Communication & Documentation

The nurse learns the patient's blood drawn on admission was positive for human immunodeficiency virus (HIV). Which action by the nurse is appropriate?

About which expected side effect does the nurse educate the patient prescribed colchicine for treatment of gout?

The patient with seizures has been prescribed carbamazepine (Tegretol). Which medication, if found on the patient's current medication list, prompts the nurse to hold the medication and contact the provider for clarification?

The nurse is discussing palliative care with the patient with metastatic colorectal cancer. The patient responds, "I'm not ready to give up. I want to keep fighting this disease." Which response from the nurse is most appropriate? 

Which patient with dyspnea is seen first in the emergency department?

The patient with a spinal cord injury has a history of recurrent urinary tract infections due to an inability to completely empty the bladder. The nurse provides the patient with which instruction?

Following an industrial accident, the patient is immobile. The student nurse is creating a care plan for the patient to prevent respiratory decompensation. Which intervention, if included in the care plan for this nursing diagnosis, would prompt the nurse to provide additional education to the student nurse?

The public health nurse is planning an informational session about recognizing the signs of Alzheimer’s disease in a loved one. Which initial signs of the disease does the nurse include in the presentation? Select all that apply.

The nurse is providing education to the patient’s spouse regarding the patient’s new diagnosis of Alzheimer’s disease. Which statement indicates the teaching was successful?

The nurse is planning care for the patient with moderate Alzheimer’s disease. Which expected outcomes does the nurse include? Select all that apply.

The home health nurse is evaluating the home life of a patient with mild Alzheimer’s disease. The nurse provides reeducation to the family if which action is observed?

The patient has the following visual field test for the left eye in which the black spots represent where the patient cannot see. Which interpretation of the test result is correct?

The patient with arteriovenous malformation who takes a monoamine oxidase inhibitor for depression develops an upper respiratory infection. The nurse requests a prescription for which medication?

The nurse is caring for a patient with Guillain-Barré syndrome. The patient has an order for a pureed diet. Which assessment prompts the nurse to clarify the order with the provider?

The nurse is providing education to the patient who presented with a cluster of blisters spreading from her upper lip to beneath her nose on one side of her face. The patient states her mother has similar symptoms sporadically, but this is her first experience with the blisters. Which statements by the patient indicate the teaching was effective? Select all that apply.

Which is the inclusive diagnostic term for benign skin lesions caused by the human papillomavirus (HPV) that infect mucous membranes and the stratified epithelium of the skin?

The 17-year-old patient is seeking advice on testing for sexually transmitted diseases. He states, “I kissed my girlfriend with my tongue inside her mouth. What do I need to be tested for?” Which is the most therapeutic response by the nurse?

The patient is admitted to the intensive care unit after starting antibiotics and experiencing a severe drug reaction and erythema multiforme syndrome. The patient has severe mucocutaneous bullae over 42% of the body surface area. The nurse anticipates which diagnosis for this patient?

The 5-year-old patient has been prescribed phenytoin for the treatment of seizures. Which statement by the patient’s mother prompts the nurse to contact the provider for an alternative prescription?

The patient presents to the emergency department (ED) with flu-like symptoms and mucocutaneous erythematous rash and bullae formation over 38% of the body. The nurse asks the patient if which medications had been taken in the last month? Select all that apply.

The nurse plans which intervention for the patient with toxic epidermal necrolysis?

The nurse is administering intravenous fluids to the patient with toxic epidermal necrolysis. Which parameters are most helpful to assess when determining the appropriate fluid rate for the patient?

The patient developed toxic epidermal necrolysis after receiving phenytoin for seizures. The nurse prioritizes nursing interventions to address which life-threatening comorbidities? Select all that apply.

The nurse is auditing the use of personal protective equipment (PPE) on the unit. Which provider removes the PPE correctly?

The nurse intervenes if the provider attempts to remove which article of personal protective equipment first after contact with the patient with active tuberculosis?

The nurse is observing the student nurse in the care of the patient with a wound infected with methicillin-resistant Staphylococcus aureus. Prior to exiting the room, the student nurse removes the gloves and grasps the front of the gown to remove it. Which response by the nurse is most appropriate?

The infectious disease team is reviewing proper glove use with the nursing staff. Which statement indicates a need for further teaching?

The nurse in the long-term care facility is assessing a new resident who has Parkinson's disease. The nurse usually explains which group activities are available during the intake interview. Which communication technique is most helpful for the nurse to utilize with this resident?

The nurse is answering questions regarding a new prescription of a monoamine oxidase type B inhibitor (MAOI-B) for the patient recently diagnosed with Parkinson's disease. Which reminders does the nurse include in teaching? Select all that apply.

The nurse questions which drug prescribed to a patient also receiving carbamazepine for psychomotor seizures?

The registered nurse is observing the licensed practical/vocational nurse (LPN/LVN) administering pantoprazole during morning medication rounds. Which action by the LPN/LVN prompts the nurse to intervene and provide additional education?

The patient with a history of depression and generalized anxiety disorder presents to the clinic seeking information on advance directives. Which action(s) by the nurse are appropriate? Select all that apply.

The nurse is planning an informational session at the community center to help parents identify when their children are at an increased risk for suicide. The nurse includes information about which activities in the class? Select all that apply.

The community health nurse is teaching an outreach course on how parents can help to prevent suicide attempts in their at-risk children. Which statement by a parent indicates a need for further teaching?

The 17-year-old male patient is brought to the clinic for a yearly check-up. The nurse observes the patient to be unkempt, with greasy hair and significant body odor. The patient has a flat affect during questioning. When the nurse provides education on safety practices such as wearing a seatbelt when in the car, not driving with impaired persons, and using protection during sexual intercourse, the patient retorts, “I don’t really see the point in wearing a seatbelt, if it helps me die more quickly.” Which initial response by the nurse is most appropriate?

The community health nurse is developing an initiative to prevent long-term morbidity of cerebrovascular accidents by raising awareness of transient ischemic attacks. To which patient populations does the nurse direct these efforts? Select all that apply.

The patient is brought to the emergency department (ED) after being found on the floor in the garage by his wife. His right cheek balloons with each expiration and his right leg drags when he walks. While being assisted to the magnetic resonance imaging suite, the patient’s facial drooping resolves and he no longer walks with a limp. Which action does the nurse take first?

The patient is hospitalized following a cerebrovascular accident (CVA). The patient calls out to report a sudden, pounding headache. Which assessments are the priority? Select all that apply.

The nurse has received orders for the patient admitted following a hemorrhagic stroke and clarifies orders for which medications? Select all that apply.

The patient has been unconscious for 36 hours after a massive stroke. The nurse enters the room to see the unlicensed assistive personnel (UAP) cleaning the patient after an episode of fecal incontinence. The UAP states, “I can’t imagine not even being able to clean myself. What a sad existence.” Which response by the nurse is most appropriate?

The nurse is reviewing the chart of the patient who is scheduled for a laparoscopic cholecystectomy in one hour. Signed consent is found, as well as blood transfusion consent, anesthesia evaluation, blood type, and emergency contacts. The nurse asks the patient, “Do you have any questions about your upcoming gallbladder removal surgery?” The patient replies, “Gallbladder removal? I thought they were just taking out my gallstones. I’ll be glad to get rid of those.” Which response by the nurse is most appropriate?

The patient requires an indwelling catheter to be placed prior to surgery. Which action does the nurse take first?

Which order does the nurse clarify for the patient in the intensive care unit following a hemorrhagic stroke?

During a comprehensive neurologic exam, the provider brushes a wisp of cotton over the patient’s cornea, which causes the patient to blink. The nurse notes that which cranial nerve is intact based on this test?

The nurse is supervising the student nurse in the irrigation of the patient’s right eye. Which action by the student nurse prompts the nurse to intervene with additional education?

The patient presents to the urgent care clinic complaining of eye pain and feeling like there’s a foreign object in the eye. The provider examines the patient and orders a 500 mL irrigation of sterile saline. After warming the solution to 37°C and positioning the patient, the nurse begins to administer the irrigation. The patient cries out in pain and jerks away from the nurse. Which response by the nurse is most appropriate?

The nurse is testing the patient’s eyes for accommodation by holding a finger in front of the eyes and asking the patient to look at a point over the nurse’s shoulder then look at the finger. The nurse documents which bilateral response as normal?

The nurse utilizes the ophthalmoscope to assess the patient’s retina and notes narrowing in the vessels where the arteries and veins cross. Which vital sign is consistent with this finding?

The nurse is preparing the patient for an ophthalmoscopic exam in which cyclopentolate drops must be instilled to allow for better visualization of the retina. Which characteristics, if present in the patient’s medical history, prompt the nurse to hold the drops and contact the provider for further instruction? Select all that apply.

Which instruction does the nurse give the patient prior to administering cyclopentolate eye drops?