A nurse notices that a patient has a structural curvature of the spine associated with vertebral rotation. Which condition will the nurse most likely find documented in the patient’s medical record?

A nurse is caring for a patient who is experiencing some symptoms related to arthritis. The nurse is teaching the patient about this process. Which information will the nurse include in the teaching session?

The nurse providing care to a bedridden patient raises the height of the bed. What is the rationale for the nurse’s action?

A nurse is following the no-lift policy when working to prevent personal injury from twisting. Which type of personal back injury is the nurse most likely trying to prevent?

The nurse is caring for a patient in the emergency department with an injured shoulder. Which type of joint will the nurse assess?

The nurse is caring for a patient with inner ear problems. Which goal is the priority?

A nurse is teaching a health promotion class about isotonic exercises. Which types of exercises will the nurse give as examples?

An adolescent tells the nurse that a health professional said the fibrous tissue that connects bone and cartilage was strained in a sporting accident. On which structure will the nurse focus an assessment?

A nurse is developing an exercise plan for a middle-aged patient. In which order will the nurse instruct the patient to execute the plan, beginning with the first step?

1. Design the fitness program.

2. Assemble equipment.

3. Assess fitness level.

4. Monitor progress.

. Get started.

The nurse gives instructions to a nursing assistive personnel (NAP) regarding exercise for a patient. Which action by the NAP indicates a correct understanding of the directions?

The nurse is starting an exercise program in a local community as a health promotion project. Which information will the nurse include in the teaching session?

The patient is eager to begin an exercise program with a 2-mile jog. The nurse instructs the patient to warm up. The patient does not want to waste time with a “warm-up.” Which information will the nurse share with the patient?

The nurse is caring for a patient who cannot bear weight but needs to be transferred from the bed to a chair. The nurse decides to use a transportable hydraulic lift. What action indicates the nurse is aware of appropriate hydraulic life use?

The nurse is preparing to move a patient to a wheelchair. Which action indicates the nurse is following recommendations for safe patient handling?

A nurse is working in a facility that follows a comprehensive safe patient-handling program. Which finding will alert the nurse to intervene?

The patient is brought to the emergency department with possible injury to the left shoulder. Which area will the nurse assess to best determine joint mobility?

The nurse is evaluating care of a patient for crutches. Which finding indicates a successful outcome?

The patient reports being tired and weak and lacks energy. Upon assessment, the nurse finds that patient has gained weight, and blood pressure and pulse are elevated after climbing stairs. Which nursing diagnosis will the nurse add to the care plan?

The patient weighs 450 lbs (204.5 kg) and reports shortness of breath with any exertion. The health care provider has recommended beginning an exercise program. The patient states that she can hardly get out of bed and just cannot do anything around the house. Which nursing diagnosis will the nurse add to the care plan?

A patient diagnosed with diabetes mellitus is starting an exercise program. Which types of exercises will the nurse suggest?

A patient is admitted after having experienced a stroke. The outcome of this disorder is uncertain, but the patient is unable to move the right arm and leg. The nurse starts passive range-of-motion (ROM) exercises. Which finding indicates successful goal achievement?

A nurse is assessing a patient with activity intolerance for possible orthostatic hypotension. Which finding will help confirm orthostatic hypotension?

The nurse is teaching a patient how to use a cane. Which information will the nurse include in the teaching session?

A nurse is assisting the patient to perform isometric exercises. Which action will the nurse take?

The nurse is developing a plan of care for a patient diagnosed with activity intolerance. Which strategy will the nurse use to provide the best chance of maintaining patient compliance?

The nurse is preparing to transfer an uncooperative patient who does not have upper body strength. Which piece of equipment will be best for the nurses to obtain?

The nurse is teaching a patient how to sit with crutches. In which order will the nurse present the instructions starting with the first step?

1. Place both crutches in one hand.

2. Grasp arm of chair with free hand.

3. Completely lower self into chair.

4. Transfer weight to crutches and unaffected leg.

The nurse is caring for a group of patients. Which patient will the nurse see first?

A nurse is preparing to move a patient who is able to assist. Which principles will the nurse

consider when planning for safe patient handling? (Select all that apply.)

A nurse is assessing activity tolerance of a patient. Which areas will the nurse assess? (Select all that apply.)

A nurse is working in a facility that uses no-lift policies. Which benefits will the nurse observe in the facility? (Select all that apply.)

A nurse writes the following outcomes for a patient who has chronic obstructive pulmonary disease to improve activity level: Diastolic blood pressure will remain below 70 mm Hg with systolic below 130 mm Hg. Resting heart rate will range between 65 and 75. The last goal is that the patient will exercise 3 times a week. Which evaluative findings indicate successful goal achievement? (Select all that apply.)

A 55-year-old patient is preparing to start an exercise program. The health care provider wants 60% of maximum target heart rate. Calculate the heart rate that the nurse will add to the care plan as the target heart rate. Record answer as a whole number. _________ maximum heart rate

A nurse is preparing to provide hygiene care. Which principle should the nurse consider when planning hygiene care?

A patient’s hygiene schedule of bathing and brushing teeth is largely influenced by family customs. For which age group is the nurse most likely providing care?

The patient has been diagnosed with diabetes. When admitted, the patient is unkempt and is in need of a bath and foot care. When questioned about hygiene habits, the nurse learns the patient takes a bath once a week and a sponge bath every other day. To provide ultimate care for this patient, which principle should the nurse keep in mind?

The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the patient says “I always bathe in the evening.” Which action by the nurse is best?

A nurse is completing an assessment of the patient. Which principle is a priority?

When providing hygiene for an older-adult patient, the nurse closely assesses the skin. What is the rationale for the nurse’s action?

The nurse is bathing a patient and notices movement in the patient’s hair. Which action will the nurse take?

The patient has been brought to the emergency department following a motor vehicle accident. The patient is unresponsive. The driver’s license states that glasses are needed to operate a motor vehicle, but no glasses were brought in with the patient. Which action should the nurse take next?

A nurse is assessing a patient’s skin. Which patient is most at risk for impaired skin integrity?

The nurse caring for a patient who is immobile frequently checks for impaired skin integrity. What is the rationale for the nurse’s action?

The nurse is caring for a patient diagnosed with diabetes mellitus and circulatory insufficiency, who is also experiencing peripheral neuropathy and urinary incontinence. On which areas does the nurse focus care?

The nurse is caring for a patient who has undergone surgery for a broken leg and has a cast in place. What should the nurse do to prevent skin impairment?

Which action by the nurse will be the most important for preventing skin impairment in a mobile patient with local nerve damage?

After performing foot care, the nurse checks the medical record and discovers that the patient has a disorder on the sole of the foot caused by a virus. Which condition did the nurse most likely observe?

The nurse is caring for a patient diagnosed with diabetes who is reporting severe foot pain due to corns. The patient has been using oval corn pads to self-treat the corns. Which information will the nurse share with the patient?

The patient diagnosed with athlete’s foot (tinea pedis) states that he is relieved because it is only athlete’s foot, and it can be treated easily. Which information about this condition should the nurse consider when formulating a response to the patient?

When assessing a patient’s feet, the nurse notices that the toenails are thick and separated from the nail bed. What does the nurse most likely suspect is the cause of this condition?

The nurse is providing education about the importance of proper foot care to a patient diagnosed with diabetes mellitus. Which primary goal is the nurse trying to achieve?

The nurse is providing oral care to an unconscious patient and notes that the patient has extremely bad breath. Which term will the nurse use when reporting to the oncoming shift?

The nurse is caring for a patient diagnosed with diabetes. Which task will the nurse assign to the nursing assistive personnel?

The patient is being treated for cancer with weekly radiation therapy to the head and intravenous chemotherapy treatments. Which assessment is the priority?

The nurse is providing oral care to an unconscious patient. Which action should the nurse take to protect the patient from injury?

The nurse is teaching the patient about flossing and oral hygiene. Which instruction will the nurse include in the teaching session?

The nurse is teaching the parents of a child who has head lice (pediculosis capitis). Which information will the nurse include in the teaching session?

A patient has scaling of the scalp. Which term will the nurse use to report this finding to the oncoming staff?

A nurse is providing a bath. In which order will the nurse clean the body, beginning with the first area?

1. Face

2. Eyes

3. Perineum

4. Arm and chest

5. Hands and nails

6. Back and buttocks

7. Abdomen and legs

The nurse is caring for a patient who has multiple ticks on lower legs and body. What should the nurse do to rid the patient of ticks?

The nurse is providing oral care to a patient. In which order will the nurse clean the oral cavity, starting with the first area?

1. Roof of mouth, gums, and inside cheek

2. Chewing and inner tooth surfaces

3. Outer tooth surfaces

4. Tongue

The nurse is caring for an older-adult patient diagnosed with Alzheimer’s disease who is ambulatory but requires total assistance with activities of daily living (ADLs). The nurse notices that the patient is edentulous. Which area should the nurse assess?

A self-sufficient bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel?

The nurse is preparing to provide a complete bed bath to an unconscious patient. The nurse decides to use a bag bath. In which order will the nurse clean the body, starting with the first area?

1. Neck, shoulders, and chest

2. Abdomen and groin/perineum

3. Legs, feet, and web spaces

4. Back of neck, back, and then buttocks

5. Both arms, both hands, web spaces, and axilla

The female nurse is caring for a male patient who is uncircumcised but not ambulatory and has full function of all extremities. The nurse is providing the patient with a partial bed bath. How should perineal care be performed for this patient?

A nursing assistive personnel (AP) is providing AM care to patients. Which action by the NAP will require the nurse to intervene?

A nurse is providing AM care to patients. Which action will the nurse take?

The nurse is providing a complete bed bath to a patient using a commercial bath cleansing pack (bag bath). What should the nurse do?

A nurse is providing perineal care to a female patient. Which washing technique will the nurse use?

Which instruction will the nurse provide to the nursing assistive personnel when providing foot care for a patient with diabetes?

The debilitated patient is resisting attempts by the nurse to provide oral hygiene. Which action will the nurse take next?

A nurse is providing oral care education to a patient with stomatitis. Which instructions will the nurse provide?

The nurse is teaching a patient about contact lens care. Which instructions will the nurse include in the teaching session?

The patient reports to the nurse about a perceived decrease in hearing. When the nurse examines the patient’s ear, a large amount of cerumen buildup at the entrance to the ear canal is observed. Which action will the nurse take next?

The patient is being fitted with a hearing aid. In teaching the patient how to care for the hearing aid, which instructions will the nurse provide?

The patient is reporting an inability to clear nasal passages. Which action will the nurse take?

A patient uses an in-the-canal hearing aid. Which assessment is a priority?

The nurse is caring for a patient with cognitive impairments. Which actions will the nurse take during AM care? (Select all that apply.)

The nurse is caring for a patient who has peripheral neuropathy. Which clinical manifestations does the nurse expect to find upon assessment? (Select all that apply.)

A nurse is providing hygiene care to a bariatric patient using chlorhexidine gluconate (CHG) wipes. Which actions will the nurse take? (Select all that apply.)

Which patients will the nurse determine are in most need of regular perineal care? (Select all that apply.)

The patient must stay in bed for a bed change. Which actions will the nurse implement? (Select all that apply.)

A nurse is teaching staff about the conduction of the heart. In which order will the nurse present the conduction cycle, starting with the first structure?

1. Bundle of His

2. Purkinje network

3. Intraatrial pathways

4. Sinoatrial (SA) node

5. Atrioventricular (AV) node

A nurse is teaching the patient with mitral valve problems about the valves in the heart. Starting on the right side of the heart, describe the sequence of the blood flow through these valves.

1. Mitral

2. Aortic

3. Tricuspid

4. Pulmonic

A nurse explains the function of the alveoli to a patient with respiratory problems. Which information about the alveoli’s function will the nurse share with the patient?

A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close?

The nurse is teaching about the process of exchanging gases through the alveolar capillary membrane. Which term will the nurse use to describe this process?

A nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority?

The patient is breathing normally. Which process does the nurse consider is working properly when the patient inspires?

The home health nurse recommends that a patient with respiratory problems install a carbon monoxide detector in the home. What is the rationale for the nurse’s action?

While performing an assessment, the nurse hears crackles in the patient’s lung fields. The nurse also learns that the patient is sleeping on three pillows to help with the difficulty breathing during the night. Which condition will the nurse most likely observe written in the patient’s medical record?

A patient has experienced a myocardial infarction. On which primary blood vessel will the nurse focus care to reduce ischemia?

A nurse is teaching a health class about the heart. Which information from the class members indicates teaching by the nurse is successful for the flow of blood through the heart, starting in the right atrium?

The nurse suspects the patient has increased cardiac afterload. Which piece of equipment should the nurse obtain to determine the presence of this condition?

Myocardial contractility  myocardial blood flowA patient has been diagnosed with heart failure and cardiac output is decreased. Which formula can the nurse use to calculate cardiac output?

A patient’s heart rate increased from 94 to 164 beats/min. What will the nurse expect as a result?

Which determination is the nurse trying to achieve by monitoring a patient’s cardiac output?

A nurse is caring for a group of patients. Which patient should the nurse see first?

A patient has inadequate stroke volume related to decreased preload. Which treatment does the nurse prepare to administer?

A nurse is preparing to suction a patient. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning?

The patient is experiencing right-sided heart failure. Which finding will the nurse expect when performing an assessment?

A nurse is reviewing the electrocardiogram (ECG) results. Which portion of the conduction system does the nurse consider when evaluating the P wave?

A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis?

The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia?

A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation?

A nurse is preparing a patient for nasotracheal suctioning. In which order will the nurse perform the steps, beginning with the first step? 1. Insert catheter. 2. Apply suction and remove.

3. Have patient deep breathe.

4. Encourage patient to cough.

5. Attach catheter to suction system.

6. Rinse catheter and connecting tubing

A patient is experiencing carbon dioxide retention from lung problems. Which type of diet will the nurse most likely suggest for this patient?

A nurse caring for a patient prescribed warfarin discovers that the patient is taking garlic to help with hypertension. Which condition will the nurse assess for in this patient?

Upon auscultation of the patient’s chest, the nurse hears a whooshing sound at the fifth intercostal space. What does this finding indicate to the nurse?

A nurse is caring for a patient diagnosed with chronic obstructive pulmonary disease (COPD) who is receiving 2 L/min of oxygen. Which oxygen delivery device is most appropriate for the nurse to administer the oxygen?

The nurse plans to closely monitor the oxygen status of an older-adult patient undergoing anesthesia because of which age-related change?

The nurse determines that an older-adult patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention of infection for the patient?

The nurse is caring for a patient experiencing fluid volume overload. Which physiological effect does the nurse most likely expect?

A nurse is caring for a patient prescribed continuous cardiac monitoring for heart dysrhythmias. Which rhythm will cause the nurse to intervene immediately?

The patient is experiencing angina pectoris. Which assessment finding does the nurse expect when conducting a history and physical examination?

StressWhich risk factor for cardiopulmonary disease should the nurse describe as modifiable?

The nurse is creating a plan of care for an obese patient who is experiencing fatigue related to ineffective breathing. Which intervention best addresses a short-term goal the patient could achieve?

A patient experiencing left-sided hemiparesis has developed bronchitis and has a heart rate of 105 beats/min, blood pressure of 156/90 mm Hg, and respiration rate of 30 breaths/min. Which nursing diagnosis is a priority?

Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an older-adult patient?

The nurse is assessing a patient diagnosed with emphysema. Which assessment finding requires further follow-up with the health care provider?

A patient diagnosed with chronic obstructive pulmonary disease (COPD) asks the nurse why clubbing occurs. Which response by the nurse is most therapeutic?

A patient experiencing a pneumothorax has a chest tube inserted and is placed on low constant suction. Which finding requires immediate action by the nurse?

The nurse is caring for a patient who has had a tracheostomy tube inserted. Which nursing intervention is most effective in promoting effective airway clearance?

The nurse is educating a student nurse on caring for a patient with a chest tube. Which statement from the student nurse indicates successful learning?

Which coughing technique will the nurse use to help a patient clear central airways?

The nurse is suctioning a patient with a tracheostomy tube. Which action will the nurse take?

The nurse is caring for a patient who is prescribed oxygen via a nasal cannula. Which task can the nurse delegate to the nursing assistive personnel?

The nurse is using a closed suction device. Which patient will be most appropriate for this suctioning method?

While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. Which action will the nurse take first?

A nurse is following the How-to Guide to prevent ventilator-associated pneumonia. Which strategies is the nurse using? ( select all that apply )

A nurse is teaching a community health promotion class and discusses the flu vaccine. Which information will the nurse include in the teaching session? (Select all that apply.)

A nurse is caring for a patient being treated for sleep apnea. Which types of ventilator support should the nurse be prepared to administer for this patient? (Select all that apply.)

A patient is experiencing dehydration. While planning care, the nurse considers that the majority of the patient’s total water volume exists in with compartment?

The nurse is teaching about the process of passively moving water from an area of lower particle concentration to an area of higher particle concentration. Which process is the nurse describing?

The nurse observes edema in a patient who is experiencing venous congestion as a result of right heart failure. Which type of pressure facilitated the formation of the patient’s edema?

The nurse administers an intravenous (IV) hypertonic solution to a patient expects the fluid shift to occur in what direction?

A nurse is preparing to start peripheral intravenous (IV) therapy. In which order will the nurse perform the steps starting with the first one?

1. Clean site.

2. Select vein.

3. Apply tourniquet.

4. Release tourniquet.

5. Reapply tourniquet.

6. Advance and secure.

7. Insert vascular access device.

The nurse is laboratory blood results will expect to observe which cation in the most abundance?

The nurse receives the patient’s most recent blood work results. Which laboratory value is of greatest concern?

The nurse observes that the patient’s calcium is elevated. When checking the phosphate level, what does the nurse expect to see?

Four patients arrive at the emergency department at the same time. Which patient will the nurse see first?

The patient has an intravenous (IV) line and the nurse needs to remove the gown. In which order will the nurse perform the steps, starting with the first one?

1. Remove the sleeve of the gown from the arm without the IV.

2. Remove the sleeve of the gown from the arm with the IV.

3. Remove the IV solution container from its stand.

4. Pass the IV bag and tubing through the sleeve.

A 2-year-old child has ingested a quantity of a medication that causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor this child?

A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe?

Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis?

A nurse is caring for a patient whose electrocardiogram (ECG) presents with changes characteristic of hypokalemia. Which assessment finding will the nurse expect?

In which patient will the nurse expect to see a positive Chvostek’s sign?

A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient?

A nurse is caring for a patient prescribed peripheral intravenous (IV) therapy. Which task will the nurse assign to the nursing assistive personnel?

The nurse is caring for a diabetic patient in renal failure who is in metabolic acidosis. Which laboratory findings are consistent with metabolic acidosis?

The nurse is assessing a patient and notes crackles in the lung bases and neck vein distention. Which action will the nurse take first?

A patient receiving chemotherapy has gained 5 pounds in 2 days. Which assessment question by the nurse is most appropriate?

The health care provider has ordered a hypotonic intravenous (IV) solution to be administered. Which IV bag will the nurse prepare?

The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for monitoring both of these patients?

A nurse is caring for a patient diagnosed with cancer who presents with anorexia, blood pressure 100/60, and elevated white blood cell count. Which primary purpose for starting total parenteral nutrition (TPN) will the nurse add to the care plan?

A patient presents to the emergency department with reports of vomiting and diarrhea for the past 48 hours. The health care provider orders isotonic intravenous (IV) therapy. Which IV will the nurse prepare?

A nurse administering a diuretic to a patient is teaching about foods to increase in the diet. Which food choices by the patient will best indicate successful teaching?

The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patient with hypernatremia. Which finding indicates goal achievement?

The nurse is calculating intake and output on a patient. The patient drinks 150 mL of orange juice at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice chips, and for lunch consumes 75 mL of chicken broth. Which totals for intake and output will the nurse document in the patient’s medical record?

Which assessment finding should cause a nurse to further assess for extracellular fluid volume deficit?

A patient is to receive 1000 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr. The nurse is using microdrip gravity drip tubing. Which rate will the nurse calculate for the minute flow rate (drops/min)?

A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 50 mL/hr. At what time should the infusion be completed?

A nurse caring for a diabetic patient with a bowel obstruction has orders to ensure that the volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice chips. The patient also has an NG suction tube set to low continuous suction that had 300-mL output. The patient has voided 400 mL of urine. After reporting these values to the health care provider, which order does the nurse anticipate?

A nurse is caring for a patient who is receiving peripheral intravenous (IV) therapy. When the nurse is flushing the patient’s peripheral IV, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse’s initial action?

A nurse is assisting the health care provider in inserting a central line. Which action indicates the nurse is following the recommended bundle protocol to reduce central line-associated bloodstream infections (CLABSI)?

The nurse is caring for a group of patients. Which patient will the nurse see first?

A nurse is administering a blood transfusion. Which assessment finding will the nurse report immediately?

A nurse has just received a bag of packed red blood cells (RBCs) for a patient. What is the longest time the nurse can let the blood infuse?

A patient has an acute intravascular hemolytic reaction to a blood transfusion. After discontinuing the blood transfusion, which is the nurse’s next action?

A nurse assessing a patient who is receiving a blood transfusion finds that the patient is anxiously fidgeting in bed. The patient is afebrile but dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention. On which transfusion complication will the nurse focus interventions?

A nurse preparing to start a blood transfusion will use which type of tubing?

The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority?

Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL?

While the nurse is taking a patient history, the nurse discovers the patient has a type of diabetes that results from a head injury and does not require insulin. Which dietary change should the nurse share with the patient?

A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will the nurse take? (Select all that apply.)

Which assessments will alert the nurse that a patient’s IV has infiltrated? (Select all that apply.)

A nurse is discontinuing a patient’s peripheral IV access. Which actions should the nurse take? (Select all that apply.)

A patient has 250 mL of a jejunostomy feeding with 30 mL of water before and after feeding and 200 mL of urine. Thirty minutes later the patient has 100 mL of diarrhea. At 1300 the patient receives 150 mL of blood and voids another 200 mL. Calculate the patient’s intake. Record your answer as a whole number. _____ mL

A patient has recently had surgery. Which action is best for the nurse to take to assess this patient’s pain?

A nurse is caring for a patient who recently had abdominal surgery and is experiencing severe pain. The patient’s blood pressure is 110/60 mm Hg, and heart rate is 60 beats/min. Additionally, the patient does not appear to be in any physical distress. Which response by the nurse is most therapeutic?

A nurse teaches the patient about the gate control theory. Which statement made by a patient reflects a correct understanding about the relationship between the gate control theory of pain and the use of meditation to relieve pain?

A nurse is planning care for an older-adult patient who is experiencing pain. Which statement made by the nurse indicates the supervising nurse needs to follow up?

The nurse is caring for two patients; both are having a hysterectomy. The first patient is having the hysterectomy after a complicated birth. The second patient has uterine cancer. What will most likely influence the experience of pain for these two patients?

The nurse is preparing pain medications. To which patient does the nurse anticipate administering an opioid fentanyl patch?

A patient is receiving opioid medication through an epidural infusion. Which action will the nurse take to protect the patient’s safety?

A woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient?

A nurse is teaching a patient about patient-controlled analgesia (PCA). Which statement made by the patient indicates to the nurse that teaching is effective?

A nurse is caring for a patient who is experiencing pain following abdominal surgery. Which information is important for the nurse to share with the patient when providing patient education about effective pain management?

A nurse is caring for a patient who recently had spinal surgery. The nurse knows that patients usually experience acute pain following this type of surgery. The patient refuses to get up and walk and is not moving around in the bed. However, the patient is stoic and denies experiencing pain at this time. What most likely explains this patient’s behavior?

A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with a prescription for hydrocodone. Which important patient education should the nurse provide?

A patient arrives at the emergency department experiencing a headache and rates the pain as 7 on a 0 to 10 pain scale. Which nonpharmacological intervention does the nurse implement for this patient while awaiting orders for pain medication from the health care provider?

A patient diagnosed with type 2 diabetes 26 years ago is beginning to experience peripheral neuropathy in the feet and lower leg. The nurse is providing education to the patient to prevent injury to the feet by wearing shoes or slippers when walking. Which statement made by the nurse best explains the rationale for this instruction?

A nurse is assessing a patient who began experiencing severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, “The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most.” Which type of pain does the nurse document the patient is having at this time?

A patient injured in a motor vehicle crash 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). Which assessment finding indicates effective pain management with the PCA?

The nurse is caring for a patient and is focusing on modifiable factors that contribute to pain. Which areas does the nurse focus on with this patient?

The nurse is evaluating the effectiveness of guided imagery for pain management as used for a patient who has second- and third-degree burns and needs extensive dressing changes. Which finding best indicates the effectiveness of guided imagery?

A nurse is providing medication education to a patient who just started been prescribed ibuprofen. Which information will the nurse include in the teaching session?

The nurse has brought a patient the scheduled pain medication. The patient asks the nurse to wait to give pain medication until the time for the dressing change, which is 2 hours away. Which response by the nurse is most therapeutic?

A nurse receives an order from a health care provider to administer hydrocodone and acetaminophen to a patient who is experiencing 8/10 postsurgical pain. The order is to give 2 tablets every 6 hours by mouth as needed for pain. What is the nurse’s next best action?

The nurse is caring for a 4-year-old child who is demonstrating signs of pain. Which technique will the nurse use to best assess pain in this child?

A nurse is caring for a group of patients. Which patient will the nurse see first to best manage patient needs?

A nurse is caring for a patient diagnosed with chronic pain. Which statement by the nurse indicates an understanding of pain management?

The nurse is assessing how a patient’s pain is affecting mobility. Which assessment question is most appropriate?

The nurse is teaching a student nurse about pain assessment scales. Which statement by the student indicates effective teaching?

The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first?

The nurse is assessing a patient for opioid tolerance. Which finding supports the nurse’s assessment?

A nurse is caring for a patient with rheumatoid arthritis who is now going to be taking 2 acetaminophen tablets every 6 hours to control pain. Which part of the patient’s social history is the nurse most concerned about?

The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse’s first priority?

The nurse is caring for a group of patients. Which task may the nurse delegate to the unlicensed assistive personnel (UAP)?

A nurse is caring for a patient with chronic pain from arthritis. Which action is best for the nurse to take?

A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. The patient describes the pain as throbbing. Which type of pain does the nurse document in this patient’s medical record?

The nurse is caring for an infant in the intensive care unit. Which information should the nurse consider when planning care for this patient?

The nurse is administering ibuprofen to an older patient. Which assessment data causes the nurse to hold the medication? (Select all that apply.)

A nurse is teaching about the energy needed at rest to maintain life-sustaining activities for a specific period of time. What form of energy is the nurse discussing?

In general, when a patient’s energy requirements are completely met by kilocalorie (kcal) intake in food, which assessment finding will the nurse observe?

A nurse is asked how many kcal/g are provided by fats. How should the nurse answer?

A nurse is teaching a patient about proteins that must be obtained through the diet since they cannot be synthesized in the body. Which term used by the patient indicates teaching is successful?

A nurse is caring for a patient with a postsurgical wound. When planning care, which goal will be the priority?

In providing diet education for a patient on a low-fat diet, which information is important for the nurse to share?

A patient has a decreased gag reflex, left-sided weakness, and drooling. Which action will the nurse take when feeding this patient?

The patient who has been diagnosed with cardiovascular disease and placed on a low-fat diet, asks the nurse, “How much fat should I have? I guess the less fat, the better.” Which information will the nurse include in the teaching session?

The nurse is describing the ChooseMyPlate program to a patient. Which statement from the patient indicates successful learning?

The nurse is teaching a health class about the ChooseMyPlate program. Which guidelines will the nurse include in the teaching session?

The nurse is providing nutrition education to a Korean patient using the five food groups. In doing so, what should be the focus of the teaching?

A nurse is teaching a nutrition class about the different daily values. When teaching about the referenced daily intakes (RDIs), which information should the nurse include?

The nurse is planning care for a group of stable patients. Which task will the nurse assign to the nursing assistive personnel?

In teaching mothers-to-be about infant nutrition, which instruction should the nurse provide?

When planning care for an adolescent who plays sports, which modification should the nurse include in the care plan?

In providing prenatal care to a pregnant patient, what does the nurse teach the expectant mother?

The patient is an 80-year-old male who is visiting the clinic today for a routine physical examination. The patient’s skin turgor is fair, but the patient reports fatigue and weakness. The skin is warm and dry, pulse rate is 116 beats/min, and urinary sodium level is slightly elevated. Which instruction should the nurse provide?

The nurse is assessing a patient for nutritional status. Which action will the nurse take?

The patient has a calculated body mass index (BMI) of 34. How will the nurse classify this finding?

Which patient diagnosis increases the risk for developing neurogenic dysphagia?

The patient has been diagnosed with Helicobacter pylori. The nurse should encourage which action initially?

Which assessment finding is consistent with the diagnosis of malnutrition?

A nurse is preparing to administer an enteral feeding. In which order will the nurse implement the steps, starting with the first one?

1. Elevate head of bed to at least 30 degrees.

2. Check for gastric residual volume.

3. Flush tubing with 30 mL of water.

4. Verify tube placement.

5. Initiate feeding

The patient is admitted with facial trauma, including a broken nose, and has a history of esophageal reflux and of aspiration pneumonia. With which tube will the nurse most likely administer the feeding?

The nurse is preparing to insert a nasogastric tube. To determine the length of the tube needed to be inserted, how should the nurse measure the tube?

Before giving the patient an intermittent gastric tube feeding, what should the nurse do?

A small-bore feeding tube is placed. Which technique will the nurse use to best verify tube placement?

The nurse is concerned about pulmonary aspiration when providing care to the patient with an intermittent tube feeding. Which action is the priority?

The patient is to receive multiple medications via the nasogastric tube. The nurse is concerned that the tube may become clogged. Which action is best for the nurse to take?

The patient has just started on enteral feedings, and is now reporting abdominal cramping. Which action will the nurse take next?

The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours. What does the nurse suspect is the most likely cause of the diarrhea?

A patient develops a foodborne disease from Escherichia coli. When taking a health history, which food item will the nurse most likely find the patient ingested?

The nurse is caring for a patient receiving total parenteral nutrition (TPN). Which action will the nurse take?

The patient is having at least 75% of nutritional needs met by enteral feeding, so the health care provider has ordered the parenteral nutrition (PN) to be discontinued. However, the nurse notices that the PN infusion has fallen behind. What should the nurse do?

The patient is on parenteral nutrition is lethargic while reporting thirst and headache and has had increased urination. Which problem does the nurse prepare to address?

In providing diabetic teaching for a patient with type 1 diabetes mellitus, which instructions will the nurse provide to the patient?

The patient diagnosed with cardiovascular disease is receiving dietary instructions from the nurse. Which information from the patient indicates teaching is successful?

The nurse is providing home care for a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Which dietary intervention will the nurse add to the care plan?

A patient is on a full liquid diet. Which food item choice by the patient will cause the nurse to intervene?

A nurse is caring for a group of patients. Which patient will the nurse see first?

The nurse is preparing to check the gastric aspirate for pH. Which equipment will the nurse obtain?