Communication & Documentation

The patient is being transferred from a nursing home to an acute care facility. The receiving nurse performs which actions during the medication reconciliation process? Select all that apply.

A nurse is caring for a patient who is recovering from total hip replacement surgery. The patient has required increasing doses of IV morphine for pain control. The patient is again reporting 10/10 pain despite receiving 10 mg of morphine from the nurse, which is the top of the range ordered by the physician. The nurse monitors which of the following most closely?

The parent reports giving the child 1 teaspoon of ibuprofen suspension. The nurse charts which volume in milliliters?

A patient with gram-negative sepsis is in the ICU after cardiac arrest. He requires a vasopressor for severe hypotension. Which patient characteristic would prompt the nurse to hold the infusion and contact the provider?

The nurse mistakenly administered a long-acting benzodiazepine to the patient with end-stage liver disease, a drug that was not ordered. As a result, the patient had to remain in the hospital an extra night. The nurse wants to apologize to the patient for the mistake. Which of the following is most accurate?

The physician writes an order for diphenhydramine 250 mg PRN for sleep. Which part of the order does the nurse question?

The nurse is teaching a woman ways to prevent mastitis. Which statement by the patient indicates that more teaching is needed?

The nurse makes which patient top priority?

The extremely low birth weight neonate born at 22 weeks gestation is not expected to live through the night. The family has described to the nurse the importance of their church and Christian faith. Which action by the nurse demonstrates the nurse's ability to recognize and address the family's grief? 

The patient with congestive heart failure in the cardiac intensive care unit (CICU) is ordered to receive IV furosemide once per day. The lab just called and reported the patient’s serum potassium is 2.9 mEq/L. The next dose of furosemide is due now. Which is the appropriate nursing action?

The nurse is caring for a woman wearing a hijab. The woman does not speak English and has come to the emergency department (ED) with fever, vaginal bleeding, and abdominal pains. An interpreter is present for the interaction. Which question is appropriate for the nurse to ask first?

The nurse is supervising the nursing student in the provision of a complete bed bath to the patient. Which action by the nursing student indicates successful learning?

The physical therapist trained a patient with stress incontinence how to perform pelvic floor muscle (Kegel) exercises. Which statement by the patient suggests more education is needed?

Viewing the patient’s chart, the nurse notes the patient has 20/100 vision. How does the nurse interpret these results?

The patient with terminal cancer was placed on hospice care; although he has deteriorated, he is still alive after 6 months. How is the patient’s hospice care affected?

The nurse is supervising a nursing student performing a comprehensive shift assessment on a patient hospitalized with severe abdominal pain from an unknown cause. Which action, if performed by the nursing student, prompts the nurse to intervene and provide additional teaching?

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?

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 38-year-old patient has increased intracranial pressure following a massive stroke. Select the vital signs that together indicate the patient is at an immediate risk for brainstem herniation.

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 unconscious patient with elevated intracranial pressure secondary to an ischemic stroke has a jugular bulb catheter in place to monitor cerebral oxygenation (SJO₂). The patient’s oxygen saturation (read by peripheral pulse oximetry probe) is 98% on 30% FiO₂ administered via endotracheal tube. The SJO₂ is 85%. How does the nurse interpret these results?

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

The patient in the intensive care unit is intubated, sedated, and chemically paralyzed following decompensation due to necrotizing pneumonia. During the routine neurological check, the nurse notes these pupils: How does the nurse interpret this assessment?

The very low birth weight infant was born at 0.9 kg and now weighs 1.3 kg. The neonate is on full feeds receiving 24 kcal/oz formula with a daily kcal goal of 120 kcal/kg/day. The patient eats every 3 hours around the clock. How many milliliters does the nurse administer with each feeding? Enter your answer using a whole number.

The patient who has severely elevated intracranial pressure following a traumatic brain injury is intubated, sedated, and chemically paralyzed. Which intervention does the nurse include in the plan of care?

The patient is hospitalized with severe asthma. Which assessment prompts the nurse to call the rapid response team?

Which statement by the patient with asthma indicates a need for further teaching?

The condition of the patient with a pulmonary hypertensive crisis due to pneumonia has improved. Which order does the nurse question?

Upon auscultation of the anterior chest wall, the nurse notes a rubbing sound. Which action does the nurse take next?

The triage nurse asks the patient presenting with abdominal pain which question to satisfy the “P” section of the PQRST mnemonic?

The patient presents with concern for a respiratory virus with a cough. The nurse uses which question to assess the “Q” in the PQRST mnemonic?

The nurse volunteers to be on the quality improvement team examining shift change safety and patient satisfaction. Which is the best suggestion for this quality improvement project?

The emergency room nurse is caring for a patient who ambulated into the triage room wearing sunglasses and a scarf. Upon request, the patient removed her sunglasses and scarf, revealing bruising around her neck and eyes in various stages of healing. The patient became hysterical and stated her husband tried to kill her. Which response by the nurse is the most appropriate?

The nurse is caring for a patient who experienced traumatic limb loss of her upper and lower right extremities. The patient is ready to begin regaining her strength and relearning life skills such as eating, dressing, and hygiene. The nurse enlists the help of which member of the healthcare team to assist the patient with learning these tasks?

The nurse is reviewing a patient’s medications during discharge. Which further education can the nurse provide regarding spironolactone when the patient asks, “I thought that I took a furosemide pill for my water?”

A man is admitted to the hospital for treatment of burns caused by a brush fire. He was attempting to control the flames and his clothes caught fire. He has burns of various depths on the front and back of both arms, his back, and the back of his head. What is the estimated total body surface area burned?

The nurse questions the order for an infusion of 0.45% NaCl in the patient with which condition?

Which patient characteristic prompts the nurse to hold the infusion of Lactated Ringer’s and contact the provider?

The patient calls the nurse to the room to report pain at the site of an IV. The nurse notes warmth, redness, and purulent drainage. Which action does the nurse take first?

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

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?

The patient has returned from abdominal surgery with a gauze dressing. The nurse notes a moderate amount of sanguineous drainage on the dressing. Which action does the nurse take?

The nurse is assessing the patient 4 hours after a cholecystectomy and notes the skin around the umbilicus to be blue. The nurse contacts the provider to report which positive sign?

The patient underwent colon resection one day ago. The nurse is performing a shift assessment and notes absent bowel sounds after listening for 5 minutes. Which action by the nurse is most appropriate?

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?

The patient has not yet voided in the 3 hours following a total knee replacement surgery. Which action by the nurse is appropriate?