Disease Prevention

Which interventions increase the risk for impaired skin integrity in the patient with congestive heart failure who requires total care? Select all that apply.

Which patient is at highest risk for skin breakdown?

The nurse identifies which patient at highest risk for delayed wound healing?

The nurse advocates for a guaiac test to be performed on the patient with which stool?

During routine tracheostomy cleaning and care, the nurse notes a strong smell of dirty gym socks coming from the dressing around the stoma. Which action by the nurse is most appropriate?

The patient is being transferred from a nursing home to an acute care facility. The receiving nurse performs which actions during the medication reconciliation process? Select all that apply.

Following a motor vehicle accident, the patient is brought to the emergency department with concern for a brainstem injury. Which tests are performed to assess the integrity of this patient’s brainstem? Select all that apply.

The patient who takes milk of magnesia every day is at risk for which electrolyte imbalance?

The patient returns from Mexico with severe diarrhea lasting 4 days. The nurse anticipates the serum electrolyte levels to reflect which imbalances? Select all that apply.

The nurse is caring for a patient diagnosed with measles. Which precautions does the nurse utilize during the patient’s care? Select all that apply.

The nurse is educating a middle-aged wellness group on lifestyle changes that may prevent Alzheimer’s disease. Which diet does the nurse recommend?

Which parasite is the causative agent of malaria?

The patient calls the nurse to the room to report pain at the site of an IV. The nurse notes warmth, redness, and purulent drainage. Which action does the nurse take first?

Which instruction does the nurse give the patient during preoperative teaching prior to a middle ear surgery?

The nurse is providing preoperative teaching to the patient who is scheduled for a total knee replacement next Tuesday at 1000. The nurse instructs the patient to have no solid food after which time?

The patient presents prior to a right elbow repair surgery. The surgeon speaks with the patient, answers questions, and obtains informed consent. Prior to leaving, the surgeon states, “Good; your hospital ID bracelet is on your right arm. That will signal to us we have the correct limb.” Which response by the nurse is most appropriate?

The patient is scheduled for an ankle reconstruction surgery at 1000 today. During the admission interview, the patient reports drinking a fruit and yogurt smoothie at 0800 this morning. Which action does the nurse take?

The patient underwent colon resection one day ago. The nurse is performing a shift assessment and notes absent bowel sounds after listening for 5 minutes. Which action by the nurse is most appropriate?

Following surgery for a bowel obstruction, the patient has a nasogastric tube in place for gastric decompression. The nurse aspirates fluid from the tube and notes a pH of 2. Which action by the nurse is appropriate?

The nurse is instructing the patient on how to move in bed after an open abdominal surgery. Which statement by the nurse is appropriate?

The patient is 3 hours postop from an open abdominal surgery. Flexion and extension of which joints are most appropriate for this patient to perform to prevent complications of immobility while minimizing the risk of evisceration? Select all that apply.

The patient underwent a femoral cardiac catheterization at 1000 today. The nurse informs the patient that he must remain supine in bed until which time at the earliest? Enter your answer using four-digit military time.

The nurse is checking on the patient who underwent cardiac catheterization via the femoral artery 2 hours after the procedure. The patient appears to be sleeping and the nurse notes that the bruise at the insertion site has increased in size since the last assessment. Which action does the nurse take first?

Following colon resection, the nurse is vigilant for which early symptoms of septic shock? Select all that apply.

The patient is 24-hours-postop from a pelvic reconstruction surgery after fracturing the pelvis in a fall. The patient reports severe abdominal pain and nausea. Upon assessment, the patient’s abdomen is grossly distended and firm. The patient’s skin is diaphoretic and the patient is tachypneic and tachycardic. Pulses and capillary refill time are adequate. During the assessment, the patient vomits a moderate amount of light green liquid. The nurse contacts the provider to report suspicion of which postoperative complication?

The patient has not defecated for 24 hours after an appendectomy. The patient’s abdomen is distended and the patient reports nausea. Upon auscultation, the nurse notes absent bowel sounds after 5 minutes of auscultation. Which action does the nurse take first?

The nurse is called to the intubated patient’s room by the patient's child who reports a large gush of red-tinged fluid from a transverse abdominal wound after the patient coughed. While calling for help, the nurse ensures the patients bed is set to which degree angle?

On day four postop following an open abdominal surgery, the patient develops a cough. During an assessment, the patient coughs, and the wound dehisces. The nurse notes intestinal loops are visible outside of the wound. Which initial intervention by the nurse is appropriate?

The nurse recommends transcutaneous electrical nerve stimulation (TENS) to which patients? Select all that apply.

The patient currently undergoing emergency aspiration of an intracranial hematoma after a construction site accident has a nursing diagnosis of risk for contractures related to immobility. The nurse plans postoperative care to include which intervention to achieve the expected outcome associated with this nursing diagnosis?

The patient is recovering from a lower spinal cord injury that has resulted in paraplegia and lack of sensation below the umbilicus. Which instruction is most important to help the patient protect skin integrity?

The patient being treated for a skin wound and cellulitis is in a semi-private room with another patient; the hospital is near capacity. The culture of the wound has grown methicillin-resistant staphylococcus aureus. Which action is most appropriate? 

During an active shooter situation, the nurse closes patient’s rooms and bars entry to the unit. This is an example of which ethical principle?

The patient is being discharged from hospital on total parenteral nutrition (TPN). Which information does the nurse include in discharge teaching?

The American Cancer Society recommends the patient's initial cervical cancer screening occurs at which time?

Which statement is true regarding single use items?

Which patient is seen first in the emergency department?

Body mass index (BMI) is calculated using which measurement(s)?

The nurse is caring for the patient on methadone treatment as an outpatient. The provider has ordered a dose of methadone that is far higher than what the nurse has ever administered. Which action by the nurse is appropriate?

Which statements are true regarding the care of the 2-year-old with whooping cough? Select all that apply.

The patient with a spinal cord injury has a history of recurrent urinary tract infections due to an inability to completely empty the bladder. The nurse provides the patient with which instruction?

Following an industrial accident, the patient is immobile. The student nurse is creating a care plan for the patient to prevent respiratory decompensation. Which intervention, if included in the care plan for this nursing diagnosis, would prompt the nurse to provide additional education to the student nurse?

The nurse is evaluating the patient with amyotrophic lateral sclerosis. Which symptom is most concerning?

The nurse is helping the patient with amyotrophic lateral sclerosis to select food for a meal. Which meal choice is appropriate?

The nurse is providing education to the patient with Bell’s palsy. Which instruction does the nurse give the patient to promote safety?

Which statement by the patient indicates a need for further teaching about the new diagnosis of Bell’s palsy?

The nurse is caring for a patient with Guillain-Barré syndrome. The patient has an order for a pureed diet. Which assessment prompts the nurse to clarify the order with the provider?

The 17-year-old patient is seeking advice on testing for sexually transmitted diseases. He states, “I kissed my girlfriend with my tongue inside her mouth. What do I need to be tested for?” Which is the most therapeutic response by the nurse?

The nurse is vigilant for Candida albicans infections in patients with which conditions? Select all that apply.

The nurse is exiting the room after providing care for the patient diagnosed with tuberculosis. In which order does the nurse remove the personal protective equipment?