Communication & Documentation

The nurse is instructing the patient on how to move in bed after an open abdominal surgery. Which statement by the nurse is appropriate?

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.

The patient is 24-hours-postop from a pelvic reconstruction surgery after fracturing the pelvis in a fall. The patient reports severe abdominal pain and nausea. Upon assessment, the patient’s abdomen is grossly distended and firm. The patient’s skin is diaphoretic and the patient is tachypneic and tachycardic. Pulses and capillary refill time are adequate. During the assessment, the patient vomits a moderate amount of light green liquid. The nurse contacts the provider to report suspicion of which postoperative complication?

The patient has not defecated for 24 hours after an appendectomy. The patient’s abdomen is distended and the patient reports nausea. Upon auscultation, the nurse notes absent bowel sounds after 5 minutes of auscultation. Which action does the nurse take first?

The nurse is called to the intubated patient’s room by the patient's child who reports a large gush of red-tinged fluid from a transverse abdominal wound after the patient coughed. While calling for help, the nurse ensures the patients bed is set to which degree angle?

On day four postop following an open abdominal surgery, the patient develops a cough. During an assessment, the patient coughs, and the wound dehisces. The nurse notes intestinal loops are visible outside of the wound. Which initial intervention by the nurse is appropriate?

In the days following a colon resection and ileostomy creation, which patient action indicates an alteration in body image?

Which term does the nurse use to describe the patient who takes oxycodone daily for pain associated with deteriorating knee cartilage and requests a higher dosage for breakthrough pain?

During an admission assessment, the patient reports burning pain that shoots up the leg. The nurse uses which term to document this patient’s pain?

The patient with poorly controlled type II diabetes mellitus reports burning pain in the feet and legs that keep him up at night. The nurse passes this report along the provider and advocates for which medication for the patient?

The 18-year-old patient presents to the emergency department (ED) complaining of severe pain in the ankle after falling at work. Range of motion in the ankle is decreased and +1 edema is present. On x-ray, the bones of the foot and ankle are intact and the patient is diagnosed with a mild sprain. How does the nurse assess this patient’s pain?

Which assessments indicate the patient is experiencing chronic pain? Select all that apply.

Two days after undergoing surgery for a ruptured appendix, the patient responds to the nurse in only short, clipped statements, becoming visibly frustrated and angry during a routine vital signs check. Which response by the nurse is most appropriate?

The patient has been taking oral oxycodone for 5 months and has experienced relief of pain caused by a bulging disc in the lower back. The patient presents to the clinic to report breakthrough pain that is more severe than before treatment. Which action by the nurse is most appropriate?

The nurse is evaluating discharge teaching for the patient receiving hydrocodone/acetaminophen for the treatment of acute pain due to femur fracture. Which statement by the patient indicates teaching was effective?

The patient is brought to the emergency department (ED) after falling down and being briefly unconsciousness. The patient’s wife is with him and tells the nurse in private, “He’s not been like himself. He’s verbally abusive, now, and mean. He was always the sweetest man I ever knew.” The nurse suspects testing will reveal a lesion in which lobe of the brain?

The patient is brought to the emergency department (ED) after hitting their head during a fall. The patient does not arouse when their name is called, but opens the eyes and attempts to remove the hand that is pinching him. Once aroused, the patient responds with, “Bubble,” when asked what year it is. The nurse records the patient’s mental status using the Glasgow Coma Scale as which number? Enter your response using a whole number.

Following a motor vehicle accident, the patient is brought via ambulance to the emergency department (ED). The patient is unconscious during the mental status exam. The nurse attempts to arouse the patient by calling her name, but the patient does not respond. Following a firm sternal rub, the patient’s flexes the arms into the chest and moans. The nurse documents the patient’s Glasgow Coma Scale score as which number? Enter your response using a whole number.

The patient’s father is observed pressing the patient’s patient-controlled analgesia (PCA) pump while the patient is asleep. The nurse attempts to arouse the patient, who only opens the eyes after being pinched. Once aroused, the patient is able to raise the hand upon request. When asked what the year is, the patient responds with the previous year. The nurse reports the patient’s condition to the provider with which number on the Glasgow Coma Scale? Enter your response using a whole number.

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 with epilepsy is observed to be staring off into the distance and cannot be aroused from this state for roughly a minute. The nurse documents which type of seizure in the patient?

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 is recovering from a lower spinal cord injury that has resulted in paraplegia and lack of sensation below the umbilicus. Which instruction is most important to help the patient protect skin integrity?

The patient has right-sided hemiplegia following a cerebrovascular accident. Interventions to prevent which complication are the priority of care?

The nurse is educating the student nurse on the management of the patient who is mechanically ventilated via an endotracheal tube in the intensive care unit. Which information does the nurse provide to the student nurse?

The nurse elevates the legs of the patient with congestive heart failure who has significant dependent edema. Which rationale does the nurse give the patient for this intervention?

The patient underwent surgery for creation of a colostomy 2 days ago. Upon assessment, which stoma color prompts the nurse to document the finding and continue with the assessment?

The patient receiving hospice care reports constant, severe dry mouth. Which interventions does the nurse include in the patient's care plan? Select all that apply.

The patient is being discharged from hospital on total parenteral nutrition (TPN). Which information does the nurse include in discharge teaching?

Which drug, if ordered for the patient with second-degree heart block, does the nurse hold and contact the provider?

The patient with a heart rate of 50 bpm is found to have strong pulses and no other symptoms. Which action is most appropriate?

The patient is found to have the following rhythm on electrocardiogram (ECG): Pulses are noted on assessment. The nurse documents which rhythm in the patient's chart?

The patient is found to have the following rhythm on electrocardiogram (ECG): The nurse documents which rhythm in the patient's chart?

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

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

While reviewing the patient’s chart in preparation for admission to the intensive care unit, the nurse learns the patient is exhibiting ataxic breathing. Which pattern does the nurse expect to observe in the patient?

Which is a patient responsibility?

A patient scheduled to undergo a Whipple procedure (pancreaticoduodenectomy) is extremely agitated and apprehensive, though still wants to undergo the procedure. Which interventions does the nurse employ to decrease the patient's anxiety? Select all that apply.

The patient with schizophrenia has refused medication for several days. When the nurse attempts to administer the medication he responds, "I don’t need this. Give it to somebody who has a mental disorder." The nurse suspects which condition?

The single parent of the child with a severe developmental disorder confides in the nurse that caring for the child is becoming impossible to do alone. Which actions by the nurse are most appropriate? Select all that apply. 

During the initial home visit, the home health nurse assesses which of the elderly patient's basic activities of daily living? Select all that apply.

The provider orders albumin for a patient with traumatic amputation and hemorrhage. Which patient characteristic prompts the nurse to clarify the order with the provider?

The nurse is caring for the patient on methadone treatment as an outpatient. The provider has ordered a dose of methadone that is far higher than what the nurse has ever administered. Which action by the nurse is appropriate?

The parents of a 6-month-old baby are introducing solid foods into the baby's diet and would like to know which foods are appropriate. How does the nurse respond?

The 18-year-old woman with anorexia nervosa has just learned she is pregnant. Which nursing intervention is appropriate?

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?