Ask the patient to describe the pain
A pt presses the call bell and requests pain
medication for a severe headache. To
assess the quality of the pt. Pain, which
approach should the nurse use?
Gloves
The nurse is wearing personal protective
equipment while caring for a pt. When
exiting the room, which PPE should be
removed first?
Increasing confusion of the pt.
An older pt is brought to the ED with a
sudden onset of confusion that occurred
after experiencing a fall at home. The
daughter, who has power of attorney, has
brought the client's prescriptions. Which
information should the nurse provide first
when reporting to the healthcare provider
using SBAR communication?
Ask the pt for a description of the exercise schedule that is being followed
A pt tells the nurse about working out with a
personal trainer and swimming three times a
week in an effort to lose weight and sleep
better. The pt states that it still is taking
hours to fall asleep at night. Which action
should the nurse implement?
-review safe transfer strategies
2 days prior to discharge from the rehab -develop a nutritional plan
facility, the nurse is teaching a pt who is -help identify community support
recovering from Guillain-Barre syndrome
about home. Which actions should the nurse
include when providing discharge teaching
to the pt and spouse? SATA
pt who develop disease complications promptly received rehabilitation
The nurse implements a tertiary prevention
program for type 2 diabetes in a rural health
clinic. Which outcome indicates that the
program was effective?
participation of community leaders in planning the program
The nurse has received funding to design a
health promotion project for African
American women who are at risk for
developing breast cancer. Which resource is
most important in designing this program?
use gown, mask, and gloves with dressing changes
A pt with multiple injuries is being treated in
the burn trauma unit just hours after the
injuries occurred. The healthcare provider
instructs the nurse to avoid auto
contamination when performing dressing
changes. Which intervention is most
important for the nurse to implement?
Stimulate the pt to take deep breaths
A pt is recovering in the critical care unit
following a cardiac cath. IV nitro and heparin
are infusing. The pt is sedated but responds
to instructions. After changing positions, the
pt complains of pain at the right groin
insertion site. What action should the nurse
, Continue to obtain pt data needed to complete the fall risk survey
While the nurse is assessing an older pt fall
risk, the pt reports living at home alone and
never falling. Which action should the nurse
take?
Teach coughing and deep breathing exercises
The nurse is feeding an older adult who was
admitted with aspiration pneumonia. The pt
is weak and begins coughing while
attempting to drink through a straw. Which
intervention should the nurse implement?
Empty the pouch when it is half full.
The nurse is teaching the pt about home
care after surgery for an ileal conduit
placement. When reviewing the information,
which statement should the nurse recognize
as needing additional education?
initiate prescribed IV fluids
A 12 week gestation is admitted to the
antepartum unit with a dx of hyperemesis
gravidarum. Which action is most important
for the nurse to implement?
Picture with the bed sitting up
A pt with dyspnea is being admitted to the
medical unit. To best prepare for the pt
arrival, the nurse should ensure that the pt
bed is in which position?
Instruct pt to write down questions
A pt who is scheduled for a bronchoscopy in
the morning is anxious and asking the nurse
numerous questions about the procedure. In
preparing the pt for the procedure, which
intervention has the highest priority?
culture for sensitive organisms
While caring for a pt post operative dressing,
the nurse observes purulent drainage at the
wound. Before reporting this finding to the
provider, the nurse should review which of
the pt lab values?
Cinnamon apple sauce
A pt with a lower respiratory tract infection
receives a prescription for ciprofloxacin
500mg PO every 12hrs. When the client
requests an afternoon snack, which dietary
choice should the nurse provide?
Send emesis to lab
An older male reporting abd pain is admitted Elevate HOB
from a facility. It has been 7 days since his complete focused assessment
last BM and his abd is distended, and he just offers PRN pain meds
vomited 150ml of dark brown emesis. In
what order should the nurse implement
, take metformin for type 2 diabetes
A pt is scheduled for a spiral CT scan with
contrast to evaluate for pulmonary
embolism. Which information in the client's
history requires follow up by the nurse?
Spironolactone
The nurse should withhold which medication
if the client's serum potassium level is 6.2
mEq/?
Assess for weakness or dizziness
A nurse receives a report on a pt who is four
hours post-total abdominal hysterectomy.
The previous nurse reports that it was
necessary to change the client's perineal
pad hourly and that it is again saturated. The
previous nurse also reports that the client's
urinary output has decreased. Which action
should the nurse implement first?
-Observe breathing patterns
A pt who is admitted for primary -assess blood pressure
hypothyroidism has early signs of -measure body temp
myxedema coma. In assessing the pt, in -palpate for pedal edema
which sequence should the nurse complete
these actions?
Blurred Vision
Flat Affect
The nurse is taking the blood pressure frequent syncope
measurement of a client with Parkinson's
disease. Which information in the admission
assessment is relevant to the nurse's plan
for taking the blood pressure reading? SATA
Ask the pt about gastrointestinal pain
After administering a proton pump inhibitor,
which action should the nurse take to
evaluate the effectiveness of the
medication?
platelet count
A pt is receiving enoxaparin 30 mg
subcutaneously twice a day. In assessing for
adverse effects of the medication, which
serum laboratory value most important for
the nurse to monitor
Bradycardia
A pediatric client is taking the beta-
adrenergic blocking agent propranolol. In
developing a teaching plan, the nurse should
teach the parents to report which sign of
overdose?
Place the pt locked wheelchair on the pt strong side next to the bed
The nurse is demonstrating correct transfer
procedures to the unlicensed assistive
, A tuna fish sandwich with chips and ice cream
The nurse has completed the diet teaching
of a client who is being discharged following
tx of a leg wound. A high protein diet is
encouraged to promote wound healing.
Which lunch choice by the pt indicates that
the teaching was effective?
Fresh Turkey slices and berries
When conducting diet teaching for a pt who chick bouillon soup and toast
was dx with a myocardial infarction, which raw unsalted almonds and apples
snack foods should the nurse encourage the
pt to eat? SATA
Observe the appearance of the stool
A pt taking clopidogrel reports the onset of
diarrhea. Which nursing action should the
nurse implement first?
Risk for injury related to vertigo
A pt is dx with Meniere's disease. Which
problem should the nurse identify as most
important in the plan of care?
Suggest the nurse use 20g needle
A new nurse preparing to irrigate an IV
catheter is attaching a 24 gauge needle.
Which action should the charge nurse
implement?
A pt taking corticosteroids who has become disoriented in the last two hours.
A nurse working on an Endocrine Unit
should see which client first?
Notify the healthcare provider of the results
After an older pt receives tx for drug toxicity
the healthcare provider prescribes a 24 hr
creatinine clearance, the nurse notes that
the pt serum creatinine is 0.3mg. Which
action should the nurse implement?
Serum Creatinine of 2mg/dl
An older adult pt with Systemic inflammatory
syndrome (SIRS) has a temp of 101.8, HR
of 110, and RR of 24 breaths/min. Which
additional finding is most important to report
to the healthcare provider?
Explain that this is normal recreation and can be assessed at the next visit.
A pt in the third trimester of pregnancy
reports that she feels some lumpy places in
her breasts and that her nipples sometimes
leak a yellowish fluid. She has an
appointment with her healthcare provider in
two weeks. What actions should the nurse
take?
begin continuous fetal monitoring
A pt presents to the labor and delivery unit
with a report of leaking fluid that is greenish-
brown vaginal discharge. Which action
should the nurse take first?
This is a common newborn rash that will resolve after several days.
The mother of a 2 day old infant girl
expresses concern about a flea bite type
rash on her daughter's body. The nurse
identifies a pink papular rash with vesicles
superimposed over the thorax, back,
buttocks, and abdomen. Which explanation
A pt presses the call bell and requests pain
medication for a severe headache. To
assess the quality of the pt. Pain, which
approach should the nurse use?
Gloves
The nurse is wearing personal protective
equipment while caring for a pt. When
exiting the room, which PPE should be
removed first?
Increasing confusion of the pt.
An older pt is brought to the ED with a
sudden onset of confusion that occurred
after experiencing a fall at home. The
daughter, who has power of attorney, has
brought the client's prescriptions. Which
information should the nurse provide first
when reporting to the healthcare provider
using SBAR communication?
Ask the pt for a description of the exercise schedule that is being followed
A pt tells the nurse about working out with a
personal trainer and swimming three times a
week in an effort to lose weight and sleep
better. The pt states that it still is taking
hours to fall asleep at night. Which action
should the nurse implement?
-review safe transfer strategies
2 days prior to discharge from the rehab -develop a nutritional plan
facility, the nurse is teaching a pt who is -help identify community support
recovering from Guillain-Barre syndrome
about home. Which actions should the nurse
include when providing discharge teaching
to the pt and spouse? SATA
pt who develop disease complications promptly received rehabilitation
The nurse implements a tertiary prevention
program for type 2 diabetes in a rural health
clinic. Which outcome indicates that the
program was effective?
participation of community leaders in planning the program
The nurse has received funding to design a
health promotion project for African
American women who are at risk for
developing breast cancer. Which resource is
most important in designing this program?
use gown, mask, and gloves with dressing changes
A pt with multiple injuries is being treated in
the burn trauma unit just hours after the
injuries occurred. The healthcare provider
instructs the nurse to avoid auto
contamination when performing dressing
changes. Which intervention is most
important for the nurse to implement?
Stimulate the pt to take deep breaths
A pt is recovering in the critical care unit
following a cardiac cath. IV nitro and heparin
are infusing. The pt is sedated but responds
to instructions. After changing positions, the
pt complains of pain at the right groin
insertion site. What action should the nurse
, Continue to obtain pt data needed to complete the fall risk survey
While the nurse is assessing an older pt fall
risk, the pt reports living at home alone and
never falling. Which action should the nurse
take?
Teach coughing and deep breathing exercises
The nurse is feeding an older adult who was
admitted with aspiration pneumonia. The pt
is weak and begins coughing while
attempting to drink through a straw. Which
intervention should the nurse implement?
Empty the pouch when it is half full.
The nurse is teaching the pt about home
care after surgery for an ileal conduit
placement. When reviewing the information,
which statement should the nurse recognize
as needing additional education?
initiate prescribed IV fluids
A 12 week gestation is admitted to the
antepartum unit with a dx of hyperemesis
gravidarum. Which action is most important
for the nurse to implement?
Picture with the bed sitting up
A pt with dyspnea is being admitted to the
medical unit. To best prepare for the pt
arrival, the nurse should ensure that the pt
bed is in which position?
Instruct pt to write down questions
A pt who is scheduled for a bronchoscopy in
the morning is anxious and asking the nurse
numerous questions about the procedure. In
preparing the pt for the procedure, which
intervention has the highest priority?
culture for sensitive organisms
While caring for a pt post operative dressing,
the nurse observes purulent drainage at the
wound. Before reporting this finding to the
provider, the nurse should review which of
the pt lab values?
Cinnamon apple sauce
A pt with a lower respiratory tract infection
receives a prescription for ciprofloxacin
500mg PO every 12hrs. When the client
requests an afternoon snack, which dietary
choice should the nurse provide?
Send emesis to lab
An older male reporting abd pain is admitted Elevate HOB
from a facility. It has been 7 days since his complete focused assessment
last BM and his abd is distended, and he just offers PRN pain meds
vomited 150ml of dark brown emesis. In
what order should the nurse implement
, take metformin for type 2 diabetes
A pt is scheduled for a spiral CT scan with
contrast to evaluate for pulmonary
embolism. Which information in the client's
history requires follow up by the nurse?
Spironolactone
The nurse should withhold which medication
if the client's serum potassium level is 6.2
mEq/?
Assess for weakness or dizziness
A nurse receives a report on a pt who is four
hours post-total abdominal hysterectomy.
The previous nurse reports that it was
necessary to change the client's perineal
pad hourly and that it is again saturated. The
previous nurse also reports that the client's
urinary output has decreased. Which action
should the nurse implement first?
-Observe breathing patterns
A pt who is admitted for primary -assess blood pressure
hypothyroidism has early signs of -measure body temp
myxedema coma. In assessing the pt, in -palpate for pedal edema
which sequence should the nurse complete
these actions?
Blurred Vision
Flat Affect
The nurse is taking the blood pressure frequent syncope
measurement of a client with Parkinson's
disease. Which information in the admission
assessment is relevant to the nurse's plan
for taking the blood pressure reading? SATA
Ask the pt about gastrointestinal pain
After administering a proton pump inhibitor,
which action should the nurse take to
evaluate the effectiveness of the
medication?
platelet count
A pt is receiving enoxaparin 30 mg
subcutaneously twice a day. In assessing for
adverse effects of the medication, which
serum laboratory value most important for
the nurse to monitor
Bradycardia
A pediatric client is taking the beta-
adrenergic blocking agent propranolol. In
developing a teaching plan, the nurse should
teach the parents to report which sign of
overdose?
Place the pt locked wheelchair on the pt strong side next to the bed
The nurse is demonstrating correct transfer
procedures to the unlicensed assistive
, A tuna fish sandwich with chips and ice cream
The nurse has completed the diet teaching
of a client who is being discharged following
tx of a leg wound. A high protein diet is
encouraged to promote wound healing.
Which lunch choice by the pt indicates that
the teaching was effective?
Fresh Turkey slices and berries
When conducting diet teaching for a pt who chick bouillon soup and toast
was dx with a myocardial infarction, which raw unsalted almonds and apples
snack foods should the nurse encourage the
pt to eat? SATA
Observe the appearance of the stool
A pt taking clopidogrel reports the onset of
diarrhea. Which nursing action should the
nurse implement first?
Risk for injury related to vertigo
A pt is dx with Meniere's disease. Which
problem should the nurse identify as most
important in the plan of care?
Suggest the nurse use 20g needle
A new nurse preparing to irrigate an IV
catheter is attaching a 24 gauge needle.
Which action should the charge nurse
implement?
A pt taking corticosteroids who has become disoriented in the last two hours.
A nurse working on an Endocrine Unit
should see which client first?
Notify the healthcare provider of the results
After an older pt receives tx for drug toxicity
the healthcare provider prescribes a 24 hr
creatinine clearance, the nurse notes that
the pt serum creatinine is 0.3mg. Which
action should the nurse implement?
Serum Creatinine of 2mg/dl
An older adult pt with Systemic inflammatory
syndrome (SIRS) has a temp of 101.8, HR
of 110, and RR of 24 breaths/min. Which
additional finding is most important to report
to the healthcare provider?
Explain that this is normal recreation and can be assessed at the next visit.
A pt in the third trimester of pregnancy
reports that she feels some lumpy places in
her breasts and that her nipples sometimes
leak a yellowish fluid. She has an
appointment with her healthcare provider in
two weeks. What actions should the nurse
take?
begin continuous fetal monitoring
A pt presents to the labor and delivery unit
with a report of leaking fluid that is greenish-
brown vaginal discharge. Which action
should the nurse take first?
This is a common newborn rash that will resolve after several days.
The mother of a 2 day old infant girl
expresses concern about a flea bite type
rash on her daughter's body. The nurse
identifies a pink papular rash with vesicles
superimposed over the thorax, back,
buttocks, and abdomen. Which explanation
