Assessment

The patient states, “I’m trying to be healthy, so I’ve taken twice the daily recommended doses of all my vitamins for years to ensure I get even more effect from them.” The nurse assesses for signs of toxicity from overconsumption of which nutrients? Select all that apply.

The nurse is conducting a mental health assessment and plans to begin by taking the patient’s health history. Which behavioral clues does the nurse observe upon entering the room? Select all that apply.

The parent of the 5-year-old child reports that the child, who was potty trained at 3-years-old, has been stooling in places other than the toilet a couple times per month for 4 months. The nurse uses which term to document this symptom?

The nurse is collecting data from the parents of a seven-year-old boy who often has liquid stool in his underwear. The parents report he developed urinary and stool incontinence at four years of age and this problem started about six months ago. Their son excretes small pellets of stool every night before bed, and the parents wonder if he is soiling his clothing on purpose. Which additional testing does the nurse anticipate at this point?

A ten-year-old patient presents to the emergency department (ED) complaining of abdominal pain. He states, “I poop every day. It sometimes hurts to go and the poop is small, hard pieces. Which response does the nurse anticipate when the child is asked, “How much water do you drink in a day?”

The nurse is caring for a patient after the surgical amputation of the left leg below the knee. The nurse expects the patient to attain which level of mobility with rehabilitation and prosthesis training?

The patient with bilateral leg amputations is being fitted for a new wheelchair. The nurse knows that the patient’s center of gravity is offset in which direction?

The patient has been receiving sildenafil 5 mg by mouth, three times daily. Which assessment finding indicates the drug has had the intended effect?

The patient receiving bosentan therapy for pulmonary arterial hypertension presents to the emergency department (ED) complaining of dyspnea. Which nursing assessment is most important for this patient?

The patient presents to the emergency department (ED) and states, “I don’t know what happened! I was walking and ran into a door with my right shoulder. I closed my right eye and my vision was normal, but when I closed my left eye, I couldn’t see anything at all!” The patient’s assessment is otherwise normal. The nurse reports this to the provider immediately for assessment. Which question is most important for the nurse to ask the patient while waiting for the provider to write orders for treatment?

The patient with a history of hypertension and atherosclerosis presents to the emergency department (ED) complaining of severe lower back pain. Which question by the nurse is most important?

The patient with chronic obstructive pulmonary disorder has an oxygen saturation of 89% on room air. Which order does the nurse clarify with the provider?

The patient in heart failure exhibits the following respiratory pattern. The nurse uses which term to document the patient’s respiratory effort?

The patient with Raynaud’s phenomenon has received teaching on how to manage the disorder. Which statement by the patient indicates a need for further teaching?

Which term is used to describe normal dark red vaginal bleeding in the postpartum period?

Which pulse is assessed by palpating the lateral side of the wrist?

Which evening meal choice is appropriate for this patient? Look at the patient’s chart to make a selection.

Which food item, if selected by the patient, would prompt the nurse to provide additional education? Review the patient’s chart to make selection.

Which meal selection is appropriate for this patient? Review the patient’s chart to make a selection.

The nurse has received an order to initiate nasogastric tube feedings for the patient with long-standing anorexia. After the tube feeding is initiated, the nurse is vigilant for which electrocardiogram changes which may indicate the patient is experiencing life-threatening complications of tube feeding? Select all that apply.

The unit is experiencing increased patient census. Which patients, if suggested for pairing with the 28-year-old patient with epilepsy, does the bedside nurse question? Select all that apply.

Which patient in the emergency department (ED) must be treated first?

The nurse is a first responder after a gas explosion at an apartment complex. Which patient does the nurse mark to be treated first?

The nurse is assisting the provider in performing triage of 30 patients after a mass casualty incident. The nurse observes the resident changing the triage tag for the unresponsive patient with an open skull fracture who is not breathing spontaneously from black to red and calls the EMT over to transport the patient to the hospital. Which response by the nurse is most appropriate?

The nurse is first on the scene following a multivehicle accident. After activating emergency services and verifying the safety of the scene, the nurse begins the triage process. The first patient is unconscious and not breathing. Which action does the nurse take first?

The nurse receives report of four issues at 0800. Which situation is addressed first?

The nurse preceptor is supervising the graduate nurse during shift handoff. Which statements by the graduate nurse would prompt the veteran nurse to clarify for the oncoming nurse? Select all that apply.

The nurse is supervising the student nurse who is making a call to the provider about a patient who is decompensating. The student states, “Hello, Dr. Smith. This is Carly and I’m taking care of Alex Wright in room 433. He is in the hospital after surgery for a ruptured appendix. Over my shift his temperature has increased by 4 degrees and his heart rate is elevated. His blood pressure is decreased from the previous shift as well. Could you please come examine him?” Which additional comments are the priority for the nurse to add? Select all that apply.

The postpartum nurse is supervising new parents placing their newborn into the car seat to drive home during a snowstorm. Which observation is most concerning?

The patient in the intensive care unit who was intubated with a central venous catheter, peripheral arterial catheter, and chest tube has expired. Which question by the nurse who enters the room to assist the patient care nurse is most appropriate?

The nurse is creating a tool to screen for patients who are risk for vitamin A deficiency. The nurse includes which conditions in the screening tool? Select all that apply.

The nurse is performing an admission assessment and interview of the patient diagnosed with paranoid schizophrenia. Which therapeutic communication techniques are used by the nurse to conduct the interview? Select all that apply.

The patient is scheduled to undergo a Wood’s light examination. Which instruction does the nurse include in preprocedure teaching?

Which wound most likely requires healing by second intention?

The nurse receives report and learns the patient has a wound that is healing by third intention. Which intervention is most important to include in the patient’s care plan?

The 60-year-old patient who was recently laid off from his factory job of 38 years presents to the emergency department complaining of severe superficial pain over the flank. Which assessment will be most important for diagnosis?

The patient in Arizona calls the nurse line to report being stung by a scorpion. Which follow-up question by the nurse is most important?

The patient presents to the dermatology clinic for a skin cancer check and a small red papule is found on the right chest. It is noted to have a crater in the middle and have pearly borders. How does the nurse interpret this finding?

The nurse is planning care for a patient who sustained third degree burns over 42% of the body during an industrial accident the previous day. The patient is intubated, sedated, and chemically paralyzed. Which patient problem is most important for the nurse to address?

Several tenants from an apartment building are brought to the emergency department with concern for carbon monoxide poisoning. One patient presents with reddish-purple skin, a blood pressure of 94/48 mmHg, heart rate of 118 bpm, and altered consciousness (arouses when his name is shouted). The nurse anticipates testing will reveal which carbon monoxide level?

The nurse in the burn ICU is caring for a patient with third degree burns over 33% of the body. Which assessment best indicates that fluid resuscitation has been adequate?

The patient sustained third degree burns to the entirety of bilateral hands and forearms 96 hours ago. Which nursing intervention is most important to ensure the patient is able to keep the hands?

The nurse anticipates administering cobalamin and folic acid to the patient presenting with which symptoms? Select all that apply.

The patient with a history of colon cancer presents to the emergency department reporting significant abdominal pain, bloating, and vomiting. Which question to garner more information about the emesis is most important?  

Four hours after a rectal resection for treatment of rectal cancer, the patient is noted to be pale and diaphoretic. Which assessments are the priority? Select all that apply.  

At 48 hours after a bowel resection surgery for colon cancer, the colostomy is noted to be moist and purple. Which additional assessment is most important?  

The nurse is caring for a patient 6 hours after a transurethral resection of the prostate and notes decreased urine output. Which is the most likely cause of the decreased urine output? 

During postoperative day 1 after a suprapubic prostatectomy, which assessment is most important for the drainage from the surgical wound?  

The nurse most closely monitors the temperature for the patient who underwent which procedure?  

The patient undergoing continuous bladder irrigation (CBI) following a prostatectomy reports an extreme need to urinate. Which action by the nurse is most appropriate?