Communication & Documentation

The nurse is caring for a 55-year-old female patient who is scheduled for a Venous Doppler examination. Which of the following instructions will likely be on the patient instruction sheet?

The nurse is caring for a 48-year-old male patient who is receiving 20 mg of furosemide (Lasix) OD. Which information is most important to tell the oncoming nurse?

The nurse teaching the patient with major depressive disorder taking tranylcypromine (Parnate) about necessary diet modifications. Which food, if selected by the patient, indicates a need for further teaching?  

The nurse is providing medication teaching to a patient receiving lithium for management of bipolar disorder. The nurse instructs the patient to take in similar levels of which nutrient each day?

The nurse observes the patient with schizophrenia to be speaking monotonously without facial expressions. Which term does the nurse use to document this finding? 

The nurse is teaching a 50-year-old patient with rheumatoid arthritis self-care and management of the condition. Which morning activity does the nurse recommend to the patient to facilitate further activities?

The 82-year-old patient has voided 240 mL in a 24-hour period. Which term does the nurse use to report this finding?

The nurse is caring for the patient who recently underwent right above-knee amputation and complains of pain in the amputated limb. Which response by the nurse is most appropriate?

Which tool does the nurse use to assess pain in the 4-year-old patient who sustained minor injuries on the playground? 

​The nurse is supervising the care of the patient prior to a surgical procedure who has been ordered to receive a clear liquid diet. Which food item, if provided to the patient by the unlicensed assistive personnel, prompts the nurse to intervene with further education? 

Following a minor abdominal surgical procedure, the patient is complaining of abdominal discomfort when coughing. Which nursing intervention is most important?

Which information does the nurse provide to the patient scheduled to receive intravenous cyclophosphamide for stage III breast cancer regarding hair loss? 

The 72-year-old male patient was recently diagnosed with prostate cancer. The nurse anticipates which additional complaint? 

The nurse is caring for a 50-year-old male patient with osteoarthritis who is prescribed a non-steroidal anti-inflammatory drug for pain. Which instruction does the nurse provide to the patient?

Two days after receiving a kidney transplant, the patient complains of flank pain. Which urine output, if reported by the unlicensed assistive personnel, is most concerning to the nurse? 

The patient is in a coma following evacuation of an acute subdural hematoma. Which intervention does the nurse utilize to increase the patient's level of consciousness? 

A patient of sound mind is scheduled to undergo a minor surgical procedure in 30 minutes and has just been given a light sedative. The nurse realizes that no consent form has been signed for the procedure. Which action does the nurse take?

An 18-year-old patient asks the nurse for assistance in choosing a birth control method. She tells the nurse that she smokes infrequently and has trouble remembering to take her daily vitamins. Which method does the nurse recommend to the patient?

The nurse in the emergency department is obtaining a medical history from a female patient. Her husband answers the nurse’s questions before the patient can respond. The patient is quiet, trembling, and the nurse notes bruising to her face and arms. How does the nurse proceed?

The nurse is providing pre-procedure education to a patient prior to surgery requiring general anesthesia. Which question by the patient indicates a need for further teaching?

A client reports that since her husband died five months ago, she continues to feel sad and depressed, and dreads the upcoming holiday season. She has no history of depression, is able to function normally at work, and is sleeping and eating normally. Which is the best response by the nurse?

The Health Insurance Portability and Accountability Act (HIPAA) includes a Privacy Rule, the federal law that covers a client’s protected health information. Which action by the nurse violates the Privacy Rule?

The patient with a terminal illness wishes not to receive heroic measures to prolong her life should her heart stop beating. The nurse encourages the patient to sign which document to ensure her wishes are followed?

The patient presents to the emergency department complaining of a fever, cough, and runny nose. Upon assessment, the nurse notes Koplik spots inside the client’s mouth; the client’s temperature is 102.5 °F (39.1 °C). Which infection control measures does the nurse institute?

A 54-year-old client admitted with new-onset atrial fibrillation is prescribed warfarin. Which instruction does the nurse include when teaching the client about warfarin?

A client with chronic liver disease is admitted with community-acquired pneumonia and is prescribed ceftriaxone 2 g IV every 12 hours. Which intervention does the nurse perform first?

The nurse is teaching a client with new-onset type 1 diabetes mellitus about his care. Which statement by the client indicates that teaching was effective?

A patient that has been clinically diagnosed with Rocky Mountain spotted fever (RMSF) is prescribed doxycycline. The patient states, “My blood tests didn’t prove I have RMSF. I don’t want to take antibiotics unless I know for sure I have it.” Which response by the nurse is the most appropriate?

The labor and delivery nurse is assigned to a 25-year-old G2P1 female with a viable intrauterine pregnancy at 40-weeks estimated gestational age. After the patient had PROM, dark green fluid was noted, which was not malodorous. Which of the following terms does the nurse use to document this finding?

The patient has sustained a complete spinal cord injury at the C3 level. The patient’s wife asks the nurse what his life will be like. Which of the following responses by the nurse is most appropriate?

The nurse is participating in long-term care planning for a patient who sustained a spinal cord injury at C8. Which of the following long-term goal(s) of care are most appropriate for this patient? Select all that apply.

The nurse is providing discharge teaching to an individual who suffered a spinal cord injury at T11. Which of the following statements by the patient indicates a need for further teaching?

A 25-year-old patient presents to the emergency department unconscious following a motor vehicle accident. The nurse is unable to wake the patient and the provider determines the patient requires emergency surgery due to internal bleeding. No emergency contact can be found for the patient. Which of the following is the most appropriate next course of action?

The nurse is providing education to a patient with an acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following body positions does the nurse teach the patient to assume to help him breathe more easily?

The nurse is assessing the patient with a right-sided chest tube and notes rapid bubbling in the water seal chamber. Which of the following is the next best step in management?

The nurse is preparing to remove a patient’s chest tube. Which instruction does the nurse give the patient?

The patient with a chest tube on suction becomes delirious and climbs out of bed causing the chest tube to become dislodged. Which of the following actions should the nurse take first?

The nurse is performing an admission assessment on a bedridden patient transferred from an assisted living facility. The nurse notes an area, 10 cm by 12 cm, on the patient’s sacrum that is intact but maroon in color. Which of the following is the most appropriate term for the nurse to use when documenting this finding?

During hourly rounds, the nurse notes a patient’s right heel has an erythematous area that is warm to the touch. The skin is intact but does not blanch with pressure. Which of the following terms is most appropriate for the nurse to use when documenting this finding?

The nurse is assessing the skin of a patient who uses a wheelchair for mobility. The nurse notes an area over the patient’s left ischium that is shiny and pinkish-red with a serous exudate. The area measures 5 cm x 4 cm and depth of the wound is insignificant. Which of the following terms is the most appropriate for the nurse to use when documenting this finding?

A patient is admitted to hospital with a wound on her sacrum. The nurse notes the wound bed is beefy red with areas of shiny white tissue. The center of the wound is covered in black, hardened tissue with yellow, foul-smelling soft tissue surrounding it. Which of the following terms is the most appropriate for the nurse to use when documenting this finding?

The nurse removes the dressing from a patient’s stage IV pressure injury and notes a foul odor and yellow drainage on the dressing and from the wound bed. Which of the following is the most appropriate next course of action?

The nurse is changing the dressing of a patient with a stage IV pressure injury. Upon removal of the gauze dressing, the nurse notes the wound bed appears dry. The wound bed is clear of slough or eschar. The nurse cleans and measures the wound. Which of the following is the best wound care strategy for this patient?

The nurse is preparing to administer hyaluronidase to a patient who experienced an IV extravasation. Which of the following statements should the nurse use to describe the rationale for using this drug to the patient?

The nurse is providing education to parents of young children regarding car seat safety. Which statement by the parent indicates the teaching was effective?

The nurse is assessing a neonate’s fit in the car seat for safety. The nurse notes the parent has placed the clip snugly against the infant’s chest at the level of the armpits; the nurse cannot pinch any slack at the shoulder straps. Which response by the nurse is appropriate?

The nurse is supervising a student nurse in the care of a patient following a percutaneous liver biopsy. The student nurse instructs the patient to lie on his left side following the procedure. Which response by the nurse is most appropriate?

The nurse is reviewing the chart of a patient scheduled to undergo a percutaneous liver biopsy in 2 hours. Which of the following characteristics, if present in the patient’s chart, would prompt the nurse to contact the provider immediately?

The nurse is providing discharge education to a patient with hemochromatosis. Which of the following statements by the patient indicates teaching was effective?

The patient with hemochromatosis has been prescribed deferasirox. Which of the following instructions should the nurse include in discharge teaching?