Communication & Documentation

The nurse is planning care for the 78-year-old patient with recurrent fecal impaction. The patient has prostate cancer that has metastasized to the bone. In addition to palliative chemotherapy, the patient receives a fentanyl transdermal patch and intravenous hydromorphone. The patient is neutropenic and thrombocytopenic. The nurse works with the provider to plan which intervention to manage the opioid-induced constipation and subsequent fecal impaction? 

The 30-year-old couple presents to the infertility clinic after trying to conceive for 14 months. The man’s sperm analysis reveals sperm that have good motility and are adequate in number. On exam today, the woman’s cervical mucus is thin and stringy, with ferning on the slide. Which statement by the nurse is most appropriate?  

A 16-year-old boy is brought to the clinic by his mother with complaints of strange noises and movements. The boy states, “I can’t stand that I make this weird noise with my mouth. I can feel it coming, and I try to stop it for as long as I can, but eventually it just comes out. The other kids at school make fun of me. It’s so embarrassing.” The mother reports that the boy gets good grades and has no trouble concentrating at home when doing homework. Which information does the nurse give the patient and his mother about the medication he will be prescribed?  

The 68-year-old patient is admitted after 3 days of extremely foul-smelling watery diarrhea with a temperature of 37.8°C, heart rate 122 bpm, and blood pressure 96/50 mmHg. The patient’s recent medical history is significant for being treated 2 weeks ago for a diverticulitis flare-up. Upon assessment, the patient is pale, diaphoretic, and has a tense, distended abdomen that he does not guard with palpation. Lab studies reveal an elevated creatinine (1.9 mg/dL), high white blood cell count (20,000 cells/mL), and normal hemoglobin and hematocrit. Which medication does the nurse administer without further discussion with the provider? 

The nurse is caring for a 57-year-old woman who is intubated and sedated in the post-anesthesia care unit following a radical hysterectomy. The patient remained stable throughout the 6 hour surgery during which she experienced a 2 L blood loss. The nurse has emptied the patient’s indwelling catheter every hour for the 3 hours the patient has been in the PACU with the following volumes: 54 mL, 23 mL, 12 mL, and 5 mL. Her heart rate is 112 bpm, oxygen saturation is 99%, and blood pressure is 82/54 mmHg. The nurse contacts the provider to report these findings and advocate for which initial order?  

The patient with acquired immunodeficiency syndrome who has been noncompliant with highly active antiretroviral therapy (HAART) presents to the emergency department with a productive cough, fever, night sweats, and weight loss. The patient’s chest x-ray reveals diffuse infiltrates bilaterally and the CD4 count is 182 cells/µL. Which question by the nurse is most important?  

The 48-year-old patient is brought via ambulance to the emergency room after being found unresponsive by her son. She has a prescription for transdermal fentanyl patches for treatment of cancer pain related to her breast cancer that has metastasized to her pelvis. The patient’s heart rate is 72 bpm, respiratory rate is 4 breaths per minute, and her oxygen saturation is 88%. Her arterial blood gas results are: pH 7.21, PaCO₂ 72 mmHg, PaO₂ 74, HCO₃¯ 23. A thorough assessment reveals 2 fentanyl patches on the patient’s skin. The nurse advocates for which initial action?  

The nurse is preparing the otherwise healthy 54-year-old patient for a right knee replacement surgery and checks to see if the patient is allergic to which medication? 

The 22-month-old child is brought to the emergency department with large, blistered burns to both buttocks by his mother’s boyfriend. The mother’s boyfriend states the child has been in his care while the mother is away on a business trip. He reports the child accidentally fell into the bath during the preparation before the water had had a chance to cool. The child’s second-degree wounds are dressed after intravenous morphine is administered. The nurse works with the healthcare team to perform which intervention? 

The 23-year-old patient is brought to the emergency department after contacting emergency services to report profound weakness that started in his feet and worsened and spread cranially over the past few days. He reports severe diarrhea after a camping trip a week ago. Upon assessment, strength, sensation, and deep tendon reflexes are significantly reduced, with the lower extremities more severely affected than his upper extremities. Vital signs are normal and the patient seems to be breathing well. There is increased protein in the cerebrospinal fluid found after a lumbar puncture. The patient is admitted to the intensive care unit for further management and observation. The ICU nurse includes which interventions in the plan of care? Select all that apply.  

The 31-year-old patient G2P1 woman presents to the clinic for 30 week appointment. She was diagnosed at 24 weeks with gestational diabetes. For 6 weeks, she changed her diet and exercised more regularly while checking her blood sugars. She logged fasting glucose levels of 108-135 mg/dL. She has no proteinuria or glycosuria. The nurse provides which information to the patient?  

The 50-year-old previously healthy patient complains of shortness of breath, especially on exertion or when laying down to sleep. She takes over-the-counter allergy medicine for seasonal allergies and melatonin to help her sleep sometimes. Her vital signs are heart rate of 64 bpm, respirations 22, oxygen saturation 99%, and blood pressure 114/68 mmHg. Her assessment is notable for crackles over the bilateral lung bases and a moderate diastolic apical murmur. Her electrocardiogram is normal. Her echocardiogram shows normal function of the left ventricle and severe stenosis of the mitral valve. The nurse provides which information to the patient?  

The 38-year-old patient who strictly adheres to a vegan diet complains of weakness and tingling in her lower extremities. She retains the strength in her lower extremities but proprioception is decreased.  Her complete blood count reveals a megaloblastic anemia. Which statement by the nurse is most appropriate? 

The 58-year-old patient presents to the emergency department of a community hospital complaining of worsening back pain that started a few days ago. He states, “I thought maybe I had slept wrong and gotten a spasm, but I’m not sure. I didn’t fall or get hit or anything. The ibuprofen I took definitely didn’t help.” His blood pressure is 174/96 mmHg and heart rate is 96 bpm. He reports being out of his antihypertensive medication for the past week while he was out of town. Other history is notable for arthritis in the hands and a 44-pack-year smoking history. He drinks socially but denies illicit drug use. A pulsating abdominal mass is noted; otherwise, his assessment is benign. The nurse advocates for which treatment option? 

During the provider’s exam of the 6-hour-old neonate, the provider reports observing a red reflex in the neonate’s right eye, but not the left. The provider observes whiteness at the back of the eye. Enucleation is performed and the diagnosis of retinoblastoma with clear tumor margins is confirmed. No chemotherapy or radiation is required. The infant is ready to be discharged home as a healthy baby. Which health screening information is most relevant to this family? 

The 7-year-old child is being evaluated for attention deficit or learning disability. The child’s teachers report a lack of attention to detail and an inability to follow direction. The child’s parents report issues at home, too – not doing what is asked and not remembering what has been said. While being evaluated, the child begins to blink rapidly for 20 seconds. Once the episode ends, the child does not remember what happened or the purpose of the appointment. The nurse educates the parents about which adverse effects of first line therapy? Select all that apply.  

The patient with active syphilis asks the nurse how the prescribed medication treats the infection. Which response by the nurse is correct?  

The nurse clarifies which order for the patient admitted with cellulitis caused by methicillin-resistant staphylococcus aureus?   

The 59-year-old female reports vaginal bleeding. She experienced menarche at 12 years of age and menopause at 56. Endometrial carcinoma is found with endometrial biopsy. Further testing reveals no lymph node involvement or metastasis. The nurse prepares the patient for which initial therapy?  

The patient with human immunodeficiency virus and a CD4 count of 158 has a purified protein derivative (PPD) skin test performed and is found to have a 7-mm induration with circumferential erythema. Which statement does the nurse make to the patient?  

The 28-year-old patient checks himself into a center for detoxification from opiates, which he has used daily for 3 years. The patient begins to experience pain, diarrhea, salivation, and diaphoresis and is started on buprenorphine. Worsening pain throughout the body and uncontrollable diarrhea prompts stepwise increase of buprenorphine dose to the maximum dose without relief of withdrawal symptoms. The nurse contacts the provider to request an order for which medication?  

The nurse witnesses a healthy 19-year-old collapse while playing football. The individual is arousable but confused and irritable. The skin is warm, dry, and flushed. The nurse instructs a teammate to bring the water cooler and pours it over the victim. The teammate shouts, “Why did you do that?! Won’t he go into shock?”  The nurse bases the response on the need for rapid cooling to prevent which conditions? Select all that apply.  

The semi-professional athlete requests intravenous hydration after a particularly grueling practice. Which response by the nurse is most appropriate? 

The 2-year-old patient who has a history of drug-induced hemolysis, anemia, and hyperbilirubinemia presents to the clinic complaining of urinary urgency and dysuria. The patient has a fever and the urinalysis is positive for leukocyte esterase as well white blood cell casts. Which medications, if prescribed for the patient, prompt the nurse to clarify with the provider prior to administering them? Select all that apply.  

The nurse is teaching a community class on cardiopulmonary resuscitation (CPR). Which rationale is best to give the class for the difference between infant CPR with one rescuer, infant CPR with two rescuers, adult CPR with one rescuer, and adult CPR with two rescuers?

The nurse is supervising the student nurse in the insertion of a peripheral intravenous catheter. The nurse observes the student nurse apply a tourniquet, clean the insertion site, and insert the needle into the skin and get a flash of blood in the chamber. The nurse continues to quietly observe if the student nurse performs which action? 

The nurse is observing the student nurse preparing a 6-year-old for the insertion of an intravenous catheter. Which statement by the student nurse prompts the nurse to intervene? 

The nurse is caring for the patient with prostate cancer that has metastasized to the bone. The physician has prescribed extended-release oxycodone to treat severe bone pain. The patient expresses to the nurse he is concerned he will become addicted to the opioid pain medication given what you see on television. Which response from the nurse is most appropriate?

The patient who has a positive human chorionic gonadotropin test tells the nurse, “I don’t understand how this happened! I take my combined hormonal contraceptive (CHC) pill every single day at the exact same time!” The nurse asks the patient which question(s)? Select all that apply.