Basic Care and Comfort

The patient presents to the urgent care clinic complaining of eye pain and feeling like there’s a foreign object in the eye. The provider examines the patient and orders a 500 mL irrigation of sterile saline. After warming the solution to 37°C and positioning the patient, the nurse begins to administer the irrigation. The patient cries out in pain and jerks away from the nurse. Which response by the nurse is most appropriate?

Which medications are antibiotics used to treat urinary tract infections? Select all that apply. 

Which statement describes the purpose of the left ventricular assist device? 

During a routine checkup, the patient reports undergoing a scleral buckling procedure since the last visit. Which follow-up question does the nurse ask regarding this event?

The nurse receives report on the patient with acute bowel obstruction. The patient’s problem list includes controlled hypertension, uncontrolled diabetes, and presbycusis. Which action by the nurse is appropriate?

The nurse is providing discharge education to the patient with acute laryngitis. Which information does the nurse include?

The nurse learns in report that the patient has a Jackson-Pratt drain. Which nursing intervention will be required for this patient immediately after emptying the drain?

The nurse empties the patient’s Jackson-Pratt drain 24 hours after a partial colon resection. There is 10 mL drainage that is noted to be light red and thin. There is no odor and the fluid is free of sediment or clots. How does the nurse document this assessment in the medical record that is charted by exception?

The student nurse is preparing to perform an irrigation of the patient’s indwelling urethral catheter. Which action by the student nurse prompts the supervising nurse to intervene immediately?

Place the steps for indwelling urinary catheter irrigation into the correct order.

The nurse is attempting to perform an irrigation of the patient’s indwelling urinary catheter but it is unable to instill the irrigant with normal force. Which action does the nurse take?

Which sport does the nurse recommend to the child with osteogenesis imperfecta who is interested in physical fitness?

The patient is seeking dietary information on the difference between macronutrients and micronutrients. Which statement by the nurse is appropriate?

Which is the main source of energy and fiber in the human diet?

Linoleic (omega-3) and linolenic (omega-6) acids belong to which macronutrient group?

The women in the fertility clinic states, “I read an article that said I should increase my omega-3 fatty acid intake to improve my chances of conceiving. Which foods should I eat?” The nurse responds with which foods? Select all that apply.

The patient states, “I’m trying to be healthy, so I’ve taken twice the daily recommended doses of all my vitamins for years to ensure I get even more effect from them.” The nurse assesses for signs of toxicity from overconsumption of which nutrients? Select all that apply.

The nurse is caring for a patient who is seeking medical attention for chronic muscle aches and nonspecific pain. Upon assessment, the nurse detects bone pain upon applying moderate pressure to the patient’s sternum and tibia. The patient works with computers and has severe outdoor allergies. The nurse encourages the patient to increase intake of foods rich in which nutrient?

The nurse is preparing to care for a patient admitted from an institutional setting. The nurse notes that the patient’s serum albumin level was measured at 2.9 g/dL and BMI (body mass index) was calculated to be 16. Which clinical finding does the nurse anticipate to observe?

The nurse is completing a nutrition and diet assessment and asks if the patient is taking any medications or supplements. The patient becomes defensive and questions why the nurse needs to know. Which is the best response by the nurse?

The nurse is caring for a seven-year-old girl whose parents have expressed concern over the child wetting the bed at night. The nurse directs questioning to assess for which conditions? Select all that apply.

Parents of a four-year-old boy are worried because their son has been wetting the bed. The nurse informs the parents the child may continue to have nocturnal enuresis for how many more years? Enter your answer using a whole number.

The mother of a six-year-old child brings the child to the pediatrician requesting treatment for nocturnal enuresis. The nurse prepares information for the mother about which treatment?

The nurse is developing a care plan with a nine-year-old girl to end her nocturnal enuresis. The nurse is focused on which goal when communicating with the child?

The parent of the 5-year-old child reports that the child, who was potty trained at 3-years-old, has been stooling in places other than the toilet a couple times per month for 4 months. The nurse uses which term to document this symptom?

The nurse is collecting data from the parents of a seven-year-old boy who often has liquid stool in his underwear. The parents report he developed urinary and stool incontinence at four years of age and this problem started about six months ago. Their son excretes small pellets of stool every night before bed, and the parents wonder if he is soiling his clothing on purpose. Which additional testing does the nurse anticipate at this point?

A ten-year-old patient presents to the emergency department (ED) complaining of abdominal pain. He states, “I poop every day. It sometimes hurts to go and the poop is small, hard pieces. Which response does the nurse anticipate when the child is asked, “How much water do you drink in a day?”

A new mother calls the nurse hotline concerned that her 4-day-old infant is sleeping too much. The nurse bases the response on which understanding of the newborn and postpartum period?

The nurse is preparing to discharge a newborn and her mother. The nurse checks that the mother is able to state which principle of safe sleeping?

Which statement is true regarding the sleep of older adults?

The nurse is caring for a patient after the surgical amputation of the left leg below the knee. The nurse expects the patient to attain which level of mobility with rehabilitation and prosthesis training?

The nurse is educating the patient with a spinal cord injury on safe wheelchair use. Which important features does the nurse emphasize to the patient? Select all that apply.

The patient with bilateral leg amputations is being fitted for a new wheelchair. The nurse knows that the patient’s center of gravity is offset in which direction?

The nurse recommends removal of which items from the home of the patient who will be discharged home in a wheelchair? 

The older adult patient recently diagnosed with a spinal cord injury and limited mobility is referred to a physical therapist to discuss using a wheelchair for increased mobility. The patient asks the nurse, “Do I really have to see the physical therapist? I broke my leg as a kid and used one then.” Which response by the nurse is appropriate?

The patient with heart failure has an order written to be weighed daily. When does the nurse instruct the unlicensed assistive personnel to weigh the patient?

The nurse is creating a bladder retraining program for the 74-year-old female patient who is incontinent of urine. Which aspect of the training program is most important?

Which evening meal choice is appropriate for this patient? Look at the patient’s chart to make a selection.

Which food items does the nurse encourage the patient to eat? Look at the patient’s chart to make selections and select all that apply.

Which food item, if selected by the patient, would prompt the nurse to provide additional education? Review the patient’s chart to make selection.

Which meal selection is appropriate for this patient? Review the patient’s chart to make a selection.

After reviewing the patient’s chart, which instruction does the nurse give the unlicensed assistive personnel working with the patient?

The nurse has received an order to insert a nasojejunal tube. The nurse measures the patient as 15 cm from the nose to the tragus and an additional 30 cm to the xiphoid process. What is the total length of tube that should be inserted for this patient?

The nurse has received an order to initiate nasogastric tube feedings for the patient with long-standing anorexia. After the tube feeding is initiated, the nurse is vigilant for which electrocardiogram changes which may indicate the patient is experiencing life-threatening complications of tube feeding? Select all that apply.

The patient receiving tube feeding experiences confusion, diaphoresis, pallor, and tremors two hours after receiving a bolus tube feeding. The nurse requests an order for which test?

The patient with a subtotal gastrectomy has been advanced to a regular diet. Which information does the nurse provide the patient? Select all that apply.

Which food is a priority for the nurse to encourage the patient to eat? Look at the patient’s chart to make a selection.

The patient in the intensive care unit who was intubated with a central venous catheter, peripheral arterial catheter, and chest tube has expired. Which question by the nurse who enters the room to assist the patient care nurse is most appropriate?

The nurse is providing post-mortem care to a patient on hospice after being treated for stage 4 colon cancer that metastasized to the bladder. Which action by the nurse is most appropriate?

A bodybuilder is brought to the emergency room after being found unresponsive. The patient is found to have no brain activity due to hypoxia caused by a massive myocardial infarction. Care is withdrawn and the patient passes away. Which statements does the nurse make to the nursing student who is assisting in providing post-mortem care? Select all that apply.