Nursing Interventions

The nurse is providing preoperative teaching to the patient who is scheduled for a total knee replacement next Tuesday at 1000. The nurse instructs the patient to have no solid food after which time?

Which statements are true regarding peripherally inserted central catheters (PICCs)? Select all that apply.

The nurse ensures which laboratory study is collected regularly to monitor the effectiveness and safety of the patient's continuous unfractionated heparin infusion?

The patient receiving hospice care reports constant, severe dry mouth. Which interventions does the nurse include in the patient's care plan? Select all that apply.

The American Cancer Society recommends the patient's initial cervical cancer screening occurs at which time?

How many chest compressions per minute are performed during cardiopulmonary resuscitation of the adult?

The hospitalized patient is found unresponsive and the cardiopulmonary monitor shows ventricular fibrillation. Upon assessment, no pulse or respiratory effort are appreciated. A code blue is called and the defibrillator is being brought to the room. Which initial intervention is appropriate?

The hospitalized patient is found to be in ventricular tachycardia on electrocardiogram. Upon assessment, no pulse or respiratory effort are noted. Which medication is administered first?

The nurse is caring for the patient in cardiac arrest. Which rhythm, if found on electrocardiogram, does the nurse most anticipate to be treated with unsynchronized defibrillation?

The patient with narrow QRS complex supraventricular tachycardia is found to be hemodynamically stable. Which initial intervention is appropriate? 

The nurse is notified the patient's heart monitor shows ventricular fibrillation. Initial assessment reveals strong peripheral pulses and even, unlabored respirations with an oxygen saturation of 98%. Which action does the nurse take first?

Which statement is true regarding the provision of cardiopulmonary resuscitation (CPR) in the community with an automated external defibrillator (AED)?

The patient with a central venous catheter develops substernal chest pain, hypotension, and cough. There is evidence of air in the line. Which action does the nurse take first​?

The patient’s wound is producing copious amounts of exudate and the gauze dressing is saturated within two hours of placement. Which intervention does the nurse perform?

The nurse is reviewing the medication list of the patient who wishes to become pregnant. One of the medications is listed as Category X. The nurse knows this medication poses which level of risk to the fetus?

The patient is being evaluated for obstructive sleep apnea. For which test does the nurse prepare the patient?

The patient with diabetes insipidus has been prescribed vasopressin. The nurse instructs the student nurse about which characteristic of the medication?

The single parent of the child with a severe developmental disorder confides in the nurse that caring for the child is becoming impossible to do alone. Which actions by the nurse are most appropriate? Select all that apply. 

An adult weighing 70 kg just arrived to the emergency department (ED) with burns on the front of both legs and the genital region. Using the Parkland formula, how much fluid is to be administered to the patient over the next 8 hours?

The patient who eats a vegan diet requires assistance selecting meals while inpatient. Which items does the nurse select for the patient? Select all that apply.

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

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 resident of a large, long-term care facility has reactivated tuberculosis and is infectious. Which action does the nurse take?

The nurse is caring for the patient with a stage 2 pressure injury on the right heel. The wound is pink with minimal serous drainage and attached borders. Periwound skin is clean, dry, and intact. Which intervention is appropriate for this patient?

The nurse receives report on the patient with acute bowel obstruction. The patient’s problem list includes controlled hypertension, uncontrolled diabetes, and presbycusis. Which action by the nurse is appropriate?

The nurse is providing medication teaching to the mother of a 4-year-old patient with recurrent otitis media infections who requires daily instillation of antibiotic drops into the ear. Which action indicates effective teaching?

The nurse is educating the 2-year-old patient’s parents on how to instill ear drops to treat acute otitis media. Which statement indicates a need for further teaching?

The patient has undergone a right myringotomy. Which nursing intervention is appropriate?

The nurse learns in report that the patient has a Jackson-Pratt drain. Which nursing intervention will be required for this patient immediately after emptying the drain?

The nurse is attempting to perform an irrigation of the patient’s indwelling urinary catheter but it is unable to instill the irrigant with normal force. Which action does the nurse take?

The patient has a peritoneal dialysis catheter. The nurse notes the dressing is saturated and prepares to change it. Upon removing the dressing, the nurse notes a foul odor and purulent drainage around the site, which is red. Which action does the nurse take next?

Following traumatic bilateral leg amputations, the 5-year-old child requires a STAT blood transfusion to treat hemorrhagic shock. The child's blood type is unknown. Which action is most appropriate? 

The nurse provides which instruction to the patient prescribed incentive spirometry following lower limb orthopedic surgery? 

The patient with laryngitis requests tips on nonpharmacological symptom management. The nurse makes which suggestion?

The nurse is caring for a patient with left-sided weakness in the hospital who had vocal cord surgery this morning. Which intervention is most important to promote safety?

The nurse is creating a bladder retraining program for the 74-year-old female patient who is incontinent of urine. Which aspect of the training program is most important?

Which evening meal choice is appropriate for this patient? Look at the patient’s chart to make a selection.

Which food items does the nurse encourage the patient to eat? Look at the patient’s chart to make selections and select all that apply.

Which meal selection is appropriate for this patient? Review the patient’s chart to make a selection.

Which patient does the nurse advocate to be transferred to the intensive care unit?

The nurse receives report of four issues at 0800. Which situation is addressed first?

The postpartum nurse is supervising new parents placing their newborn into the car seat to drive home during a snowstorm. Which observation is most concerning?

A fire breaks out on multiple floors of the hospital and the charge nurse has been instructed to evacuate the patients. In which order are the patients evacuated?

The nurse is providing post-mortem care to a patient on hospice after being treated for stage 4 colon cancer that metastasized to the bladder. Which action by the nurse is most appropriate?

The nurse is planning care for the elderly patient with dementia who experiences increased agitation and confusion during the evening hours. Which interventions does the nurse include to decrease evening agitation and confusion? Select all that apply.

The nurse is performing an admission assessment and interview of the patient diagnosed with paranoid schizophrenia. Which therapeutic communication techniques are used by the nurse to conduct the interview? Select all that apply.

The nurse receives report and learns the patient has a wound that is healing by third intention. Which intervention is most important to include in the patient’s care plan?

The patient receiving which medication is most likely to also require a prescription for miconazole?

The nurse is supervising the care of a patient with a stage II pressure injury on the coccyx. Which intervention by the student nurse prompts the nurse to intervene with further education?

Following an explosion at a factory, the patient is brought by ambulance to the emergency department. The patient has soot on the face and around the mouth and is coughing up black sputum. He verbalizes severe pain in his leg and his voice is noted to be a hoarse whisper. Further assessment reveals full thickness burns to the arms and hands and partial thickness burns to the legs. Shrapnel appears to have been embedded in the patient’s thigh. While moving the leg to assess the inner thigh, a piece of shrapnel shifts and the patient begins bleeding profusely from the wound. The patient cries out in pain and requests pain relief. Which action does the nurse take first?