Communication & Documentation

The nurse is preparing the patient for a magnetic resonance imaging (MRI) scan with intravenous contrast. Which question is most important for the nurse to ask the patient?

The bedridden patient has been admitted to the floor. When transferring the patient from the stretcher to the hospital bed, which action does the nurse perform first?

Which patient statement is most appropriate to report to the social worker?

The nurse is caring for the patient who was admitted to the hospital in septic shock due to Escherichia coli bacteremia. Which patient assessment is most appropriate to report to the inpatient pharmacist on the patient’s medical team?

The patient admitted with asthma is receiving beclomethasone HFA PRN and nebulized albuterol PRN. Which patient assessment is most appropriate to report to the respiratory therapist assigned to care for the patient?

The patient tells the nurse, “When is Sally working again? She has been my favorite nurse so far.” Which response by the nurse is appropriate?

The nurse is riding the staff elevators with several other healthcare professionals and overhears a provider discussing the lab results for another nurse’s patient. Which response by the nurse is most appropriate?

The provider left a patient’s electronic health record (EHR) open on the computer screen in the nurse’s station when he left to assess a patient. Which action by the nurse is most appropriate?

The 40-year-old woman is pregnant for the first time. She undergoes prenatal testing and is found to have an elevated serum alpha-fetoprotein and asks the nurse to explain what this could mean for her baby. Which response by the nurse is most appropriate?

The 30-week gestation pregnant woman reports her fetus moved two times in an hour during her assessment of fetal activity. Which response by the nurse is best?

The patient who is 33 weeks pregnant reports fetal activity of 8 kicks/hour. Which action by the nurse is appropriate?

The patient in the rehabilitation hospital following a spinal cord injury sustained in a motor vehicle accident is preparing for discharge home. The patient tells the nurse, “I had a huge support network back home. Since I moved to this new state for my husband’s job, I feel so out of touch. I don’t know how I’ll get to my therapy and doctor appointments when my husband is at work.” To which interdisciplinary team member does the nurse report the patient’s comments?

The patient has been prescribed enalapril and spironolactone for the treatment of hypertension. The nurse is providing medication education to the patient regarding diet. Which food, if selected by the patient, indicates a need for further teaching?

The nurse receives report that the patient will undergo brain death testing and is aware the patient must meet which criteria to be diagnosed with brain death? Select all that apply.

An emergency room nurse is caring for a patient admitted by ambulance after a motor vehicle collision. The patient was transported with a long spine board and rigid cervical collar. Thirty minutes after arrival, the patient has been log-rolled off the spine board, completed imaging studies of the spine, and is requesting removal of the cervical collar. Which is the nurse’s next action?

The nurse is creating an educational class for community members who care for an older relative in the home about brain injury in the older adult. Which factors does the nurse include to impress upon the individuals the high mortality risk associated with brain injuries in the older adult? Select all that apply.

The patient was admitted to the critical care unit following a fall from a balcony. Emergency responders were unable to adequately ventilate the patient until arrival at the emergency department. The patient has been unresponsive since the fall and is now receiving mechanical ventilation and continuous intracranial pressure monitoring. The nurse assesses for signs of which complications in this patient? Select all that apply.

The nurse is educating the parents of a patient who experienced a moderate traumatic brain injury. The patient is expected to be discharged to a rehabilitation facility within the next week. Which statement by the parents indicates a need for further teaching?

The nurse assessing the patient in liver failure documents the patient’s report of pain in which region as an expected finding for this patient?

The patient is awake and alert when being admitted directly to the unit from the cardiac catheterization lab after transferring from the primary care doctor. The patient’s spouse calls the unit looking for the patient. Which response by the nurse is most appropriate?

The nurse is teaching a community health promotion class for older adults and includes a discussion on modifying which risks for hypertension?

The nurse is completing discharge education with the parents of a child with congenital heart disease. Which statement by the mother indicates a need for further teaching?

The 78-year-old male patient diagnosed with Parkinson’s disease verbalizes frustration with his incontinence of urine. The nurse provides education about which type of incontinence associated with neurological disorders and detrusor hyperreflexia?

The nurse prepares the nursing student for the administration of which short-acting cardiovascular drug that can be used to help maintain the patient’s ventricular function after cardiac surgery?

Pregnancy is confirmed in the patient who states, “How did this happen? We were careful and wore condoms every time we had sex.” Which response by the nurse is most appropriate?

The nurse is counseling the patient following the removal of a copper intrauterine device. Which statement is most important for the nurse to include in teaching?

The nurse is providing preprocedure education to the patient who will have the copper intrauterine device (IUD) removed. Which statement by the patient indicates an understanding of the teaching?

The first-time mom requests information from the nurse about providing foods other than breast milk to her 3-month-old child. Which response by the nurse is most appropriate?

The mother of a 1-month-old child tells the nurse, “I’m concerned because my child does not hold his head up during tummy time.” Which response by the nurse is appropriate?

The nurse receives an alert that a packed red blood cell transfusion has been ordered for the patient who was admitted after a laparoscopic cholecystectomy. Which is the nurse’s initial action?

The nurse is caring for a patient on the night shift in respiratory distress due to influenza. Over the last few hours, the patient has become increasingly confused, perfusion has decreased, and urine output has fallen to zero. The nurse contacts the resident physician to come assess the patient and requests an order for transfer to the intensive care unit. The physician orders the nurse to administer 1L 0.9% NaCl via IV infusion. One hour after the infusion is complete, the patient has made no improvement. What is the nurse’s next action?

The nurse is asked to help properly dispose of the patient’s soiled linens. Which question is most important for the nurse to ask?

The nurse is planning care for the patient receiving adalimumab. Which nursing intervention does the nurse utilize to prevent complications of the medication?

The nurse is providing discharge teaching to a patient who will receive chemotherapy at home for cervical cancer. Which statement by the patient indicates a need for further teaching?

The mother brings her 18-month-old child to the clinic with concerns for developmental delay. She states, “She says ‘Mama’ and ‘Dada’, and ten or so other words. I keep working with her but I’m concerned she is falling behind.” Which response by the nurse is most appropriate?

The nonverbal patient is improving in the intensive care unit following a motor vehicle accident; as such, the continuous hydromorphone infusion is being weaned according to a schedule. The nurse provides education to the patient’s guardian about which signs and symptoms that the pain medicine is being weaned too quickly? Select all that apply.

The 14-year-old patient was admitted following surgical reduction of an open femur fracture. The patient, who has reported good pain control with the patient-controlled analgesia (PCA) pump, is sleeping peacefully. During hourly rounding, the nurse observes the parent press the button to administer the bolus of pain medication. Which action by the nurse is appropriate?

The nurse advocates for the use of secukinumab in which patient?

The LPN/LVN informs the supervising RN, “I didn’t realize until after administering the medication, but I was supposed to give the patient a half tablet of levothyroxine; I gave him a whole tablet.” Which action does the nurse take first?

The nurse is planning care for the patient who will undergo hip replacement surgery in a month. When is the best time to provide teaching about the use of a patient-controlled analgesia (PCA) pump?

The patient has experienced an extravasation of norepinephrine in the right forearm. It is cool to the touch, firm, and pale. Distal to peripheral pulses are not well felt and the fingertips are dusky. Which order does the nurse clarify with the provider?

The female patient tells the nurse, “I think the man I had unprotected sex with last night might have herpes. I’m so afraid I’m going to get it, too.” Which response by the nurse is most appropriate?

The 32-weeks-pregnant woman who presents with genital lesions is diagnosed with herpes simplex virus-2. The nurse prepares a patient information handout for which medication for this patient?

The full-term neonate (3.2 kg) born precipitously to a mother of unknown infectious disease status has had a positive rapid plasma reagin (RPR) test. The nurse plans care to perform which intervention first?

The patient is admitted to the hospital with systemic syphilis infection. The patient is ordered to receive a 14-day course of penicillin G 20 million units/day intravenously. Prior to administering the medication, the nurse checks the patient’s allergies and learns the patient experienced anaphylaxis after receiving ampicillin. Which action does the nurse take?

The elderly patient experienced a large skin tear to the right forearm. Which action by the provider prompts the nurse to intervene?

The nurse requests analgesia for the 76-year-old patient who must undergo cleansing and dressing change for a healing stage 3 pressure ulcer on the coccyx. In response, the provider ordered topical EMLA cream to be applied to the wound 30 minutes before the procedure. Which action by the nurse is appropriate?

Which interventions increase the risk for impaired skin integrity in the patient with congestive heart failure who requires total care? Select all that apply.

The nurse advocates for a guaiac test to be performed on the patient with which stool?

The nurse removes the dressing of a stage 3 pressure injury on the sacrum and finds the wound bed to be reddish-pink and the edges are attached but rolled and ridged. The nurse uses which term to document the wound edges?