Communication & Documentation

The nurse is providing preoperative teaching to the parents of a neonate diagnosed with short-segment Hirschsprung disease. Which statement by the patient’s mother indicates an understanding of the education?

The patient in the intensive care unit who is intubated and mechanically ventilated abruptly requires a drastically increased fraction of inspired oxygen (FiO2) and is hypoxic, hypotensive, and tachycardic. Which intervention does the nurse perform first?

The nurse is teaching the nursing student the care of a patient with a tracheostomy. Which action by the nursing student when preparing to change the tracheostomy tube would prompt the nurse to intervene immediately?

Upon assessment of the patient with a chest tube, the nurse notes intermittent bubbling in the water-seal chamber that follow the patient’s respirations. During rounds the provider instructs the nurse to clamp the chest tube in preparation for removal later in the day. Which response by the nurse is appropriate?

The nurse assesses the patient with a chest tube and notes continuous bubbling in the water seal of the chest tube drainage system. Which action does the nurse take first?

A famous football player is brought to a local hospital following a severe, on-field injury. A nurse and avid sports fan comes to the hospital on his day off to find out the status of the injury. The nurse caring for the player is asked to provide him with an update on the player’s health. What is the appropriate response?

In the weeks after a stroke, which patient problem is of the highest priority?

A nurse is discussing abortion with a distraught pregnant woman. The nurse understands that the patient is most likely struggling with which pair of ethical principles?

An infant has been admitted to the hospital for gastroenteritis. Friends of the family stayed in the room while the patient’s father talks to other family members in the lobby. The nurse prepares to remove an infiltrated IV line and place a new one. The visitor stops the nurse and insists that the nurse obtains consent from the parents. Which is the most appropriate response?

An unlicensed assistive personnel (UAP) reports that a patient has greenish discharge around the tracheostomy. Which response by the nurse is most appropriate?

Which tasks can be delegated to an unlicensed assistive personnel (UAP)? Select all that apply.

The nurse provides care for the client diagnosed with Barrett's esophagus. Which goals does the nurse establish in the plan of care? Select all that apply.

Which event does the nursing manager address because it violates the Health Insurance Portability and Accountability Act (HIPAA)? Select all that apply.

Which actions are violations of the Emergency Medical Treatment and Active Labor Act (EMTALA)? Select all that apply.

The family practice nurse is reviewing telephone messages from patients. Which call is to be returned first?

The nursing supervisor overhears a nurse discussing the Health Insurance Portability and Accountability Act (HIPAA) guidelines with a group of nursing students. Which statement by the nurse prompts the nursing supervisor to intervene immediately?

Which actions can the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

The nurse receives shift report on four patients. In which order does the nurse see the patients? Place the answer options in the correct order.

Which statement by a patient in the obstetrician's clinic is most concerning?

The nurse is creating a tool to screen patients for depression and includes questions about which symptoms in the tool? Select all that apply.

The nurse is planning care for the patient with severe liver disease who has substantial ascites and peripheral edema. Which interventions are included in the care plan? 

The nurse is instructing the student nurse on proper sterile technique. Which statements are included in the teaching? Select all that apply.

The patient has undergone cataract surgery and is preparing for discharge. Which statement by the patient indicates an understanding of discharge teaching?

The nurse is reviewing the chart of the patient scheduled for a cardiac catheterization. Which characteristics, if present in the patient's chart, alert the nurse to an increased risk for cerebrovascular complications due to the procedure? Select all that apply. 

The patient with a hearing deficit has been stabilized in the emergency department following a spontaneous pneumothorax. Which action does the nurse take first?

The nurse is caring for the patient with a nursing diagnosis of sleep pattern disturbance. Which are appropriate outcomes for this diagnosis? Select all that apply.

The 61-year-old patient with liver cirrhosis reports extreme fatigue on a daily basis. The nurse pursues which intervention?

The nurse instructs the patient with diabetes mellitus to store prefilled insulin syringes in which location?

The patient is brought to the emergency department after a motorcycle accident which resulted in head trauma. The nurse observes a hematoma and bruising around the mastoid bone. Which term does the nurse use to document the finding?

The nurse is instructing the unlicensed assistive personnel (UAP) on the proper care of dentures. Which actions by the UAP indicate an understanding of the teaching? Select all that apply.

A child with “staring fits” is diagnosed with absence seizures. The nurse prepares patient education materials on which medication?

The home health nurse is working with a patient who is a fall risk. During a home visit, the nurse sees the patient repeatedly using a step stool. Which intervention is the most appropriate?

The nurse receives a call from the patient with type 2 diabetes who has nausea, vomiting, and is eating less. Which statement by the patient indicates that further education is needed?

Which statement does the nurse include in preprocedure teaching for the patient who will undergo abdominal paracentesis?

The nurse is helping a woman who is 12 weeks pregnant develop a diet plan. Which initial action by the nurse is appropriate?

The 58-year-old patient asks the nurse if he is at risk of heart disease. Which response by the nurse is appropriate?

During an assessment of the patient who just completed a cross-country flight, the nurse elicits a positive Homan's sign. Based on this finding, the nurse suspects which condition?

The patient is in the post-anesthesia care unit (PACU) following abdominal surgery. Which finding would prompt the nurse to delay discharge from the PACU to a hospital bed?

A missed menstrual period is which type of sign of pregnancy?

The patient is brought to the emergency department after being pulled from a structure fire by rescue personnel. A stat bronchoscopy is ordered. The nurse informs the patient's spouse of which rationale for this order?

The 31-week-gestation woman is brought to the emergency department after being struck in the abdomen when the airbags deployed during a motor vehicle accident. Initial screening labs reveal the mother is blood type A-. The nurse advocates for which additional lab to assess the status of the pregnancy?

The nurse is performing an assessment of an infant born 8 hours ago. The infant’s POC blood glucose level is 25 mg/dL. Which action does the nurse take first?

The patient presents to the ED with acute left lower quadrant abdominal pain and vaginal bleeding. Transvaginal ultrasound shows ectopic pregnancy in the left oviduct. The patient begins to cry and states, "We have tried for so long to get pregnant. Is there anyway I can keep the baby?" Which response by the nurse is most appropriate?

The lab calls the nurse and reports an adult patient’s serum calcium of 5.9 mg/dL and serum potassium of 6.2 mEq/dL. Which action by the nurse is appropriate?

Which are components of informed consent? Select all that apply.

The woman who delivered her first baby will be discharged tomorrow. After a bedside education program in the hospital, the patient tells the nurse that she does not have a crib, bottles, or diapers to care for her new baby. Which action is most appropriate?

The nurse is providing medication teaching to the patient who was just prescribed warfarin. Which statements does the nurse include in teaching? Select all that apply. 

The patient who has recurrent seizures and is no longer legally able to drive has developed a depressed mood and stays home almost all of the time. Which action by the nurse is most appropriate?

The nurse provides education to the pregnant woman about the signs of blood clots due to which cause of increased blood clotting risk during pregnancy?

The patient with human immunodeficiency virus (HIV) presents to the clinic for a follow-up visit. The nurse provides education to the patient about which cardiovascular complication the patient is most likely to experience related to the disease process?