Communication & Documentation

The nurse is compiling research to institute a new evidence-based practice regarding pressure injury prevention and finds a randomized controlled trial from a multi-site healthcare system on the west coast. Which level of evidence does the nurse assign to this source?

The nurse finds a study about a novel anticoagulation therapy tested in mice. Which statement indicates an understanding of this research?

The nurse wishes to decrease ventilator-associated pneumonia rates in the intensive care unit. Which source will provide the best evidence from which to develop a process improvement project?

Which type of study is retrospective?

The nurse is reviewing clinical practice guidelines on central line management in order to create a process improvement project that decreases central-line associated bloodstream infections (CLABSI). Which level of evidence is the nurse using?

Which document delineates the patient’s responsibilities and rights while hospitalized?

Prior to inserting an intravenous catheter, the nurse tells the patient, “I promise this won’t hurt a bit.” Which ethical principle does the nurse risk breaking with this statement?

The bedside nurse asks the unlicensed assistive personnel (UAP) to administer a tube feeding to a patient with a nasogastric tube. The UAP has never performed this task. Which action by the UAP is most appropriate?

Which aspect of delegation is the most crucial to ensure patient safety?

The unlicensed assistive personnel (UAP) performs a delegated task after failing to complete the yearly mandatory education and skills check-off and an adverse event occurs. Who is most responsible for the adverse event?

The bedside nurse asks the unlicensed assistive personnel (UAP) to help a stable patient to the bedside commode. Upon standing, the patient complains of being dizzy and lightheaded, but insists on using the commode. The UAP calls out to the bedside nurse for help, but the nurse had left the floor with another patient. The patient falls and sustains a mild head injury. Which individual is most responsible for the patient’s injury?

The nurse is assigned to a 32-year-old male admitted with bowel obstruction status post exploratory laparotomy. Which telephone call from the nurse to the provider is most appropriate?

The nurse calls the provider with this report: “Hi, Dr. Smith, the patient Mrs. Welch is complaining of an 8/10 pain in her lower abdomen. Her abdomen is distended but is soft with positive bowel sounds in all four quadrants. I have tried ambulation, warm compresses, and position changes, to no avail. Could you please come assess her?” Which component of SBAR communication does the nurse need to elaborate for this patient?

The nurse is assigned to care for several patients in the NICU. The nurse calls the advanced practice nurse about one of the patients and says, “Hello, this is Kelly Smith, a nurse working in the NICU. Can you please come assess the patient, Michael Doh, in bed 552? I’m concerned about him. Thanks!” Which component(s) of the SBAR communication does the nurse need to elaborate? Select all that apply.

The nurse is assigned several patients on the surgical floor. He calls the provider and says, “Hi there, the post-op day 1 in bed 14 asked me to call and request an order for increased dosage of his IV pain medication. His blood pressure has been consistently elevated and he has been tachycardic for the last 3 hours. Would you consider adding an adjuvant pain control medication?” Which aspect of this SBAR communication is most appropriate?

The nurse is assigned to care for a patient who has long-standing type 1 diabetes mellitus. Which of the following orders for subcutaneous insulin is most appropriate?

The nurse is caring for a G3P0 female at 40 weeks estimated gestational age in the second stage of labor. The patient does not have an epidural in place. After how many hours does the nurse contact the provider to report a prolonged second stage of labor?

A 31-year-old G2P1 female at 37 weeks estimated gestational age presents reporting contractions. Which question by the nurse would best determine if the patient is in labor?

The 25-year-old G1P0 female at 31 weeks estimated gestational age presents to the labor and delivery unit. The nurse assesses the patient and palpates the head of the fetus to be 2 inches above the maternal ischial spines. Which term does the nurse use to document this finding?

The nurse is performing a psychosocial assessment on an 84-year-old male in a hospice. The patient says, “I have had a good life. My children are grown and successful, and I was a successful businessman.” How does the nurse document this patient’s psychosocial development?

During a routine clinic visit by a 25-year-old male, which question does the nurse use to appropriately assess the psychosocial development of the individual according to Erikson's psychosocial stages?

The nurse is assigned to care for a 27-year-old male who presented with acute onset personality changes and neuropsychiatric symptoms. Upon entering the patient’s room, the nurse notices the patient is staring at the ceiling and muttering. Which action by the nurse is most appropriate?

The nurse is caring for a 32-year-old patient admitted for neuropsychiatric evaluation. The patient says to the nurse, “Can’t you hear them? The voices are telling me to end it. I’m so scared.” Which response by the nurse is most appropriate?

Following a mass casualty event, the nurse is called in to the hospital to work in accordance with the city's emergency response plan. The nurse is instructed to discharge as many current inpatients as possible to assist with reallocation of resources. Which patient is most appropriate to be discharged?

The nurse is assigned to care for a 65-year-old male patient who is diagnosed with atrial fibrillation. The nurse realizes during the shift report that six hours ago she administered 0.6 mg of this patient’s antiarrhythmic medication instead of 6.0 mg. Which action does the nurse perform first?

An unconscious patient presents to the emergency department following a benzodiazepine overdose and is noted to have the words, “Do Not Resuscitate,” tattooed across the chest. Which action by the medical team is most appropriate?

A terminally ill patient has attempted to commit suicide by swallowing an entire bottle of opioid pain medication.The patient is brought to the emergency department and found to have a “Do Not Resuscitate” tattoo on her chest along with a handwritten note that states that she is tired of suffering and wishes her life to end. Which next step by the medical team is most appropriate?

The nurse is assigned to care for a 45-year-old G2P1 female at 35 weeks estimated gestational age who is admitted with preeclampsia. On morning rounds, the patient says she is having considerable abdominal pain, so the provider writes multiple medication orders for her. Which medication order can the nurse carry out without clarification?

The nurse is assigned to care for a 14-year-old male who has repeatedly ripped out his IV line and attempted to harm himself with various objects found in the room despite a family member sitting at his bedside around the clock. He is placed in wrist restraints that are secured to the bed per physician order. If the current order was written at 1030, at what time that same day does the order expire?

A nurse is assigned to care for a 28-year-old patient with seizures and neuropsychiatric symptoms secondary to cocaine abuse. The patient is combative and prone to hurting himself despite a 24-hour bedside sitter, so the provider writes for physical restraints. Which options are included in this order? Select all that apply.

The 29-year-old male patient admitted with schizophrenia has pulled out 4 IVs in the last 12 hours. Which intervention does the nurse include in this patient’s care plan?

The nurse would like to institute a process improvement project to improve the cleanliness of the patient rooms. Which key stakeholders does the nurse include? Select all that apply.

The nurse is admitting a patient positive for human immunodeficiency virus (HIV). A fellow nurse states, “This patient is on contact precautions for his HIV status. You need to wear an isolation gown in addition to your gloves.” Which response by the nurse is most appropriate?

A 12-year-old male patient has received the first dose of the human papillomavirus vaccine in May of this year. When will the nurse schedule an appointment for him to come back to receive his second and third doses?

The nurse is caring for a patient who has undergone surgery following a motor vehicle accident. The patient is stable and resting comfortably; he is expected to make a full recovery. Upon entering the room, the nurse notes the patient’s wife is holding his hand and crying. Which statement by the nurse is most appropriate?

The nurse is teaching a patient how to walk with a cane following a cerebrovascular accident that left the patient with right-sided weakness. Which action by the patient indicates the teaching was effective?

The nurse receives an order to administer digoxin 0.125 mg intramuscularly each morning to a patient in heart failure. Which part of the order does the nurse question?

The nurse on the telemetry floor is reviewing EKG readings of the patients. The nurse notes one patient, who is taking digoxin, to have peaked T waves and a prolonged PR interval. The nurse contacts the provider to report concerns for which possible impending condition?

The patient who is scheduled for a cardiac catheterization is unable to read or write. How does the medical team obtain informed consent for the procedure? 

Prior to transporting a patient to surgery, the nurse ensures which items are in the patient's chart? Select all that apply. 

The nurse has counseled the patient who has been admitted for an exacerbation of chronic obstructive pulmonary disease about the dangers of smoking tobacco. Which statement by the patient indicates a need for further teaching? 

The nurse is assessing the 75-year-old female patient whose spouse died unexpectedly six months ago. Which statement by the patient reflects ineffective coping mechanisms?

A 14-year-old patient presents to the clinic complaining of right outer ear pain. Which characteristic most likely explains the cause of the pain?

The nurse prepares the patient who has been newly prescribed atorvastatin (Lipitor) for which periodic laboratory evaluation prior to the first dose?

Upon arrival of the patient to the post-anesthesia recovery unit (PACU), which assessment does the nurse perform first?

The patient with major depressive disorder has been prescribed a monoamine oxidase inhibitor (MAOI). The nurse has educated the patient on dietary restrictions that are required while taking an MAOI. Which statement by the patient indicates further teaching is required?

The patient reports being hungry prior to the breakfast tray delivery. When the nurse checks on the patient an hour after the tray was delivered, the nurse notes the patient has not eaten any of the food. Which initial nursing action is most appropriate? 

The woman who is 32-weeks-pregnant presents to a prenatal appointment reporting irregular contractions that occur a few times per day. Upon assessment, the patient's cervix is noted to be closed, long, and high. Which action by the nurse is most appropriate? 

Which finding is expected in the patient with diabetic ketoacidosis (DKA)?

The patient who underwent an upper gastrointestinal radiographic study requires which post-procedure instruction?