Communication & Documentation

Place the nursing interventions for a 16-year-old patient in the hospital for severe malnutrition and depression with a history of falls in order from highest priority to lowest priority.

The patient is brought to the emergency department following a serious motor vehicular accident (MVA). List the assessments the nurse performs in order from highest to lowest priority.

The emergency department nurse is assessing the unconscious patient following a fall from the ladder while he was doing home improvement work. Which assessment is performed first?

The nurse is involved in a motor vehicular accident in which a minor injury from the seatbelt was sustained. Which action does the nurse take first in helping the other victims?

A local celebrity is admitted to hospital following rupture of the appendix. The charge nurse submits an incident report if which individual accesses the patient’s chart?

The nurse learns that a fellow nurse is viewing the electronic chart of a patient with whom she went to high school. Which action does the nurse take first?

The grandparents of a baby in the newborn intensive care unit (NICU) ask the nurse about the age of another baby. Which response by the nurse is most appropriate?

The nurse delegates a pre-prandial blood sugar check to the unlicensed assistive personnel who fails to perform it before the patient’s food tray arrives and the patient eats breakfast. Who is most at fault?

As instructed by the registered nurse, the unlicensed assistive personnel (UAP) obtained vitals on a patient. The UAP obtained and charted the following vital signs monitoring results: blood pressure 90/42 mm Hg, pulse 128 bpm, oxygen saturation 86% on room air, and temperature 38.2°C. (100.8°F). The UAP left the floor for a break after charting the results, but did not tell the nurse. Thirty minutes later the patient is found unresponsive and a code blue is initiated. Who is responsible for this patient’s deterioration of condition?

Which task is most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?

The patient from India tells the nurse that, in addition to his conventional medical treatment, he would also like to be treated according to the principles of Ayurvedic medicine. The nurse plans care based on which understanding of the focus of Ayurvedic medicine?

The patient with malignant hypertension has suffered from a transient ischemic attack. He asks the nurse if he can continue taking his St. John’s wort for depression. Which answer by the nurse is most appropriate?

The nurse is assigned to care for a patient who speaks minimal English but is fluent in Farsi. Which is the best practice for the nurse to take when communicating with this patient?

The nurse is providing discharge instructions and education to a patient with stomach cancer who is interested in alternative/complementary medicine. Which low-risk therapies does the nurse include in the discussion? Select all that apply.

The patient reports an interest in using a herbal supplement to help with his depression. The nurse discusses herbal supplements with the patient based on which understanding of the nurse’s role in alternative and complementary medicine?

A medical-surgical floor nurse is asked to float to the intensive care unit (ICU) to alleviate understaffing. Which reason for refusing the assignment is legal?

The surgeon is attempting to obtain informed consent from a capable patient about to undergo a surgical procedure who says he is squeamish and doesn’t wish to know any details about the procedure. Which statement is correct regarding informed consent for this patient?

The patient with human immunodeficiency virus (HIV) wishes his diagnosis to remain confidential. The patient’s insurance company calls to ask questions about the diagnosis prior to releasing payment for his medical treatment. Which response by the nurse is appropriate?

A hospital administrator requests access to the medical record of a patient with a terminal illness for a quality review project. Which action does the nurse take?

The nurse mistakenly gives the patient with malignant hypertension the wrong dose of antihypertensive medication, and the patient complains of several hours of dizziness. Which action by the nurse is most appropriate?

The nurse receives a telephone order from the healthcare provider for intravenous pain medication to be administered to a patient with cancer pain. Which statement is correct regarding this medication order?

A nurse suspects that a co-worker is abusing drugs and is under the influence while at work. Which action does the nurse take?

The nurse hears the patient calling for help and enters the room to find the patient on the floor. One of the side rails is down on the bed. Which documentation is most appropriate?

The nurse has just assisted an elderly client safely back into bed after a fall, and it has been determined by the nurse and the provider that no injury is present. After submitting an incident report form, which nursing action is the priority?

The nurse makes an error while documenting a patient’s history. Which action does the nurse take to correct the error?

The patient who is admitted for surgery for resection of a malignant lung tumor has a living will. In addition to making sure a copy of the living will is included with the patient’s electronic medical record, which action does the nurse take?

The nurse attempts, but is unable, to contact the provider to clarify a prescription that is much higher than the normal dosage. Which action by the nurse is appropriate?

Which term is used to describe the delivery system of nursing in which the nurse is assigned to a set of tasks delegated by the charge nurse?

The nurse assumes responsibility for developing the patient’s plan of care and for delegating works assignments. Which term describes this system of nursing?

The nurse is assigned to care for a diabetic patient with a non-healing leg wound. Which task does the nurse delegate to an unlicensed assistive personnel?

The nurse is helping to ambulate a patient who is recovering from hip surgery and is a fall risk. An unlicensed assistive personnel (UAP) tells the nurse that another one of her assigned patients is in severe pain and requires pain medication. Which is the most appropriate action?

Which is the most appropriate patient assignment to assign to an unlicensed assistive personnel (UAP)?

The charge nurse is making patient assignments for an unlicensed assistive personnel, a registered nurse, and a licensed vocational/practical nurse. Which patient is the most appropriate assignment for the LVN/LPN?

The patient with cervical cancer has an implanted sealed internal radiation device. The nurse provides which instruction to the patient?

Which tool is most effective for promoting safety when ambulating an elderly patient who is a fall risk?

The provider orders physical restraints for a patient in alcohol withdrawal who is delirious, combative, and a fall risk. Which statement is true regarding use of physical restraints for this patient?

The nurse is the first responder to a 3-year-old male who is with his mother, having recently ingested a large quantity of household cleaner. The patient is unconscious but is hemodynamically stable and breathing. An ambulance has already been called. Which action by the nurse is appropriate?

The patient with neurosyphilis who has attempted to stab the nurse with scissors, pulled out several IVs, and is a fall risk is placed in wrist restraints per physician order. How frequently does the nurse assess the patient’s skin integrity?

The nurse is called to the hospital to assist in caring for patients brought to the hospital following a massive gas explosion in the community. Which statement is true regarding the nurse’s involvement with this incident?

The nurse is supervising the care of a patient with a wound infected with methicillin-resistant staphylococcus aureus (MRSA). Which action by the student nurse would prompt the nurse to intervene?

The nurse is supervising the care of a diabetic patient with stomach cancer. After surgery, the patient is placed on total parenteral nutrition (TPN). Which information does the nurse provide the nursing student about the TPN?

The nurse is teaching a nursing student about hand washing. Which statement by the nursing student indicates understanding of the teaching?

Which statement by the patient indicates an understanding of the nurse’s teaching about Buck’s traction?

During a lumbar puncture, which event warrants immediate intervention by the nurse?

Which statement by the patient who has recently undergone a radical mastectomy indicates they understand teaching by the nurse?

A patient comes into the ER with HR 122 bpm, BP 110/72 mm Hg, Temp 99.4 F, and RR 22. They report a racing feeling in their heart and have also been experiencing diarrhea for the last several months. Which lab result does the nurse anticipate?

Which task is most appropriate for the registered nurse to delegate to an unlicensed assistive personnel?

Which statement by a patient newly diagnosed with type 1 diabetes mellitus indicates understanding of the nurse’s discharge teaching?

Which patient must be triaged for emergency department care first?

The patient requiring mechanical ventilation is dying of tuberculosis and is responsive only to tactile and painful stimulation. The family would like to give him holy water to drink in order to have peace in the afterlife. Which response by the nurse is most appropriate?