You are to obtain informed consent for a Spanish-speaking patient scheduled for surgery. You do not speak Spanish and are having difficulty communicating with your patient. Which of the following resources would be most appropriate to utilize in order to obtain consent?
The hospitals language interpreter
You’re reviewing the discharge medication list of a patient diagnosed with gastric ulcer. Which of the following medication should you question?
Acetylsalicylic acid ( Bauer buffered aspirin)
When taking care of a patient with pancreatitis, which of the following lab should be reviewed?
Lipase and amylase
You’re caring for a 12 hour postoperative parathyroidectomy patient. Which assessment finding would indicate an emergency?
Laryngeal strider
Which of the following actions would be considered a violation of Hyppa?
Looking through the chart of a coworker admitted to your unit
Sinus tachycardia
You are taking care of a patient who is admitted for left flank pain with a kidney stone of 1.5 cm. He asks you about the procedure what would be the most therapeutic response?
Due to the size of the kidney stone it is an appropriate treatment?
NOT:Print reading materials about the subject and give it to the patient
The nurse is taking care of a patient who is terminally ill and has a DNR on file. Their patient has a sudden cardiac arrest and family wants CPR initiated. How should you respond?
Honor the patient’s wishes
Not normal sinus rhythm into a flutter
Correct answer is ventricular fibrillation
Your patient began deteriorating rapidly after complaining of shortness of breath. And ABG was drawn and the results are pH? HCO3 – 23. These values indicate the patient is experiencing:
Your inserting a urinary catheter into a male patient. As you inflate a balloon, the patient complains of discomfort what is the best action?
Aspirate the fluid, advance the catheter farther, then re-inflate the balloon
When assessing a patient, you notice crepitus on the right upper shoulder. You notify the physician and anticipate which diagnosis?
Subcutaneous emphysema
You are providing patient education to a patient prior to administering IV Protonix…. When there is no history of GERD
Protonix is given as G.I. prophylaxis to prevent stress ulcers
Normal sinus with VTach
The patient has a morphine PCA post operatively. On rounding you notice respirations at eight per minute O2 saturation of 82%. What medication would be given in the situation?
Narcan
You were caring for a patient who is 18 hours postop after a right BKA a. They report sudden chest pain pulse ox at 86%. The patient may be experiencing:
Pulmonary embolism
Cardiac strip
Unable to determine
At 0500, you know your patient to be diaphoretic, clammy, and their hands are shaking. The patient’s blood sugar is currently 60. Which of the following is the most appropriate intervention
Have the patient drink 120 ML’s of orange juice
Ventricular tachycardia
Normal sinus rhythm
Which of the following food items would you question in the menu of your patient who is diagnosed with celiac disease?
Wheat bread
A postoperative laparoscopic appendectomy patient is receiving morphine PCA for pain findings with alert you to the potential of a narcotic overdose?
A respiratory rate of 8 breaths per minute
Paced rhythm
Your patient was admitted with severe dehydration. Which of the following orders would you question
KCI 40 mEq IV push STAT
What is the first sign of increased intracranial pressure?
Change in LOC
A patient suddenly complains of new onset of chest pain. The doctor is suspecting a possible?… What is most likely to be ordered?
Morphine Duramorph, oxygen, nitrates,
Aceticsalicylic acid, bayer buffered aspirin
The Glasgow, scale ranges from:
3 to 15
You deserve the nurse aid removing her gloves and immediately using alcohol hand sanitizer in a room with a patient who has C-Diff. What education should you provide to the nurse aide
And washing with soap and water is mandatory because alcohol based hand sanitizers do not kill C-diff
Heart rate
80
Which of the following assessment findings should you report immediately to the physician for a patient who just had a bronchoscopy and biopsy?
Sputum with streaks of blood
NOT: increased salivation
Your patient was just returned from surgery with a Jackson-Pratt JP drain in place which of the following is the best nursing action?
Compress the drain, then plug the bulb to establish suction
Patient is admitted for shortness of breath. Do you notice the spouse adjusting the oxygen on the wall and she states “she always takes care of my husband” what would be an appropriate response?
Educate the spouse on oxygen use as a medical device in the hospital
Deposition has ordered for your patience to begin a 24 hour urine collection. Your patient voids for the first time two hours after the orders received. What should be done with this urine sample?
Discarded, then begin the 24 hour collection
Which of the following lab values would you expect to see in a patient diagnosed with?….
Lipase – 196
You were caring for a patient admitted with abdominal pain. Your patient has a bowel movement and you know dark tarry stool what would be the diagnosis?
Upper G.I. bleed
Your COPD patient is complaining of wheezing and increased shortness of breath
Assess your patient for a change in condition
What information is vital for you to know prior to administering an ordered dose of digoxin
Heart rate
Your patient has been diagnosed with a hemorrhagic CVA
Heparin infusion per pharmacy protocol
A 56-year-old man has an acute onset of shortness of breath, chest pain, apprehension, rapid pulse, cough with bloody sputum, diaphoresis, and syncope. The symptoms are indicative of:
Pulmonary embolism?
NOT: tuberculosis
You’re reviewing the menu list of a patient on Warfran what food should they not eat?
Spinach
Which of the following issues should be reported up the chain of command
A coworker arriving to work under the influence of alcohol
You’re providing discharge instructions to a CHF patient.
Increase shortness of breath
cardiac rhythm
V-Tach
Which of the following electrolyte value should be Addressed immediately by the nurse
Potassium 2.5 mEq/L
Which of the following medication may cause urine discoloration
Rifampin
Calculate the 12 hour intake for a patient that has received the following during your shift: normal saline 750 ML, 24 ounces of sprite, Levaquin 50 ML, 650 ML urine in Foley catheter
1520
When caring for a patient experiencing a tonic clonic seizure, the most appropriate nursing intervention is:
Protecting the patient’s head and extremities from contact with surrounding objects
You went to the room of a 58-year-old female. You find that the patient’s cardiac monitor shows asystolye, what should be your first action?
Assess the patient
Not: start CPR
Didn’t nurse ask you about the typical signs and symptoms of myocardial infarction
Women could have pain in their arm, neck, back or jaw
While performing the narcotic count at the end of the shift, my coworker admits to something, coworker to sign for the ways that you did not witness
Refused to sign for the waste
Cardiac strip
Sinus rhythm with PAC
You’re preparing your patient for discharge need to provide dietary education related to his diagnosis what should you instruct the patient to avoid?
Canned meats
Your patient complains of not being able to urinate since 0500. It is now 1900. What should be your next step?
Perform a bladder scan
The doctor ordered Lasix 40 mg IV push, 100mg/10 mL
4ml
After a patient completes dialysis, you should anticipate seeing an improvement in which of the following lab values?
NOT: ammonia
Your patient fell and hit his head on the bed rail during a physical therapy session. Upon initial assessment you observe a blood pressure of 90/45, heart rate of 28, and a constricted pupil. The patient is lying in a supine position. What should be your first response?
Call a rapid response
Which of the following antidiabetic medication is contraindicated 48 hours after receiving contrast dye
Metformin
You’re a king for a patient who is postop after surgical removal of fibroids. She hears a pop sound after coughing in her surgical wound has dehisced
Apply sterile saline soap towels over the extruding site
One of the signs of left sided heart failure is:
Pulmonary edema
NOT: pedal edema
Your patient had a TB skin test done on Thursday at 2:45 PM
Saturday at 3 PM
1.2 milligrams is equal to how many micrograms?
1200 mcg
Your post-op patient has a Jackson-Pratt (JP) drain in place. How do you ensure effective drain function?
Compress the drain, then plug the bulb to establish suction
Your male patient complains of discomfort while inflating the balloon during insertion of an indwelling urinary catheter. What would be the MOST appropriate action?
Deflate the balloon, advance the catheter further, then reinflate the balloon
Your patient has symptomatic anemia but is refusing a blood transfusion for religious reason. What is an appropriate response?
Respect his wishes and notify the provider
Your patient is admitted with diverticulitis. What type of diet do you expect to be ordered for the patient?
broth, jello, soft fruit no skin,
You were hired to work the medical unit and when you arrive at work the charge nurse has assigned you to the post-surgical unit since they are understaffed. Which is the MOST appropriate action?
Report to the post-surgical unit.
What is a proton pump inhibitor, such as pantoprazole (Protonix) used for?
Acid Reduction
Which adaptive equipment would be MOST appropriate to use for a severely contracted patient who is unable to bear weight when transferring from the bed to the chair?
Patient lift (e.g., Hoyer)
Which tool should you use to assess pain in you 80-year-old patient with severe dementia?
PAINAD scale
Your patient is admitted from the ED with failure to thrive and advanced dementia. You note he is extremely underweight, appears unbathed for some time, and has a stage 4 pressure injury to his coccyx. You were told in report that he lives at home with family members. What should you do?
Notify the charge nurse and social worker of your concerns.
Your 85-year-old patient with atrial fibrillation fell at home 3 days ago. You notice she has been having several episodes of acute confusion since being admitted to your unit. What is the MOST important order you should anticipate from the provider?
Stat CT of head
Your patient has a temp of 102.3 F, HR 122, and has had 15 mL of urine from the indwelling urinary catheter in the last 2 hours. What is your patient MOST likely experiencing.
Sepsis
What type of personal protective equipment (PPE) is applied prior to entering a room for a patient with C. diff?
Gown and gloves
Your patient continues to pull at their IV site located in their left forearm despite verbal reminders and increased observation. The nursing assistant recommends using soft mitt restraints on the patient. What is your recommendation?
Request an order for soft mitts as they are the least restrictive
Your patient was admitted for a hypertensive crisis and has a history of HTN, Parkinson’s disease, depression, and alcohol use. On his second hospitalized day, you notice he is more anxious and restless than his baseline. What would be your FIRST nursing intervention?
Ask the patient when his last drink of alcohol was.
What is the BEST indication of an acute neurological problem?
Change in level of consciousness
While in a supine position your patient states, “I’m tired and cannot catch my breath.” Physical assessment reveals jugular vein distention and a third heart sound (S3). These symptoms are indicative of what condition?
Heart failure
Your new admission presents with a cough, unintentional weight loss, frequent night sweats, and bloody sputum. What type of isolation precautions should you initiate, if any?
Airborne precautions
Patients with diabetes are at high risk for complications from damage to what body areas?
Nerve and kidney damage
If your patient with a known history of diabetes is displaying symptoms of diaphoresis, cool skin, lethargy, and shakiness. What is your first action?
Check the patient’s blood glucose level.
Your patient tells you, “I hope I don’t die, but if I do I don’t want to be brought back.? You notice on her chart and wrist band that she is a full code. What would be the MOST appropriate action?
Discuss code status with the patient and follow up with provider to ensure the medical record reflects her wishes.
Your coworker posted photos on social media from a birthday party they had for her in the unit breakroom. What should be your NEXT course of action?
No action is necessary because no PHI was displayed.
Your new patient understands very limited English. How should you communicate with them when completing the admission assessment?
Use the organization’s interpreter services.
You are caring for a patient with a history of diabetes mellitus. You walk into the room and find the patient lethargic and diaphoretic. What is your first action?
Obtain capillary blood glucose level.
Your patient is 4 hours post open appendectomy and has not voided yet. You note his lower abdomen is distended. What should you do NEXT?
Perform a bladder scan
A patient with peritonitis presents with tachycardia, hypotension, and dehydration. What other assessment finding would you anticipate as part of your physical assessment?
Severe abdominal pain or rebound tenderness
What is the EARLIEST sign indicating increased intracranial pressure (ICP)?
Level of consciousness
In addition to pain, pallor, and pulselessness, a neurovascular assessment also includes checking for:
Paresthesia and paralysis
You received a report on a patient that sustained a right hemisphere CVA 48 hours ago. What do you expect the patient to exhibit?
Left sided weakness of the leg, arm, and face.
You are ordered to give digoxin (Lanoxin). Your patients vital signs are: BP 130/70, Temp 97.9F, HR 52, RR 16, O2 Sat 100% on room air. What should you do NEXT?
Hold digoxin (Lanoxin) and call the provider
Upon entry to your patient’s room, you find her sitting in High Fowler’s position and complaining of shortness of breath. Her respiratory rate is 34 breaths/min and O2 sat is 84%. Which mode of oxygen delivery would MOST likely reverse these symptoms?
Non-rebreather mask
Your patient is on contact precautions for active MRSA. What proper PPE should you use before entering the room?
Gown and gloves
Your patient recently had a G-tube placed and intermittent enteral feedings have been initiated. What symptoms may indicate intolerance to the feedings?
Vomiting and diarrhea
Upon entering your patient’s room, you note that they are having a seizure. What is your FIRST action?
Position the patient on their side to maintain the airway.
Your 18-year-old female patient was admitted with dehydration secondary to anorexia nervosa. During your assessment you note she has a flat affect and says, “I just want to die. I’m tired of my life.” What should be your FIRST intervention?
Stay with the patient and ask fi she has a plan to carry out this wish.
Your patient has a non-productive cough and presence of secretions in his tracheostomy. Prior to suctioning the patient, what should you do FIRST?
Hyperoxygenate patient.
Your patient takes 5 mg of warfarn (Coumadin/Jantoven) daily and reports having black colored stool today. What do you most likely suspect?
Gastrointestinal bleeding
Your new patient was admitted with blunt force trauma to the abdomen following a motor vehicle accident (MVA). A NG tube is in place for decompression; however, you note during the assessment that the stomach is rigid and hard during palpation. What condition do you suspect?
Hemorrhage
Which of the following nursing diagnoses is MOST important for a patient with chronic obstructive pulmonary disease (COPD)?
Impaired gas exchange
You have a patient going for dialysis. Their medications include lisinopril (Prinivil), ondansetron (Zofran), famotidine (Pepcid), and atorvastatin (Lipitor). Which medication would you possibly hold and seek clarification?
famotidine (Pepcid)
What is an early symptom that the patient is developing a complication of heart failure?
Edema in the legs and feet
Black and tarry colored stools are CLASSIC symptoms of what condition?
Bleeding gastric ulcer
You have 4 patients who have high priority needs. One needs to go to surgery, one needs STAT lab draws from a PICC line, another has chest pain rated 8/10, and another needs toileting. Which patient should you tend to FIRST?
The patient with chest pain
Your patient with Hepatitis C exhibits signs of jaundice and a distended abdomen. What procedure would you anticipate being performed by the provider at the bedside for this patient?
Paracentesis
What is clubbing of the fingers MOST likely associated with?
Chronic oxygen deficiency
A patient on warfarin (Coumadin/Jantoven) has an INR of 6. Which medication would you anticipate administering?
Vitamin K
To reduce the risk of infection and phlebitis in an adult patient with a peripheral IV, what is the MINIMUM duration the catheter should remain in place before ROUTINE replacement?
72 hours
You are caring for a patient post lobectomy with a chest tube in place for drainage. What is a priority in care for this patient?
Encourage the patient to cough and deep breathe.
What patient population is the pneumococcal vaccine, PPSV23 indicated for?
Adults aged 65 years and older
Your patient with stave IV terminal lung cancer continues to experience increasing pain as each day passes. What would you anticipate the provider ordering for this patient?
Palliative care consult
The provider gives you a telephone order to explain a surgical procedure to your patient and obtain surgical consent. How should you respond?
Inform the provider that explaining the procedure is outside the nurse’s scope of practice.
The patient has diltiazem HCl (Cardizem CD) ordered and is requesting the capsule be mixed into her morning yogurt. How should you respond?
“Sorry, it is a slow-release medication that cannot be opened or crushed.”
Your 72-year-old male patient is admitted for colon cancer related complications and has a history of CHF, stroke, and a recent knee replacement. Based on your patient’s risk assessment, you determine he is at risk for venous thromboembolism (VTE). What is an appropriate VTE prophylaxis order for this patient?
Enoxaparin (Lovenox) once daily and intermittent pneumatic compressions (IPC)
You receive a provider’s order that is not consistent with evidence-based practice. What is your FIRST step?
Clarify the order with the provider.
When would sucralfate (Carafate) 4 times daily be scheduled for?
1 hour before meals and at bedtime
Your patient’s morning labs revealed a hemoglobin level of 6.3 and hematocrit of 18. What blood product do you expect to administer?
PRBCs
Your 68-year-old patient is a Type 1 diabetic with a history of schizophrenia and exhibits signs and symptoms of tardive dyskinesia. What long-term medication is associated with signs and symptoms of tardive dyskinesia?
risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, paliperidone, lurasidone, chlorpromazine, fluphenazine, haloperidol, perphenazine
Your 80-year-old patient is being discharged home post CVA. She lives alone, yet still requires assistance with ADLs. What referral is MOST appropriate to ensure her needs are met?
Case Manager
Central Telemetry calls and tells you your patient is experiencing bradycardia. What is the first thing you should do after entering the room?
Assess the patient and take vital signs.
Your patient is currently under 1:1 observation for suicide precautions. He states he needs to have a bowel movement and would like some privacy to use the bathroom. What is the MOST appropriate response?
“I must be within an arms’ length view of you at all times for your safety, including while using the bathroom.”
A female patient requests a female nurse to provide care for her based on her religious beliefs. What is the MOST appropriate action to take?
Accommodate her request if possible.
Your patient is a 40-year-old female with a recent history of hair loss, extremely dry skin, a nd a 20-point weight loss in the last 3 weeks. She also exhibits occasional episodes of tremors in her upper extremities. What condition do these symptoms MOST likely indicate?
Hyperthyroidism
Insulin lispro (Humalog) is orders via sliding scale a.c. for your patient with diabetes. When is the best time to administer insulin lispro (Humalog)?
15 min before the meal arrives
Which of the following would be used as part of the preop procedure to prevent infection?
Prophylactic antibiotics
Two days after surgery, your 72-year-old patient is showing signs of agitation and confusion, which is not his baseline. The severity fluctuates throughout the day. His medications include hydromorphone (Dilaudid), amlodipine (Norvasc), alprazolam (Xanax), and carbidopa-levodopa (Sinemet). What condition do you MOST likely suspect?
Delirium
What is the proper technique when suctioning a tracheostomy?
Suction in a circular motion while the catheter is being pulled out.
Your new patient admitted for cholecystitis expresses she has a history of anxiety disorder. She is feeling panicked and does not think she can handle staying in the hospital for her surgery. What action is MOST appropriate for you to take?
Sit calmly next to her and offer her compassion and a sense of security.
The provider orders and IV infusion of D5W 1000 mL to infuse over the next 6 hours. How many mLs per hour should the IV pump be set to?
167 mL/hr
You are assigned a new admission and note a Braden score of 11 after completing your assessment. Which interventions would be MOST appropriate based on your assessment?
Turn q 2hours, request nutrition consult, request low airloss mattress.
Your patient may have tuberculosis TB) and is placed in airborne precautions. What test would you expect to be ordered?
Acid-fast bacilli sputum
Your patient starts to complain of difficulty breathing while laying down, and states that he has been coughing up pink sputum. While performing your assessment, you notice jugular vein distention and coarse crackles in both lungs on auscultation. What diagnosis do you suspect?
Congestive heart failure
You received a patient post op transurethral resection of the prostate (TURP). Which of the following symptoms would cause you the MOST concern?
Hemorrhage and hypotension
Your patient with C. diff (Clostridioides difficile) has a family member about to leave the room. What education about performing hand hygiene should you give?
Hand hygiene with soap and water
Your patient has a diagnosis of urinary tract infection (UTI) and is currently taking medication that has recently made her urine reddish-orange. Which of the following medications would cause this side effect?
Phenazopyridine (Pyridium)
Your patient is taking digoxin (Lanoxin) and has a potassium level of 3.0. How might this affect the patient?
Increase risk of digoxin toxicity
You are preparing to hang 1 unit PRBC’s to administer to your patient. The patient states, “I don’t take blood products.” What is the MOST appropriate response?
“You have the right to refuse the blood transfusion. I will inform the provider of your decision.”
An older adult patient arrives on the unit looking emaciated, disheveled, and with soiled clothes. The patient claims that his daughter cares for him at home. What would you suspect?
Neglect
You just left your patient’s room with her husband at bedside. You then receive a phone call from someone states that she is your patient’s mother and demands updates about your patient. What should you do NEXT?
Verify your patient’s consent to release information to her mother.
The provider orders Heparin 4 units/kg SQ. Your patient weighs 176 pounds. How many units should you administer?
320 units
What diagnostic finding would support a diagnosis of deep vein thrombosis?
Positive D-dimer
You are caring for a combative 85-year-old male with a history of dementia, CHF, UTI, and anemia. The family states he appears to be more confused than his baseline. What tests do you expect the provider to order?
Urinalysis with cultures, CBC
A patient has recently been diagnosed with terminal cancer. Her responses are caustic and abrasive. What is the BEST way to respond?
Acknowledge her feelings, understanding this is expected in the grieving process.
You notice your patient who recently had a stroke is coughing intermittently during meals. What is the MOST likely cause of this?
He could be aspirating.
A patient with acute diverticulitis is MOST likely to complain of abdominal pain with what quadrant?
Left lower quadrant
Which of the following is MOST important in preventing a catheter associated urinary tract infection (CAUTI)?
Using sterile technique when inserting the catheter
The provider orders a Heparin infusion of 900 units/hr. Your IV medication on hand has 25,000 units of Heparin in 500 mL of D5W. How many mL/hr will you infuse?
18 mL/hr
Your patient has developed a productive cough and fever. The provider is suspecting influenza. Which actions should you take FIRST?
Initiate droplet precautions
What medication would you anticipate to be ordered for a patient who has a LDL > 200 mg/dL?
Statin
Fifteen minutes after starting a blood transfusion, the patient complains of lower back pain, shortness of breath, and chills. What is your FIRST action?
Stop the tranfusion.
Your patient had a transurethral resection of the prostate (TURP) 24 hours ago. What signs require further intervention?
Bright red urine
What condition (not medication related) might cause an elevation in the patients PT/INR level?
Liver disease
Your patient admitted for small bowel obstruction has been vomiting for the last 3 days. What electrolyte imbalance would you expect to be associated with this patient?
Hypokalemia
Digoxin (Lanoxin) 125 mcg is equivalent to how many mg?
0.125mg
As you are walking down the hallway you overhear your colleague discussing her personal family issues with a patient. What would be the MOST appropriate response?
Remind her later of her responsibility for establishing and maintaining professional boundaries with patients.
Your patient, who has soft wrist restraints for safety (non-violent), is working with the occupational therapist at the bedside. The nursing assistant enters and says, “The patient is not allowed to have his restraints untied.” How do you respond?
“Restraints can be temporarily off while directly working with staff. Let me know when the therapy session is finished and I will re-apply them.”
Your patient suddenly develops signs and symptoms of shortness of breath, restlessness, tachypnea, hemoptysis, and decreased oxygen saturations despite being on 2L/min of O2 by nasal cannula. What do you expect is happening?
Pulmonary embolism
The dosage of which drug must be tapered down slowly to prevent acute adrenal insufficiency?
Prednisone
Your patient with CHF states, “I can still eat the same food, I just have to weight myself everyday.” Based on this statement, which nursing diagnosis would be appropriate?
Knowledge Deficit
patient arrives on unit. you do an assessment and notice lice in her hair. what is your first action?
Secure a private room
Patient presents dusky pallor and pulseless. First action
Initiate facility code procedure
1.2 milligrams is equal to how many micrograms?
1200 mcg
Your post-op patient has a Jackson-Pratt (JP) drain in place. How do you ensure effective drain function?
Compress the drain, then plug the bulb to establish suction
Your male patient complains of discomfort while inflating the balloon during insertion of an indwelling urinary catheter. What would be the MOST appropriate action?
Deflate the balloon, advance the catheter further, then reinflate the balloon
Your patient has symptomatic anemia but is refusing a blood transfusion for religious reason. What is an appropriate response?
Respect his wishes and notify the provider
Your patient is admitted with diverticulitis. What type of diet do you expect to be ordered for the patient?
broth, jello, soft fruit no skin,
You were hired to work the medical unit and when you arrive at work the charge nurse has assigned you to the post-surgical unit since they are understaffed. Which is the MOST appropriate action?
Report to the post-surgical unit.
What is a proton pump inhibitor, such as pantoprazole (Protonix) used for?
Acid Reduction
Which adaptive equipment would be MOST appropriate to use for a severely contracted patient who is unable to bear weight when transferring from the bed to the chair?
Patient lift (e.g., Hoyer)
Which tool should you use to assess pain in you 80-year-old patient with severe dementia?
PAINAD scale
Your patient is admitted from the ED with failure to thrive and advanced dementia. You note he is extremely underweight, appears unbathed for some time, and has a stage 4 pressure injury to his coccyx. You were told in report that he lives at home with family members. What should you do?
Notify the charge nurse and social worker of your concerns.
Your 85-year-old patient with atrial fibrillation fell at home 3 days ago. You notice she has been having several episodes of acute confusion since being admitted to your unit. What is the MOST important order you should anticipate from the provider?
Stat CT of head
Your patient has a temp of 102.3 F, HR 122, and has had 15 mL of urine from the indwelling urinary catheter in the last 2 hours. What is your patient MOST likely experiencing.
Sepsis
What type of personal protective equipment (PPE) is applied prior to entering a room for a patient with C. diff?
Gown and gloves
Your patient continues to pull at their IV site located in their left forearm despite verbal reminders and increased observation. The nursing assistant recommends using soft mitt restraints on the patient. What is your recommendation?
Request an order for soft mitts as they are the least restrictive
Your patient was admitted for a hypertensive crisis and has a history of HTN, Parkinson’s disease, depression, and alcohol use. On his second hospitalized day, you notice he is more anxious and restless than his baseline. What would be your FIRST nursing intervention?
Ask the patient when his last drink of alcohol was.
What is the BEST indication of an acute neurological problem?
Change in level of consciousness
While in a supine position your patient states, “I’m tired and cannot catch my breath.” Physical assessment reveals jugular vein distention and a third heart sound (S3). These symptoms are indicative of what condition?
Heart failure
Your new admission presents with a cough, unintentional weight loss, frequent night sweats, and bloody sputum. What type of isolation precautions should you initiate, if any?
Airborne precautions
Patients with diabetes are at high risk for complications from damage to what body areas?
Nerve and kidney damage
If your patient with a known history of diabetes is displaying symptoms of diaphoresis, cool skin, lethargy, and shakiness. What is your first action?
Check the patient’s blood glucose level.
Your patient tells you, “I hope I don’t die, but if I do I don’t want to be brought back.? You notice on her chart and wrist band that she is a full code. What would be the MOST appropriate action?
Discuss code status with the patient and follow up with provider to ensure the medical record reflects her wishes.
Your coworker posted photos on social media from a birthday party they had for her in the unit breakroom. What should be your NEXT course of action?
No action is necessary because no PHI was displayed.
Your new patient understands very limited English. How should you communicate with them when completing the admission assessment?
Use the organization’s interpreter services.
You are caring for a patient with a history of diabetes mellitus. You walk into the room and find the patient lethargic and diaphoretic. What is your first action?
Obtain capillary blood glucose level.
Your patient is 4 hours post open appendectomy and has not voided yet. You note his lower abdomen is distended. What should you do NEXT?
Perform a bladder scan
A patient with peritonitis presents with tachycardia, hypotension, and dehydration. What other assessment finding would you anticipate as part of your physical assessment?
Severe abdominal pain or rebound tenderness
What is the EARLIEST sign indicating increased intracranial pressure (ICP)?
Level of consciousness
In addition to pain, pallor, and pulselessness, a neurovascular assessment also includes checking for:
Paresthesia and paralysis
You received a report on a patient that sustained a right hemisphere CVA 48 hours ago. What do you expect the patient to exhibit?
Left sided weakness of the leg, arm, and face.
You are ordered to give digoxin (Lanoxin). Your patients vital signs are: BP 130/70, Temp 97.9F, HR 52, RR 16, O2 Sat 100% on room air. What should you do NEXT?
Hold digoxin (Lanoxin) and call the provider
Upon entry to your patient’s room, you find her sitting in High Fowler’s position and complaining of shortness of breath. Her respiratory rate is 34 breaths/min and O2 sat is 84%. Which mode of oxygen delivery would MOST likely reverse these symptoms?
Non-rebreather mask
Your patient is on contact precautions for active MRSA. What proper PPE should you use before entering the room?
Gown and gloves
Your patient recently had a G-tube placed and intermittent enteral feedings have been initiated. What symptoms may indicate intolerance to the feedings?
Vomiting and diarrhea
Upon entering your patient’s room, you note that they are having a seizure. What is your FIRST action?
Position the patient on their side to maintain the airway.
Your 18-year-old female patient was admitted with dehydration secondary to anorexia nervosa. During your assessment you note she has a flat affect and says, “I just want to die. I’m tired of my life.” What should be your FIRST intervention?
Stay with the patient and ask fi she has a plan to carry out this wish.
Your patient has a non-productive cough and presence of secretions in his tracheostomy. Prior to suctioning the patient, what should you do FIRST?
Hyperoxygenate patient.
Your patient takes 5 mg of warfarn (Coumadin/Jantoven) daily and reports having black colored stool today. What do you most likely suspect?
Gastrointestinal bleeding
Your new patient was admitted with blunt force trauma to the abdomen following a motor vehicle accident (MVA). A NG tube is in place for decompression; however, you note during the assessment that the stomach is rigid and hard during palpation. What condition do you suspect?
Hemorrhage
Which of the following nursing diagnoses is MOST important for a patient with chronic obstructive pulmonary disease (COPD)?
Impaired gas exchange
You have a patient going for dialysis. Their medications include lisinopril (Prinivil), ondansetron (Zofran), famotidine (Pepcid), and atorvastatin (Lipitor). Which medication would you possibly hold and seek clarification?
famotidine (Pepcid)
What is an early symptom that the patient is developing a complication of heart failure?
Edema in the legs and feet
Black and tarry colored stools are CLASSIC symptoms of what condition?
Bleeding gastric ulcer
You have 4 patients who have high priority needs. One needs to go to surgery, one needs STAT lab draws from a PICC line, another has chest pain rated 8/10, and another needs toileting. Which patient should you tend to FIRST?
The patient with chest pain
Your patient with Hepatitis C exhibits signs of jaundice and a distended abdomen. What procedure would you anticipate being performed by the provider at the bedside for this patient?
Paracentesis
What is clubbing of the fingers MOST likely associated with?
Chronic oxygen deficiency
A patient on warfarin (Coumadin/Jantoven) has an INR of 6. Which medication would you anticipate administering?
Vitamin K
To reduce the risk of infection and phlebitis in an adult patient with a peripheral IV, what is the MINIMUM duration the catheter should remain in place before ROUTINE replacement?
72 hours
You are caring for a patient post lobectomy with a chest tube in place for drainage. What is a priority in care for this patient?
Encourage the patient to cough and deep breathe.
What patient population is the pneumococcal vaccine, PPSV23 indicated for?
Adults aged 65 years and older
Your patient with stave IV terminal lung cancer continues to experience increasing pain as each day passes. What would you anticipate the provider ordering for this patient?
Palliative care consult
The provider gives you a telephone order to explain a surgical procedure to your patient and obtain surgical consent. How should you respond?
Inform the provider that explaining the procedure is outside the nurse’s scope of practice.
The patient has diltiazem HCl (Cardizem CD) ordered and is requesting the capsule be mixed into her morning yogurt. How should you respond?
“Sorry, it is a slow-release medication that cannot be opened or crushed.”
Your 72-year-old male patient is admitted for colon cancer related complications and has a history of CHF, stroke, and a recent knee replacement. Based on your patient’s risk assessment, you determine he is at risk for venous thromboembolism (VTE). What is an appropriate VTE prophylaxis order for this patient?
Enoxaparin (Lovenox) once daily and intermittent pneumatic compressions (IPC)
You receive a provider’s order that is not consistent with evidence-based practice. What is your FIRST step?
Clarify the order with the provider.
When would sucralfate (Carafate) 4 times daily be scheduled for?
1 hour before meals and at bedtime
Your patient’s morning labs revealed a hemoglobin level of 6.3 and hematocrit of 18. What blood product do you expect to administer?
PRBCs
Your 68-year-old patient is a Type 1 diabetic with a history of schizophrenia and exhibits signs and symptoms of tardive dyskinesia. What long-term medication is associated with signs and symptoms of tardive dyskinesia?
risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, paliperidone, lurasidone, chlorpromazine, fluphenazine, haloperidol, perphenazine
Your 80-year-old patient is being discharged home post CVA. She lives alone, yet still requires assistance with ADLs. What referral is MOST appropriate to ensure her needs are met?
Case Manager
Central Telemetry calls and tells you your patient is experiencing bradycardia. What is the first thing you should do after entering the room?
Assess the patient and take vital signs.
Your patient is currently under 1:1 observation for suicide precautions. He states he needs to have a bowel movement and would like some privacy to use the bathroom. What is the MOST appropriate response?
“I must be within an arms’ length view of you at all times for your safety, including while using the bathroom.”
A female patient requests a female nurse to provide care for her based on her religious beliefs. What is the MOST appropriate action to take?
Accommodate her request if possible.
Your patient is a 40-year-old female with a recent history of hair loss, extremely dry skin, a nd a 20-point weight loss in the last 3 weeks. She also exhibits occasional episodes of tremors in her upper extremities. What condition do these symptoms MOST likely indicate?
Hyperthyroidism
Insulin lispro (Humalog) is orders via sliding scale a.c. for your patient with diabetes. When is the best time to administer insulin lispro (Humalog)?
15 min before the meal arrives
Which of the following would be used as part of the preop procedure to prevent infection?
Prophylactic antibiotics
Two days after surgery, your 72-year-old patient is showing signs of agitation and confusion, which is not his baseline. The severity fluctuates throughout the day. His medications include hydromorphone (Dilaudid), amlodipine (Norvasc), alprazolam (Xanax), and carbidopa-levodopa (Sinemet). What condition do you MOST likely suspect?
Delirium
What is the proper technique when suctioning a tracheostomy?
Suction in a circular motion while the catheter is being pulled out.
Your new patient admitted for cholecystitis expresses she has a history of anxiety disorder. She is feeling panicked and does not think she can handle staying in the hospital for her surgery. What action is MOST appropriate for you to take?
Sit calmly next to her and offer her compassion and a sense of security.
The provider orders and IV infusion of D5W 1000 mL to infuse over the next 6 hours. How many mLs per hour should the IV pump be set to?
167 mL/hr
You are assigned a new admission and note a Braden score of 11 after completing your assessment. Which interventions would be MOST appropriate based on your assessment?
Turn q 2hours, request nutrition consult, request low airloss mattress.
Your patient may have tuberculosis TB) and is placed in airborne precautions. What test would you expect to be ordered?
Acid-fast bacilli sputum
Your patient starts to complain of difficulty breathing while laying down, and states that he has been coughing up pink sputum. While performing your assessment, you notice jugular vein distention and coarse crackles in both lungs on auscultation. What diagnosis do you suspect?
Congestive heart failure
You received a patient post op transurethral resection of the prostate (TURP). Which of the following symptoms would cause you the MOST concern?
Hemorrhage and hypotension
Your patient with C. diff (Clostridioides difficile) has a family member about to leave the room. What education about performing hand hygiene should you give?
Hand hygiene with soap and water
Your patient has a diagnosis of urinary tract infection (UTI) and is currently taking medication that has recently made her urine reddish-orange. Which of the following medications would cause this side effect?
Phenazopyridine (Pyridium)
Your patient is taking digoxin (Lanoxin) and has a potassium level of 3.0. How might this affect the patient?
Increase risk of digoxin toxicity
You are preparing to hang 1 unit PRBC’s to administer to your patient. The patient states, “I don’t take blood products.” What is the MOST appropriate response?
“You have the right to refuse the blood transfusion. I will inform the provider of your decision.”
An older adult patient arrives on the unit looking emaciated, disheveled, and with soiled clothes. The patient claims that his daughter cares for him at home. What would you suspect?
Neglect
You just left your patient’s room with her husband at bedside. You then receive a phone call from someone states that she is your patient’s mother and demands updates about your patient. What should you do NEXT?
Verify your patient’s consent to release information to her mother.
The provider orders Heparin 4 units/kg SQ. Your patient weighs 176 pounds. How many units should you administer?
320 units
What diagnostic finding would support a diagnosis of deep vein thrombosis?
Positive D-dimer
You are caring for a combative 85-year-old male with a history of dementia, CHF, UTI, and anemia. The family states he appears to be more confused than his baseline. What tests do you expect the provider to order?
Urinalysis with cultures, CBC
A patient has recently been diagnosed with terminal cancer. Her responses are caustic and abrasive. What is the BEST way to respond?
Acknowledge her feelings, understanding this is expected in the grieving process.
You notice your patient who recently had a stroke is coughing intermittently during meals. What is the MOST likely cause of this?
He could be aspirating.
A patient with acute diverticulitis is MOST likely to complain of abdominal pain with what quadrant?
Left lower quadrant
Which of the following is MOST important in preventing a catheter associated urinary tract infection (CAUTI)?
Using sterile technique when inserting the catheter
The provider orders a Heparin infusion of 900 units/hr. Your IV medication on hand has 25,000 units of Heparin in 500 mL of D5W. How many mL/hr will you infuse?
18 mL/hr
Your patient has developed a productive cough and fever. The provider is suspecting influenza. Which actions should you take FIRST?
Initiate droplet precautions
What medication would you anticipate to be ordered for a patient who has a LDL > 200 mg/dL?
Statin
Fifteen minutes after starting a blood transfusion, the patient complains of lower back pain, shortness of breath, and chills. What is your FIRST action?
Stop the tranfusion.
Your patient had a transurethral resection of the prostate (TURP) 24 hours ago. What signs require further intervention?
Bright red urine
What condition (not medication related) might cause an elevation in the patients PT/INR level?
Liver disease
Your patient admitted for small bowel obstruction has been vomiting for the last 3 days. What electrolyte imbalance would you expect to be associated with this patient?
Hypokalemia
Digoxin (Lanoxin) 125 mcg is equivalent to how many mg?
0.125mg
As you are walking down the hallway you overhear your colleague discussing her personal family issues with a patient. What would be the MOST appropriate response?
Remind her later of her responsibility for establishing and maintaining professional boundaries with patients.
Your patient, who has soft wrist restraints for safety (non-violent), is working with the occupational therapist at the bedside. The nursing assistant enters and says, “The patient is not allowed to have his restraints untied.” How do you respond?
“Restraints can be temporarily off while directly working with staff. Let me know when the therapy session is finished and I will re-apply them.”
Your patient suddenly develops signs and symptoms of shortness of breath, restlessness, tachypnea, hemoptysis, and decreased oxygen saturations despite being on 2L/min of O2 by nasal cannula. What do you expect is happening?
Pulmonary embolism
The dosage of which drug must be tapered down slowly to prevent acute adrenal insufficiency?
Prednisone
Your patient with CHF states, “I can still eat the same food, I just have to weight myself everyday.” Based on this statement, which nursing diagnosis would be appropriate?
Knowledge Deficit
patient arrives on unit. you do an assessment and notice lice in her hair. what is your first action?
Secure a private room
Patient presents dusky pallor and pulseless. First action
Initiate facility code procedure
Which adaptive equipment would be most appropriate to use for a severely contracted patient who is unable to bear weight when transferring from bed to chair
Patient Lift example hoyer
What lab values are expected to be in a patient with end stage renal disease on hemodialysis
BUN 32, CREATNINE 8.32
Your 85 year old patient with atrial fibrillation fell at home 3 days ago. You notice she has been having several episodes of acute confusion since being admitted to your unit. What is the most important order you should anticipate from the provider? You’re?
Hold wayfaring (coumadin) for the next 48 hours
Your new admission presents with a cough, unintentional weight loss, frequent knot sweats, and bloody sputum. What type of isolation precautions should you initiate, if any?
Airborne precautions
Upon entering your patient’s room you note that they are having a seizure. What is your 1st action?
Position the patient on their side to maintain the airway
You find your coworker looking through your patient’s medical record.. She States how is Mr. Smith doing? He is my best friend’s dad. We are so worried about him. What is the best course of action?
Tell her you cannot give her information and report her actions to your manager.
Your male patient complaints of discomfort while inflating the balloon during insertion of a endwelling urinary catheter. What would be the most appropriate action?
Deflate the balloon, advance the catheter further, then reinflate the balloon.
Your patient takes regular insulin and NPH twice A-day for glucose control. What times should the patient be taught to be alert for signs of hypoglycemia?
Is late afternoon and early morning
What is a proton pump inhibitor, such as pantoprazole (protonix) used for?
Reduce gastric acid secretion
Your patient has a non productive cough and presence of secretions in his tracheostomy. Prior to sectioning the patient, what should you do 1st?
Hyperoxygenate patient
dietary teaching for a patient with chronic renal failure should include choices that are:
Low potassium, low protein, moderate fat
Which of the following nursing diagnosis is most important for a patient with chronic obstructive pulmonary disease(COPD)
Impaired gas exchange
Your patient is admitted from the ED with failure to thrive and advanced dementia. You note he is extremely underweight, appears unbathed for some time, and has a stage 4 pressure injury to his coccyx. You were told in report that he lives at home with family members. What should you do?
Notify the charge nurse and social worker of your concerns.
You have a patient going for dialysis. There are medications include Lisinopril(prinivil), ondansetron (zofran), famotidine(pepcid) and atorvastatin(lipitor). Which medication would you possibly hold and seek clarification?
LISINOPRIL(PRINIVIL)
What is the best indication of an acute neurological problem?
Change in level of consciousness
Your patient is admitted with diverticulitis. What type of diet do you expect to be ordered for the patient?
Clear liquids
Which tool should you use to assess pain in your 80 year old patient with severe dementia?
?
Your post op patient has a Jackson – Pratt drain in place. how do you ensure effective drain function?
Compress the drain, then plug the bulb to establish suction.
Is a patient with peritonitis Presents with tachycardia, hypotension , and dehydration. What other assessment finding would you anticipate as part of your physical assessment?
Severe abdominal pain or rebound tenderness
Your patient with a known history of diabetes is displaying symptoms of diaphoresis, Cool skin, lethargy, And shakiness. What is your 1st action?
Check the patient’s blood glucose level
a patient on warfarin(Coumadin/jantoven) has an INR of 6. Which medication would you anticipate administering?
Vitamin K
While in a supine position your patient States” I’m tired and cannot catch my breath”. Physical assessment reveals juggler vein distention and a 3rd heart sound(S3). These symptoms are indicative of what condition?
Heart failure
Upon entry to your patient’s room, you find her sitting in high Fowler’s Position and complaining of shortness of breath. Her respiratory rate is 34 breaths/minute And 02 sat is 84%. Which mode of oxygen delivery would most likely reverse the symptoms?
Non rebreather mask
Your patient continues to pull at their iv located in their left forearm despite verbal reminders And increased observation. The nursing assistant recommends using soft mitt Restraints on the patient. What is your recommendation?
Request and order for soft mitts As they are the least restrictive..
What is an early symptom that a patient is developing a complication of heart failure?
Edema in the legs and feet
You were hired to work the medical unit and when you arrive at work the charge nurse has assigned you to the post surgical unit since they are under staffed. Which is the most appropriate action?
Report to the post surgical unit
What type of personal protective equipment(Ppe) Is applied prior to entering a room for a patient with with C diff?
Gown and gloves
When would sucralfate(Carafate) 4 times daily be scheduled for?
1 hour before meals and at bedtime
Your new patient was admitted with Blunt force trauma to the abdomen Following a motor vehicle accident. A NG Tube is in place for decompression, however, you note during the assessment that the stomach is rigid and hard during palpation. What condition do you suspect.
Hemorrhage
What is clubbing of the fingers most likely associated with?
Chronic oxygen deficiency
Is your patient with hepatitis C Exhibits signs of jaundice and a distended abdomen. What procedure would you anticipate being performed by the provider at the bedside for this patient?
Paracentesis
Is the provider gives you a telephone order to explain a surgical procedure to your patient and obtain surgical consent. How should you respond?
Inform the provider that explaining the procedure is outside the nurse’s scope of practice.
You’re patient Recently had a G Tube Placed and interminent enteral Feedings have been initiated. What symptoms may indicate intolerance to the feedings?
Vomiting and diarrhea
You are caring for a patient post lobotomy With a chest tube in place for drainage. What is a priority in caring for this patient?
Encourage the patient to cough and deep breathe.
Your new patient understands very limited English. How should you communicate with them when completing the admission assessment?
Use the organizations interpreter services
You are ordered to give Digoxin(lanoxin). Your patience vital signs are BP 130/75, temp 97.9F, HR 52, RR 16, o2 sat 100% on room air. What should you do next?
HOLD DIGOXIN AND CALL PROVIDER
Your patient tells you I hope I don’t die, but if I do I don’t want to be brought back. You notice on her chart and wrist band that she is a full code. What would be the most appropriate action?
Discuss code status with the patient and follow up with the provider to ensure the medical record reflects her wishes
What are the most common causes of acute onset pancreatitis?
Alcoholism and gallstones
Your 18 year old female patient was admitted with dehydration secondary to anorexia nervosa. During your assessment you note she has a flat effect and says” I just want to die, I’m tired of my life “. What should be your 1st intervention?
Stay with the patient and ask if she has a plan to carry out this wish
A patient with diabetes who is receiving peritoneal dialysis Is at risk for which of the following?
?
To reduce the risk of infection and phlebotomy in an adult patient with a peripherL IV, What is the minimum duration the catheter should remain in place before routine replacement.
72 hours
Your patient was admitted for a hypertensive crisis and has a history of HTN. Parkinson disease, depression and alcohol use. On his 2nd hospitalized day, you notice he is more anxious and restless than his baseline. What would be your 1st nursing intervention?
Ask the patient when his last drink of alcohol was
Black and tarry Colored stools are classic symptoms of what condition?
Bleeding gastric ulcer
In addition to pain, pallor, and pulselssness, a neurovascular assessment Also includes checking for
Parasthesia and paralysis
After scrolling through your social media, you notice a coworker posted a photo with a patient from your unit. What is the most appropriate action to take?
Report the situation to the hospital compliance officer.
Your patient’s morning labs revealed a hemoglobin level of 6.3 and hematocrit of 18. What blood product do you expect to administer?
PRBCs
What medication is contraindicated In a patient with A hemorrhagic CVA?
Heparin
Your patient appears dusky colored and you cannot palpate a pulse. What is the 1st thing you should do?
Initiate a code per facility protocol and begin CPR
Your 68 year old patient is a is a Type one diabetic with a history of schizophrenia And exhibit signs and symptoms of tardiness dyskinesia. Is what long term medication is associated with signs and symptoms of tardive dyskinesia?
Chlorpromazine(thorazine)
You received a report on a patient that sustained a right hemisphere CVA 48 hours ago. What do you expect the patient to exhibit?
Lift sided weakness of the leg, arm, and face and face
You have 4 patients who have high priority needs. One needs to go to surgery, 1 needs stat lab draws From a PICC line, Another has chest pain rated 8/10 And another needs toileting. Which patient should you tend to 1st?
The patient with chest pain
Your coworker posted photos on social media from a birthday party they had for her in the unit break room. What should be your next course of action?
No action is necessary because no PHI was displayed.
Is your patient with stage IV Terminal lung cancer continues to experience increasing pain as each day passes. What would you anticipate the provider ordering for this patient?
Palliative care consult
Your 72 Year old male patient is admitted for colon cancer Related complications and has a history of CHF, stroke and a recent Knee replacement.Based on your patient’s risk assessment,You determine he is at risk for Venous thromboembolism (VTE) What is an appropriate VTE prophylaxis prophylaxis order for this patient?
Enoxaparin(Lovenox) once daily and intermittent pneumatic compressions(IPC)
1.2 Milligrams is equal to how many micrograms
1200 mcg
Your patient is on contact precautions for active MRSA. What proper PPE should you use before entering the room?
Gown and gloves
You are caring for a patient with history of diabetes mellitus. You walk into the room and find the patient lethargic and diaphoretic. What is your 1st action?
Obtain capillary blood glucose level
Your patient has symptomatic anemia but is refusing a blood transfusion for religious reasons. What is an appropriate response?
Respect his wishes and notify the provider
Your patient has a temp of 102.3 F, HR 122, and has had 15ml of urine from the indwelling urinary catheter in the last 2 hours. What is your patient most likely experiencing?
?
Patients with diabetes are at a high risk for complications for damage in what body areas?
Nerve and kidney damage
Your patient is 4 hours post open appendectomy Anne has not voided yet. You note his lower abdomen is distended. What should you do next?
Perform a bladder scan
You receive a provider’s order that is not consistent with evidence based practice.What is your 1st step?
Clarify the order with the provider
Is what is the earliest sign indicating increased intracranial pressure(ICP)?
Level of consciousness
What patient population is the pneumococcal vaccine PPSV23 indicated for?
Adults aged 65 years and older
Your patient takes 5 mg of warfarin(coumadin) day and reports having black cored stool today. What do you most likely suspect?
Gastrointestinal bleeding
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