Communication & Documentation

The parent of the 5-year-old child reports that the child, who was potty trained at 3-years-old, has been stooling in places other than the toilet a couple times per month for 4 months. The nurse uses which term to document this symptom?

The nurse is collecting data from the parents of a seven-year-old boy who often has liquid stool in his underwear. The parents report he developed urinary and stool incontinence at four years of age and this problem started about six months ago. Their son excretes small pellets of stool every night before bed, and the parents wonder if he is soiling his clothing on purpose. Which additional testing does the nurse anticipate at this point?

A ten-year-old patient presents to the emergency department (ED) complaining of abdominal pain. He states, “I poop every day. It sometimes hurts to go and the poop is small, hard pieces. Which response does the nurse anticipate when the child is asked, “How much water do you drink in a day?”

A new mother calls the nurse hotline concerned that her 4-day-old infant is sleeping too much. The nurse bases the response on which understanding of the newborn and postpartum period?

The nurse is preparing to discharge a newborn and her mother. The nurse checks that the mother is able to state which principle of safe sleeping?

The nurse provides which education to parents of a 1-day-old infant to prevent Sudden Infant Death Syndrome? Select all that apply.

The nurse is educating the patient with a spinal cord injury on safe wheelchair use. Which important features does the nurse emphasize to the patient? Select all that apply.

The nurse recommends removal of which items from the home of the patient who will be discharged home in a wheelchair? 

The older adult patient recently diagnosed with a spinal cord injury and limited mobility is referred to a physical therapist to discuss using a wheelchair for increased mobility. The patient asks the nurse, “Do I really have to see the physical therapist? I broke my leg as a kid and used one then.” Which response by the nurse is appropriate?

The patient newly diagnosed with idiopathic pulmonary arterial hypertension is prescribed bosentan. The result of which test is most important for the nurse to verify prior to administering the medication?

The patient receiving bosentan therapy for pulmonary arterial hypertension presents to the emergency department (ED) complaining of dyspnea. Which nursing assessment is most important for this patient?

The patient is prescribed bosentan. Which statement does the nurse include in teaching about this medication?

Which report from the ophthalmologist indicates the patient with type 2 diabetes mellitus is experiencing early signs of poor glycemic control?

The patient presents to the emergency department (ED) and states, “I don’t know what happened! I was walking and ran into a door with my right shoulder. I closed my right eye and my vision was normal, but when I closed my left eye, I couldn’t see anything at all!” The patient’s assessment is otherwise normal. The nurse reports this to the provider immediately for assessment. Which question is most important for the nurse to ask the patient while waiting for the provider to write orders for treatment?

The patient with laryngitis requests tips on nonpharmacological symptom management. The nurse makes which suggestion?

The nurse is caring for a patient with left-sided weakness in the hospital who had vocal cord surgery this morning. Which intervention is most important to promote safety?

The patient with heart failure has an order written to be weighed daily. When does the nurse instruct the unlicensed assistive personnel to weigh the patient?

The patient with a history of hypertension and atherosclerosis presents to the emergency department (ED) complaining of severe lower back pain. Which question by the nurse is most important?

The patient with chronic obstructive pulmonary disorder has an oxygen saturation of 89% on room air. Which order does the nurse clarify with the provider?

The 58-year-old patient with chronic obstructive pulmonary disorder (COPD) presents to the clinic requesting the pneumococcal vaccine. Which response by the nurse is appropriate?

The patient in heart failure exhibits the following respiratory pattern. The nurse uses which term to document the patient’s respiratory effort?

The patient with Raynaud’s phenomenon has received teaching on how to manage the disorder. Which statement by the patient indicates a need for further teaching?

The nurse is providing education to the patient recently diagnosed with Raynaud’s phenomenon. Which information does the nurse include in teaching?

Which pulse is assessed by palpating the lateral side of the wrist?

The nurse is creating a bladder retraining program for the 74-year-old female patient who is incontinent of urine. Which aspect of the training program is most important?

Which evening meal choice is appropriate for this patient? Look at the patient’s chart to make a selection.

Which food items does the nurse encourage the patient to eat? Look at the patient’s chart to make selections and select all that apply.

Which food item, if selected by the patient, would prompt the nurse to provide additional education? Review the patient’s chart to make selection.

Which meal selection is appropriate for this patient? Review the patient’s chart to make a selection.

After reviewing the patient’s chart, which instruction does the nurse give the unlicensed assistive personnel working with the patient?

The patient with a subtotal gastrectomy has been advanced to a regular diet. Which information does the nurse provide the patient? Select all that apply.

A mass casualty incident has occurred and the charge nurse must make beds available in the intensive care unit for incoming victims. Which patients can be safely downgraded to the floor? Select all that apply.

Following a major natural disaster, the charge nurse receives instruction from superiors to pair patients as roommates to increase the number of available rooms. The first patient to be paired is a 42-year-old patient with cellulitis who has a 103°C fever and tachycardia. The charge nurse places her in a room with which patient?

The unit is experiencing increased patient census. Which patients, if suggested for pairing with the 28-year-old patient with epilepsy, does the bedside nurse question? Select all that apply.

Which patient does the nurse advocate to be transferred to the intensive care unit?

Which patient in the emergency department (ED) must be treated first?

Four patients have been ordered to receive a 12-lead electrocardiogram (ECG) but the floor only has one EKG machine. Which patient must receive the test first?

The nurse is a first responder after a gas explosion at an apartment complex. Which patient does the nurse mark to be treated first?

The nurse is assisting the provider in performing triage of 30 patients after a mass casualty incident. The nurse observes the resident changing the triage tag for the unresponsive patient with an open skull fracture who is not breathing spontaneously from black to red and calls the EMT over to transport the patient to the hospital. Which response by the nurse is most appropriate?

The nurse is first on the scene following a multivehicle accident. After activating emergency services and verifying the safety of the scene, the nurse begins the triage process. The first patient is unconscious and not breathing. Which action does the nurse take first?

The nurse has instituted a process improvement project to reduce the number of central line-associated bloodstream infections (CLABSI) in the intensive care unit. During the first month after instituting the process change, the incidence of CLABSIs dropped from 8 the previous month to 2 for the month. Which action by the nurse is most appropriate?

The nurse receives report of four issues at 0800. Which situation is addressed first?

The nurse preceptor is supervising the graduate nurse during shift handoff. Which statements by the graduate nurse would prompt the veteran nurse to clarify for the oncoming nurse? Select all that apply.

The nurse is supervising the student nurse who is making a call to the provider about a patient who is decompensating. The student states, “Hello, Dr. Smith. This is Carly and I’m taking care of Alex Wright in room 433. He is in the hospital after surgery for a ruptured appendix. Over my shift his temperature has increased by 4 degrees and his heart rate is elevated. His blood pressure is decreased from the previous shift as well. Could you please come examine him?” Which additional comments are the priority for the nurse to add? Select all that apply.

The patient is scheduled for a percutaneous liver biopsy at the bedside at 0730. The nurse is reviewing the patient’s chart prior to the procedure. Which initial statement by the nurse is most appropriate? Review the chart to determine the correct answer.

Review the chart and decide the best room for the patient.

The nurse is assisting a provider with a sterile procedure. During the procedure, the nurse observes the provider lower his right hand holding sterile forceps below his waist. He states, “These forceps are no longer sterile. Could you please obtain another one?” Which response by the nurse is most appropriate?

The nurse is preparing for the insertion of a peripherally inserted central catheter (PICC). Which action prompts the nurse’s orientee to clarify sterile technique?

The nurse is setting up the sterile field for a sterile dressing change. A sterile gauze 4x4 falls with the corner 2 cm from the sterile field. Which action by the nurse is most appropriate?

The nurse receives a set of orders for a patient. After reviewing the patient’s chart, the nurse clarifies which orders? Review the patient’s chart then select all that apply.