?

The 58-year-old patient asks the nurse if he is at risk of heart disease. Which response by the nurse is appropriate?

The patient is in the post-anesthesia care unit (PACU) following abdominal surgery. Which finding would prompt the nurse to delay discharge from the PACU to a hospital bed?

The nurse is assisting the physician with insertion of a central venous catheter into the patient's left internal jugular vein. Into which position does the nurse place the patient? 

The patient who has recurrent seizures and is no longer legally able to drive has developed a depressed mood and stays home almost all of the time. Which action by the nurse is most appropriate?

The patient is scheduled for bariatric surgery in one month. During the preoperative physical, the nurse notes the patient takes St. John's wort. The nurse instructs the patient to stop taking St. John's wort 5 days prior to the surgery for which reason?