Nursing Interventions

The nurse is caring for the patient who recently underwent right above-knee amputation and complains of pain in the amputated limb. Which response by the nurse is most appropriate?

The nurse is instructing the nursing student on indwelling urinary catheterization. Which statement does the nurse include in the teaching? 

​The nurse is supervising the care of the patient prior to a surgical procedure who has been ordered to receive a clear liquid diet. Which food item, if provided to the patient by the unlicensed assistive personnel, prompts the nurse to intervene with further education? 

Following a minor abdominal surgical procedure, the patient is complaining of abdominal discomfort when coughing. Which nursing intervention is most important?

The nurse is caring for a 55-year-old patient who is experiencing dyspnea. What is the most appropriate position for the patient?

The patient is in a coma following evacuation of an acute subdural hematoma. Which intervention does the nurse utilize to increase the patient's level of consciousness? 

The patient with decreased mobility complains of neck and lower back pain during a bed bath. Which initial intervention does the nurse utilize to promote relaxation and comfort to the patient? 

The patient in the emergency room has a traumatic leg wound which has been cleaned and dressed. The nurse enters the room to reassess the wound prior to discharging the patient and notes bright red drainage on the dressing that is increasing in size. Which action does the nurse take first?

The patient presents to the urgent care clinic with a hand laceration sustained while using pruning shears in the garden. Which vaccine is most important for this patient?

The nurse is assigned to a patient with acute lymphocytic leukemia (ALL) about to undergo his first round of chemotherapy. The patient’s WBC is 120,000/uL and his LDH is 3 times the upper limit of normal. Which intervention is most important?

The patient with severe fatigue and muscle wasting due to acquired immunodeficiency syndrome (AIDS) is experiencing pain. Which nonpharmacological therapy is most appropriate to include in this patient’s treatment plan?

Place the steps of therapeutic touch in the correct order.

The patient appears to be fatiguing before daily bathing and grooming is finished. Which action by the nurse is most appropriate?

The nurse is instructed to assess the patient’s postvoid urine residual volume. Which is the best method by the nurse to perform this task?

Which order does the nurse complete first in the patient with acute respiratory failure?

The nurse is preparing to draw blood from a patient who requires multiple laboratory tests. Which lab does the nurse draw first?

The nurse is assigned to care for a 27-year-old male who presented with acute onset personality changes and neuropsychiatric symptoms. Upon entering the patient’s room, the nurse notices the patient is staring at the ceiling and muttering. Which action by the nurse is most appropriate?

Following a mass casualty event, the nurse is called in to the hospital to work in accordance with the city's emergency response plan. The nurse is instructed to discharge as many current inpatients as possible to assist with reallocation of resources. Which patient is most appropriate to be discharged?

A fire has started in one of the medical surgical units, and the staff has been instructed to perform a horizontal evacuation. Which action does the nurse take first?

The nurse is assigned to care for a patient with human immunodeficiency virus (HIV) with an infected boil that requires lancing. Which personal protective equipment does the nurse don? Select all that apply.

A nurse is assigned to care for a 28-year-old patient with seizures and neuropsychiatric symptoms secondary to cocaine abuse. The patient is combative and prone to hurting himself despite a 24-hour bedside sitter, so the provider writes for physical restraints. Which options are included in this order? Select all that apply.

The nurse is teaching a patient how to walk with a cane following a cerebrovascular accident that left the patient with right-sided weakness. Which action by the patient indicates the teaching was effective?

A 6-day-old neonate in the newborn intensive care unit has been prescribed oxacillin for a suspected central line-associated bloodstream infection. The nurse receives the following order: oxacillin IV 50 mg/kg/day, divided q12h. The neonate weighs 2 lb. 11 oz and the pharmacy dispenses the medication in a concentration of 20 mg/mL. How many milliliters will the nurse administer for each dose? Round your answer to the nearest tenth decimal place.

The client presents to the emergency department following a blow to the abdomen during a baseball game. He is unresponsive with a blood pressure of 82/48 mmHg, heart rate of 118 bpm, a respiratory rate of 18, and an oxygen saturation of 95% on room air. The nurse anticipates taking which action first to treat this patient?

The nurse anticipates seeing the effect of which medication most quickly? 

Prior to transporting a patient to surgery, the nurse ensures which items are in the patient's chart? Select all that apply. 

Following an assault by an unknown assailant, the patient is diagnosed with post-traumatic stress disorder. Which intervention must be implemented first for this patient? 

The patient reports being hungry prior to the breakfast tray delivery. When the nurse checks on the patient an hour after the tray was delivered, the nurse notes the patient has not eaten any of the food. Which initial nursing action is most appropriate? 

The patient who underwent an upper gastrointestinal radiographic study requires which post-procedure instruction?

Which patient is appropriate to assign to a licensed practical/vocational nurse (LPN/LVN)?

The nurse is providing education to a patient with localized shingles. Which statement by the patient indicates the teaching was effective?

The 8-year-old presents with a generalized rash. The patient's mother reports that some areas of the rash have developed into pimples that are oozing clear fluid. The nurse places this patient on which type of precaution(s)? Select all that apply.

The patient’s stool sample is positive for Entamoeba histolytica. The nurse plans education about which class of medication for this patient?

Which exercise is appropriate for the patient who has a Glasgow Coma Scale of 4?

Which patient requires the most immediate attention?

The patient with bloody diarrhea and liver abscess is diagnosed with an Entamoeba histolytica infection. The nurse anticipates administering which medication?

The 15-year-old patient is hospitalized after harming herself when her mother would not let her use her cell phone. While she is awaiting inpatient psychiatric placement, she repeatedly expresses a desire to leave. Which intervention is most helpful to prevent the patient from eloping?

The patient with advanced dementia accuses the nurse of trying to poison him with his scheduled medications. Which nursing intervention is most appropriate?

The nurse is planning care for a patient returning from surgery for a colon resection and ileal pouch-anal anastomosis. Which interventions does the nurse employ to prevent surgical site infection? Select all that apply.

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?

Place the nursing interventions for a 16-year-old patient in the hospital for severe malnutrition and depression with a history of falls in order from highest priority to lowest priority.

Which nursing intervention is the highest priority for the patient admitted with a chronic obstructive pulmonary disease (COPD) exacerbation?

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?

A local celebrity is admitted to hospital following rupture of the appendix. The charge nurse submits an incident report if which individual accesses the patient’s chart?

The grandparents of a baby in the newborn intensive care unit (NICU) ask the nurse about the age of another baby. Which response by the nurse is most appropriate?

The nurse delegates a pre-prandial blood sugar check to the unlicensed assistive personnel who fails to perform it before the patient’s food tray arrives and the patient eats breakfast. Who is most at fault?

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 patient from India tells the nurse that, in addition to his conventional medical treatment, he would also like to be treated according to the principles of Ayurvedic medicine. The nurse plans care based on which understanding of the focus of Ayurvedic medicine?

The nurse is assigned to care for a patient who speaks minimal English but is fluent in Farsi. Which is the best practice for the nurse to take when communicating with this patient?