Communication & Documentation

The nurse is preparing the patient for a pneumotonometry test. Which instruction does the nurse give the patient?

Which test is used to assess the retina and fundus of the patient with severe cataracts?

The nurse is educating the patient on self-administering antibiotic eye drops. Which instruction does the nurse include?

The patient has undergone an extracapsular cataract extraction. Which discharge instructions does the nurse give the patient? Select all that apply.

The 7-month-old infant is sitting quietly on the mother’s lap. Which assessment does the nurse perform first?

Which statement does the nurse include in discharge teaching to the parents of the 9-year-old who underwent tonsillectomy and adenoidectomy?

Which statement by the woman in her third trimester of pregnancy is most concerning to the nurse?

The nurse is providing safety teaching to the woman who has just tested positive for human chorionic gonadotropin. Which statement by the woman indicates the teaching was successful?

A patient tells the nurse in an outpatient endocrinology clinic that he is unhappy with his diabetes care and wants to see another physician. The nurse provides which advice?

Which term does the nurse use to document a 1.5 cm, dark red, fluid-filled lesion on the patient's cheek?

Which term does the nurse use to document the pinpoint, non-blanchable rash in the child who has invasive meningococcal disease (IMD) caused by Neisseria meningitidis? 

Which statement describes the nurse's legal responsibility in administering regular insulin to the mentally competent adult patient? 

The nurse is providing preoperative teaching to the patient scheduled to undergo an iridectomy. Which statement indicates a need for further teaching?

During a routine checkup, the patient reports undergoing a scleral buckling procedure since the last visit. Which follow-up question does the nurse ask regarding this event?

Following a scleral buckling procedure, the patient complains of nausea. Which action does the nurse take?

The patient is scheduled to undergo a trabeculectomy for the treatment of refractory glaucoma. The nurse is providing preoperative teaching to the patient. Which statement indicates a need for further teaching?

The nurse is visiting the home of a patient who recently underwent a trabeculectomy. Which statement improves patient safety?

The nurse is performing an admission assessment on the 73-year-old patient. Which question does the nurse ask to determine if the patient is experiencing cataract development?

The patient walks into to the emergency department (ED) complaining of significant pain in the right eye. It appears red and swollen. The pupils are not equal in size or reactivity – the right pupil remains dilated despite the bright exam room and the flash light. The patient cringes from the bright light, though, and complains the bright lights are hurting his head. He reports that over the last week, both eyes have been aching and he has been seeing halos around lights. The nurse prepares for which test to be performed first?

The patient with a sore throat has tested positive for group A beta-hemolytic Streptococcus pyogenes. The nurse educates the patient to complete the entire course of antibiotics in order to prevent which complications? Select all that apply.

The nurse receives report on the patient with acute bowel obstruction. The patient’s problem list includes controlled hypertension, uncontrolled diabetes, and presbycusis. Which action by the nurse is appropriate?

The nurse is providing discharge education to the patient with acute laryngitis. Which information does the nurse include?

Which instruction does the nurse provide to the patient with recurrent otitis externa infections?

The nurse is providing medication teaching to the mother of a 4-year-old patient with recurrent otitis media infections who requires daily instillation of antibiotic drops into the ear. Which action indicates effective teaching?

The school nurse is creating a health pamphlet to send home with the students prior to summer break on how to prevent otitis externa. Which information does the nurse include on the cause of otitis externa?

The nurse is educating the 2-year-old patient’s parents on how to instill ear drops to treat acute otitis media. Which statement indicates a need for further teaching?

The patient has undergone a right myringotomy. Which nursing intervention is appropriate?

Following an infection with rhinovirus, the patient reports initial improvement followed by significant congestion and upper teeth pain. The nurse anticipates which diagnosis?

The patient has been diagnosed with ethmoid sinusitis. The nurse anticipates the patient to complain of tenderness upon percussion of which area?

Which radiologic finding indicates frontal sinusitis?

The patient presents to the emergency department (ED) with green sputum and severe pain over the top teeth, cheeks, and forehead following a respiratory viral infection. The provider requests the nurse use the transilluminator to assess for sinusitis. Which assessment indicates maxillary sinusitis?

The patient has been prescribed amoxicillin for the treatment of sinusitis. The patient states, “I thought I just had a cold. I don’t want to take antibiotics for a cold.” Which response by the nurse is most appropriate?

The nurse palpates bilateral carotid pulses and notes the pulse begins at 100 and drops to 48 beats per minute. The patient complains of dizziness. Which nursing action is most appropriate?

The nurse anticipates which alteration in heart sounds in the patient with chronic obstructive pulmonary disease?

The patient has a history of mitral valve stenosis. In which position does the nurse place the patient to properly auscultate for this condition?

Upon auscultating the patient’s heart, the nurse notes an S3 heart sound in the mitral area. How does the nurse interpret this assessment?

The patient first experienced chest pain 12 hours ago and was diagnosed with a myocardial infarction. The patient’s myoglobin level is noted to be roughly 5 times the normal level. The nurse makes which prediction about the patient’s myoglobin level in 12 hours from the current level?

The nurse auscultates an opening snap after the second heart sound when the stethoscope is placed to the left of the lower sternum. Which additional heart sound does the nurse expect to hear?

The nurse is reviewing the admission assessment of a new patient and notes a IV/VI murmur was heard during auscultation of the heart. The nurse anticipates making which assessment?

The nurse is performing the patient’s initial cardiovascular assessment and palpates a heave over the location where a loud murmur is auscultated. Which terminology is most appropriate for the nurse to report this finding to the provider?

The patient who is hospitalized for a knee replacement develops sudden onset crushing chest pain, tachycardia, and tachypnea. On 12-lead electrocardiogram (EKG), ST-segment elevation is noted. Labs are drawn within 30 minutes of onset of chest pain. The nurse anticipates an elevation in which result to confirm diagnosis of acute myocardial infarction?

The patient presents to the emergency department (ED) after a hard workout lifting weights complaining of chest pain. An electrocardiogram is performed and cardiac enzymes are drawn. The patient’s myoglobin level is found to be elevated. Which interpretation of this result is most appropriate?

Which lab result is best for differentiating between myocardial and skeletal muscle damage?

The patient with Marfan syndrome presents with difficulty breathing in the supine position and fatigue. Upon palpation, a heave is noted. The nurse anticipates auscultating which heart sound?

The patient has been ordered to wear a Holter monitor for the next 24 hours. Which statement by the patient indicates a need for further teaching about the test?

During a well-child visit for the 4-month-old child, the nurse palpates hard nodules where each rib joins the sternum. The nurse reports this finding to the provider and requests which lab studies for this patient? Select all that apply.

The nurse is creating a presentation on rickets in the community. The nurse focuses on which group of individuals for this teaching?

The mother of the healthy baby born 12 hours ago at 42 weeks’ gestation asks the nurse why the baby’s arms and legs quiver when she cries. Which response by the nurse is most appropriate?

The mother of a 1-month-old neonate brings the child to the clinic with concerns that the child’s head seems large. The nurse measures the occipitofrontal circumference (OFC) and notes a 4 cm increase in the OFC since birth. When reporting this information to the provider, the nurse requests which test?

On the initial assessment after birth, the neonate is found to have a 1 cm x 0.5 cm hemangioma on the right cheek. Which additional assessment does the nurse make related to this finding?