1.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?: Ask the patient to describe the pain
2.The nurse is wearing personal protective equipment while caring for a
pt. When exiting the room, which PPE should be removed first?: Gloves
3.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?: Increasing confusion of the pt.
4.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?: Ask the pt for a description of the
exercise schedule that is being followed
5.2 days prior to discharge from the rehab facility, the nurse is teaching a
pt who is recovering from Guillain-Barre syndrome about home. Which
actions should the nurse include when providing discharge teaching to the
pt and spouse? SATA: -review safe transfer strategies
-develop a nutritional plan
-help identify community support
6.The nurse implements a tertiary prevention program for type 2 diabetes
in a rural health clinic. Which outcome indicates that the program was
effective?: pt who develop disease complications promptly received
rehabilitation
- 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?:
participation of community leaders in planning the program
8.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?: use
gown, mask, and gloves with dressing changes
- 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 implement?: Stimulate the pt to take
deep breaths
10.Prior to obtaining a trapeze bar for a pt with limited mobility, which pt
assessment is most important for the nurse to obtain?: upper body
muscle strength
11.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?:
Continue to obtain pt data needed to complete the fall risk survey
12.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?:
Teach coughing and deep breathing exercises
13.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?: Empty the
pouch when it is half full.
14.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?: initiate prescribed IV fluids
15.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 posi- tion?: Picture with the bed sitting up
16.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?: Instruct pt to write down questions
17.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?: culture for
sensitive organisms
18.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?:
Cinnamon apple sauce - An older male reporting abd pain is admitted from a facility. It has been
7 days since his last BM and his abd is distended, and he just vomited