Reduction of Risk Potential

Which statement does the nurse include in preprocedure teaching for the patient who will undergo abdominal paracentesis?

During an assessment of the patient who just completed a cross-country flight, the nurse elicits a positive Homan's sign. Based on this finding, the nurse suspects which condition?

The patient is brought to the emergency department after being pulled from a structure fire by rescue personnel. A stat bronchoscopy is ordered. The nurse informs the patient's spouse of which rationale for this order?

The 31-week-gestation woman is brought to the emergency department after being struck in the abdomen when the airbags deployed during a motor vehicle accident. Initial screening labs reveal the mother is blood type A-. The nurse advocates for which additional lab to assess the status of the pregnancy?

The nurse is assessing the elderly patient in the long-term care facility. Which findings suggest urinary catheter-associated urinary tract infection (CAUTI)? Select all that apply.

The nurse is inserting a nasogastric (NG) tube. To ease the process and increase chances for success, which instruction does the nurse give the patient to perform during insertion?

The nurse is providing medication teaching to the patient who was just prescribed warfarin. Which statements does the nurse include in teaching? Select all that apply. 

The gravida 1 para 1 woman delivered an infant at 41 weeks gestation that weighed 9 lbs. 2 oz. She received oxytocin during labor and forceps were used to assist in the delivery. The nurse is most concerned for which complication?

The patient with angina is experiencing crushing chest pain but the ECG shows no abnormalities. Which lab result indicates the patient is experiencing a non-ST segment elevation myocardial infarction (NSTEMI)? 

The nurse reviews the woman’s complete blood count (CBC) and finds the red blood cell count is 3.9 million cells per microliter. The nurse suspects the patient will be diagnosed with which condition?

The patient with diabetes is brought to the emergency department with severe confusion and is unable to follow commands. A point-of-care (POC) glucose measurement reveals a blood sugar of 44 g/dL. The nurse begins a 50 mL infusion of D50W. Which action does the nurse take next?

The day after administering a blood product to the anemic patient, the nurse learns it was contaminated with a fungal pathogen due to improper processing. The nurse is vigilant for which symptom(s)?

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?  

Which type of bowel sounds does the nurse expect to hear when auscultating the abdomen of a patient with watery diarrhea?

The nurse provides education to the pregnant woman about the signs of blood clots due to which cause of increased blood clotting risk during pregnancy?

The nurse notes the fetal heart rate (FHR) monitor is reflecting variable decelerations. Which action does the nurse take first?

The 82-year-old patient presents to the emergency department with chest pain that started four hours ago. Vascular access is a challenge and the nurse is only able to draw enough blood for one test. The nurse sends the sample to the lab for which test?

The patient with a T4 spinal cord injury has a blood pressure of 160/98 mm Hg. Which interventions does the nurse take? Select all that apply.

The healthcare team is answering questions for a 24-year-old black woman scheduled for a thyroidectomy. She states her mother had the same procedure and has a huge scar that is bigger than the original incision. The nurse understands the mother experienced which type of wound derangement?

The nurse is advising a 20 pack-year smoker about smoking cessation. The patient knows about increased risk of lung cancer, but wants to know if smoking is linked to other forms of cancer. The nurse explains that smoking increases the risk of which cancers? Select all that apply.

While individual labs vary, which is the normal range of thyroid-stimulating hormone (TSH) levels in healthy individuals?

The nurse is educating the pregnant woman at 13 weeks’ gestation with a newly placed cerclage. The nurse tells the patient to contact the provider if which events occur? Select all that apply.

Rett syndrome is associated with which condition?

Which information does the nurse include in patient teaching about cholesterol testing? Select all that apply.

Which instruction does the nurse give the patient with epilepsy who is 6 weeks pregnant?

The child suffered a radial fracture that has just been immobilized with a plaster cast. Which action by the nurse is appropriate? 

Which nursing interventions are performed for the patient after an uneventful colonoscopy? Select all that apply.

The nurse notices that the patient’s peripheral IV insertion site is red and indurated. What action does the nurse perform first?

The nurse is providing preprocedure education to the family of the child with type 1 diabetes mellitus who must undergo a tonsillectomy. Which information does the nurse include?

The nurse provides which instruction to the patient who will undergo guaiac stool testing?

A nurse is caring for a woman who is at 39 weeks' gestation and in active labor. What is the correct order of the four Leopold's maneuvers?

The nurse receives report from the operating room regarding a postoperative craniotomy patient and recognizes the patient is at risk for which complications? Select all that apply.

The patient in the intensive care unit is being weaned off of a continuous morphine infusion after being extubated 6 hours ago. Which assessments indicate the patient is failing to tolerate the treatment plan? Select all that apply.

The patient intubated in the intensive care unit has the following arterial blood gas results: pH 7.21 PCO2 51 PaO2 38 HCO3 16 Base Excess -7 Which action does the nurse take first?

Which arterial blood gas result is most indicative that the intubated and mechanically ventilated patient is ready to have the ventilator rate weaned?

The nurse is reviewing the lab results of a patient in the intensive care unit and finds the patient’s lactate to be 5.4 mmol/L. Which additional value is most responsible for this value?

The patient has hyperlactatemia. Which lab value concerns the nurse the most about the patient’s risk for long-term sequelae?

The patient’s arterial blood gas and serum electrolyte results are as follows: pH 7.28, PCO2 = 32, PaO2 = 59, HCO3- = 16, SaO2 = 88%, Sodium = 149, Potassium 3.9, Chloride 112. Calculate this patient’s anion gap. Enter your answer using a whole number.

The patient with metabolic acidosis is determined to have an anion gap of 11 mmol/L. The nurse advocates for which additional lab test?

The 56-year-old intubated and sedated patient’s arterial blood gas results are as follows: pH = 7.25, PCO2 = 36, PaO2 = 50, HCO3- = 15, SaO2 = 86%. Other lab values are notable for a hemoglobin of 7.9 mg/dL, albumin of 2.5 g/dL, sodium of 152 mEq/L, potassium of 2.1 mEq/L, chloride of 118 mEq/L. Vital signs are notable for a heart rate of 118 bpm, blood pressure of 86/38 mmHg, temperature of 102°F, and pulse oximetry of 85% on room air. The nurse advocates for which order?

The patient has pulmonary artery hypertension. The nurse most anticipates hypertrophy of which cardiac structure will be seen on chest x-ray?

The patient has had a positive rapid plasma reagin (RPR) test. Further testing will most likely reveal the presence of which organism?

Which patient on the surgical floor is at the greatest risk for abdominal wound dehiscence?

During routine tracheostomy care, the nurse notes increased drainage from the stoma and a fruity, grape juice odor. The nurse obtains a culture of the secretions and anticipates the results will reveal which organism?

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?

Which statement is true regarding the nonstress test (NST)?

The gravida 3 para 2 pregnant woman is being screened for gestational diabetes. Which characteristics increase the woman's risk? Select all that apply.

The patient with chronic obstructive pulmonary disease (COPD) is brought to the post-anesthesia care unit (PACU) after abdominal surgery. Which symptom alerts the nurse to an impending complication?

The nurse on the neurological intensive care unit would intervene if the provider attempted to assess the oculovestibular reflex in the patient with which recent injury?