Nursing Interventions

The nurse is providing discharge education to the 48-year-old patient with a third grade reading level about his new prescription for valsartan. Which is the best way for the nurse to assess the patient’s understanding of the teaching?

The nurse has provided teaching to the patient regarding the use of crutches after she broke her ankle. Which is the best way for the nurse to assess the patient’s understanding of the teaching?

The nurse is assessing the patient’s ability to live independently. The patient ambulates with a cane but cannot manage stairs (lives in a one-level home). Due to advancing macular degeneration, the patient has forfeited her driving license. The patient has a daughter who is able to assist with transport to doctor appointments but cannot visit regularly. The macular degeneration is affecting the patient’s ability to tell the difference between her many pills. Which level of nursing care is appropriate for the patient?

The nurse receives report on four patients at the start of the shift. Which patient does the nurse visit first?

The home care nurse visits the home of an elderly married couple who lives with their adult children. Medication bottles and loose pills are found throughout the house. The nurse provides which information about safe storage of medications? Select all that apply.

The patient with a lung mass that was discovered on imaging is scheduled for a flexible bronchoscopy. Which nursing action is appropriate to prepare the patient for the procedure?

The nurse notices that the patient’s peripheral IV insertion site is red and indurated. What action does the nurse perform first?

The patient wants to quit smoking before starting hormonal birth control. Using motivational interviewing, which statement by the nurse would best elicit change talk from the patient?

The nurse orders which items for the patient who has been ordered to receive a clear liquid diet? Select all that apply.

The patient with a history of epilepsy has a seizure in the emergency department. He has stopped convulsing, but cannot be aroused. Once the patient is admitted to a room, the patient then starts convulsing again. Which action by the nurse is appropriate?

The patient presents to the emergency department with abdominal pain, dehydration, a blood glucose level of 425 mg/dL. Blood testing reveals metabolic acidosis, hypokalemia, and ketones. The patient is alert and conversant, but in moderate distress. The nurse anticipates administering which medication?

The nurse receives shift report on four patients. Which patient does the nurse see first?

The patient with a severe peanut allergy was inadvertently exposed to peanuts at work. Dyspnea persists despite the patient using the epinephrine autoinjector and emergency medical services was contacted. Which concentration of epinephrine does the first responder prepare for intramuscular injection?

The nurse assesses the cuff pressure of the patient's tracheostomy. Which cuff pressure prompts the nurse to document the finding and proceed with the assessment?

The nurse is supervising the student nurse preparing for the return of a neonate from surgery to repair a myelomeningocele. Which item, if brought into the room by the student nurse, does the nurse remove immediately?

The nurse is preparing to perform open tracheostomy suctioning for a patient with methicillin-sensitive Staphylococcus aureus (MSSA) tracheitis. Which personal protective equipment does the nurse utilize for this procedure? Select all that apply.

The nurse is assisting the provider in lancing the abscess of a patient whose medical history is notable for anaphylaxis after ingestion of oysters. The nurse enters the room as the provider begins swabbing the affected skin with povidone-iodine solution. Which response by the nurse is appropriate?

The nurse is preparing the patient for a magnetic resonance imaging (MRI) scan with intravenous contrast. Which question is most important for the nurse to ask the patient?

The patient admitted with asthma is receiving beclomethasone HFA PRN and nebulized albuterol PRN. Which patient assessment is most appropriate to report to the respiratory therapist assigned to care for the patient?

The nurse helps the patient into which position in preparation for the removal of an intrauterine device?

The first-time mom requests information from the nurse about providing foods other than breast milk to her 3-month-old child. Which response by the nurse is most appropriate?

The 14-year-old patient was admitted following surgical reduction of an open femur fracture. The patient, who has reported good pain control with the patient-controlled analgesia (PCA) pump, is sleeping peacefully. During hourly rounding, the nurse observes the parent press the button to administer the bolus of pain medication. Which action by the nurse is appropriate?

The patient receiving patient-controlled analgesia (PCA) with morphine is found to be sleeping deeply and minimally responsive. Which action does the nurse take first?

The nurse is planning care for the patient who will undergo hip replacement surgery in a month. When is the best time to provide teaching about the use of a patient-controlled analgesia (PCA) pump?

The patient intubated in the intensive care unit has the following arterial blood gas results: pH 7.21 PCO2 51 PaO2 38 HCO3 16 Base Excess -7 Which action does the nurse take first?

The 3.2 kg patient with persistent pulmonary hypertension of the newborn (PPHN) has the following order: Infuse norepinephrine 0.05 mcg/kg/min IV and titrate q15 minutes by 0.05 mcg/kg/min to maintain mean arterial pressure between 45 and 55 mm Hg. Overnight, the norepinephrine had been titrated to 0.25 mcg/kg/min for persistent hypotension. At 0900, the MAP rose to 62 mm Hg and the nurse decreased the infusion from 0.25 mcg/kg/min to 0.20 mcg/kg/min. At 0905, the patient’s blood pressure fell to 42 mm Hg. Which action does the nurse take first?

The patient has experienced an extravasation of norepinephrine in the right forearm. It is cool to the touch, firm, and pale. Distal to peripheral pulses are not well felt and the fingertips are dusky. Which order does the nurse clarify with the provider?

The nurse assesses the peripheral IV site of the patient who is receiving norepinephrine, which was started for profound, life-threatening hypotension and finds the hand to be firm to the touch, cool, and pale. Which action does the nurse take?

The asymptomatic patient tested positive for Neisseria gonorrhoeae during routine screening for sexually transmitted infections (STI). The nurse anticipates administering which medications? Select all that apply.

The 32-weeks-pregnant woman who presents with genital lesions is diagnosed with herpes simplex virus-2. The nurse prepares a patient information handout for which medication for this patient?

The full-term neonate (3.2 kg) born precipitously to a mother of unknown infectious disease status has had a positive rapid plasma reagin (RPR) test. The nurse plans care to perform which intervention first?

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?

The patient presents to the emergency department (ED) after being bitten by a friend’s dog with two puncture marks and an abrasion. Prior to dressing the wound, the nurse uses which substance to clean the wound?

The nurse requests analgesia for the 76-year-old patient who must undergo cleansing and dressing change for a healing stage 3 pressure ulcer on the coccyx. In response, the provider ordered topical EMLA cream to be applied to the wound 30 minutes before the procedure. Which action by the nurse is appropriate?

The patient returns from cholecystectomy surgery with a wound closed with sutures. There is no drainage from the wound. Which dressing does the nurse apply?

Which interventions increase the risk for impaired skin integrity in the patient with congestive heart failure who requires total care? Select all that apply.

Which patient is at highest risk for skin breakdown?

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.

During routine tracheostomy care, the nurse notes increased drainage from the stoma and a fruity, grape juice odor. The nurse obtains a culture of the secretions and anticipates the results will reveal which organism?

The nurse advocates for a guaiac test to be performed on the patient with which stool?

During routine tracheostomy cleaning and care, the nurse notes a strong smell of dirty gym socks coming from the dressing around the stoma. Which action by the nurse is most appropriate?

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 nurse is teaching a woman ways to prevent mastitis. Which statement by the patient indicates that more teaching is needed?

The nurse makes which patient top priority?

The nurse is supervising the nursing student in the provision of a complete bed bath to the patient. Which action by the nursing student indicates successful learning?

The very low birth weight infant was born at 0.9 kg and now weighs 1.3 kg. The neonate is on full feeds receiving 24 kcal/oz formula with a daily kcal goal of 120 kcal/kg/day. The patient eats every 3 hours around the clock. How many milliliters does the nurse administer with each feeding? Enter your answer using a whole number.

The patient who has severely elevated intracranial pressure following a traumatic brain injury is intubated, sedated, and chemically paralyzed. Which intervention does the nurse include in the plan of care?

The nurse is caring for a patient diagnosed with measles. Which precautions does the nurse utilize during the patient’s care? Select all that apply.

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.

Which patient characteristic prompts the nurse to hold the infusion of Lactated Ringer’s and contact the provider?