Reduction of Risk Potential

The patient with a traumatic brain injury has symptoms of life-threatening elevated intracranial pressure. The provider instructs the nurse to prepare the patient for the insertion of an intraventricular catheter to monitor intracranial pressure (ICP) and drain cerebrospinal fluid as necessary. Which lab value prompts the nurse to clarify the safety of the procedure with the patient?

The drowning victim is admitted to the intensive care unit (ICU) after being without oxygen for 10 minutes. When he was found, he did not have a pulse and was resuscitated at the site. Once return of spontaneous circulation (ROSC) occurred, he was transported to the hospital. He was found to be profoundly hypotensive and was fluid resuscitated in the ambulance. In the ICU, his Glasgow coma score is found to be 7. He is intubated and has a central line and a peripheral arterial catheter in place. Which constellation of symptoms concern the nurse the most?

The 16-year-old patient presents to the emergency department (ED) complaining of a headache, fever, malaise, and nuchal rigidity. The patient is found to have a fever of 106°F, heart rate 132 bpm, and blood pressure 135/62 mmHg. A complete blood count is normal with the exception of leukocytosis. Additional assessment reveal sunsetter eyes and papilledema. Which test, if instructed to perform first, prompts the nurse to question the order?

The patient with global cerebral ischemia requires the placement of a jugular venous catheter to measure cerebral oxygen saturation. The nurse prepares the patient for the provider to insert the catheter into which location?

Determine the Cᴇᴏ₂ (cerebral oxygen extraction) for the patient receiving 100% FiO₂ whose jugular vein oximetry reads 54% and the peripheral pulse oximetry reads 92%. Input your answer using a whole number.

The patient comes to the clinic for an evoked potential study. The nurse understands the patient is being examined for which condition?

The patient is receiving therapeutic hypothermia treatment following a massive myocardial infarction with return of spontaneous circulation (ROSC) after 30 minutes of cardiopulmonary resuscitation (CPR). It is most important to plan care to address which complication of therapeutic hypothermia?

The nurse observes the following pupils in the patient: (R,L) The nurse alerts the provider to which possible scenario?

Following a motor vehicle accident, the unconscious patient presents with a respiratory rate of 28 and the following respiratory pattern: The nurse expects which acid-base derangement?

In which location of the spine does the provider introduce the needle for a lumbar puncture?

Which patients are at risk for restrictive pulmonary disease? Select all that apply.

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 patient has received an infusion of packed red blood cells for the treatment of anemia. The nurse anticipates which lab result following the transfusion?

The nurse is concerned the patient is experiencing hypocalcemia following the removal of the thyroid. In which location does the nurse assess for the Chvostek’s sign?

The patient with a calcium level of 11.4 mEq/L is at risk for which life-threatening complication?

The nurse is supervising a student nurse in caring for a postoperative patient at high risk for surgical wound evisceration. The nurse prepares the student to perform which interventions if the wound eviscerates? Select all that apply.

Which patient does the emergency department nurse assess first?

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

The patient has a phosphorus level of 5.2 mg/dL. Which additional lab value does the nurse anticipate in the patient related to the phosphorus level?

The patient who is NPO has an order to receive enemas until the intestines are devoid of stool. After 3 enemas, the patient is still passing a moderate amount of loose stool. Which action by the nurse is appropriate?

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?

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?

Two days after an abdominal surgery, the patient develops abdominal distention, tachycardia, fever, and nausea. The provider suspects sepsis. Which order does the nurse implement first?

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.

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

The nurse tests which cranial nerves to assess for increased intracranial pressure? Select all that apply.

During a comprehensive physical assessment, the nurse instructs the patient to stand still with the eyes closed. After a few seconds, the patient begins to sway and the nurse guides the patient into the chair. How does the nurse document this finding?

The nurse is preparing the patient for a computed tomography (CT) scan of the brain following a blow to the head. Which instruction does the nurse give the patient?

The patient with severe anxiety and claustrophobia is administered intravenous midazolam prior to an outpatient magnetic resonance imaging (MRI) scan of the brain. The nurse informs the patient’s companion that the patient can leave at which time following the procedure?

On the complete blood cell count with differential, the nurse notes the patient has an elevated number of eosinophils. The nurse explains to the patient that eosinophils become elevated due to which causes? 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 has right-sided hemiplegia following a cerebrovascular accident. Interventions to prevent which complication are the priority of care?

Carotid duplex testing utilizes which type of energy?

The nurse anticipates which symptom in the patient newly diagnosed with Graves' disease?

Which actions does the nurse take to prevent infection around the use of a peripheral IV? Select all that apply.

The nurse ensures which laboratory study is collected regularly to monitor the effectiveness and safety of the patient's continuous unfractionated heparin infusion?

Which is a late sign of hypoxemia?

The 7-year-old child who has been diagnosed with which respiratory condition will have normal breath sounds?

Which respiratory assessment in the infant prompts the nurse to alert the provider immediately?

The nine-month-old infant appears to be in distress. For rapid assessment, which pulse does the nurse palpate?

The anxious 5-year-old child is found to have tachypnea, stridor on inspiration, and a “barking” cough. The nurse suspects which condition?

A school nurse is caring for an elementary school student who is gasping for breath after being stung by a bee. The child's airway is currently patent and heart rate is 100 bpm. No epinephrine or advanced airway is available. Which intervention is appropriate?

The patient with a central venous catheter develops substernal chest pain, hypotension, and cough. There is evidence of air in the line. Which action does the nurse take first​?

The patient is being evaluated for obstructive sleep apnea. For which test does the nurse prepare the patient?

The patient receiving sliding scale insulin requests the subcutaneous insulin to be injected into the abdomen. Immediately prior to administration, the nurse notes the site is stringy, slightly indurated, and has several fat masses. Which action by the nurse is appropriate?

The nurse is preparing to discharge the patient following surgical creation of an arteriovenous fistula. For which complication is this patient most at risk?

The patient has Stage I pressure ulcers on her heels bilaterally. The patient's husband asks the nurse if he can massage her feet. Which is the most appropriate response by the nurse?