Physiological Adaptation

The patient presents to the urgent care clinic complaining of a blister rash on the arm that burns and itches. The nurse notes a large vesicle on the forearm with streaks of smaller vesicles surrounding it. Which question will be most helpful to diagnose this condition?

The patient in Arizona calls the nurse line to report being stung by a scorpion. Which follow-up question by the nurse is most important?

An individual calls the nurse line to report his friend has been bitten by a water moccasin snake on the hand. Which statement by the individual requires correction by the nurse?

The nurse is supervising the care of a patient with second-degree frostbite. Which action by the student nurse prompts the nurse to intervene with further instruction?

The patient presents to the dermatology clinic for a skin cancer check and a small red papule is found on the right chest. It is noted to have a crater in the middle and have pearly borders. How does the nurse interpret this finding?

The nurse is supervising the care of a patient with a stage II pressure injury on the coccyx. Which intervention by the student nurse prompts the nurse to intervene with further education?

Following an apartment fire, the patient is brought to the emergency department by ambulance. The patient has third degree burns on the anterior bilateral lower legs and thighs, abdomen, and anterior bilateral arms. Soot is noted on the face; the patient appears to be speaking normally. Place the actions in the order the nurse performs them.

Following an explosion at a factory, the patient is brought by ambulance to the emergency department. The patient has soot on the face and around the mouth and is coughing up black sputum. He verbalizes severe pain in his leg and his voice is noted to be a hoarse whisper. Further assessment reveals full thickness burns to the arms and hands and partial thickness burns to the legs. Shrapnel appears to have been embedded in the patient’s thigh. While moving the leg to assess the inner thigh, a piece of shrapnel shifts and the patient begins bleeding profusely from the wound. The patient cries out in pain and requests pain relief. Which action does the nurse take first?

The nurse is planning care for a patient who sustained third degree burns over 42% of the body during an industrial accident the previous day. The patient is intubated, sedated, and chemically paralyzed. Which patient problem is most important for the nurse to address?

The nurse in the burn ICU is caring for a patient with third degree burns over 33% of the body. Which assessment best indicates that fluid resuscitation has been adequate?

The 22-year-old patient is brought to the emergency room with decreased level of consciousness after ingesting 3,4-methylenedioxymethamphetamine. The patient is noted to have a rectal temperature of 40°C. The nurse performs which interventions? Select all that apply.

Which patient characteristic increases the risk for pernicious anemia following a subtotal gastrectomy?  

The patient with a history of colon cancer presents to the emergency department reporting significant abdominal pain, bloating, and vomiting. Which question to garner more information about the emesis is most important?  

In the postoperative period following a Whipple procedure, the nurse includes which interventions in the care plan? 

The nurse is caring for the patient who underwent colon resection and ileostomy creation two days ago. Upon assessment, the nurse notes 40 mL of dark green liquid in the ostomy bag. Which action by the nurse is correct?  

At 48 hours after a bowel resection surgery for colon cancer, the colostomy is noted to be moist and purple. Which additional assessment is most important?  

The nurse is providing preoperative education regarding total laryngectomy to the patient with laryngeal cancer. Which statement indicates a need for further teaching?   

The nurse is providing preoperative teaching to the patient prior to a total laryngectomy. Which information does the nurse include in teaching? Select all that apply.

The nurse learns the patient has a tracheoesophageal fistula following a resection of laryngeal cancer. How does the nurse interpret this information?  

The nurse is caring for a patient 6 hours after a transurethral resection of the prostate and notes decreased urine output. Which is the most likely cause of the decreased urine output? 

The nurse counsels the patient with prostate cancer to choose transurethral resection of the prostate based on which characteristic? 

The nurse assesses the patient who has received continuous bladder irrigation (CBI) therapy since a transurethral resection of the prostate (TURP) 24 hours ago. Which assessment is the priority to report?  

Following a bone marrow transplant, the patient exhibits a 10-pound weight gain in 3 days, increased abdominal circumference, and yellow tinge to the sclera and skin. The nurse notifies the provider and prepares to perform which intervention?  

The nurse assesses the patient with acute myelogenous leukemia after a bone marrow transplant. Which symptom concerns the nurse the most?

The patient is scheduled for a posterior pelvic exenteration and the nurse has provided preprocedural teaching. Which statement indicates a need for further teaching?  

The nurse provides which instructions to the unlicensed assistive personnel who is assisting in the care of a patient postoperative day one following a radical hysterectomy? Select all that apply. 

Which interventions does the nurse include in care for the patient who underwent a total pelvic exenteration for a cancer diagnosis one day ago? Select all that apply.  

The nurse in a tertiary medical center with attached pediatric hospital is caring for the 28-year-old gravida 3 para 2 woman who is 40-weeks pregnant and presents to the labor and delivery unit 1 hour after spontaneous rupture of membranes. Patient had good prenatal care, an amniotic fluid index of 12, and pregnancy is complicated only by the antenatal diagnosis of fetal single ventricle anatomy.  Labor is progressing well and the fetus is tolerating contractions well with moderate variability in fetal heart tones. The nurse is most concerned with having which item in the delivery room? 

The patient presents to the emergency department with severe, unrelenting abdominal pain. Which findings prompt the nurse to suspect the patient will require a Whipple procedure? Select all that apply.  

The nurse is caring for the patient recently diagnosed with colon cancer. Which assessment prompts the nurse to call for the provider immediately?  

The patient presents to the emergency department complaining of severe gastrointestinal distress after meals that has persisted for 36 hours. He reports that these symptoms have occurred off and on for a few years now, but he is seeking care now because they are interrupting his ability to sleep. Which additional assessment indicates the poorest prognosis for this patient?  

The home health nurse is assessing the patient with a colostomy. Which finding indicates the patient is performing the tap water irrigations too frequently?  

The patient is brought to the emergency department following a gunshot wound to the right chest. The patient is noted to have tracheal deviation to the left side with absent breath sounds on the right. Review of the chest radiograph indicates a large amount of free air in the superior chest as well as fluid in the inferior chest. Which procedure is performed first? 

The 13-year-old patient presents to the emergency room following a sports practice in the late summer heat with severe joint pain, malaise, splenomegaly, tachypnea, and tachycardia. Upon assessment, the patient’s oxygen saturation is 92%. Which order does the nurse carry out first?

The nurse is providing health promotion teaching to the parents of a child recently diagnosed with sickle cell anemia. Which statement does the nurse include in teaching? 

The nurse questions which orders for the 12-year-old patient in sickle cell crisis? Select all that apply.

The 72-year-old patient is brought via the ambulance to the emergency department after his wife observed him collapsing after dinner. At the scene, emergency medical service (EMS) personnel determined he was in asystole, and began cardiopulmonary resuscitation (CPR). An advanced airway was placed and a peripheral intravenous catheter was inserted. The defibrillator was placed and read ventricular fibrillation; a shock was administered, chest compressions were restarted, and a 1 mg epinephrine dose was administered via peripheral IV. Upon arrival to the emergency department, the patient was found to be in pulseless electrical activity after 5 complete rounds of CPR (including epinephrine, defibrillation, and 30:2 chest compressions to ventilated breaths ratio). The nurse advocates for which intervention?

The parent of the 8-year-old with sickle cell disease (SCD) reports the child complains of constant generalized pain rated at 4/10. Which response by the nurse is most appropriate?  

The 18-year-old patient presents with pallor, shortness of breath, and bleeding from the gums. Extensive testing is performed and a diagnosis of very severe aplastic anemia is made. Which additional information is most important to direct treatment? 

The 1-year-old with sickle cell disease is in crisis following gastroenteritis. While hospitalized, the patient abruptly exhibits seizures, decreased level of consciousness, right-sided facial asymmetry when crying, coughing and sputtering during a bottle feeding, and decreased movement of the right leg and arm. The nurse contacts the provider and prepares to provide which initial interventions? Select all that apply.  

The patient is hospitalized after being diagnosed with aplastic anemia. Which question is most important to ask the patient?   

The 18-year-old female patient reports menorrhagia, easy bruising, and epistaxis. Her family history is notable for maternal hypertension, a brother with hemophilia A, and a father who died of stroke at age 48. Which question is most important to ask the patient?   

The patient with β-thalassemia major exhibits complications of therapy. The nurse prepares to provide which intervention? 

The nurse learns the previously healthy 13-year-old child was walking at school and collapsed; x-ray revealed a broken femur. The nurse is most concerned about which disorder?  

The 3-week-old neonate of the mother who desires to formula feed is noted to have musty urine and excessive vomiting. Which initial intervention is most appropriate?  

The 13-year-old girl is brought to the clinic for treatment of vaginal candidiasis for the 2nd time in 6 months. Which question is most helpful by the nurse?  

The nurse is providing discharge teaching to the parents of the 3-year-old patient who was recently diagnosed with type 1 diabetes mellitus. Which item, if identified by the parents as the most important item to carry at all times, indicates effective teaching?  

The patient in the emergency department begins projectile vomiting. Which intervention is most important?  

The 3-year-old patient is brought to the clinic after three days of nausea, vomiting, and diarrhea. Which assessment most prompts the nurse to advocate for hospital admission?  

The 8-month-old patient has had 4 skin abscesses in the past 3 months that have required draining. Each abscess drains less than 5 mL non-purulent fluid. The infant appears well otherwise and the parents deny respiratory infections. The infant’s complete blood count shows an elevated white blood cell count without bands or segmented cells. Immunoglobulin levels are appropriate for the age of the infant. The patient has a positive nitroblue test. The nurse plans care to include which intervention?