Communication & Documentation

During a routine physical, the patient states, “I feel more comfortable taking herbal remedies than prescription medications for my high blood pressure.” Which response by the nurse is most important?  

The nurse is helping to recruit patients for a study about the effectiveness of a new delivery system for somatropin. The nurse filters the records for patients with which conditions? Select all that apply.

The patient with short stature associated with Noonan syndrome is being considered for somatropin injections. The nurse ensures which test is performed before therapy is started? 

The nurse is supervising a nursing student in the emergency department. Which actions by the nursing student indicate effective learning? Select all that apply.  

The nurse places a call to the provider that the 74-year-old patient’s potassium level is 7.1 mEq/dL. The nurse is prepared to answer which questions from the provider? Select all that apply.  

The patient is receiving a continuous heparin infusion that started at 0000 for the treatment of a deep vein thrombosis in the leg. Prior to the initiation of therapy, the patient’s activated partial thromboplastin time (aPTT) level was 35 seconds. The aPTT level drawn at 0800 was found to be 70 seconds. The nurse reports this information to the provider and advocates for which intervention?  

The patient who was started on warfarin sodium for the treatment of atrial fibrillation has reached steady state with the current dose. Which instruction is most important to give the patient?

The patient on bowel rest has been prescribed 10% dextrose total parenteral nutrition at 50 mL/h, intravenous lipids 3 grams/kg/day, and 10 mg intravenous famotidine every other day. Which information in the patient’s chart prompts the nurse to contact the provider? 

The 21-year-old patient with a body mass index of 10.1 undergoes placement of a peripherally inserted central catheter (PICC) at 1000 and total parenteral nutrition (TPN) is initiated at 1200. At 1600, 160 mL have infused and the patient is noted to be breathing shallowly, there is blood oozing from the PICC insertion site, and the patient is exhibiting confusion. Which action does the nurse perform first? 

The patient is receiving parenteral nutrition while NPO for a bowel obstruction. Review the patient’s lab results and decide which change to the parenteral nutrition the nurse clarifies with the provider.   Blood urea nitrogen = 34 mg/dL   Serum Creatinine = 2.1 mg/dL  Potassium = 6.1 mEq/dL  Sodium = 131 mEq/dL  Chloride = 100 mEq/dL  Bicarbonate = 18 mEq/dL

The nurse is supervising the student nurse in performing a cap change for a peripherally inserted central catheter (PICC) in a patient who recently sustained a traumatic brain injury. Which action by the student nurse best indicates effective learning?

At the beginning of the shift, the nurse assesses the patient receiving total parenteral nutrition (TPN) via a peripherally inserted central catheter and notes a crack in the tubing with TPN leaking. The nurse notifies the provider and anticipates receiving which order first? 

The nurse is providing preprocedural teaching for the patient scheduled for a cystectomy for bladder cancer. Which statement by the patient indicates teaching was effective? 

The patient with bladder cancer is scheduled for a cystectomy and creation of an internal ileal reservoir. Which statement by the patient indicates an understanding of the teaching?  

The patient has undergone a cystectomy with ureterosigmoidostomy. Which nursing interventions are included in the care plan? Select all that apply. 

The nurse finds the patient’s vaginal radiation implant in the bed while turning the patient. Which action by the nurse is most appropriate?   

Following a bone marrow transplant, the patient exhibits a 10-pound weight gain in 3 days, increased abdominal circumference, and yellow tinge to the sclera and skin. The nurse notifies the provider and prepares to perform which intervention?  

The nurse has provided self-care teaching to the patient who has undergone radiation therapy for breast cancer. Which action by the patient indicates a need for further teaching?  

The nurse is caring for the patient who is at the nadir for bone marrow suppression. Which order does the nurse clarify with the provider?  

The patient is scheduled for a radical orchiectomy for treatment of testicular cancer. Which preprocedural teaching is most important to provide the patient? 

The nurse advocates for cervical cancer screening for patients with which complaints? Select all that apply. 

The patient’s activated partial thromboplastin time (aPTT) is 138 seconds. Review the chart to determine the most important question for the charge nurse to ask the bedside nurse.

The nurse provides which instructions to the unlicensed assistive personnel who is assisting in the care of a patient postoperative day one following a radical hysterectomy? Select all that apply. 

Which interventions does the nurse include in care for the patient who underwent a total pelvic exenteration for a cancer diagnosis one day ago? Select all that apply.  

The patient presents to the emergency department with severe, unrelenting abdominal pain. Which findings prompt the nurse to suspect the patient will require a Whipple procedure? Select all that apply.  

The nurse is caring for the patient recently diagnosed with colon cancer. Which assessment prompts the nurse to call for the provider immediately?  

The nurse is evaluating the understanding of the patient who has been taught to perform a colostomy irrigation. Which action requires further teaching? 

The nurse reviews the patient’s chart and notes a positive sickle-turbidity test. Which statement does the nurse make to the patient’s parents?  

The nurse creates the plan of care for the patient with crescent-shaped hemoglobin who presented with severe joint pain and stiffness with priority given to which type intervention? 

The 13-year-old patient presents to the emergency room following a sports practice in the late summer heat with severe joint pain, malaise, splenomegaly, tachypnea, and tachycardia. Upon assessment, the patient’s oxygen saturation is 92%. Which order does the nurse carry out first?

The nurse questions which orders for the 12-year-old patient in sickle cell crisis? Select all that apply.

The nurse is providing health promotion and disease prevention education to the 15-year-old patient receiving chemotherapy. Which statement does the nurse include?  

The 72-year-old patient is brought via the ambulance to the emergency department after his wife observed him collapsing after dinner. At the scene, emergency medical service (EMS) personnel determined he was in asystole, and began cardiopulmonary resuscitation (CPR). An advanced airway was placed and a peripheral intravenous catheter was inserted. The defibrillator was placed and read ventricular fibrillation; a shock was administered, chest compressions were restarted, and a 1 mg epinephrine dose was administered via peripheral IV. Upon arrival to the emergency department, the patient was found to be in pulseless electrical activity after 5 complete rounds of CPR (including epinephrine, defibrillation, and 30:2 chest compressions to ventilated breaths ratio). The nurse advocates for which intervention?

The parent of the 8-year-old with sickle cell disease (SCD) reports the child complains of constant generalized pain rated at 4/10. Which response by the nurse is most appropriate?  

During a routine physical, the 58-year-old patient reports aching chest pain that occurs only when doing yardwork or heavy cleaning. However, it does not occur every time he is performing these chores. He denies regular exercise and reports a sedentary lifestyle. The nurse anticipates providing which instruction to the patient related to the patient's new prescription for this condition?   

The 3-year-old with sickle cell disease is preparing for discharge following a crisis during which the patient received several blood transfusions. The nurse is providing teaching regarding appropriate food choices for the child. Which foods, if selected by the parents, indicate a need for further teaching? Select all that apply.  

The nurse is providing medication teaching to the patient being treated for microcytic, hypochromic anemia. Which statement by the patient indicates effective teaching?  

The patient is hospitalized after being diagnosed with aplastic anemia. Which question is most important to ask the patient?   

The 18-year-old female patient reports menorrhagia, easy bruising, and epistaxis. Her family history is notable for maternal hypertension, a brother with hemophilia A, and a father who died of stroke at age 48. Which question is most important to ask the patient?   

The nurse assessing the 4-month-old brought to the emergency room for poor feeding and signs of dehydration notes the infant seems to be looking down and sclera is visible superior to the iris. The nurse reports this assessment to the provider and receives orders for care. Which order does the nurse question? 

The nurse is caring for the 16-year-old patient undergoing treatment for Ewing sarcoma. Which intervention is most helpful for the patient?  

The 13-year-old girl is brought to the clinic for treatment of vaginal candidiasis for the 2nd time in 6 months. Which question is most helpful by the nurse?  

The home health nurse is planning care for the 14-year-old with type 2 diabetes mellitus. Which intervention will best decrease the patient’s risk for long-term complications?  

The nurse is providing discharge teaching to the parents of the 3-year-old patient who was recently diagnosed with type 1 diabetes mellitus. Which item, if identified by the parents as the most important item to carry at all times, indicates effective teaching?  

The nurse is providing health promotion teaching for the 22-year-old patient with phenylketonuria. Which food, if selected by the patient, prompts the nurse to intervene?  

The nurse is supervising the assessment of a 4-year-old patient with a Wilms tumor who was brought to the emergency department for profuse vomiting. Which statement by the student nurse requires prompt intervention by the nurse? 

The 3-year-old patient is brought to the clinic after three days of nausea, vomiting, and diarrhea. Which assessment most prompts the nurse to advocate for hospital admission?  

The 58-year-old patient presents to the clinic for a follow-up appointment. Upon assessment, the nurse notes expiratory wheezes across all lung fields. Review the patient’s chart to determine the most likely cause of this new symptom.

The nurse reviews the patient’s chart and advocates for which intervention?

The 8-month-old patient has had 4 skin abscesses in the past 3 months that have required draining. Each abscess drains less than 5 mL non-purulent fluid. The infant appears well otherwise and the parents deny respiratory infections. The infant’s complete blood count shows an elevated white blood cell count without bands or segmented cells. Immunoglobulin levels are appropriate for the age of the infant. The patient has a positive nitroblue test. The nurse plans care to include which intervention?