Assessment

The patient in the intensive care unit is being weaned off of a continuous morphine infusion after being extubated 6 hours ago. Which assessments indicate the patient is failing to tolerate the treatment plan? Select all that apply.

The patient receiving patient-controlled analgesia (PCA) with morphine is found to be sleeping deeply and minimally responsive. Which action does the nurse take first?

The patient intubated in the intensive care unit has the following arterial blood gas results: pH 7.21 PCO2 51 PaO2 38 HCO3 16 Base Excess -7 Which action does the nurse take first?

Which arterial blood gas result is most indicative that the intubated and mechanically ventilated patient is ready to have the ventilator rate weaned?

The 56-year-old intubated and sedated patient’s arterial blood gas results are as follows: pH = 7.25, PCO2 = 36, PaO2 = 50, HCO3- = 15, SaO2 = 86%. Other lab values are notable for a hemoglobin of 7.9 mg/dL, albumin of 2.5 g/dL, sodium of 152 mEq/L, potassium of 2.1 mEq/L, chloride of 118 mEq/L. Vital signs are notable for a heart rate of 118 bpm, blood pressure of 86/38 mmHg, temperature of 102°F, and pulse oximetry of 85% on room air. The nurse advocates for which order?

The patient presents to the clinic complaining of a painful sore on his penis. Upon assessment, the nurse notes an ulceration with a yellow slough wound base that is soft with an irregular border. The inguinal lymph node on the ipsilateral side of the wound is enlarged and firm. The nurse suspects which organism is the cause of the wound?

Which patient is at highest risk for skin breakdown?

During routine tracheostomy care, the nurse notes increased drainage from the stoma and a fruity, grape juice odor. The nurse obtains a culture of the secretions and anticipates the results will reveal which organism?

The nurse identifies which patient at highest risk for delayed wound healing?

The nurse advocates for a guaiac test to be performed on the patient with which stool?

During routine tracheostomy cleaning and care, the nurse notes a strong smell of dirty gym socks coming from the dressing around the stoma. Which action by the nurse is most appropriate?

A nurse is caring for a patient who is recovering from total hip replacement surgery. The patient has required increasing doses of IV morphine for pain control. The patient is again reporting 10/10 pain despite receiving 10 mg of morphine from the nurse, which is the top of the range ordered by the physician. The nurse monitors which of the following most closely?

The nurse reviews which components of total parenteral nutrition (TPN) prior to administering them? Select all that apply.

Which statement is true regarding the nonstress test (NST)?

The patient with chronic obstructive pulmonary disease (COPD) is brought to the post-anesthesia care unit (PACU) after abdominal surgery. Which symptom alerts the nurse to an impending complication?

Which patients are at risk for restrictive pulmonary disease? Select all that apply.

The patient returns from Mexico with severe diarrhea lasting 4 days. The nurse anticipates the serum electrolyte levels to reflect which imbalances? Select all that apply.

The nurse is concerned the patient is experiencing hypocalcemia following the removal of the thyroid. In which location does the nurse assess for the Chvostek’s sign?

The patient presents with a blood pressure of 135/95 mm Hg and appears jaundiced. She has a history of alcoholism, cirrhosis, and untreated hepatitis C. While the oncoming nurse is receiving report, the patient begins vomiting a large amount of blood. The nurse knows which to be the most likely cause of the patient’s hematemesis?

The 40-week-gestation patient is brought to the emergency department in active labor. Which assessment alerts the nurse to an impending emergency?

Which patient characteristic prompts the nurse to hold the infusion of Lactated Ringer’s and contact the provider?

The patient has not yet voided in the 3 hours following a total knee replacement surgery. Which action by the nurse is appropriate?

Following colon resection, the nurse is vigilant for which early symptoms of septic shock? Select all that apply.

The nurse anticipates which symptom in the patient newly diagnosed with Graves' disease?

The patient underwent surgery for creation of a colostomy 2 days ago. Upon assessment, which stoma color prompts the nurse to document the finding and continue with the assessment?

The nurse ensures which laboratory study is collected regularly to monitor the effectiveness and safety of the patient's continuous unfractionated heparin infusion?

Which is a late sign of hypoxemia?

The American Cancer Society recommends the patient's initial cervical cancer screening occurs at which time?

The patient with chest pain is undergoing an electrocardiogram (ECG). Which ECG finding prompts the activation of the cardiac catheterization lab?

The patient with a heart rate of 50 bpm is found to have strong pulses and no other symptoms. Which action is most appropriate?

The nurse is notified the patient's heart monitor shows ventricular fibrillation. Initial assessment reveals strong peripheral pulses and even, unlabored respirations with an oxygen saturation of 98%. Which action does the nurse take first?

The unresponsive patient was pulled from a frozen lake. A regular heart rhythm is noted on the monitor with a rate of 28 bpm. Upon assessment, there is no palpable pulse. The first responders report which rhythm to the receiving hospital?

The patient is found to have the following rhythm on electrocardiogram (ECG): Pulses are noted on assessment. The nurse documents which rhythm in the patient's chart?

The patient is found to have the following rhythm on electrocardiogram (ECG): The nurse documents which rhythm in the patient's chart?

The 7-year-old child who has been diagnosed with which respiratory condition will have normal breath sounds?

Which respiratory assessment in the infant prompts the nurse to alert the provider immediately?

The nine-month-old infant appears to be in distress. For rapid assessment, which pulse does the nurse palpate?

The anxious 5-year-old child is found to have tachypnea, stridor on inspiration, and a “barking” cough. The nurse suspects which condition?

A school nurse is caring for an elementary school student who is gasping for breath after being stung by a bee. The child's airway is currently patent and heart rate is 100 bpm. No epinephrine or advanced airway is available. Which intervention is appropriate?

The nurse is examining the waveform produced by the patient's central venous pressure (CVP) catheter. Atrial contraction occurs at which point on the waveform?

The nurse is examining the waveform produced by central venous pressure (CVP) catheter. At which point on the waveform does atrial relaxation occur?

The nurse is examining the waveform produced by central venous pressure (CVP) catheter. Ventricular contraction occurs at which point of the waveform?

The nurse is examining the waveform produced by central venous pressure (CVP) catheter. Tricuspid valve opening is reflected at which point on the waveform?

The nurse is examining the waveform produced by central venous pressure (CVP) catheter. Passive filling of the atria occurs at which point on the waveform?

The nurse is reviewing the medication list of the patient who wishes to become pregnant. One of the medications is listed as Category X. The nurse knows this medication poses which level of risk to the fetus?

The patient is being evaluated for obstructive sleep apnea. For which test does the nurse prepare the patient?

The child had a cast applied the previous day for a broken tibia. The mother returns the child to the provider to report swelling and significant pain. Upon assessment, the nurse notes pale, cool toes with a capillary refill time of 6 seconds. The child denies feeling the nurse's assessment but screams in pain when the leg is moved. The nurse anticipates which treatment for this patient? 

Which patient is seen first in the emergency department?

The patient with schizophrenia has refused medication for several days. When the nurse attempts to administer the medication he responds, "I don’t need this. Give it to somebody who has a mental disorder." The nurse suspects which condition?

Which is a symptom of schizophrenia?