Communication & Documentation

The nurse caring for the patient with rheumatoid arthritis who is scheduled for an operation under general anesthesia advocates for which test prior to the procedure?

The patient is admitted to the hospital with acute diverticulitis. Which order does the nurse question?

The nurse receives vitals and information about four patients from the unlicensed assistive personnel an hour after shift report. With which patient does the nurse follow up first?

The nurse empties the patient’s Jackson-Pratt drain 24 hours after a partial colon resection. There is 10 mL drainage that is noted to be light red and thin. There is no odor and the fluid is free of sediment or clots. How does the nurse document this assessment in the medical record that is charted by exception?

The student nurse is preparing to perform an irrigation of the patient’s indwelling urethral catheter. Which action by the student nurse prompts the supervising nurse to intervene immediately?

Place the steps for indwelling urinary catheter irrigation into the correct order.

The nurse is attempting to perform an irrigation of the patient’s indwelling urinary catheter but it is unable to instill the irrigant with normal force. Which action does the nurse take?

The patient has a peritoneal dialysis catheter. The nurse notes the dressing is saturated and prepares to change it. Upon removing the dressing, the nurse notes a foul odor and purulent drainage around the site, which is red. Which action does the nurse take next?

The patient with kidney failure is scheduled to undergo the placement of a peritoneal dialysis catheter. Which instruction does the nurse give the patient?

The nurse is providing discharge teaching to the patient who will be discharged with a peritoneal dialysis catheter. Which statement indicates a need for further teaching?

The nurse is assessing the arteriovenous fistula in the patient’s right arm; it is without thrill or bruit. Which action does the nurse take next?

The patient found unresponsive in the park is determined to be in ventricular fibrillation. After cardiopulmonary resuscitation and defibrillation, the patient experienced return of spontaneous circulation. Initial survey upon arrival to the emergency department (ED) reveals a cachectic appearance and an edematous mass on the right forearm; upon palpation, the nurse palpates a thrill. The nurse is aware life-saving measures will have which aim?

The grown child of an elderly woman with dementia is trying to provide his mother with in-home hospice. The caregiver providing in-home hospice for the elderly patient with dementia reports nearly constant verbal and physical abuse at the hands of the patient including degrading talk, biting, and scratching. How does the nurse manage this situation?

The woman with human immunodeficiency virus (HIV) who has a high CD4 count is concerned her fetus may be infected with the virus. Which statement by the nurse is appropriate?

The patient who was admitted overnight is scheduled to receive an assortment of oral medications in the morning. The patient tells the nurse he does not recognize these pills. Which response by the nurse is appropriate?

The nurse suspects the patient dealing with a longstanding psychiatric trauma is entering Phase 3 of general adaptation syndrome. Which term is used to describe this phase?

The elderly patient with moderate Alzheimer’s disease was brought to the emergency department (ED) for rapidly worsening mental status, fever, and anorexia over the last 24 hours. Portable chest x-ray shows a consolidation in the left lower lobe.Which diagnosis is most accurate?

The nurse questions the diagnosis of bulimia nervosa if which patient characteristic is present?

The patient presents to the emergency department exhibiting stiff, jerky movements of the face and neck. The nurse reviews the patient's medical history for a prescription for which medication? 

After failing to experience symptom relief from other antidepressants, the patient is prescribed a tricyclic antidepressant. The nurse instructs the patient to expect which side effect? 

The patient with an automated implantable cardioverter-defibrillator (AICD) experiences a discharge of the device. The nurse reports this event to the provider with the knowledge that the patient experienced which arrhythmia?

The nurse provides which instruction to the patient prescribed incentive spirometry following lower limb orthopedic surgery? 

The obstetrician performs a pelvic exam and reports that the 39-weeks-gestation woman is at 4 cm and zero station. The nurse interprets the fetus's head to be in which location? 

The nurse is providing education to the patient with an ileostomy. Which statement by the patient suggests additional education is needed?

The patient receiving mechanical ventilation opens the eyes, attempts to talk, and appears to be in distress. Which action does the nurse take first?

The nurse working in the pediatric unit finds the two-year-old patient crying on the floor near his hospital crib. The child's parents were present for the fall, are visibly upset, and tell the nurse that she crawled over the edge and fell to the floor. Which action by the nurse is appropriate?

Which information does the nurse provide to the patient with epilepsy who has been prescribed phenytoin?

Which interventions does the nurse include in the plan of care for the 2-day-old infant who requires phototherapy for hyperbilirubinemia? Select all that apply.

At which age does the nurse instruct the parent to bring the child in to the clinic for the measles, mumps, and rubella (MMR) vaccine?

A high school wide receiver suffered substantial head trauma during a tackle. The school nurse is concerned about concussion. The nurse provides which information to the adolescent and parents? Select all that apply.

The nurse is completing a nutrition and diet assessment and asks if the patient is taking any medications or supplements. The patient becomes defensive and questions why the nurse needs to know. Which is the best response by the nurse?

The nurse is conducting a mental health assessment and plans to begin by taking the patient’s health history. Which behavioral clues does the nurse observe upon entering the room? Select all that apply.

The patient presents to the clinic with complaints of feeling down and depressed for a month. The nurse guides questioning to assess for which additional signs required for diagnosis of depression? Select all that apply.

The partner of a patient with obsessive-compulsive disorder is seeking information. Which information does the nurse provide for compulsions?

While completing a patient’s history, the patient states: “I just don’t like the life I am living. I wish it were over.” Which is the most appropriate response from the nurse?

The nurse is conducting a history during a wellness exam. The patient states, “Honestly, I’m really stressed right now. My son is going to college, and my dad is moving in with us. Thankfully, I got a promotion at work so we will be able to move to a place without stairs. I’ve been leaning on my wife and friends a lot and trying to keep exercising and doing yoga.” How does the nurse interpret the patient’s reports?

The nurse is receiving bedside report on a patient experiencing tremors in his hands, profuse diaphoresis, and agitation during attempts to interview or exam him. Which information does the nurse make a priority to collect?

A patient seeing her primary care physician responds “no” to the domestic violence screening question, “Do you feel safe in your home?” Which action does the nurse take next?

Which is the best response by the nurse interviewing a patient who has just stated she feels unsafe in her own home?

The nurse is caring for a patient after abdominal surgery and significant blood loss. A life-saving blood transfusion has been ordered but the patient refuses it. Which action does the nurse take first?

The nurse is caring for a patient who was just pronounced dead. The patient’s adult children are with the patient. Which is the best response by the nurse to the family?

The nurse is caring for a patient transitioning to hospice care and completing his admission assessment. Which question will help the nurse most effectively attend to his spiritual needs?

The nurse working in the emergency room is assigned to care for an older Hispanic man seeking care for a hand injury sustained while working outside. The nurse hears the patient speaking in Spanish to the person who accompanied him. Which action does the nurse take next?

A Muslim man becomes ill on a cruise ship and is transported to a hospital in Anchorage, Alaska. While conducting his history, the nurse asks, “Are there any spiritual needs we can help you address?” The man replies that he is Muslim and will pray five times a day and asks, “Which way do I face to pray to Mecca?” Which is the best response by the nurse?

The nurse is creating an ethics training module. Which definition does the nurse use for ethnicity?

The nursing staff is undergoing cultural competence training. Which statement indicates a need for further teaching?

The nurse is conducting a detailed medical history interview. Which communication techniques demonstrate effective therapeutic communication skills? Select all that apply.

Parents of a four-year-old boy are worried because their son has been wetting the bed. The nurse informs the parents the child may continue to have nocturnal enuresis for how many more years? Enter your answer using a whole number.

The mother of a six-year-old child brings the child to the pediatrician requesting treatment for nocturnal enuresis. The nurse prepares information for the mother about which treatment?

The nurse is developing a care plan with a nine-year-old girl to end her nocturnal enuresis. The nurse is focused on which goal when communicating with the child?