Nursing Interventions

The nurse is providing discharge instructions and education to a patient with stomach cancer who is interested in alternative/complementary medicine. Which low-risk therapies does the nurse include in the discussion? Select all that apply.

The patient reports an interest in using a herbal supplement to help with his depression. The nurse discusses herbal supplements with the patient based on which understanding of the nurse’s role in alternative and complementary medicine?

The nurse mistakenly gives the patient with malignant hypertension the wrong dose of antihypertensive medication, and the patient complains of several hours of dizziness. Which action by the nurse is most appropriate?

The nurse receives a telephone order from the healthcare provider for intravenous pain medication to be administered to a patient with cancer pain. Which statement is correct regarding this medication order?

The patient who is admitted for surgery for resection of a malignant lung tumor has a living will. In addition to making sure a copy of the living will is included with the patient’s electronic medical record, which action does the nurse take?

The nurse attempts, but is unable, to contact the provider to clarify a prescription that is much higher than the normal dosage. Which action by the nurse is appropriate?

The nurse is assigned to care for a diabetic patient with a non-healing leg wound. Which task does the nurse delegate to an unlicensed assistive personnel?

The charge nurse is making patient assignments for an unlicensed assistive personnel, a registered nurse, and a licensed vocational/practical nurse. Which patient is the most appropriate assignment for the LVN/LPN?

The patient with cervical cancer has an implanted sealed internal radiation device. The nurse provides which instruction to the patient?

Which tool is most effective for promoting safety when ambulating an elderly patient who is a fall risk?

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?

The patient with tears of the right medial meniscus asks the nurse about the use of therapeutic massage. Which response by the nurse is appropriate?

The provider orders that the patient transition to a full liquid diet. Which new item is the patient now allowed to have?

The nurse is teaching a nursing student about hand washing. Which statement by the nursing student indicates understanding of the teaching?

During a lumbar puncture, which event warrants immediate intervention by the nurse?

Which statement by the patient who has recently undergone a radical mastectomy indicates they understand teaching by the nurse?

Which nursing intervention will be most effective in preventing the spread of Clostridium difficile between patients?

The patient is pale and dizzy following a gunshot wound to the groin. Minimal bleeding is noted at the site. Vital signs are notable for a heart rate of 125 bpm and a blood pressure of 73/39 mm Hg. Two unsuccessful attempts have been made to establish an IV site. He loses consciousness. Which action does the nurse take next?

Which statement by the patient with systolic heart failure indicates an understanding of discharge teaching?

A cesarean section is the only safe method of delivery for the fetus when the pregnant woman has which condition? 

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?

Which interventions does the nurse implement for the patient diagnosed with Clostridium difficile? Select all that apply.

A patient with a signed Do Not Resuscitate (DNR) order suddenly becomes unresponsive and goes into cardiac arrest. His wife, who is his healthcare power of attorney, starts yelling hysterically, “Do everything you can! Save him! I don’t care that he didn’t want to be resuscitated, he would want to live for me!” Which action by the nurse is best?

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 patient is being treated for obsessive-compulsive disorder with medication and behavioral therapy. At a follow-up visit, the patient reports near complete resolution of symptoms. The nurse anticipates discussing which treatment plan?  

The nurse instructs parents on which type of diet to decrease the risk for lead poisoning in their children? 

The nurse is caring for a 48-year-old female diagnosed with acute kidney injury. Laboratory results reveal that the patient is experiencing mild hyperkalemia. Which independent nursing action is appropriate to manage the patient's hyperkalemia?

The nurse is caring for a 71-year-old who was recently diagnosed with age-related macular degeneration (AMD) in the left eye. The nurse encourages the patient to increase dietary intake of which substances? 

The patient with persistent shoulder pain with associated numbness of the hand is scheduled for a magnetic resonance imaging (MRI) scan. The patient tells the nurse, "I'm terrified of enclosed spaces. I just don't know if I'll survive this test." After relaying the patient's concerns to the provider, which response does the nurse expect from the provider? 

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 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 parents of a 12-year-old girl with severe anemia decline a blood transfusion because it is against their religion. When responding to the parent's decision, the nurse utilizes which ethical principle?

The patient with bipolar disorder is verbally threatening the staff and other patients in the medical surgical unit. Which initial action is most appropriate? 

The nurse is preparing a 56-year-old male for a surgery that will take several hours. The nurse performs which intervention to decrease the patient's risk of pressure injury during the procedure?

Following electroconvulsive therapy, the patient with bipolar disorder tells the nurse he does not remember whether he arrived by bus or car. Which response by the nurse is appropriate? 

The patient with delusional disorder tells the nurse that he needs to see the Pope in Rome because he is a messenger of God. Which response by the nurse is most therapeutic?

The nurse prioritizes which intervention in caring for the patient with borderline personality disorder? 

The nurse is caring for a 22-year-old patient who is experiencing sickle-cell crisis. Which is the priority nursing consideration?

The nurse is assigned to a 45-year-old HIV-positive male patient who is admitted with a MRSA skin infection on his right arm secondary to intravenous drug use. The patient is prescribed intravenous vancomycin. Twenty minutes after starting the vancomycin infusion, the patient develops a mild erythematous macular rash on the face, trunk and extremities. Which action is performed first?

The nurse is assigned to care for a 31-year-old male with a past medical history significant for long-standing diabetes mellitus and hypertension. Current medications are metformin, furosemide, and captopril. Laboratory tests reveal serum potassium of 3.2 mEq/L, so the patient is started on spironolactone. The nurse provides education about which side effect of therapy?

The nurse is caring for a patient receiving total parenteral nutrition (TPN). After morning rounds, the nurse notices the rate of TPN infusion is slower than what is ordered for the patient and is three hours behind schedule. There are no nursing notes, and the rate was not mentioned on sign-out. Which initial action is most appropriate?

The 4-hour-old neonate in the nursery begins making rhythmic movements with the hands and smacking of the lips. An electroencephalogram is performed, and seizures are observed. The nurse prepares to administer which medication?

The nurse is assigned to a 4-year-old patient admitted with a vaso-occlusive crisis secondary to sickle cell anemia. The boy is in agonizing pain. He has apparently taken off his hospital wristband. Before administering the pain medication, the nurse should perform which of the following actions?

The nurse is assigned to a patient with epilepsy. Which nursing intervention is most important for this patient? 

Following nephrectomy surgery, the patient is groggy and continuously pulls at the IV inserted in the right arm. Which intervention is most appropriate to protect the IV?

The nurse is assigned to a 52-year-old patient who is admitted for elective cholecystectomy. While undergoing preoperative evaluation, the patient mentions to the nurse an allergy that is not documented in the health record. Which action by the nurse is most appropriate?

The nurse informs the parent of an 18-month-old patient at the well-child visit that screening for an autism spectrum disorder at which time(s)?

The 15-year-old patient with anorexia nervosa has been prescribed nasogastric tube feeding for malnutrition. Which intervention is helpful in promoting the patient’s autonomy?

How frequently does the nurse clean the toys of a pediatric patient with measles?