Communication & Documentation

The family of a patient who is dying expresses a desire to feed him a traditional fruit and herb paste to ensure that his soul can have peace in the afterlife in accordance with their religious beliefs. The patient is NPO due to the risk of aspiration and is unable to make his wishes known due to decreased cognition. Which action by the nurse is most appropriate?

Which nursing intervention will be most effective in preventing the spread of Clostridium difficile between patients?

The patient has a 20 gauge IV in the left antecubital fossa and is receiving D5W at 150 mL/h. Upon assessment, the nurse notes the site is swollen and cool to the touch; there is no erythema. Which term does the nurse use to document this finding? 

Which statement by the patient with systolic heart failure indicates an understanding of discharge teaching?

An 84-year-old patient being treated for a chronic obstructive pulmonary disorder (COPD) exacerbation starts to become disoriented after the evening meal and will not stay in bed. Which intervention does the nurse take first?

The nursing student is reviewing the pregnant patient’s chart and notes the patient is gravida 4 para 2. Which interpretation of the patient’s obstetric history by the nursing student most likely requires correction by the nurse?

A newborn was delivered one minute ago. He is not breathing, has a heart rate of 128 bpm, has a moderate amount of lanugo, has some muscle tone without active movement, does not grimace with stimuli, and has a pink body with blue extremities. Which APGAR score is correct?

A patient with a documented Do Not Resuscitate (DNR) order suddenly develops pulseless ventricular tachycardia. Which intervention by the nurse is most appropriate?

Which statement by the patient being prepared for a coronary angiogram indicates an understanding of the nurse’s teaching on the procedure?

The patient is brought to the emergency room by her husband with slurred speech and facial drooping. Which question does the nurse ask first?

The patient is diagnosed with new, rapid atrial fibrillation and thinks the problem has been going on for two weeks. Which statement by the patient indicates an understanding of teaching about the diagnosis?

The patient is undergoing cardioversion for symptomatic atrial flutter. Which event requires immediate intervention by the nurse?

A 21-year-old male presents with sudden onset shortness of breath. He has no history of smoking, alcohol use, recent injuries or trauma. He is 5’11” tall, weighs 130 pounds, and works as a forklift driver. His vital signs are: BP 115/64 mm Hg, HR 104 bpm, RR 26, Temp 99.0 F, and O2 Sat 91%. The nurse suspects which condition?

A patient presents to the ER after having impaled his hand with a nail from a pneumatic nail gun at work. His friend removed the nail at the scene. Which statement indicates the patient understands the teaching provided by the nurse?

A patient with a signed Do Not Resuscitate (DNR) order suddenly becomes unresponsive and goes into cardiac arrest. His wife, who is his healthcare power of attorney, starts yelling hysterically, “Do everything you can! Save him! I don’t care that he didn’t want to be resuscitated, he would want to live for me!” Which action by the nurse is best?

The patient’s family requests a second opinion after being told the patient will never regain consciousness following a motor vehicle accident. The family is exhibiting which of the Kubler-Ross stages of grief?

Which statement by the patient indicates a need for further teaching regarding postoperative care for a total hip arthroplasty?

Which statement by the patient’s spouse indicates an understanding of the teaching about bipolar disorder?

The nurse is caring for a 62-year-old female who was recently diagnosed with glaucoma. The patient is given docusate. Which of the following is the primary reason for giving the patient a stool softener?

Which characteristic is considered to be a positive symptom of schizophrenia?

The 51-year-old male with major depressive disorder is ordered to receive trazodone 25 mg PO at bedtime. The nurse instructs the patient about which primary indication of trazodone for this patient? 

The 33-year-old patient presents to the clinic with signs and symptoms of gastroesophageal reflux disease. The nurse prepares the patient for which test? 

The 50-year-old patient receiving chemotherapy for breast cancer has developed a fungal bloodstream infection. Which intervention is the nurse’s first consideration?

The nurse is counseling the parents of a 7-year-old child who are concerned because of a strong family history of type 2 diabetes mellitus. The nurse instructs the parents that the initial screening for type 2 diabetes mellitus will occur at which time? 

The patient is being treated for obsessive-compulsive disorder with medication and behavioral therapy. At a follow-up visit, the patient reports near complete resolution of symptoms. The nurse anticipates discussing which treatment plan?  

The nurse instructs parents on which type of diet to decrease the risk for lead poisoning in their children? 

The nurse is assessing the patient in the emergency room who is complaining of severe joint pain. Which term does the nurse use to document this complaint?

The nurse uses which technique to counsel a patient with chronic obstructive pulmonary disorder (COPD) about quitting smoking? 

The nurse is caring for a 71-year-old who was recently diagnosed with age-related macular degeneration (AMD) in the left eye. The nurse encourages the patient to increase dietary intake of which substances? 

The 62-year-old patient presents to the emergency department complaining of chest pain. After a battery of tests and exams, the physician tells the nurse the patient's chest pain was likely due to coronary artery spasm. The nurse prepares education for the patient about which condition? 

The patient with persistent shoulder pain with associated numbness of the hand is scheduled for a magnetic resonance imaging (MRI) scan. The patient tells the nurse, "I'm terrified of enclosed spaces. I just don't know if I'll survive this test." After relaying the patient's concerns to the provider, which response does the nurse expect from the provider? 

Following a motor vehicle accident, the patient is brought to the emergency department with a head injury. Upon assessment, the nurse notes otorrhea and mastoid bruising. The nurse reports the findings to the provider and suspects further testing will reveal which injury? 

The patient with acquired immunodeficiency syndrome (AIDS) is receiving zidovudine (AZT). The nurse requests an order for which lab test to monitor adverse effects of the drug?

The nurse notes the patient being treated for chemical burns is hyperventilating. The nurse suspects which medication is the culprit of the patient's symptoms?

The nurse is supervising the student nurse passing medications on the medical surgical floor. The nurse allows the patient to continue after which verbalization to the patient? 

The nurse is collecting a urine specimen from a 44-year-old woman with dysuria. Which instructions does the nurse provide to the patient? Select all that apply.

The nurse observes the affected eye of the patient with newly diagnosed Bell's palsy is not closing fully and performs which interventions? Select all that apply.

The parents of a 12-year-old girl with severe anemia decline a blood transfusion because it is against their religion. When responding to the parent's decision, the nurse utilizes which ethical principle?

The 5-year-old boy with measles cries when the nurse enters the room and turns on the lights. The nurse is most concerned about which reason behind the patient's behavior?

The patient with bipolar disorder is verbally threatening the staff and other patients in the medical surgical unit. Which initial action is most appropriate? 

The nurse learns in report the patient with schizophrenia has mainly exhibited negative symptoms. The nurse most expects to make which observation? 

The patient with chronic pain and generalized anxiety disorder has been prescribed alprazolam. Which medication, if also prescribed to the patient, prompts the nurse to clarify the order with the provider?

Which question does the nurse ask to determine the patient's risk for suicide in the patient with major depressive disorder? 

The nurse is asking a 36-year-old man with schizophrenia to interpret the proverb, “Seize the day”. Which clinical symptom is assessed by the nurse?

Following electroconvulsive therapy, the patient with bipolar disorder tells the nurse he does not remember whether he arrived by bus or car. Which response by the nurse is appropriate? 

The nurse is assessing the patient with major depressive disorder. Which characteristic alerts the nurse that the patient may be planning to commit suicide? 

The 34-year-old G1P1 patient who just delivered a healthy baby via cesarean section four hours ago. The patient sits on the bed watching her newborn lying in the bed but does not touch or hold the baby. Which response by the nurse is most appropriate? 

The patient with delusional disorder tells the nurse that he needs to see the Pope in Rome because he is a messenger of God. Which response by the nurse is most therapeutic?

The nurse prioritizes which intervention in caring for the patient with borderline personality disorder? 

The nurse is caring for a 22-year-old patient who is experiencing sickle-cell crisis. Which is the priority nursing consideration?