Communication & Documentation

The nurse notes the patient’s electrocardiogram shows peaked T waves with a prolonged PR interval. Which lab test does the nurse expect the provider to order?

A nurse is obtaining health information history of the patients through interviews and physical examination. Which of the following phases of the nursing process is this?

The patient complains of poor sleep on a regular basis. Which statement by the patient provides an opportunity for education about sleep hygiene?

A 17-year-old patient is declared brain dead after a motor vehicle accident in which he sustained a liver laceration, severe subdural hematoma, and high cervical spinal cord injury. The parents have decided to donate their son’s organs. Which statement by the nurse is appropriate?

The patient with end stage renal disease is on the transplant waiting list for a kidney. The nurse is aware this patient’s wait time will depend on which factors? Select all that apply.

The patient tells the nurse, “My provider told me to increase my dietary intake of vitamin C, but I’m not sure how to get it.” Which food does the nurse encourage the patient to eat?

The nurse would provide a meal with healthy fats to a patient taking which vitamin supplement(s) to increase vitamin absorption? Select all that apply.

The nurse is educating a patient on ways to increase dietary vitamin K intake. Which food, if selected by the patient as a good source of vitamin K, indicates a need for further teaching?

The patient tells the nurse, “My doctor wants me to take a vitamin D supplement for my osteoporosis, but I just don’t want to take another pill. What are some foods I can eat to increase my vitamin D?” The nurse counsels the patient to eat which foods high in vitamin D? Select all that apply.

The nurse is counseling a patient with a deep wound and delayed wound healing due to uncontrolled hypertension about the importance of nutrition for wound healing. Which food is most appropriate for the nurse to teach the patient?

A 16-year-old is placed on life support following a suicide attempt in which the individual overdosed on acetaminophen. The patient’s mother tells the nurse, “I know she will die from this. I hate that we didn’t find her for hours afterward. I would like her memory to live on as an organ donor. Is it possible to donate my daughter’s organs?” Which response by the nurse is appropriate?

A patient in liver failure tells the nurse, “My wife is so selfless; she has offered to donate her liver to me. I can’t let her die for me, though.” Which response by the nurse is most appropriate?

The nurse is providing discharge education about crutches to a patient who has an order to be non-weight bearing due to a broken ankle. Which action, if made by the patient, indicates a need for further teaching?

The patient is weight bearing but has left-sided weakness following a left knee injury. The provider has instructed the nurse to educate the patient on the use of a cane. How does the nurse instruct the patient to use the cane?

The nurse is supervising a patient who recently had a right hip replacement while she moves from sitting to standing with a walker. Which action would prompt the nurse to correct the patient?

The patient states, “I’m so embarrassed. I won’t feel like I have to pee for hours, then all of a sudden it hits me. I often can’t make it to the bathroom in time.” The nurse uses which term to document this patient’s report?

The patient complains of leaking urine with exercise, laughing, and sneezing. Which term does the nurse use to document this report?

The patient reports urinary incontinence when laughing or sneezing. Which education does the nurse provide the patient?

Which interventions does the nurse include in the patient’s care plan to decrease the risk for incontinence-associated dermatitis? Select all that apply.

Which intervention is most important to preventing dermatitis in the patient who is incontinent following a recent cervical spinal cord injury?

The nurse notes a mother attempting to remove the vernix from her newborn baby during a bath. Which response by the nurse is most appropriate?

The nurse is counseling the pregnant woman on care the baby will receive after birth. Which statement by the nurse is correct?

A patient with chronic anxiety has been learning to manage stress with progressive relaxation therapy. He tells the nurse, “I just don’t think this is working. I feel the muscle tension so much worse now.” Which response by the nurse is most appropriate?

Which statement by the nurse is correct when preparing a patient for meditation therapy?

The patient has requested to try electroacupuncture for chronic pain. Which of the following, if part of the patient’s past medical history, would prompt the nurse to contact the provider to have the order discontinued?

An elderly patient requests hotter water during the bath. Which action by the nurse is most appropriate?

The patient with a broken arm in a plaster cast requests to take a shower. Which response by the nurse is most appropriate?

An adolescent patient admitted to the hospital with anorexia nervosa is experiencing extreme fatigue. Which nursing intervention is most appropriate for providing hygiene care for this patient?

The nurse encourages the patient who works the night shift to hang blackout curtains in the bedroom to promote sleep. The nurse makes this recommendation based on an understanding of which physiologic process?

The nurse is providing discharge teaching to a new mother. Which of the following statements about the neonate’s sleep patterns is correct?

The parent of a two-year-old tells the nurse, “Every night, bedtime is a struggle. My child never wants to go to sleep.” Which response by the nurse is most appropriate?

The patient tells the nurse, “I fall asleep easily but wake up during the night and can’t go back to sleep.” Which question by the nurse is most helpful in determining the cause of the patient’s difficulty sleeping?

The nurse is counseling a patient on sleep hygiene practices. Which food or drink, if selected by the patient prior to bedtime, indicates the teaching was effective?

The nurse is providing preoperative teaching to a patient with bladder cancer who will have an orthotopic neobladder created. Which statement by the nurse is most appropriate?

The nurse informs a patient with a postvoid residual volume that straight catheterization must be performed to fully empty the patient’s bladder. Which rationale is most appropriate for the nurse to provide for this intervention?

The nurse is supervising the care of a patient with a urinary catheter by an unlicensed assistive personnel (UAP). Which action by the UAP would prompt the nurse to intervene immediately?

A patient complains of constipation. Which instruction should the nurse give first?

The nurse is teaching the patient about dietary modifications that enhance bowel regularity. Which food, if selected by the patient, indicate a need for further teaching?

The mother of the 16-year-old patient with schizophrenia asks the nurse, “I can hardly get him out of bed each day, he won’t ever shower, and it just doesn’t seem like he understands when I try to teach him new things. He takes his medicine like he’s supposed to. Why does he keep getting worse?” Which response by the nurse is appropriate?

The patient with major depressive disorder asks the nurse what causes the symptoms of depression. While the precise cause of depression is unknown, which response by the nurse is appropriate?

The nurse is providing education to the patient prescribed a monoamine oxidase inhibitor (MAOI). Which food, if selected by the patient, indicates a need for further teaching?

The patient with major depressive disorder has been prescribed sertraline. Which medication, if discontinued the day prior in the patient’s chart, prompts the nurse to hold the medication and contact the provider?

The patient who has been abusing benzodiazepines for 4 years tells the nurse, “I can’t let this drug control my life any longer. Take my pills; I’m quitting today.” Which response by the nurse is most appropriate?

The patient with social anxiety disorder asks the nurse to explain why she feels the way she does in social situations. The nurse bases the response on which understanding of the pathophysiology of anxiety disorder?

The 40-year-old patient has been diagnosed with early-onset Familial Alzheimer disease (FAD) and asks the nurse how likely it is that her children will have the disorder. Which response by the nurse is appropriate?

The middle-aged patient requests information on how to prevent Alzheimer disease. The nurse provides information about which diet that has shown promise in reducing the risk of developing Alzheimer disease?

The patient’s wife tells the nurse, “Even though he had atrial fibrillation, he seemed fine. Why did he have a stroke?” Which response by the nurse is appropriate?

The patient is undergoing therapeutic hypothermia following a severe cerebrovascular accident (CVA). The nurse bases education for the spouse on an understanding of which mechanism?

Which characteristic, if found in the patient’s chart, would prompt the nurse to hold the ordered bumetanide and contact the provider?

The patient who is 21 weeks pregnant complains of musculoskeletal pain and headaches and asks the nurse, “Can I take ibuprofen to treat my pain?” Which response by the nurse is most appropriate?