Communication & Documentation

The patient presents to the emergency department with chest pain. Which description of the pain prompts the nurse to suspect a myocardial infarction?

The patient who is scheduled for an elective surgery in 2 hours asks the nurse, “What time do the maids typically come to clean the hotel room?” Further questioning reveals the patient believes the hospital in the United States is a hotel in Paris, France, and the year is 20 years prior. The nurse notes that the patient signed a consent form for the procedure just minutes ago. Which action does the nurse take first?

The adult patient with type 1 diabetes mellitus and Parkinson’s disease lives alone. Which patient statement would prompt the nurse to advocate for a delay in discharge from the hospital?

Which statement by the novice nurse requires correction by the charge nurse?

Which patient must be treated first in the emergency department following a mass shooting?

Which process improvement project will be most effective in improving patient satisfaction?

Which observation prompts the nurse manager to implement a process improvement project on alarm fatigue in the unit?

Which situation in the hospital unit requires the most immediate attention?

Which patient is appropriate to assign to a licensed practical/vocational nurse (LPN/LVN)?

The nurse is caring for the patient who was admitted to the hospital after a fall at the nursing home. Which intervention does the nurse implement in order to reduce the patient’s fall risk?

The patient is rushed into the emergency department by a family member who states the patient is having a stroke. Which action does the nurse take first?

After receiving report, which patient does the nurse see first?

The nurse is providing education to a patient with localized shingles. Which statement by the patient indicates the teaching was effective?

A fire develops in the nurses’ station kitchen. Which action does the nurse take first?

The nurse learns the patient has a plan to kill as many people as possible by stabbing or shooting them. Which intervention by the nurse is most important?

Which statement by the unlicensed assistive personnel (UAP) indicates an understanding of the proper way to transfer patients?

The nurse holds the transfusion and contacts the blood bank if which anemic patient is sent B negative packed red blood cells for transfusion?

Which is an example of the mitigation phase of disaster planning?

The patient’s stool sample is positive for Entamoeba histolytica. The nurse plans education about which class of medication for this patient?

The patient with antisocial personality disorder is known to have violent outbursts. Which actions by the patient indicate the patient may become physically violent? Select all that apply.

The novice nurse is transferring a patient from the floor to the intensive care unit. Which statement, if made by the novice nurse, indicates a need for further teaching about SBAR (Situation, Background, Assessment, Recommendation) communication?

Which action by the intensive care unit (ICU) nurse is most appropriate following the resolution of an active shooter emergency in the emergency department?

Which statement by a patient with mumps indicates an understanding of the diagnosis?

The nurse is teaching a student nurse about cancer screening guidelines. Which statement by the student nurse indicates the need for further teaching?

Which statement by a patient with type 1 diabetes mellitus indicates understanding of teaching about the recommended diet?

Which statement by a patient recently diagnosed with congestive heart failure indicates an understanding of the teaching provided by the nurse?

Which statement by the family member of a patient who has Guillain-Barré Syndrome indicates that they understand the nurse’s teaching on the disease process?

Which statement by the patient with placenta accreta indicates they understand the nurse’s teaching?

The patient tells the nurse “I drink three cups of black coffee a day. Is that okay?” Which response by the nurse is best?

Following a motor vehicle accident, the patient is unable to make his wishes known and is close to death without immediate and extensive treatment. The patient’s girlfriend, who he has been living with for the last five years, wants the medical team to do everything possible to save him. The patient’s wife, who he left when he moved in with his girlfriend, states she would not like any lifesaving measures and will sign the Do-Not-Resuscitate (DNR) paperwork. The medical team looks to which entity for decision-making?

The patient with acute psychosis tells the nurse he is going to leave this earth soon and go live in a house with the little green men on Mars. Which is the best response to this statement?

A patient who has severe depression asks if electroconvulsive therapy (ECT) could help his depression. Which response is most appropriate?

The patient states he wants to kill the psychiatrist who treated him the last time that he was hospitalized. Which is the best response by the nurse?

Which signs indicate that a patient with chronic depression may be planning to commit suicide? Select all that apply.

The patient with advanced dementia accuses the nurse of trying to poison him with his scheduled medications. Which nursing intervention is most appropriate?

Which question by the student nurse assessing a potentially suicidal patient requires prompt correction by the supervising nurse?

The patient with a history of psychiatric disorders tells the nurse that her neighbor is working with Mr. Dawsom at the World Financial Organization to bring the world under their control, and that she is the only one who knows about it. Which response by the nurse is best?

The patient tells the nurse, “I really didn’t expect acupuncture to decrease my pain, but it actually did! Why did it work?” The nurse bases the response on which theory of pain control?

The nurse is providing education to the parents of a child with nephrotic syndrome. Which statement indicates an understanding of the teaching?

The nurse receives report on a 76-year-old patient who is recovering from surgery for creation of an ileal pouch-anal anastomosis. The nurse plans care to prevent which complication that is most specific to this patient?

The nurse is assisting with the development of a tool in the electronic medical record to prompt providers to screen appropriate individuals for hypothyroidism. The nurse provides which characteristics to the informatics team to include in the tool? Select all that apply.

The patient receiving thyroid supplementation for hypothyroidism reports insomnia, fatigue, tachycardia, and headache. Which statement by the nurse is appropriate?

The patient receiving levothyroxine for hypothyroidism reports treatment failure after the third dose increase. The nurse anticipates the provider to order which test for this patient?

The nurse is planning care for a patient returning from surgery for a colon resection and ileal pouch-anal anastomosis. Which interventions does the nurse employ to prevent surgical site infection? Select all that apply.

The 6-month-old infant is admitted to the pediatric intensive care unit with a diffuse purpuric rash and prolonged bleeding. The nurse notes the fingers on the right hand are pale and cool to the touch. Which question asked of the parents will be the most helpful in diagnosing this patient’s condition?

The urine output of a 40-year-old male patient with a urethral catheter has decreased from 80 mL/h to 15 mL/h. Which action should the nurse take first?

The nurse in the neonatal intensive care unit receives report from the Labor and Delivery nurse about a full-term neonate and learns the patient’s Apgar scores were 0-0-1-5 at 1, 5, 10, and 15 minutes of life, respectively. How does the nurse interpret this information?

The 3-week-old neonate has failed to return to birth weight due to projectile vomiting partially-digested breast milk after most feedings. Upon assessment, an olive-shaped mass is palpated in the upper right abdominal quadrant. The nurse anticipates which diagnosis?

The neonate of 36 weeks estimated gestational age is born via emergency cesarean section, appears limp, blue, and apneic, and is brought to the warming table. He is warmed, dried, and stimulated, and a pulse oximeter is placed on his right wrist. At 30 seconds of life, his heart rate is 66 bpm and his oxygen saturation is 54%. Positive pressure ventilation is initiated via CPAP bag and mask. At one minute of life, the heart rate is 118 bpm, the extremities are still blue but the trunk is pink, and he begins to move and cry with stimulation. The nurse documents which number for the Apgar score? Enter your answer using a whole number.

The registered nurse asks the unlicensed assistive personnel to obtain the patient’s vital signs and to assist the patient to ambulate in the hallway. Which term is used to describe this nursing function?