Communication & Documentation

The 19-year-old female patient is brought to the emergency department by her mother for severe abdominal pain. The patient denies being sexually active, but a point of care pregnancy test is positive. Which action does the nurse take next?

The nurse is helping the nursing student to relate patient findings to pathophysiological concepts. Which findings, if selected by the nursing student as characteristics that prompt the kidneys to release renin, indicates a need for further teaching?

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 admitting an 89-year-old man with end stage liver disease. He declines a palliative care consult saying, “I’m not dying today.” Which responses by the nurse are appropriate to counsel the patient? Select all that apply.

The nurse prepares a diphtheria, tetanus, and pertussis (DTaP) vaccination for a 6-year-old patient. The patient’s mother states, “Wait! He’s already gotten that vaccine, several times when he was younger. I have it written down in his records.” Which response by the nurse is appropriate?

The nurse is preparing a Haemophilus influenzae type b (Hib) immunization for the 2-month-old patient. The baby’s mother states, “I recently read the influenza vaccine isn’t given until at least a year. Are you sure he should be getting this now?” Which response by the nurse is most appropriate?

The nurse reviewing the vaccination record of a 12-month-old infant expects the infant to have completed which vaccine series?

The nurse is preparing for the well-baby visit of the 6-month-old who is up-to-date on vaccines. Which vaccinations does the nurse prepare for the visit? Select all that apply.

The 13-year-old female patient presents to the clinic in January to begin the vaccine series for human papillomavirus. The nurse instructs the patient’s mother to schedule an appointment for the next vaccine in the series during which month at the earliest?

The baby born at 32 weeks’ gestation to a mother who is hepatitis B surface antigen negative (HBsAg-negative) is taken to the Neonatal Intensive Care Unit (NICU) for care. The neonate, who weighs 1.8 kg, requires continuous positive airway pressure of 7 cm H20, intravenous fluids containing dextrose, and intravenous caffeine. After getting consent from the mother, when is the most appropriate time to administer the hepatitis B vaccine to the baby?

The 34-week-gestation neonate is born weighing 1.7 kg to a mother who is hepatitis B surface antigen (HBsAg) positive; all other infectious disease serologies are negative. Which orders are appropriate for this patient? Select all that apply.

The 1.9 kg neonate is born precipitously via vaginal delivery to a 32-year-old mother who received no prenatal care or infectious disease serology testing before delivery. The mother has a history of intravenous drug use. Which intervention does the nurse perform first?

The patient whose mother chose not to vaccinate him presents to the clinic the day after his 18th birthday to receive all eligible vaccinations. The nurse uses which statement to counsel the patient about the hepatitis B vaccine series?

The 19-year-old patient tells the nurse, “I was reviewing my vaccination records for school and noted I never received the varicella vaccination.” Which response by the nurse is most appropriate?

The 10-year-old female patient’s mother brings her to the clinic for a check-up and immunizations and requests that she receives the human papillomavirus (HPV) vaccination. Which question does the nurse ask first?

The 18-year-old patient calls the clinic two weeks after receiving the 2nd vaccination in the three-dose series for human papillomavirus (HPV). She states, “I didn’t realize it when I got the vaccine, but I was 6 weeks pregnant. Will my baby be okay?” Which response by the nurse is most appropriate?

The nurse is providing discharge education to the patient regarding immunizations following a hematopoietic stem cell transplant. When does the nurse instruct the patient to visit the clinic for the Haemophilus influenzae type b (Hib) vaccine?

The public health nurse encourages which individuals to receive the hepatitis A vaccine? Select all that apply.

The nurse has provided discharge instructions to the patient with type II diabetes. How does the nurse assess the patient’s understanding of the teaching?

The nurse is providing discharge education to the 48-year-old patient with a third grade reading level about his new prescription for valsartan. Which is the best way for the nurse to assess the patient’s understanding of the teaching?

The nurse has provided teaching to the patient regarding the use of crutches after she broke her ankle. Which is the best way for the nurse to assess the patient’s understanding of the teaching?

The nurse is reviewing the chart of the patient who is scheduled for a magnetic resonance imaging (MRI) scan of the brain. Which patient characteristic, if found in the patient’s chart, prompts the nurse to contact the provider about cancelling the test?

The nurse is reviewing the chart of the patient scheduled to undergo a magnetic resonance imaging scan (MRI) of the brain. Which disorder present in the patient’s history prompts the nurse to obtain more information from the patient?

The nurse holds the dose of propranolol and contacts the provider for which vital sign?

The nurse is teaching the patient who has been prescribed propranolol. Which statement by the patient indicates an understanding of the teaching?

The patient presents to the emergency department (ED) stating, “I started getting this terrible pressure in my chest after mowing the lawn. I just know I’m having a heart attack.” Following testing, the patient is diagnosed with angina pectoris. The patient asks, “If I didn’t have a heart attack, why did I have such bad chest pain?” Which response is appropriate?

The patient presents to the emergency room (ER) after having a fever for three days and new onset severe chest pain behind the sternum. The patient asks, “What is wrong with me? Do I have pneumonia? It hurts when I breathe.” Upon assessment, the nurse notes a heart rate of 124 bpm, temperature of 37.9°C, and an intermittent friction rub upon auscultation. The lungs are clear. The nurse suspects further testing will lead to a diagnosis of which condition?

The nurse is providing medication instructions for iron supplements to a patient with anemia. Which information is included?

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.

A patient with epilepsy asks whether he will know if a seizure is coming on. The nurse replies with which statement?

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.

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 35-year-old woman is interested in starting hormonal birth control. Which characteristic, if found in the patient's medical record, indicates the patient requires an alternative form of contraceptive?

Which is the focus of a shift report?

The nurse is caring for a 16-month-old child. The child’s father expresses concern to the nurse that his son cannot kick a soccer ball. Which response from the nurse is appropriate?

The patient has come to the emergency department by ambulance for presumed heroin overdose. The nurse expects the patient to have received which medication in the field?

The patient wants to quit smoking before starting hormonal birth control. Using motivational interviewing, which statement by the nurse would best elicit change talk from the patient?

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?

Parents bring their 12-month-old baby who was born prematurely to the pediatrician for a well-baby appointment. How does the nurse judge the adequacy of the baby's weight gain?

The nurse know which statement best describes a multidisciplinary team?

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

The nurse assesses the cuff pressure of the patient's tracheostomy. Which cuff pressure prompts the nurse to document the finding and proceed with the assessment?

Which symptoms, if present in the patient receiving a blood transfusion, indicate the patient is experiencing an acute hemolytic transfusion reaction? Select all that apply.

The neonate is diagnosed with congenital parvovirus. The nurse requests an order for which transmission prevention precaution?

The 6-month-old patient is admitted to the pediatric intensive care unit for treatment of a pertussis infection. The donning of which personal protective equipment by the unlicensed assistive personnel (UAP) entering this patient’s room would prompt the nurse to intervene and provide additional education?

The nurse observes the physician enter the room of a patient with pneumococcal pneumonia without donning personal protective equipment. Which response by the nurse is appropriate?

The nurse is providing discharge teaching to the patient admitted with anaphylaxis after blowing up a rubber balloon. Which foods, if selected by the patient as safe to eat, indicate a need for further teaching? Select all that apply.

The nurse is counseling the parents of an 8-month-old child born with myelomeningocele on appropriate baby foods to introduce to the child. Which foods, if selected by the parents, indicate teaching was effective? Select all that apply.

The nurse is assisting the provider in lancing the abscess of a patient whose medical history is notable for anaphylaxis after ingestion of oysters. The nurse enters the room as the provider begins swabbing the affected skin with povidone-iodine solution. Which response by the nurse is appropriate?