Assessment

The nurse assesses the patient’s capillary refill time to be 5 seconds. Which inference from this assessment is most appropriate?

The patient with type I diabetes mellitus has contracted influenza A. Which lab must be most closely monitored in this patient to prevent a life-threatening complication?

The patient with increased intracranial pressure has been administered mannitol. Which patient symptom indicates the drug is having its intended effect?

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 full-term neonate is born via normal spontaneous vaginal delivery (NSVD). The neonate cries at the perineum and maintained flexion against gravity but is noted to be bluish gray. Which intervention is appropriate?

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 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 the first responder to a motor vehicular accident involving the injury of a 40-year-old male. Which action is the highest priority?

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?

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 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 patient is brought to the emergency department following an accident with significant burns. The patient is conscious and alert with 3rd-degree burns over 50% of his body. The nurse helps to get a history and perform a thorough physical examination of this patient. Which type of assessment is the nurse performing?

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?

To which patient does the nurse most likely anticipate administering total parenteral nutrition (TPN)?

The nurse is caring for a patient receiving total parenteral nutrition (TPN). The nurse most closely assesses for which complication in this patient? 

The patient with chronic malnourishment is started on total parenteral nutrition (TPN). The nurse is vigilant for signs of which complication?

Which patient is most at risk for developing a decubitus ulcer?

Which events may lead to acute kidney injury (AKI)? Select all that apply.

Which lab value is most concerning for a patient who is being treated for hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?

A 41-year-old male complains of sudden onset of severe chest pain and describes it as a constant tearing sensation that radiates to his lower back. The nurse is most suspicious of which condition?

The nurse suspects that a patient has Ludwig’s angina. Which action does the nurse take first?

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? 

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 patient with severe chronic obstructive pulmonary disorder (COPD) is receiving 3 liters per minute of oxygen via nasal canal. Which oxygen saturation indicates respiratory support is adequate?

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 has a mechanical mitral valve. Where does the nurse place the stethoscope bell to auscultate for valve function?

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?

Which patient does the nurse assess first following shift change report?

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

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? 

Which assessment is most indicative of a pleural effusion?

Which diagnosis explains the patient's chronic pain in the shoulder and inability to perform passive range of motion (ROM) exercises? 

The G2P1 patient who is 33 weeks pregnant is brought via ambulance to the emergency department due to significant vaginal bleeding and abdominal pain. Which action does the nurse take first?

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 is caring for a 21-year-old diagnosed with Lyme disease. Which feature suggests this is early localized disease?

The 5-day-old infant presents to the pediatrician's office for a well-baby visit. The parents report being happy that their child is a "good baby" who sleeps a lot and rarely cries. They also report the baby eats 4 times per day, sleeping for 8 hours at night. The nurse notes the baby is at the 70th percentile for weight. Upon assessment, the baby is minimally responsive. The nurse is most concerned about which condition? 

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