Communication & Documentation

After reviewing the patient’s chart, which order(s) require clarification? Review the patient’s chart, then select all that apply.

The patient who underwent a partial thyroidectomy 1 day ago complains of tingling in the lips and tongue. Upon assessment, the nurse notes increased deep tendon reflexes. Which order does the nurse question for this patient?

The postpartum nurse is supervising new parents placing their newborn into the car seat to drive home during a snowstorm. Which observation is most concerning?

Which information does the nurse include when preparing an informational session for expectant first-time parents about car seat safety? Select all that apply

A fire breaks out on multiple floors of the hospital and the charge nurse has been instructed to evacuate the patients. In which order are the patients evacuated?

The patient in the intensive care unit who was intubated with a central venous catheter, peripheral arterial catheter, and chest tube has expired. Which question by the nurse who enters the room to assist the patient care nurse is most appropriate?

The nurse is creating a tool to screen for patients who are risk for vitamin A deficiency. The nurse includes which conditions in the screening tool? Select all that apply.

The nurse notes the patient’s nails appear to curl upwards like spoons. Which statement by the nurse is most appropriate?

The registered nurse on the medical-surgical floor is delegating tasks to an unlicensed assistive personnel, certified medication assistant, and a licensed practical/vocational nurse. Which task does the nurse delegate to the LPN/LVN?

The 2-day-old full term child has been rooming in with the mother who reports successful breastfeeding. Which information is most important to report to the provider?

The adult child of the patient with dementia who is the patient’s in-home caregiver reports the patient exhibits increased confusion and agitation after 1600 each day. Which statement by the nurse will be most helpful to the caregiver?

The nurse is planning care for the elderly patient with dementia who experiences increased agitation and confusion during the evening hours. Which interventions does the nurse include to decrease evening agitation and confusion? Select all that apply.

The nurse is performing an admission assessment and interview of the patient diagnosed with paranoid schizophrenia. Which therapeutic communication techniques are used by the nurse to conduct the interview? Select all that apply.

The family of the dying Buddhist patient requests to burn incense in the patient’s hospital room for a religious ceremony. Which response by the nurse is most appropriate?

The nurse caring for a dying patient of the Buddhist faith approaches the charge nurse in distress to state, “My patient is going to die at any time and the family is nowhere near him. I’m not sure what to do to ensure he is not alone as he passes.” Which response by the charge nurse is most appropriate?

The nurse has observed the resident physician move between patients without performing hand hygiene on multiple occasions. Each time, the nurse asks the resident physician to perform hand hygiene before moving on to the next patient; the resident physician scoffs at the nurse and continues examining patients. Which action by the nurse is most appropriate?

The patient is scheduled to undergo a Wood’s light examination. Which instruction does the nurse include in preprocedure teaching?

Which wound most likely requires healing by second intention?

The 60-year-old patient who was recently laid off from his factory job of 38 years presents to the emergency department complaining of severe superficial pain over the flank. Which assessment will be most important for diagnosis?

The 74-year-old otherwise healthy patient presents to the clinic complaining of severe pain and burning of the skin over the right flank. Upon assessment, the nurse notes two lines of vesicles that curve laterally away from the spine on the right side. The nurse provides which instruction to the patient regarding treatment?

The patient with shingles presents to the clinic for reassessment following treatment. The nurse asks the patient to perform which action to assess for complications of the condition?

The 24-year-old patient presents to the emergency department complaining of malaise and intractable sore throat with onset 24 hours previously. Upon assessment, the nurse notes swollen cervical lymph nodes and a temperature of 39.3°C. The patient denies nasal discharge or cough. Which question by the nurse is most important?

The 15-year-old emancipated minor patient who weighs 32 kg presents to the emergency department with fever, malaise, cervical lymphadenopathy, and severe throat pain that was not preceded by an upper respiratory infection. The nurse anticipates providing teaching about which prescription?

The patient presents to the urgent care clinic complaining of a blister rash on the arm that burns and itches. The nurse notes a large vesicle on the forearm with streaks of smaller vesicles surrounding it. Which question will be most helpful to diagnose this condition?

The patient seeking medical care for a spider bite asks the nurse why the Diphtheria, Tetanus, and Pertussis (DTaP) vaccine has been prescribed. Which response by the nurse is most appropriate?

The patient in Arizona calls the nurse line to report being stung by a scorpion. Which follow-up question by the nurse is most important?

An individual calls the nurse line to report his friend has been bitten by a water moccasin snake on the hand. Which statement by the individual requires correction by the nurse?

The nurse is supervising the care of a patient with second-degree frostbite. Which action by the student nurse prompts the nurse to intervene with further instruction?

The nurse is supervising the care of a patient with a stage II pressure injury on the coccyx. Which intervention by the student nurse prompts the nurse to intervene with further education?

The nurse is planning care for a patient who sustained third degree burns over 42% of the body during an industrial accident the previous day. The patient is intubated, sedated, and chemically paralyzed. Which patient problem is most important for the nurse to address?

The patient with third degree burns to bilateral lower legs is undergoing hydrotherapy to debride eschar tissue from the wounds. Prior to the procedure, the patient received a bolus of intravenous morphine in addition to the continuous infusion for pain control. During the procedure, the patient’s level of consciousness decreases to only rousable by painful stimuli. The patient’s temperature is 36.4°C, respiratory rate is 14 breaths per minute, heart rate is 82 bpm, and oxygen saturation is 93% on room air. The nurse ends the hydrotherapy session and contacts the provider to request which intervention?

The patient with a history of colon cancer presents to the emergency department reporting significant abdominal pain, bloating, and vomiting. Which question to garner more information about the emesis is most important?  

In the postoperative period following a Whipple procedure, the nurse includes which interventions in the care plan? 

Four hours after a rectal resection for treatment of rectal cancer, the patient is noted to be pale and diaphoretic. Which assessments are the priority? Select all that apply.  

The nurse is caring for the patient who underwent colon resection and ileostomy creation two days ago. Upon assessment, the nurse notes 40 mL of dark green liquid in the ostomy bag. Which action by the nurse is correct?  

The nurse is providing preoperative education regarding total laryngectomy to the patient with laryngeal cancer. Which statement indicates a need for further teaching?   

The nurse is providing preoperative teaching to the patient prior to a total laryngectomy. Which information does the nurse include in teaching? Select all that apply.

The nurse notes the patient has an increased prostate-specific antigen level. The nurse searches the chart for which information?  

The nurse learns the patient has a tracheoesophageal fistula following a resection of laryngeal cancer. How does the nurse interpret this information?  

The nurse counsels the patient with prostate cancer to choose transurethral resection of the prostate based on which characteristic? 

The nurse is preparing an informational session for individuals at risk for prostate cancer. Which statement does the nurse include in the talk?  

The nurse clarifies the order for a perineal prostatectomy for treatment of prostate cancer in the patient with which condition?   

At 48 hours postop from a prostatectomy, the patient is noted to have pink output from the continuous bladder irrigation (CBI) system. Which action by the nurse is most appropriate?  

During a shift assessment 14 hours after a prostatectomy, the nurse notes bright red drainage in the continuous bladder irrigation (CBI) drainage bag. Which assessment is most important?  

The 3-year-old patient with acute pyelonephritis has the following orders:  Medications: 8 mg/kg ciprofloxacin IV q8h  Activity level: ambulatory as tolerated  Intravenous fluids: Infuse D5W with 0.25% NaCl via peripheral IV at 50 mL/h  Diet: Normal   The nurse is coordinating care for the patient with the unlicensed assistive personnel. Which statement by the UAP prompts further education by the nurse? 

The patient with severe psoriasis has been prescribed methotrexate. The nurse instructs the patient to schedule which follow-up tests? Select all that apply.   

The patient who has been prescribed methotrexate for the treatment of severe psoriasis has received medication teaching. Which statements indicate the teaching was effective? Select all that apply.

The 62-year-old patient reports erectile dysfunction and states, “I’ve been treating it with herbal remedies prescribed by my naturopathic doctor". Which conditions, if found in the patient’s medical history, prompt the nurse to counsel the patient against these herbal remedies? Select all that apply.  

The patient with high cholesterol reports forgoing the prescribed statin medication for an herbal remedy. The nurse assesses the patient for which adverse effects? Select all that apply. 

The nurse counsels which women against the use of black cohosh as an herbal supplement?