Communication & Documentation

The nurse is creating a care plan for a patient receiving fluid resuscitation after sustaining extensive third-degree burns. Which of the following outcomes is most appropriate to use to guide fluid resuscitation in this patient?

A child has third-degree burns on the front of the torso and on both arms. What is the total body surface area affected in this child?

A child suffered burns after pulling a boiling pot of water off the stove. The child’s head, torso, and right arm have third-degree burns. What is the total percentage of body surface area affected in this patient? Input your answer using a whole number.

The nurse in the burn unit is educating graduate nurses on the Rule of Nines for estimation of total body surface area of burns. Which statement by the student nurses indicates a need for further teaching?

The nurse is performing an electrocardiogram on a patient with rhabdomyolysis. The patient asks the nurse what the rationale is for this test, since he is young and has no cardiac history. Which of the following responses by the nurse is most appropriate?

A patient found a lump in her breast during her monthly breast self-exam. Further testing revealed a tumor that is 15 mm in diameter. No regional lymph nodes are involved, and no other metastases are found. Which of the following is the proper term used to describe the stage of this patient’s breast cancer?

A 1-year-old male is brought to the hospital with a broken leg. Which action does the nurse take first?

Which of the following are unable to sign their own consent for a surgical procedure?

For which of the following cases is informed consent not required?

The nurse is called to assist with a combative patient. The patient has already injured another nurse, and the staff wants to physically restrain the patient for their safety. Which of the following is the most appropriate course of action?

The nurse notices a patient walking in the hall who has a wristband indicating he is a fall risk. Which action does the nurse take?

The nurse notices that a patient who is scheduled for surgery tomorrow did not yet sign the consent form. The nurse was not in the room when the surgeon explained the procedure to the patient. Which of the following statements is most appropriate for the nurse to make when he/she brings the consent form for the patient to sign?

The nurse is caring for a patient with metastatic bone pain due to cancer. Which of the following is the best way to assess the patient’s level of pain in order to administer pain medication?

The patient preparing for chemotherapy confides in the nurse that she is apprehensive about the side effects of the chemotherapy. Which statement by the nurse is most appropriate?

Which term refers to the legal document that grants another person the right to make health care decisions for a person if they lack the ability to make the decisions themselves?

The patient has consistently reported 8/10 pain levels despite large doses of morphine being supplied. The nurse brings the patient’s IV morphine dose to the room to administer it. The patient states, “That is way more medication than the nurse gave me all night.” The nurse verifies the dose and amount and finds it consistent with the order and the amount that has been removed from the Pyxis. Which action by the nurse is appropriate?

Which patient does the nurse assess first?

The nurse is caring for a patient who cannot read or write. The patient has a surgical procedure tomorrow and needs to give informed consent. Which of the following is the correct role for the nurse to take for obtaining consent from this patient?

The nurse is the charge nurse for the floor. During the shift, a patient is given triple the usual dose of his narcoleptic medication because the current pills were a different dosage than the nurse expected. There was no noticeable adverse effect on the patient from the increased dose and patient has no complaints about the error. Which of the following is the best course of action to take regarding this incident?

A nurse is discussing a patient’s clinical case with the treating physician and they enter a public hospital elevator. Which action by the colleagues is the most appropriate?

The nurse is caring for a celebrity patient who is suffering from generalized anxiety. Non-treating physicians and nurses have been asking the nurse about the case and clinical notes written by the nurse have been accessed by non-treating healthcare personnel. Which of the following statements are most appropriate regarding the patient’s medical confidentiality?

The nurse is caring for a patient who natively speaks Japanese and speaks English proficiently. The nurse needs to obtain informed consent for a surgical procedure the patient needs urgently. Which action does the nurse take?

A nurse on an inpatient medical unit notices that multiple patients being admitted to the unit from the emergency department are not wearing ID bands. Which of the following is the most appropriate way to address this issue?

The nurse is caring for a patient of apparently sound mind who has a chronic severe wound infection on his forearm. Amputation of the limb below the elbow is the recommended course of treatment for this patient, but he refuses to allow the procedure. Despite an understanding of the risks and benefits of the procedure as well as of refusing the procedure, the patient refuses the amputation. Which management is the most appropriate?

A decompensating ICU patient’s blood culture is positive for gram positive cocci in clusters and the patient is started on IV oxacillin. The sensitivity results indicate the organism is resistant to penicillinase-resistant penicillins. The nurse anticipates which order from the provider?

A patient is receiving IV vancomycin for gram-positive sepsis. The nurse notes the patient’s vancomycin trough is 28 mcg/mL. The patient is due for a dose. Which action by the nurse is most appropriate?

A patient’s vancomycin trough, which was drawn 30 minutes after the dose, was 32 μg/mL. Which action by the nurse is most appropriate?

The patient with pneumonia who has been taking PO azithromycin for four days contacts the clinic to report itching and burning in her vagina. Which response by the nurse is most appropriate?

The nurse is reviewing the chart of a patient who has been prescribed metronidazole for bacterial vaginosis. Which medication, if present in the patient’s current medication history would prompt the nurse to hold the metronidazole and contact the provider?

A 10-year-old patient in the pediatrician’s office has dropped from 65 pounds to 55 pounds since last seen in the office three months ago. The patient’s mother tells the nurse, “I just don’t understand how that’s possible. She eats constantly and is always thirsty. My other concern is that she has to urinate frequently; her teacher contacts me weekly to tell me she goes to the bathroom more than her peers.” The nurse anticipates this patient will be diagnosed with which condition?

A patient with type 1 diabetes mellitus asks the nurse what causes his hyperglycemia. Which response by the nurse is most appropriate?

The nurse is providing education to the parents of a 4-year-old child newly diagnosed with type 1 diabetes mellitus. Which statement by the parent indicates a need for further teaching?

The community health nurse is teaching a class on diabetes mellitus. Which symptoms of diabetes mellitus does the nurse include in the teaching? Select all that apply.

The nurse is caring for a patient recently diagnosed with type 2 diabetes mellitus. The provider has prescribed metformin. Which lab value, if present in the patient’s chart, prompts the nurse to hold the dose and contact the provider?

A patient with type 2 diabetes mellitus has been prescribed glyburide. Prior to administering the medication, the nurse reviews the patient’s allergies and notes the patient has a history of angioedema following sulfamethoxazole-trimethoprim and breaks out in hives after eating eggs. Which action by the nurse is appropriate?

The nurse is planning care for a patient who has been diagnosed with type 2 diabetes mellitus. Which intervention is likely to be most effective for this patient?

A 45-year-old overweight patient has a fasting blood glucose level of 130 mg/dL. Which is the initial therapy for this patient?

A 35-year-old man presents to the emergency department following an unrestrained head-on collision where his chest struck the steering wheel. During the initial assessment, the patient abruptly begins complaining of incredibly severe chest pain that feels like ripping in the anterior chest. He states, “I’m going to die, I know it!” The nurse alerts the provider immediately due to suspicion for which condition?

A patient hospitalized with ulcerative colitis develops worsening abdominal pain, a fever of 103 °F, heart rate of 132 bpm, and blood pressure of 82/54 mmHg. Her labs are notable for an elevated white blood cell count. What is the nurse’s first action?

The nurse is working in the emergency department when a mass casualty event occurs. Which patient will the nurse treat first?

A patient with heart failure is unable to walk from the kitchen to the bedroom without becoming dyspneic. However, the dyspnea resolves with rest. The nurse recognizes this patient has which class of heart failure according to the New York Heart Association classification system?

A patient has been diagnosed with heart failure. The nurse educates the patient about which nonpharmacological treatments?

A patient with heart failure requests assistance ordering a meal tray. Which meal does the nurse recommend for this patient?

The nurse is providing diet education to a patient with left-sided heart failure. Which meal, if ordered by the patient, indicates the teaching has been effective?

The nurse is performing an initial assessment of a patient with heart failure. Two minutes after checking the patient’s pedal pulses, the nurse notes that fingertip indentions that are 5 mm deep are left on the patient’s feet. How does the nurse document this finding?

After speaking with the child’s mother, a pediatrician choses non-pharmacologic interventions for a child diagnosed with atopic dermatitis. Which treatments does the nurse recommend to the child’s mother? Select all that apply.

The nurse is providing discharge education to a patient diagnosed with immune thrombocytopenic purpura. Which statement by the patient indicates a need for further teaching?

An adolescent’s parents reports their child tends to eat excessive amounts of food then disappears to the bathroom for an extended period immediately following the meal. The patient also frequently discusses ways to lose weight. The nurse suspects which condition?

An adolescent has been diagnosed with bulimia nervosa. Which treatment will you anticipate for this patient?

The nurse notes the physician has entered the room of a patient who is infected with methicillin-resistant staphylococcus aureus without proper personal protective equipment and begins assessing the patient. Which response by the nurse is most appropriate?