Inflammation

Which symptom can occur following vertical transmission of Neisseria gonorrhoeae?

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?

The patient is admitted to the hospital with systemic syphilis infection. The patient is ordered to receive a 14-day course of penicillin G 20 million units/day intravenously. Prior to administering the medication, the nurse checks the patient’s allergies and learns the patient experienced anaphylaxis after receiving ampicillin. Which action does the nurse take?

Which patient on the surgical floor is at the greatest risk for abdominal wound dehiscence?

Which wound heals by secondary intention?

Which cell is responsible for cleaning wounds of microorganisms?

The nurse changes the dressing of the patient with a sacral pressure injury. Upon removal of the dressing, the nurse notes yellow drainage on the dressing with a fruity odor. Place the nurse’s actions in the correct order from first to last.

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?

To which team member does the registered nurse delegate a fecal occult blood test for the patient who requires assistance to ambulate to the restroom?

The nurse is teaching the child with asthma how to use a metered-dose inhaler. Which instructions does the nurse include? Select all that apply.

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?

The unconscious patient presents with the following respiratory pattern: The nurse anticipates further testing will reveal which condition?

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

The 66-year-old patient with congestive heart failure is brought to the emergency department (ED) via ambulance with complaints of respiratory distress and increasing oxygen requirement. Which assessment indicates the patient is experiencing acute respiratory distress syndrome (ARDS) rather than a congestive heart failure (CHF) exacerbation?

The nurse is supervising a student nurse in caring for a postoperative patient at high risk for surgical wound evisceration. The nurse prepares the student to perform which interventions if the wound eviscerates? Select all that apply.

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 patient calls the nurse to the room to report pain at the site of an IV. The nurse notes warmth, redness, and purulent drainage. Which action does the nurse take first?

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

On the complete blood cell count with differential, the nurse notes the patient has an elevated number of eosinophils. The nurse explains to the patient that eosinophils become elevated due to which causes? Select all that apply.

Which statement is true regarding the neonate's immune system?

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

Which statements are true regarding intravenous immunoglobulin? Select all that apply.

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 provider orders albumin for a patient with traumatic amputation and hemorrhage. Which patient characteristic prompts the nurse to clarify the order with the provider?

Which statements are true regarding the care of the 2-year-old with whooping cough? Select all that apply.

Which statement describes the mechanism of action of erenumab (Aimovig)?

About which expected side effect does the nurse educate the patient prescribed colchicine for treatment of gout?

The patient with seizures has been prescribed carbamazepine (Tegretol). Which medication, if found on the patient's current medication list, prompts the nurse to hold the medication and contact the provider for clarification?

Patients with which characteristics are at increased risk for infective endocarditis? Select all that apply.

Which patient with dyspnea is seen first in the emergency department?

Which terms are used to describe Clostridium difficile colitis? Select all that apply.

The patient presents to primary care with two round patches of hair loss on his scalp. He reports no trauma or symptoms aside from the hair loss. The nurse gathers information about his environment, including his workplace. The patient states he recently moved to the area for a new job and that his wife, who is pregnant with their first child, works at the same company. Which diagnosis does the nurse anticipate this patient will receive?

The patient is admitted to the intensive care unit after starting antibiotics and experiencing a severe drug reaction and erythema multiforme syndrome. The patient has severe mucocutaneous bullae over 42% of the body surface area. The nurse anticipates which diagnosis for this patient?

The patient presents to the emergency department (ED) with flu-like symptoms and mucocutaneous erythematous rash and bullae formation over 38% of the body. The nurse asks the patient if which medications had been taken in the last month? Select all that apply.

The nurse plans which intervention for the patient with toxic epidermal necrolysis?

The nurse is administering intravenous fluids to the patient with toxic epidermal necrolysis. Which parameters are most helpful to assess when determining the appropriate fluid rate for the patient?

The patient developed toxic epidermal necrolysis after receiving phenytoin for seizures. The nurse prioritizes nursing interventions to address which life-threatening comorbidities? Select all that apply.

The patient presents to the primary care clinic complaining of painful itching between his toes. Examination reveals scaling skin, areas of maceration between the toes, and some fissure formation. The nurse plans care to provide education about which diagnosis?

The nurse is vigilant for Candida albicans infections in patients with which conditions? Select all that apply.

The nurse is supervising the care of the patient who suffered an embolic stroke of the right middle cerebral artery after a clot formed on the patient’s prosthetic mitral valve. Which instruction does the nurse provide to the unlicensed assistive personnel that will be most important to prevent bacterial endocarditis?

Which circumstances are an indication for surgical management of a stone in the urinary tract? Select all that apply.

The nurse assesses the patient for which signs of complications of a parathyroidectomy?

Which statement does the nurse include in discharge teaching to the parents of the 9-year-old who underwent tonsillectomy and adenoidectomy?

The child is brought to the emergency department for lacerations and abrasions to the knees, palms, and face after falling at recess. The parent informs the nurse, “He always bleeds so much with any injury." The nurse suspects which condition?

Which is indicated by a positive urea breath test?

Which respiratory assessment in the patient who has an oxygen saturation of 96% on room air is most concerning?

Which term does the nurse use to document a 1.5 cm, dark red, fluid-filled lesion on the patient's cheek?

Which term does the nurse use to document the pinpoint, non-blanchable rash in the child who has invasive meningococcal disease (IMD) caused by Neisseria meningitidis? 

The patient with vasculitis has a rash of red marks that are greater than 3 mm and do not blanch when pressed. Which term does the nurse use to document this finding?