Nursing Interventions

The nurse in the burn ICU is caring for a patient with third degree burns over 33% of the body. Which assessment best indicates that fluid resuscitation has been adequate?

The 22-year-old patient is brought to the emergency room with decreased level of consciousness after ingesting 3,4-methylenedioxymethamphetamine. The patient is noted to have a rectal temperature of 40°C. The nurse performs which interventions? Select all that apply.

In the postoperative period following a Whipple procedure, the nurse includes which interventions in the care plan? 

The patient undergoing continuous bladder irrigation (CBI) following a prostatectomy reports an extreme need to urinate. Which action by the nurse is most appropriate? 

The nurse performs a shift assessment on the patient who has been undergoing continuous bladder irrigation (CBI) following a transurethral resection of the prostate (TURP) for 3 days and notes the output to be an amber color. Which action by the nurse is most appropriate?

The nurse assesses the patient who has received continuous bladder irrigation (CBI) therapy since a transurethral resection of the prostate (TURP) 24 hours ago. Which assessment is the priority to report?  

The nurse is caring for the patient with prostate cancer and left-sided heart failure who underwent transurethral resection of the prostate (TURP) 12 hours ago. Clots are noted in the continuous bladder irrigation (CBI) outflow. Which action by the nurse is most appropriate?  

The nurse reviews the patient’s 24-hour intake and output for the patient with continuous bladder irrigation (CBI). The CBI intake is 2000 mL and the output is 2600 mL. Which action by the nurse is most appropriate?  

The nurse places a call to the provider that the 74-year-old patient’s potassium level is 7.1 mEq/dL. The nurse is prepared to answer which questions from the provider? Select all that apply.  

The patient is started on subcutaneous heparin injections 7500 units q12h for deep vein thrombosis prophylaxis at 0900. When does the nurse plan to obtain the activated partial thromboplastin time (aPTT) to determine effectiveness of therapy?  

The patient is receiving a continuous heparin infusion that started at 0000 for the treatment of a deep vein thrombosis in the leg. Prior to the initiation of therapy, the patient’s activated partial thromboplastin time (aPTT) level was 35 seconds. The aPTT level drawn at 0800 was found to be 70 seconds. The nurse reports this information to the provider and advocates for which intervention?  

The patient is scheduled for a liver biopsy tomorrow. The nurse has difficulty obtaining blood specimens from the patient and can only send one lab. Which lab test does the nurse choose? 

The patient on bowel rest has been prescribed 10% dextrose total parenteral nutrition at 50 mL/h, intravenous lipids 3 grams/kg/day, and 10 mg intravenous famotidine every other day. Which information in the patient’s chart prompts the nurse to contact the provider? 

The 21-year-old patient with a body mass index of 10.1 undergoes placement of a peripherally inserted central catheter (PICC) at 1000 and total parenteral nutrition (TPN) is initiated at 1200. At 1600, 160 mL have infused and the patient is noted to be breathing shallowly, there is blood oozing from the PICC insertion site, and the patient is exhibiting confusion. Which action does the nurse perform first? 

The nurse is supervising the student nurse in performing a cap change for a peripherally inserted central catheter (PICC) in a patient who recently sustained a traumatic brain injury. Which action by the student nurse best indicates effective learning?

The patient receiving total parenteral nutrition (TPN) is found to have received 24 hours’ worth of TPN in 4 hours. Which intervention does the nurse perform first? 

The nurse is supervising the graduate nurse in caring for intravenous lines. Which actions by the graduate nurse require intervention and further education? Select all that apply.  

The nurse finds the patient’s vaginal radiation implant in the bed while turning the patient. Which action by the nurse is most appropriate?   

Following a bone marrow transplant, the patient exhibits a 10-pound weight gain in 3 days, increased abdominal circumference, and yellow tinge to the sclera and skin. The nurse notifies the provider and prepares to perform which intervention?  

Which intervention is appropriate for the patient receiving chemotherapy for breast cancer? 

The nurse is caring for the patient who is at the nadir for bone marrow suppression. Which order does the nurse clarify with the provider?  

The patient’s activated partial thromboplastin time (aPTT) is 138 seconds. Review the chart to determine the most important question for the charge nurse to ask the bedside nurse.

Which interventions does the nurse include in care for the patient who underwent a total pelvic exenteration for a cancer diagnosis one day ago? Select all that apply.  

The nurse in a tertiary medical center with attached pediatric hospital is caring for the 28-year-old gravida 3 para 2 woman who is 40-weeks pregnant and presents to the labor and delivery unit 1 hour after spontaneous rupture of membranes. Patient had good prenatal care, an amniotic fluid index of 12, and pregnancy is complicated only by the antenatal diagnosis of fetal single ventricle anatomy.  Labor is progressing well and the fetus is tolerating contractions well with moderate variability in fetal heart tones. The nurse is most concerned with having which item in the delivery room? 

The nurse creates the plan of care for the patient with crescent-shaped hemoglobin who presented with severe joint pain and stiffness with priority given to which type intervention? 

The patient with β-thalassemia major exhibits complications of therapy. The nurse prepares to provide which intervention? 

The nurse is caring for the 16-year-old patient undergoing treatment for Ewing sarcoma. Which intervention is most helpful for the patient?  

The nurse is preparing to care for a baby antenatally diagnosed with type C esophageal atresia with tracheoesophageal fistula. Which interventions are the priority in the first day after birth?  

The 8-month-old patient has had 4 skin abscesses in the past 3 months that have required draining. Each abscess drains less than 5 mL non-purulent fluid. The infant appears well otherwise and the parents deny respiratory infections. The infant’s complete blood count shows an elevated white blood cell count without bands or segmented cells. Immunoglobulin levels are appropriate for the age of the infant. The patient has a positive nitroblue test. The nurse plans care to include which intervention? 

The 78-year-old resident of a nursing home is brought to the emergency department for abdominal pain that is not responsive to oxycodone. She takes captopril, atenolol, lovastatin, and glyburide in addition to the oxycodone. Upon assessment, her abdomen is full and mildly tender. She has positive bowel sounds and reports passing gas but no stools for 96 hours. She denies anorexia or vomiting. A digital rectal examination is performed and stool is found in the rectum. The nurse anticipates being ordered to perform which intervention for this patient?  

The nurse is planning care for the 78-year-old patient with recurrent fecal impaction. The patient has prostate cancer that has metastasized to the bone. In addition to palliative chemotherapy, the patient receives a fentanyl transdermal patch and intravenous hydromorphone. The patient is neutropenic and thrombocytopenic. The nurse works with the provider to plan which intervention to manage the opioid-induced constipation and subsequent fecal impaction? 

The nurse is caring for a 57-year-old woman who is intubated and sedated in the post-anesthesia care unit following a radical hysterectomy. The patient remained stable throughout the 6 hour surgery during which she experienced a 2 L blood loss. The nurse has emptied the patient’s indwelling catheter every hour for the 3 hours the patient has been in the PACU with the following volumes: 54 mL, 23 mL, 12 mL, and 5 mL. Her heart rate is 112 bpm, oxygen saturation is 99%, and blood pressure is 82/54mmHg. The patient received maintenance fluids during the procedure and no blood transfusions. How many liters of isotonic fluid does the nurse anticipate administering to the patient during the postoperative period? Enter your response using a whole number. 

The patient is brought to the emergency room after briefly losing consciousness. He states, “I feel like my heart has been racing for days now. I just assumed it was stress, but now it feels so much worse.” He is pale, diaphoretic, and tachypneic. His heart rate is 118 bpm and his blood pressure is 86/52 mmHg. An electrocardiogram shows an irregularly irregular RR interval without distinct P waves. The nurse prepares the patient for which intervention? 

The 23-year-old patient is brought to the emergency department after contacting emergency services to report profound weakness that started in his feet and worsened and spread cranially over the past few days. He reports severe diarrhea after a camping trip a week ago. Upon assessment, strength, sensation, and deep tendon reflexes are significantly reduced, with the lower extremities more severely affected than his upper extremities. Vital signs are normal and the patient seems to be breathing well. There is increased protein in the cerebrospinal fluid found after a lumbar puncture. The patient is admitted to the intensive care unit for further management and observation. The ICU nurse includes which interventions in the plan of care? Select all that apply.  

The 75-year-old patient presents to the emergency department complaining of a severe headache that is localized behind the right eye. The patient is nauseous and vomits upon standing. While wearing glasses, the visual acuity is 20/25 in the left eye and 20/110 in the right (records show it is normally also 20/25 corrected). Her left pupil is equal, round, and reactive to light and accommodation; it is measured at 3 mm. Her right pupil reacts only minimally to light and measures at 5 mm; it is round. The provider palpates the eye and reports that it is tense. Her heart rate is 102 bpm and blood pressure is 118/84 mmHg. The nurse anticipates providing which intervention first?  

The 31-year-old patient G2P1 woman presents to the clinic for 30 week appointment. She was diagnosed at 24 weeks with gestational diabetes. For 6 weeks, she changed her diet and exercised more regularly while checking her blood sugars. She logged fasting glucose levels of 108-135 mg/dL. She has no proteinuria or glycosuria. The nurse provides which information to the patient?  

The 38-year-old patient who strictly adheres to a vegan diet complains of weakness and tingling in her lower extremities. She retains the strength in her lower extremities but proprioception is decreased.  Her complete blood count revealed a hemoglobin of 10.2 mg/dL, white blood cell count of 9 x 10³ cells/µL, and a mean corpuscular volume of 110. Which information does the nurse provide to the patient?  

The 21-year-old intoxicated patient presents to the emergency department after sustaining an injury to the right hand during an altercation in a bar. He reports punching another individual in the face. An x-ray of the hand reveals a broken 4th proximal phalange and metacarpal. The corresponding knuckle has an open laceration. The nurse prepares the patient for which treatment?  

The 12-hour-old neonate was born at 39 weeks to a G2P2 mother after an uncomplicated pregnancy and delivery. Slight oligohydramnios was noted during the pregnancy. The neonate has not urinated. Upon assessment, the nurse notes stable vital signs and suprapubic distention. The nurse contacts the provider to advocate for which initial intervention?  

The nurse witnesses a healthy 19-year-old collapse while playing football. The individual is arousable but confused and irritable. The skin is warm, dry, and flushed. The nurse instructs a teammate to bring the water cooler and pours it over the victim. The teammate shouts, “Why did you do that?! Won’t he go into shock?”  The nurse bases the response on the need for rapid cooling to prevent which conditions? Select all that apply.  

The 20-year-old healthy soccer player is brought to the emergency department after collapsing at the end of a summer soccer game. The patient is lethargic and confused about the event. Upon assessment, the nurse notes flushed, dry skin that is warm to the touch. The oral mucosa is dry, as well. Vitals are as follows: temperature 40.7°C, heart rate 122 bpm, respiratory rate 20, and blood pressure 116/64 mmHg. Which order does the nurse carry out first?  

The 20-year-old healthy soccer player is brought to the emergency department after collapsing at the end of a summer soccer game. The patient is lethargic and confused about the event. Upon assessment, the nurse notes flushed, dry skin that is warm to the touch. The oral mucosa is dry, as well. Vitals are as follows: temperature 40.7°C, heart rate 122 bpm, respiratory rate 20, and blood pressure 116/64 mmHg. A rectal thermistor is inserted and aggressive cooling measures are instituted. After 30 minutes in the ice bath, the patient’s rectal temperature is 39.1°C and the ice is partially melted. Which action by the nurse is most important?  

The 20-year-old healthy soccer player is brought to the emergency department after collapsing at the end of a summer soccer game. The patient is lethargic and confused about the event. Upon assessment, the nurse notes flushed, dry skin that is warm to the touch. The oral mucosa is dry, as well. Vitals are as follows: temperature 40.7°C, heart rate 122 bpm, respiratory rate 20, and blood pressure 116/64 mm Hg. A rectal thermistor is inserted and aggressive cooling measures are instituted. After 30 minutes in the ice bath, the patient’s rectal temperature is 39.1°C and the ice is partially melted. The nurse notes the rectal thermistor has stopped working; there are no other rectal thermistors in the facility. Which action by the nurse is most appropriate? 

The nurse is teaching a community class on cardiopulmonary resuscitation (CPR). Which rationale is best to give the class for the difference between infant CPR with one rescuer, infant CPR with two rescuers, adult CPR with one rescuer, and adult CPR with two rescuers?

The nurse is attempting to perform an electrocardiogram on a patient. The machine alerts the nurse that the V1, V4, and V5 electrodes are not picking up correctly. The nurse adjusts the leads in which locations? Select all that apply.  

 The nurse is the first responder after a child is pulled unresponsive from the pool. There is no pulse and no breathing. The nurse sends someone for the AED, instructs another person to call 911, and begins chest compressions. By looking transversely at the chest, select the depth to which the nurse compresses the chest, if each line represents an inch of compression. 

The nurse is preparing to insert an intravenous catheter into the patient with a BMI of 39. Which angle of insertion does the nurse utilize in order to most likely maximize the chance of successfully entering the vessel? 

The nurse performs an electrocardiogram on a patient and notes right axis deviation. The nurse suspects the patient has which undiagnosed condition? 

The nurse is supervising the student nurse in the insertion of a peripheral intravenous catheter. The nurse observes the student nurse apply a tourniquet, clean the insertion site, and insert the needle into the skin and get a flash of blood in the chamber. The nurse continues to quietly observe if the student nurse performs which action? 

Upon insertion of an intravenous catheter, bright red blood is noted prior to attaching the tubing. Which initial action is appropriate?