Communication & Documentation

A new mother is discussing alcohol consumption while breastfeeding her baby. Which statement indicates a need for further teaching? 

The nurse is caring for a patient receiving total parenteral nutrition (TPN). After morning rounds, the nurse notices the rate of TPN infusion is slower than what is ordered for the patient and is three hours behind schedule. There are no nursing notes, and the rate was not mentioned on sign-out. Which initial action is most appropriate?

The nurse is assigned to a 4-year-old patient admitted with a vaso-occlusive crisis secondary to sickle cell anemia. The boy is in agonizing pain. He has apparently taken off his hospital wristband. Before administering the pain medication, the nurse should perform which of the following actions?

The nurse is caring for a patient admitted for nephrolithiasis. The patient is experiencing severe pain and the provider writes the following order: “5 mg MSO4.” Which action by the nurse is most appropriate?

The nurse is assigned to a 55-year-old patient admitted for diabetic ketoacidosis. The provider writes the patient’s insulin regimen on the admission orders as follows, - “insulin NPH 25 IU.” Which action by the nurse is most appropriate? 

The nurse is providing discharge planning and education for a 72-year-old patient who is being discharged home after a diagnosis of atrial fibrillation. The nurse focuses education on which adverse event? 

The nurse is assigned to a 52-year-old patient who is admitted for elective cholecystectomy. While undergoing preoperative evaluation, the patient mentions to the nurse an allergy that is not documented in the health record. Which action by the nurse is most appropriate?

The nurse learns the patient uses nasal irrigation to help prevent sickness during flu season. Which statement by the nurse is the most important?

The 28-year-old female patient presents to the clinic after missing her usual monthly menstrual cycle. A urine hCG level confirms that she is pregnant; further questioning estimates a gestational age of 11 weeks. The patient asks about the possibility of getting an abortion in the next few weeks. Which response by the nurse is appropriate? 

At a well-child visit, the mother of a 2-year-old child states, "My child is not keeping up with the other kids." Further evaluation reveals the patient can stack 6 cubes, walk backwards, and copy a line. The child exhibits separation anxiety and has a vocabulary of 10 words but cannot use symbols or use pronouns. Which assessment does the nurse make about the child's development?

The nurse informs the parent of an 18-month-old patient at the well-child visit that screening for an autism spectrum disorder at which time(s)?

Which statement by the patient with type 2 diabetes mellitus who has received education about foot care indicates a need for further teaching?

Following a surgical procedure the patient experiences post-operative pain that is refractory to opioid medication. The patient requests acupuncture as a mode of pain relief in addition to the medications. The nurse advocates for this treatment modality based on which understanding of its action?

The older adult patient is brought to the emergency department with sudden onset confusion, agitation, and hallucinations. The patient's past medical history is significant for type 2 diabetes managed with glyburide, anxiety managed with lorazepam, and insomnia managed with zolpidem. Upon assessment, the patient's heart rate and rhythm are regular, lungs are clear to auscultation, and bowel sounds are present. Vital signs are normal, with exception of a slightly elevated heart rate. Which is the most likely cause of the patient's symptoms?

The patient who recently lost her young child to acute lymphoblastic leukemia (ALL) tells the nurse that she is having trouble handling the grief and feels like she is to blame for her child’s death. Which response by the nurse is most appropriate? 

The patient brought to the emergency department following a motor vehicle accident is found to be brain dead. An organ donor card is found on this person and the organ procurement team is contacted. Which medical history, if found in the patient’s chart, would prompt the nurse to stop the line in the organ procurement process?

The patient with schizophrenia tells the nurse of his plans to initiate a fire in the kitchen of the psychiatric department. Which action does the nurse take first?

The surgeon is obtaining informed consent from the parents of a child in preparation for a bone biopsy. The nurse anticipates the surgeon to include which information in the discussion? Select all that apply.

Which patient characteristic renders the patient permanently incompetent to give consent for an invasive procedure?

Which condition qualifies the patient to be an emancipated minor?

Which punishment does the nurse report as child abuse?

The student nurse accidentally administered morphine sulfate (Avinza) to the wrong patient. Who is directly accountable for the student nurse's medication error?

The provider is obtaining consent from the patient in preparation for a laparoscopic ureterolithotomy. The nurse witnesses the provider dismissing the patient’s questions and repeatedly asking the patient to sign the consent form. The nurse reports which violation to the charge nurse for further management?

Which element of informed consent refers to the patient's appreciation of the relevance of surgery to the present and future conditions?

The 15-year-old patient with anorexia nervosa has been prescribed nasogastric tube feeding for malnutrition. Which intervention is helpful in promoting the patient’s autonomy?

The nurse has received a letter from the Board of Nursing citing malpractice with regards to an incident that supposedly happened twelve years ago. How does the nurse respond?

The nurse is documenting assessment findings of a 37-year-old male with abdominal pain. Which is the most appropriate manner of documenting patient’s symptoms?

The student nurse prepares to document in the nursing note, “Patient is in bad mood today.” The preceptor corrects the student nurse to document which statement instead?

The nurse mistakenly administered the antihypertensive pill to the patient twice within an hour. Which is the best time for the nurse to write an incident report?

In response to a possible mass admission of injured individuals who were involved in a bombing incident nearby, the nurse supervisor is arranging the discharge of several patients who have recuperated already. Which is the operating principle of this situation?

The patient speaks Chinese and very little English. Which action by the nurse is appropriate?

Which term refers to a feeling of indifference towards the patient for whom the nurse is providing care?

Following a motor vehicle accident, the patient is noted to have an estimated blood loss of 500 mL and the blood pressure is normal. The nurse anticipates the provider to diagnose the patient with which class of shock?

Which is considered the fifth phase of the disaster cycle?

The nurse notes a colleague consistently triages patients as more acutely ill than necessary. The nurse educates the colleague to triage appropriately in order to prevent which complication?

Which statement is most important for the nurse to include in the teaching of a male patient undergoing treatment for invasive amebiasis?

The nurse is preparing to start an intravenous catheter on an adult patient at risk for severe dehydration. The patient adamantly refuses the procedure despite thorough explanation. Which action by the nurse is appropriate?

The recently-discharged patient sends a social media message to the nurse asking for her full diagnosis. Which response by the nurse is appropriate?

The 85-year-old patient fell in the bathroom. Which score will most accurately predict the adverse effects the patient will experience from the fall?

The nurse is participating in a project to reduce infection of multidrug resistant organisms (MDRO). Which type of surveillance will assist in this endeavor?

Which error in the use of a child's car seat occurs most frequently?

A 23-year-old pregnant woman presents to the clinic stating, “I am a teacher and have heard there is a measles outbreak in my community. I want to get the measles vaccine to protect my baby and myself. Which response by the nurse is most appropriate?

The patient has a peripherally inserted central catheter (PICC) for the long-term administration of parenteral nutrition, oxacillin, and gentamicin. Which assessment findings, if present in the patient, indicate the patient is experiencing a complication of the PICC line? Select all that apply.

The patient presents to the emergency room complaining that his heart is racing and he feels dizzy. His heart rate is 220 bpm, his blood pressure is 80/40 mmHg, and his capillary refill is 5 seconds. He is diaphoretic and is becoming increasingly lethargic. The nurse anticipates which order first?

The nurse is providing discharge teaching to the patient who has experienced episodes of atrioventricular nodal reentry tachycardia (AVNRT). Which patient drink selection(s), if chosen by the patient, indicate a need for further teaching? Select all that apply.

The patient who experiences frequent episodes of atrioventricular nodal reentry tachycardia (AVNRT) that do not cause hemodynamic compromise is being discharged. The nurse is supervising the student nurse providing discharge teaching to the patient. Which method for self-treatment of AVNRT, if taught by the student nurse, would prompt the nurse to intervene immediately?

The patient with severe abdominal pain and distention, elevated white blood cell count, fever, and disorientation is diagnosed with toxic megacolon due to Clostridium difficile infection. Which order for this patient does the nurse question?

The 10-year-old patient presents to the emergency room following a fever as high as 105°F for 5 days. The patient’s mother reports the child has had red, watery eyes, poor appetite, and has felt ill during this time. The child was brought to the emergency room upon the appearance of a red rash that started on the child’s face and spread to the neck and chest. Which question will be most helpful in order to determine the cause of this patient’s symptoms?

The school nurse who works in an area with poor vaccination compliance learns a child has developed measles after being in class for the past week. Twenty other children in the class have not received the measles vaccine. The nurse anticipates how many of these children will contract measles?

The neonate with suspected Hirschsprung disease is scheduled to undergo testing to definitively diagnose the disorder. Which assessment finding prompts the nurse to request the procedure be postponed?