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A nurse is caring for a patient who is experiencing acute respiratory distress. Which intervention should the nurse prioritize? a) Administering oxygen therapy b) Checking the patient's blood pressure c) Administering pain medication d) Assisting with ambulation
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- Which technique would be most appropriate to use when the nurse is teaching a patient with a language barrier?a )Obtain an interpreter who can speak in the patient’s native tongue for teaching sessions.b) Use detailed explanations, speaking slowly and clearly.c) Assume that the patient understands the information presented if the patient has no questions.d )Provide only written instructions.Which of the following assessments should the nurse prioritize when caring for a patient with suspected compartment syndrome? a) Capillary refill b) Pedal pulses c) Skin temperature d) Range of motionThe nurse is compiling a drug history for a patient. Which question from the nurse will obtain the most information from the patient? a )“Do you depend on sleeping pills to get to sleep?” b )“Do you have a family history of heart disease?” c )“When you have pain, what do you do to relieve it? d) “What childhood diseases did you have?”
- Which of the following nursing interventions is appropriate for a patient with impaired mobility? a) Encouraging the patient to remain in bed at all times b) Assisting with range-of-motion exercises c) Restraining the patient to prevent falls d) Administering sedatives to keep the patient calmThe nurse is assessing a patient for possible substance abuse. Which assessment finding indicates possible use of amphetamines? a )Lethargy and fatigueb) Cardiovascular depressionc )Talkativeness and euphoriad )Difficulty swallowing and constipationA nurse is caring for a patient who has been admitted with dehydration. Which of the following actions is MOST appropriate for the nurse to take first according to the principles of Maslow's Hierarchy of Needs?A) Assessing the patient's fluid and electrolyte balanceB) Encouraging the patient to talk about their feelings regarding hospitalizationC) Planning a nutrition counseling session to discuss the patient's dietD) Checking the patient's most recent social support network
- A patient is admitted with a diagnosis of Guillain-Barre syndrome (GBS). Which of the following findings on physical examination would be MOST concerning for the nurse? a) Decreased muscle strength b) Absent deep tendon reflexes c) Sensory disturbances in the extremities d) Difficulty swallowingWhat action by the nurse is the best way to assess a patient’s learning needs?a) Quiz the patient daily on all medications.b )Begin with validation of the patient’s present level of knowledge.c )Assess family members’ knowledge of the prescribed medication even if they are not involved in the patient’s care.d )Ask the caregivers what the patient knows about the medicationsA patient is receiving dobutamine for shock and is complaining of feeling more “skipping beats” than yesterday. What will the nurse do next? a) Monitor for other signs of a therapeutic response to the drug.b) Titrate the drug to a higher dose to reduce the palpitations.c) Discontinue the dobutamine immediately.d) Assess the patient’s vital signs and cardiac rhythm.
- The new graduate nurse would question the order for laxative administration in which of the following clients? (Select all that apply.) A )65-year-old male with ulcerative colitis who is having a hip replacement. B)24-year-old female with a distended abdomen who has not passed stool for three days and has just arrived at the emergency department. C)40-year-old female who uses opioids for chronic pain.A D)An 18-year-old female trying to lose five more pounds for a beauty pageant. E)A 50-year-old male with chronic hemorrhoids who is having orthoscopic surgery.5. The nurse is caring for an elderly client just admitted with bronchopneumonia. Which client assessment finding is of greatest concern? a) Acute confusion b) Respirations 26 c) Bilateral Ronchi d) Yellow-colored sputumIf a patient shows signs of an allergic reaction to a medication, what steps should the nurse take first?