Nursing Interventions

The elderly patient is at risk for falls related to urinary incontinence. Which intervention is appropriate?

Which error in the use of a child's car seat occurs most frequently?

Which personal hygiene interventions will increase the patient’s risk for infection? Select all that apply.

The patient has a peripherally inserted central catheter (PICC) for the long-term administration of parenteral nutrition, oxacillin, and gentamicin. Which assessment findings, if present in the patient, indicate the patient is experiencing a complication of the PICC line? Select all that apply.

The patient presents to the emergency room complaining that his heart is racing and he feels dizzy. His heart rate is 220 bpm, his blood pressure is 80/40 mmHg, and his capillary refill is 5 seconds. He is diaphoretic and is becoming increasingly lethargic. The nurse anticipates which order first?

The patient who experiences frequent episodes of atrioventricular nodal reentry tachycardia (AVNRT) that do not cause hemodynamic compromise is being discharged. The nurse is supervising the student nurse providing discharge teaching to the patient. Which method for self-treatment of AVNRT, if taught by the student nurse, would prompt the nurse to intervene immediately?

The patient in the intensive care unit who is intubated and mechanically ventilated abruptly requires a drastically increased fraction of inspired oxygen (FiO2) and is hypoxic, hypotensive, and tachycardic. Which intervention does the nurse perform first?

The mechanically ventilated patient has a chest tube in place for the treatment of a tension pneumothorax. Which safety supplies does the nurse ensure are at bedside to prevent complications of an accidentally-removed chest tube? Select all that apply.

The 39-week-gestation neonate is born to a mother with chorioamnionitis. The provider has ordered ampicillin 75 mg/kg/day in divided doses every 8 hours and administered intravenously. The neonate weighs 4.2 kg. How many milligrams does the nurse administer with each dose? Enter your answer using a whole number.

The 25-week-gestation neonate is ordered to receive ampicillin 100 mg/kg/day intravenously divided into doses every 12 hours immediately after birth. The neonate weighs 745 grams. The pharmacy dispenses ampicillin in a 5 mL vial that contains 125 mg. How many milliliters will the nurse administer with each dose? Round your answer to the nearest tenth decimal.

The 32-week-gestation, 1.9 kg neonate has been prescribed intravenous ampicillin for concerns for sepsis. The dose is 150 mg/kg/d divided into 2 doses administered over 15 minutes. The pharmacy dispenses the medication in a 5 mL vial that contains 250 mg of medication. At what rate will the nurse program the medication to infuse? Round your answer to the nearest tenth decimal.

In the weeks after a stroke, which patient problem is of the highest priority?

A nurse is preparing discharge plans. Which patient is most likely to need home health care services?

An unlicensed assistive personnel (UAP) reports that a patient has greenish discharge around the tracheostomy. Which response by the nurse is most appropriate?

The nurse provides care for the client diagnosed with Barrett's esophagus. Which goals does the nurse establish in the plan of care? Select all that apply.

The family practice nurse is reviewing telephone messages from patients. Which call is to be returned first?

The nurse is planning care for the patient with severe liver disease who has substantial ascites and peripheral edema. Which interventions are included in the care plan? 

The physical therapist has recommended active range-of-motion exercises for a patient who had shoulder surgery. Which statement is true regarding the exercises?

The nurse is instructing the student nurse on proper sterile technique. Which statements are included in the teaching? Select all that apply.

The nurse determines the patient’s nasogastric (NG) tube is not maintaining good flow. Which intervention is appropriate?

The patient with a hearing deficit has been stabilized in the emergency department following a spontaneous pneumothorax. Which action does the nurse take first?

The 61-year-old patient with liver cirrhosis reports extreme fatigue on a daily basis. The nurse pursues which intervention?

A child with “staring fits” is diagnosed with absence seizures. The nurse prepares patient education materials on which medication?

The home health nurse is working with a patient who is a fall risk. During a home visit, the nurse sees the patient repeatedly using a step stool. Which intervention is the most appropriate?

The patient is in the post-anesthesia care unit (PACU) following abdominal surgery. Which finding would prompt the nurse to delay discharge from the PACU to a hospital bed?

The nurse is performing an assessment of an infant born 8 hours ago. The infant’s POC blood glucose level is 25 mg/dL. Which action does the nurse take first?

The nurse is assisting the physician with insertion of a central venous catheter into the patient's left internal jugular vein. Into which position does the nurse place the patient? 

The nurse applies a transparent dressing to which type of wound?

The nurse must reconstitute a medication for intravenous administration. Using a syringe, the nurse draws up an appropriate amount of diluent. Which action does the nurse should take next?

A patient with longstanding alcohol abuse problems is admitted for COPD exacerbation. After reaching the floor, the patient becomes disoriented, anxious, tachycardic, diaphoretic, and tremulous. His oxygen saturation is 95% on 2 L supplemental oxygen via nasal cannula. Which intervention is most appropriate for this patient?

The nurse is inserting a nasogastric (NG) tube. To ease the process and increase chances for success, which instruction does the nurse give the patient to perform during insertion?

The provider orders an infusion of 10mL/kg/hr for the patient who weighs 154 lbs. The nurse arranges the IV infusion pump to dispense which flow rate?

The woman who delivered her first baby will be discharged tomorrow. After a bedside education program in the hospital, the patient tells the nurse that she does not have a crib, bottles, or diapers to care for her new baby. Which action is most appropriate?

The nurse is caring for the woman in labor whose body temperature is 102.8°F and heart rate is 114 bpm. Which order does the nurse carry out first?

The patient who has recurrent seizures and is no longer legally able to drive has developed a depressed mood and stays home almost all of the time. Which action by the nurse is most appropriate?

The nurse assists with the administration of autolytic debridement for an extremity burn. Which treatment was applied?

The patient with diabetes is brought to the emergency department with severe confusion and is unable to follow commands. A point-of-care (POC) glucose measurement reveals a blood sugar of 44 g/dL. The nurse begins a 50 mL infusion of D50W. Which action does the nurse take next?

The nurse enters the patient room to find the patient grimacing in pain with the eyes closed. The patient states, "I'm just having a migraine; I get them whenever I don't sleep well." Which intervention by the nurse is appropriate? 

The elderly patient is brought to the ER by ambulance for confusion, slurred speech, and right-sided weakness. Vital signs, including body temperature and blood pressure, are normal. As the patient is waiting for an urgent head CT, the nurse performs which test first?

The nurse is caring for the preschool-age child in the hospital. Which are developmentally-appropriate comfort measures? Select all that apply.

The nurse notes the fetal heart rate (FHR) monitor is reflecting variable decelerations. Which action does the nurse take first?

The nurse is in the delivery room of a full-term neonate who requires additional stimulation to begin spontaneous respirations. The nurse removes wet blankets from below the baby to decrease cold stress due to which form(s) of heat loss? Select all that apply. 

The nurse is preparing for an infant’s two-month well-baby check-up. Which immunizations does the nurse prepare? Select all that apply.

The nurse prepares a diphtheria, tetanus, and pertussis (DTaP) vaccination for a 6-year-old patient. The patient’s mother states, “Wait! He’s already gotten that vaccine, several times when he was younger. I have it written down in his records.” Which response by the nurse is appropriate?

The nurse is preparing a Haemophilus influenzae type b (Hib) immunization for the 2-month-old patient. The baby’s mother states, “I recently read the influenza vaccine isn’t given until at least a year. Are you sure he should be getting this now?” Which response by the nurse is most appropriate?

The 34-week-gestation neonate is born weighing 1.7 kg to a mother who is hepatitis B surface antigen (HBsAg) positive; all other infectious disease serologies are negative. Which orders are appropriate for this patient? Select all that apply.

The 1.9 kg neonate is born precipitously via vaginal delivery to a 32-year-old mother who received no prenatal care or infectious disease serology testing before delivery. The mother has a history of intravenous drug use. Which intervention does the nurse perform first?

The patient whose mother chose not to vaccinate him presents to the clinic the day after his 18th birthday to receive all eligible vaccinations. The nurse uses which statement to counsel the patient about the hepatitis B vaccine series?

The nurse is providing discharge education to the patient regarding immunizations following a hematopoietic stem cell transplant. When does the nurse instruct the patient to visit the clinic for the Haemophilus influenzae type b (Hib) vaccine?

The 18-year-old healthy female presents to the clinic requesting to receive the vaccinations her mother refused for her when she was a child. Reviewing the chart, the nurse notes the patient never received the measles, mumps, rubella (MMR) vaccine. Prior to administering the vaccination, which test is most important?