Tissue Integrity

The nurse assesses which body part to detect jaundice in the patient with dark skin?

Following a minor abdominal surgical procedure, the patient is complaining of abdominal discomfort when coughing. Which nursing intervention is most important?

The nurse is caring for a 50-year-old male patient with osteoarthritis who is prescribed a non-steroidal anti-inflammatory drug for pain. Which instruction does the nurse provide to the patient?

Two days after receiving a kidney transplant, the patient complains of flank pain. Which urine output, if reported by the unlicensed assistive personnel, is most concerning to the nurse? 

The patient in the emergency room has a traumatic leg wound which has been cleaned and dressed. The nurse enters the room to reassess the wound prior to discharging the patient and notes bright red drainage on the dressing that is increasing in size. Which action does the nurse take first?

The nurse is providing teaching to the patient who suffered third degree burns two weeks ago to the bilateral anterior legs and anterior lower abdomen. Which statement by the patient indicates an understanding of the teaching? 

The patient presents to the urgent care clinic with a hand laceration sustained while using pruning shears in the garden. Which vaccine is most important for this patient?

The patient presents to the emergency department complaining of severe headache and muscle and joint pain that started two days ago. Vital signs are significant for a heart rate of 112 bpm and temperature of 103°F. Upon assessment, the nurse notes a maculopapular rash on the patient’s wrists. Which question is most helpful in determining the cause of this patient’s symptoms?

The nurse is a first responder to the scene of a motor vehicle accident in which the patient experienced burns to 35% of her body. Which action does the nurse take first?

The patient presents to the emergency department following an incident in which he sustained burns to his hands and forearms. The patient responds, “I don’t understand what everyone is concerned about – it doesn’t even hurt that bad.” Upon assessment, the nurse notes the entirety of the dermis has been destroyed and the wound base appears beefy red. The nurse anticipates the patient will be diagnosed with which type of burn?

The patient presents to the emergency department and states, "I don't remember being bitten, but it looks like I have a spider bite on my foot." Upon assessment, the nurse notes cellulitis and a large boil that is subsequently lanced and drained. The nurse anticipates administering which antibiotic?

The patient with pneumonia who has been taking PO azithromycin for four days contacts the clinic to report itching and burning in her vagina. Which response by the nurse is most appropriate?

A patient presents to the dermatology office with complaints of several areas of pruritic silver-gray patches on the elbows, knees, and trunk. The nurse anticipates which diagnosis will be made?

The 3-year-old patient is diagnosed with atopic dermatitis. The nurse provides information to the parents about which condition(s) the patient is likely to experience as he ages? Select all that apply. 

The nurse is assigned to care for a patient with human immunodeficiency virus (HIV) with an infected boil that requires lancing. Which personal protective equipment does the nurse don? Select all that apply.

A nurse is assigned to care for a 45-year-old male who is admitted for alcohol withdrawal. On the second day of admission, the patient becomes disoriented and combative, and the provider places him in bilateral wrist restraints. Which physical exam finding is most important for this patient?

The nurse is assessing a 55-year-old male in bilateral wrist and ankle restraints for violent behavior. The nurse notes that the patient’s toes have a 5 second capillary refill time. Which action by the nurse is most appropriate?

The nurse receives an order to administer digoxin 0.125 mg intramuscularly each morning to a patient in heart failure. Which part of the order does the nurse question?

A 14-year-old patient presents to the clinic complaining of right outer ear pain. Which characteristic most likely explains the cause of the pain?

Which task in the care of a patient newly diagnosed with diabetes is appropriate to delegate to an unlicensed assistive personnel?

The nurse is providing education to a patient with localized shingles. Which statement by the patient indicates the teaching was effective?

The 8-year-old presents with a generalized rash. The patient's mother reports that some areas of the rash have developed into pimples that are oozing clear fluid. The nurse places this patient on which type of precaution(s)? Select all that apply.

The patient presents to the emergency department after having a metal beam fall on his head at a work site. He was wearing a helmet which broke with the impact. He was unconscious at the scene but is awake now, and his initial assessment is completely benign. Which finding upon reassessment 30 minutes later is most concerning?

Which hospitalized patient requires continuous cardiac monitoring?

The nurse is planning care for a patient returning from surgery for a colon resection and ileal pouch-anal anastomosis. Which interventions does the nurse employ to prevent surgical site infection? Select all that apply.

At delivery, the neonate is noted to have diffuse purple lesions over the entire body and is taken to the neonatal intensive care unit for further assessment and management. The nurse notes the toes have turned black; pedal pulses are palpable. The nurse anticipates testing will reveal a deficiency in which substance?

The patient is brought to the emergency department following a serious motor vehicular accident (MVA). List the assessments the nurse performs in order from highest to lowest priority.

The nurse is involved in a motor vehicular accident in which a minor injury from the seatbelt was sustained. Which action does the nurse take first in helping the other victims?

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 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 nurse is supervising the care of a patient with a wound infected with methicillin-resistant staphylococcus aureus (MRSA). Which action by the student nurse would prompt the nurse to intervene?

Which patient is most at risk for developing a decubitus ulcer?

A paper cut represents which step in the chain of infection?

Which statement by the patient being prepared for a coronary angiogram indicates an understanding of the nurse’s teaching on the procedure?

A 21-year-old male presents with sudden onset shortness of breath. He has no history of smoking, alcohol use, recent injuries or trauma. He is 5’11” tall, weighs 130 pounds, and works as a forklift driver. His vital signs are: BP 115/64 mm Hg, HR 104 bpm, RR 26, Temp 99.0 F, and O2 Sat 91%. The nurse suspects which condition?

A patient presents to the ER after having impaled his hand with a nail from a pneumatic nail gun at work. His friend removed the nail at the scene. Which statement indicates the patient understands the teaching provided by the nurse?

The 33-year-old patient presents to the clinic with signs and symptoms of gastroesophageal reflux disease. The nurse prepares the patient for which test? 

Which diagnosis explains the patient's chronic pain in the shoulder and inability to perform passive range of motion (ROM) exercises? 

The nurse is caring for a 21-year-old diagnosed with Lyme disease. Which feature suggests this is early localized disease?

Following a motor vehicle accident, the patient is brought to the emergency department with a head injury. Upon assessment, the nurse notes otorrhea and mastoid bruising. The nurse reports the findings to the provider and suspects further testing will reveal which injury? 

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 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?

A 25-year-old female with burns is about to undergo skin autologous graft procedure. Which could be a source of the skin tissue to be transplanted to the patient?

The nurse is assigned to care for a 45-year-old patient who presents with a three-day history of fever, sore throat, chills, and myalgia. On physical assessment, the nurse notes the patient has multiple erythematous macular areas surrounding bullous lesions, some of which have ruptured and desquamated. Past medical history is significant for a recently diagnosed seizure disorder, managed with lamotrigine. Which intervention will be performed first?

The patient who has taken phenytoin for the past 12 years for seizure disorder reports feeling something strange in the mouth. The nurse anticipates observing which condition? 

The patient is prescribed phenytoin for treatment of a seizure disorder. The nurse instructs the patient about which adverse effect of treatment? 

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?

Which statement by the patient with type 2 diabetes mellitus who has received education about foot care indicates a need for further teaching?

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