WorksheetsNursing Prometric Exam Practice Questions 1
Total questions: 100
Worksheet time: 55mins
A patient with a history of asthma is experiencing shortness of breath and wheezing. What is the priority nursing intervention?
Administer the patient's prescribed bronchodilator medication.
Reassure the patient and encourage slow, deep breathing.
Assess the patient's respiratory status immediately.
Contact the physician to report the patient's symptoms.
A nurse is caring for a patient who is post-operative following an abdominal surgery. Which of the following is the most important assessment to prevent a common post-operative complication?
Assessing the surgical dressing for bleeding or drainage
Monitoring the patirent's vital signs every 4 hours
ssessing bowel sounds and the passage of flatus or stool
Evaluating the patient's pain level using pain scale
A patient with type 1 diabetes mellitus reports feeling shaky, sweaty, and confused. What is the most likely cause of these symptoms?
Hyperglycemia (high blood sugar).
Diabetic ketoacidosis (DKA).
Hypoglycemia (low blood sugar).
Hyperosmolar hyperglycemic state (HHS).
A nurse is preparing to administer an intramuscular (IM) injection. What is the correct angle for administering this type of injection?
15-degree angle
45-degree angle
90-degree angle
30-degree angle
A patient is experiencing chest pain. What is the first action the nurse should take?
Administer oxygen at 2 liters per minute via nasal cannula.
Ask the patient detailed questions about the pain.
Assess the patient's vital signs.
Notify the physician immediately.
A nurse is teaching a patient about a new medication. Which of the following is the most important information to include in the teaching?
The potential side effects of the medication
the dosage and frequency of the medication
the purpose and expected effects of the medication
the route of administration of the medication
Which of the following is the most important information to include when teaching a patient about a new medication?
The potential side effects of the medication.
The dosage and frequency of the medication.
The purpose and expected effects of the medication.
The route of administration of the medication.
A patient is at risk for falls. Which of the following nursing interventions is most important to implement?
Educating the patient about fall risks.
Assessing the patient's gait and balance.
Providing a walker or cane for ambulation.
Implementing fall precautions, such as keeping the bed in the lowest position and ensuring the call light is within reach.
A patient is diagnosed with pneumonia and has a fever and cough. What is the priority nursing diagnosis?
Risk for Impaired Gas Exchange related to alveolar inflammation.
Hyperthermia related to infectious process.
Acute Pain related to coughing.
Ineffective Airway Clearance related to increased secretions.
A nurse is preparing a sterile field. Which of the following actions violates sterile technique?
Opening sterile packages away from the sterile field.
Maintaining a 1-inch border around the sterile field.
Reaching over the sterile field.
Only sterile items are placed on the sterile field.
A patient is receiving intravenous fluids. What is the most important assessment to monitor for potential complications?
Checking the IV site for redness and swelling.
Monitoring the infusion rate as prescribed.
Assessing the patient's level of consciousness.
Monitoring for signs of fluid overload, such as increased respiratory rate and edema.
A patient is at risk for developing a pressure ulcer. Which nursing intervention is most effective in preventing this complication?
Applying lotion to the skin daily.
Massaging bony prominences frequently.
Repositioning the patient every 2 hours.
Ensuring adequate nutritional intake.
A patient is experiencing severe pain. Which of the following is the most appropriate initial nursing action?
Administering the prescribed pain medication.
Assessing the patient's pain using a pain scale.
Encouraging the patient to use relaxation techniques.
Documenting the patient's report of pain.
A nurse is caring for a patient who has a new prescription for a beta-blocker medication. What is the most important assessment to perform before administering the first dose?
Checking the patient's blood glucose level.
Assessing the patient's blood pressure and heart rate.
A patient is experiencing a sudden onset of severe shortness of breath. The nurse assesses the patient and finds the patient is anxious, using accessory muscles to breathe, and has a respiratory rate of 32 breaths per minute. What is the priority nursing intervention?
Administering oxygen via nasal cannula at 2 liters per minute.
Encouraging the patient to take slow, deep breaths.
Assessing the patient's oxygen saturation level.
Placing the patient in a high Fowler's position.
A nurse is teaching a patient about the proper use of an inhaler. Which of the following instructions is most important to include?
Rinse the mouth after each use.
Shake the inhaler well before each use.
Inhale slowly and deeply while pressing the inhaler.
Hold the breath for 10 seconds after inhaling.
A patient is experiencing a sudden onset of chest pain and reports that it feels like pressure. The nurse assesses the patient and notes that the patient is pale, diaphoretic, and has a blood pressure of 88/50 mmHg and a heart rate of 110 beats per minute. What is the most appropriate initial nursing intervention?
Administering sublingual nitroglycerin as prescribed.
Obtaining a 12-lead electrocardiogram (ECG).
Assessing the patient's pain using a pain scale.
Placing the patient in a supine position.
A patient is being discharged home with a new prescription for warfarin. Which of the following instructions is most important for the nurse to include in the discharge teaching?
Take the medication with food.
Monitor for signs of bleeding.
Avoid taking aspirin or ibuprofen.
Keep follow-up appointments for blood tests.
A nurse is caring for a patient who has just undergone a total hip replacement. Which of the following is the most important nursing intervention to prevent dislocation of the new hip joint?
Encouraging the patient to perform range-of-motion exercises as tolerated.
Maintaining the patient's affected leg in abduction.
Assisting the patient to ambulate as soon as possible.
Placing a pillow between the patient's legs when in bed.
A patient with a history of heart failure is experiencing sudden weight gain, increased shortness of breath, and swelling in the ankles. What is the most likely cause of these symptoms?
An exacerbation of heart failure.
A new onset of pneumonia.
An allergic reaction.
Dehydration.
A nurse is caring for a patient who has just been admitted with a suspected deep vein thrombosis (DVT) in the left leg. Which of the following nursing actions is most appropriate?
A patient with a history of chronic obstructive pulmonary disease (COPD) is experiencing increased dyspnea and a productive cough with yellow-green sputum. The nurse auscultates coarse crackles in the lungs. What is the most likely cause of these symptoms?
An exacerbation of COPD due to a respiratory infection.
Pulmonary embolism.
Pneumothorax.
Heart failure.
A nurse is preparing to administer a blood transfusion. Which of the following actions is most important to perform before starting the transfusion?
Checking the patient's vital signs.
Obtaining a signed consent form from the patient.
Verifying the blood product with another nurse.
Starting the IV line with a large-bore catheter.
A patient with a history of hypertension is prescribed a new antihypertensive medication. Which of the following is the most important instruction to give the patient regarding this medication?
Take the medication on an empty stomach.
Monitor blood pressure regularly and record the readings.
Avoid stopping the medication abruptly.
A nurse is assessing a patient who is postoperative after a thyroidectomy. The patient reports a feeling of tightness in the throat and is having difficulty swallowing. What is the priority nursing assessment?
Assessing the patient's voice quality.
Checking the surgical dressing for bleeding.
Auscultating the patient's breath sounds.
Observing for any signs of respiratory distress.
A patient is admitted with a diagnosis of pneumonia. The nurse assesses the patient and notes a temperature of 102.5°F, a productive cough with greenish sputum, and reports of chest pain. Which nursing diagnosis is the highest priority?
Ineffective Breathing Pattern related to inflammation of the lung tissue.
Impaired Gas Exchange related to alveolar consolidation.
Risk for Deficient Fluid Volume related to fever and increased respiratory rate.
Acute Pain related to coughing and inflammation.
A patient is experiencing a hypertensive crisis with a blood pressure of 220/130 mmHg and reports a severe headache. Which nursing intervention is the most appropriate initial action?
Administering the patient's prescribed oral antihypertensive medication.
Placing the patient in a semi-Fowler's position.
Assessing the patient for signs of end-organ damage.
Obtaining an immediate order for intravenous antihypertensive medication from the physician.
A patient with a history of asthma is experiencing an acute asthma attack. The nurse assesses the patient and notes severe wheezing, shortness of breath, and a respiratory rate of 36 breaths per minute. What is the most appropriate initial nursing intervention?
Administering the patient's prescribed oral corticosteroids.
Encouraging the patient to use their metered-dose inhaler (MDI) with a spacer.
Assessing the patient's oxygen saturation level.
Placing the patient in a high Fowler's position.
A patient with a history of diabetes mellitus reports feeling thirsty, frequent urination, and blurred vision. The nurse assesses the patient and notes a blood glucose level of 450 mg/dL. What is the most likely nursing diagnosis?
Risk for Impaired Skin Integrity related to hyperglycemia.
Deficient Fluid Volume related to osmotic diuresis.
Ineffective Health Maintenance related to poor diabetes management.
Risk for Peripheral Neurovascular Dysfunction related to diabetes.
A patient is admitted with a urinary tract infection (UTI) and reports dysuria and urinary frequency. The nurse assesses the patient and notes a temperature of 100.8°F and cloudy urine. Which nursing intervention is the highest priority?
Administering the prescribed antibiotic medication.
Encouraging the patient to increase fluid intake.
Teaching the patient about proper perineal hygiene.
Obtaining a urine specimen for culture and sensitivity.
A patient is experiencing a panic attack and is hyperventilating. The nurse observes the patient to be anxious, restless, and reporting chest tightness and dizziness. What is the most appropriate initial nursing intervention?
Administering a prescribed anxiolytic medication.
Encouraging the patient to breathe into a paper bag.
Staying with the patient and speaking in a calm, reassuring manner.
Assessing the patient's oxygen saturation level.
A patient with a history of heart failure is receiving furosemide (Lasix). The nurse should monitor the patient closely for which of the following electrolyte imbalances?
Hyperkalemia.
Hypernatremia.
Hypokalemia.
Hypocalcemia.
A patient with a history of gastroesophageal reflux disease (GERD) reports frequent heartburn, especially after meals and when lying down. Which of the following dietary instructions is most appropriate for this patient?
Eat large meals three times a day.
Avoid lying down immediately after eating.
Increase intake of citrus fruits and tomatoes.
Drink plenty of fluids with meals.
33: A patient with a history of chronic kidney disease (CKD) is admitted to the hospital. The nurse reviews the patient's most recent laboratory results. Which of the following findings would the nurse expect to see?
Elevated serum creatinine
Decreased blood urea nitrogen (BUN)
Low potassium levels
Increased glomerular filtration rate (GFR)
A patient with a history of heart failure is prescribed digoxin. The nurse knows that which of the following electrolyte imbalances can increase the risk of digoxin toxicity?
Hyperkalemia.
Hypercalcemia.
Hyponatremia.
Hypokalemia.
A patient with a history of peptic ulcer disease reports epigastric pain that is relieved by eating. The nurse anticipates that the physician will order testing for which of the following?
Helicobacter pylori.
Serum gastrin levels.
Upper endoscopy.
Fecal occult blood test.
A patient with a history of benign prostatic hyperplasia (BPH) reports difficulty initiating urination, weak urinary stream, and nocturia. The nurse anticipates that the physician may prescribe which of the following medications?
A thiazide diuretic.
An anticholinergic medication.
Which of the following is an alpha-adrenergic blocker?
An alpha-adrenergic blocker.
A beta-adrenergic blocker.
An alpha-adrenergic blocker.
A beta-adrenergic blocker.
A patient with a history of gout is experiencing an acute gout flare-up in their left big toe. The toe is red, swollen, and very painful to touch. Which of the following medications would the nurse expect the physician to prescribe for immediate relief?
Allopurinol.
Probenecid.
Colchicine.
Febuxostat.
A patient with a history of type 2 diabetes mellitus is prescribed metformin. Which of the following instructions is most important for the nurse to include in the patient's education about this medication?
Take the medication with a meal to minimize gastrointestinal upset.
Monitor blood glucose levels only when feeling symptomatic.
Stop taking the medication if experiencing any signs of hypoglycemia.
Increase intake of simple carbohydrates to prevent hypoglycemia.
A patient with a history of chronic heart failure has a prescription for enalapril. The nurse understands that this medication is prescribed for heart failure because it:
Increases the force of myocardial contraction.
Slows the heart rate, allowing for increased ventricular filling.
Dilates blood vessels and reduces afterload.
Promotes sodium and water excretion, reducing preload.
A patient with a history of deep vein thrombosis (DVT) is receiving heparin therapy via continuous intravenous infusion. Which of the following laboratory values should the nurse monitor most closely?
Serum potassium level.
Activated partial thromboplastin time (aPTT).
Prothrombin time (PT) and international normalized ratio (INR).
Platelet count.
A patient with a history of heart failure is prescribed a medication from the angiotensin receptor blocker (ARB) class. The nurse knows that ARBs have a similar therapeutic effect to ACE inhibitors but are often used in patients who:
Have developed a persistent dry cough while taking an ACE inhibitor.
Require a medication that also helps lower cholesterol levels.
Need a medication that primarily works by slowing down the heart rate.
Have a contraindication to beta-blocker therapy.
A patient with a history of a myocardial infarction (MI) is prescribed aspirin 81 mg daily. The nurse understands that aspirin is prescribed for this patient because it:
Lowers blood pressure.
Reduces the risk of blood clot formation.
Decreases cholesterol levels.
Relieves chest pain.
A patient with a history of schizophrenia is prescribed haloperidol. The nurse should monitor the patient for which of the following extrapyramidal symptoms (EPS)?
dystonia
akathisia
parkinsonism
tardive dyskinesia
A patient with a history of bipolar disorder is prescribed lithium. The nurse should provide education to the patient about the importance of:
Maintaining a high-sodium diet.
Restricting fluid intake to prevent fluid retention.
Regular monitoring of serum lithium levels.
Taking the medication on an empty stomach for better absorption.
A patient is scheduled for surgery and reports taking ginkgo biloba daily. The nurse should instruct the patient to stop taking this supplement at least how many days before the scheduled surgery?
3 days.
7 days.
14 days.
30 days.
A patient with a history of chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy at 2 L/min via nasal cannula. During morning rounds, the nurse finds the patient somnolent and difficult to arouse. The patient's respiratory rate is 8 breaths per minute, and the oxygen saturation is 90%. The nurse's immediate action should be to:
Increase the oxygen flow rate to 4 L/min.
Discontinue the oxygen therapy immediately.
A patient with a new colostomy reports feeling anxious and states, "I don't know how I'm going to manage this at home." What is the nurse's most appropriate initial response?
Don't worry, you'll get used to it.
We will make sure you have all the supplies you need.
Tell me more about what concerns you.
Many people live normal lives with a colostomy.
A patient who is postoperative following abdominal surgery reports sudden, severe calf pain. The calf is warm, red, and swollen. What is the nurse's most appropriate initial action?
Encourage the patient to ambulate to improve circulation.
Apply warm compresses to the affected calf.
Elevate the patient's leg on a pillow.
Notify the physician immediately.
A patient with a history of heart failure has gained 5 pounds (2.3 kg) in the past 24 hours. The nurse auscultates crackles in the lung bases bilaterally. Which of the following nursing interventions is the most appropriate initial action?
Administering the patient's prescribed oral potassium supplement.
Encouraging the patient to increase their oral fluid intake.
Elevating the head of the bed to high Fowler's position.
Assessing the patient's blood pressure and heart rate.
A patient with a history of type 1 diabetes mellitus is found unresponsive in their home. Emergency medical services (EMS) reports a fingerstick blood glucose level of 45 mg/dL. Which of the following interventions should the nurse anticipate the EMS providers will administer?
Intravenous insulin.
Oral glucose tablets.
Intramuscular glucagon.
Subcutaneous epinephrine.
A nurse is caring for a patient who is receiving a blood transfusion. After 15 minutes of the transfusion, the patient reports chills, itching, and back pain. What is the nurse's most appropriate first action?
Slow down the rate of the blood transfusion.
Administer the patient's prescribed antihistamine.
Stop the blood transfusion immediately.
Apply warm blankets to the patient.
A nurse is caring for a patient with a central venous catheter (CVC). During a dressing change, the nurse notes that the insertion site is red, tender, and has a small amount of purulent drainage. What is the nurse's most appropriate action?
Apply a new sterile dressing and document the findings.
Administer a broad-spectrum antibiotic as prescribed.
Remove the central venous catheter immediately.
Notify the physician of the findings.
A nurse is caring for a patient who is receiving mechanical ventilation. The high-pressure alarm on the ventilator keeps sounding. What is the nurse's first action?
Check the patient for signs of obstruction or distress.
Increase the ventilator rate.
Silence the alarm and continue monitoring.
Call the respiratory therapist immediately.
Which of the following actions should the nurse take first when the ventilator alarm sounds for increased peak inspiratory pressure?
Increase the FiO2 (fraction of inspired oxygen).
Silence the alarm and continue monitoring.
Assess the patient for the cause of the increased pressure.
Decrease the tidal volume on the ventilator.
A nurse is caring for a patient with a nasogastric (NG) tube connected to continuous suction. The nurse notes that there has been no drainage in the collection container for the past 4 hours, and the patient reports increased nausea and abdominal distension. What is the nurse's most appropriate initial action?
Irrigate the NG tube with normal saline.
Reposition the patient to their left side.
Advance the NG tube 2-3 inches further.
Discontinue the NG tube suction temporarily.
A nurse is preparing to administer an intramuscular (IM) injection to an adult patient. Which of the following sites is generally preferred for IM injections in adults to minimize the risk of nerve or blood vessel injury?
Dorsogluteal site.
Ventrogluteal site.
Deltoid muscle.
Vastus lateralis muscle.
A nurse is caring for a patient who has just undergone a lumbar puncture. Which of the following nursing interventions is most important to implement immediately post-procedure?
Encourage the patient to ambulate as soon as they feel able.
Position the patient flat on their back.
A nurse is caring for a patient who is receiving total parenteral nutrition (TPN) via a central line. The current bag of TPN is almost empty, and the new bag is not yet available from the pharmacy. What is the nurse's most appropriate immediate action?
Hang a bag of 5% dextrose in water (D5W).
Hang a bag of 10% dextrose in water (D10W).
Disconnect the TPN line until the new bag arrives.
Slow down the infusion rate of the remaining TPN.
A nurse is caring for a patient who is post-operative following a total hip arthroplasty. The patient is on bed rest. Which of the following nursing interventions is most important to implement to prevent deep vein thrombosis (DVT)?
Encouraging coughing and deep breathing exercises every 2 hours.
Applying anti-embolic stockings (TED hose).
Assisting the patient with active range of motion exercises of the affected leg.
Maintaining the patient in a high Fowler's position.
A nurse is preparing to administer medication via a nasogastric (NG) tube to a patient who is receiving continuous tube feeding. What is the most appropriate nursing action to ensure medication absorption?
Mix the medication with the tube feeding formula.
Administer the medication while the tube feeding is infusing.
A nurse is caring for a patient who is scheduled for a paracentesis. Which of the following nursing interventions is most important to implement prior to the procedure?
Administering pain medication intravenously.
Instructing the patient to empty their bladder.
Positioning the patient in the Trendelenburg position.
Obtaining informed consent for the procedure.
A nurse is caring for a patient with a chest tube connected to a three-chamber water seal drainage system. The nurse observes continuous bubbling in the water seal chamber. What does this finding indicate?
The system is functioning normally.
There is a leak in the system.
The patient has a tension pneumothorax.
The patient is ready for chest tube removal.
A nurse is caring for a patient with a tracheostomy. Which of the following nursing actions is essential to prevent tracheostomy tube occlusion?
Changing the tracheostomy ties every 24 hours.
Providing frequent oral care.
Suctioning the tracheostomy tube regularly.
Humidifying the inspired air.
A nurse is caring for a patient who is receiving continuous intravenous (IV) infusion of potassium chloride (KCl). Which of the following nursing actions is most important to prevent hyperkalemia?
Monitoring the patient for signs of phlebitis at the IV site.
Ensuring the IV infusion pump is set at the prescribed rate.
Assessing the patient's urine output hourly.
Educating the patient about foods high in potassium.
A nurse is caring for a patient who is post-operative following a thyroidectomy. Which of the following signs and symptoms should the nurse monitor for closely as a potential complication?
Increased appetite and weight gain.
Hoarseness and sore throat.
Muscle twitching and tetany.
Elevated blood pressure and tachycardia.
A nurse is caring for a patient with a deep vein thrombosis (DVT) in the left leg. Which of the following nursing interventions is contraindicated?
Elevating the affected leg when the patient is in bed.
Applying warm compresses to the affected leg.
Encouraging ambulation as tolerated.
Measuring the circumference of both calves daily.
A nurse is caring for a patient who is receiving oxygen therapy via a nasal cannula at 4 L/min. The patient's oxygen saturation is 95%, but they report feeling short of breath. What is the nurse's most appropriate next action?
A nurse is caring for a patient who is on a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. The patient removes the mask and reports feeling claustrophobic. What is the nurse's most appropriate initial intervention?
Reapply the CPAP mask immediately and firmly.
Offer the patient an oral sedative medication as prescribed.
Assess the patient's anxiety level and the fit of the mask.
Switch the patient to nasal prongs for oxygen delivery.
A nurse is caring for a patient who is receiving a blood transfusion and develops a fever of 101°F (38.3°C) and chills. What is the nurse's most appropriate first action?
Administer acetaminophen as prescribed.
Slow down the rate of the blood transfusion.
Stop the blood transfusion immediately.
Cover the patient with warm blankets.
A nurse is caring for a patient who has undergone a total knee replacement. On the first post-operative day, the nurse notes that the patient's affected leg is pale, cool to the touch, and the patient reports increased pain despite receiving analgesics. What is the nurse's most appropriate initial action?
Apply ice packs to the affected knee.
Elevate the affected leg on pillows.
A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy. The nurse observes that the patient's respiratory rate has decreased from 20 to 10 breaths per minute, and the patient appears drowsy. What is the nurse's most appropriate initial action?
Increase the patient's oxygen flow rate.
Encourage the patient to cough and deep breathe.
Assess the patient's oxygen saturation and level of consciousness.
Administer a respiratory stimulant medication as prescribed.
A nurse is caring for a patient who is scheduled for surgery in the morning. The patient expresses anxiety about the procedure and difficulty sleeping. Which of the following nursing interventions is most appropriate to implement?
Administer a prescribed hypnotic medication at bedtime.
Encourage the patient to talk about their fears and concerns.
Provide the patient with detailed information about the surgical procedure.
Limit the patient's fluid intake in the evening to prevent nighttime urination.
A nurse is caring for a patient with a new colostomy. Which of the following statements, if made by the patient, would indicate a need for further teaching?
I should empty the pouch when it is about one-third to one-half full.
I will clean the skin around the stoma with mild soap and water.
It's normal for the stoma to be reddish-pink and moist.
A nurse is caring for a patient who is receiving mechanical ventilation and has an endotracheal tube. Which of the following nursing interventions is most important to prevent ventilator-associated pneumonia (VAP)?
Administering antipyretics as needed for fever.
Providing oral care with chlorhexidine solution every 12 hours.
Elevating the head of the bed to 30-45 degrees.
Suctioning the endotracheal tube only when needed.
A nurse is caring for a patient who is receiving enteral feeding via a nasogastric (NG) tube. The nurse auscultates bowel sounds and then checks for gastric residual volume before administering the next feeding. The gastric residual volume is 350 mL. What is the nurse's most appropriate action?
Administer the scheduled feeding.
Hold the feeding and recheck the residual in 1 hour.
Administer half of the scheduled feeding.
Discard the residual and administer the feeding.
A nurse is caring for a patient with a peripheral intravenous (IV) line. During assessment, the nurse notes redness, warmth, and tenderness along the course of the vein. The patient reports pain at the IV site. What condition do these findings most likely indicate?
Infiltration.
Infection.
Phlebitis.
Thrombosis.
A nurse is preparing to administer subcutaneous heparin to a patient. Which of the following sites is generally preferred for this injection to maximize absorption and minimize irritation?
The upper outer aspect of the arm.
The anterior aspect of the thigh.
The abdomen, at least 2 inches away from the umbilicus.
The upper dorsal gluteal area.
A nurse is caring for a patient who is post-operative following abdominal surgery. The patient reports feeling like "something popped" and suddenly experiences a significant increase in serosanguineous drainage from the surgical wound. On assessment, the nurse notes that the wound edges have separated. What is the nurse's most appropriate immediate action?
Apply a dry sterile dressing to the wound.
Apply a binder to the abdomen.
Position the patient supine with knees flexed.
Cover the wound with a sterile saline-soaked dressing.
A nurse is caring for a patient who has a central venous catheter (CVC). During a dressing change, the nurse notes redness, swelling, and purulent drainage at the insertion site. The patient also reports tenderness in the area and has a fever of 100.4°F (38°C). These findings are most consistent with which of the following complications?
Air embolism.
Catheter occlusion.
Localized infection.
Systemic sepsis.
A nurse is caring for a patient with a nasogastric (NG) tube that is connected to low intermittent suction. The nurse notes that there has been no drainage in the collection container for the past 4 hours. What is the nurse's most appropriate initial action?
Increase the suction pressure.
Irrigate the NG tube with normal saline.
Reposition the patient.
Remove the NG tube.
A nurse is caring for a patient with a three-way indwelling urinary catheter for continuous bladder irrigation following a transurethral resection of the prostate (TURP). The nurse observes that the urine output is significantly less than the amount of irrigating solution instilled. What is the nurse's most appropriate initial action?
Increase the rate of the bladder irrigation.
Assess the catheter and tubing for kinks or obstructions.
Manually irrigate the bladder with sterile saline.
Notify the physician immediately.
A nurse is caring for a patient with a diagnosis of heart failure who is receiving furosemide (Lasix). Which of the following laboratory values should the nurse monitor most closely?
Serum creatinine.
Serum potassium.
Serum sodium.
Serum calcium.
A nurse is caring for a patient who has just returned from a cardiac catheterization. The femoral artery was used as the insertion site. Which of the following nursing assessments is the highest priority?
Assessing the patient's blood pressure and heart rate.
Checking the dressing at the insertion site for bleeding or hematoma.
Evaluating the patient's level of consciousness.
Assessing distal pulses in the affected leg.
A nurse is caring for a patient who is receiving total parenteral nutrition (TPN) via a central line. The current bag of TPN is almost empty, and the next bag is not yet available. What is the nurse's most appropriate temporary intervention?
Hang a bag of 10% dextrose in water (D10W).
Disconnect the TPN line until the new bag arrives.
Flush the central line with heparin solution.
Hang a bag of normal saline (0.9% NaCl).
A nurse is caring for a patient who is receiving a continuous infusion of morphine via a patient-controlled analgesia (PCA) pump. The patient reports inadequate pain relief. What is the nurse's most appropriate initial action?
Administer a prescribed PRN oral analgesic.
Increase the basal rate of the morphine infusion.
Assess the PCA pump settings and the patient's usage.
Call the physician to request a change in medication.
A nurse is caring for a patient who is scheduled for a lumbar puncture. The nurse should assist the patient into which of the following positions for this procedure?
Prone position
Lateral recumbent position with knees drawn to chest
Supine position with legs extended
Sitting upright with legs dangling
Which position is recommended for a patient with increased intracranial pressure?
Prone with a pillow under the abdomen.
Supine with knees flexed and head flat.
Lateral recumbent with knees drawn up to the chest and chin tucked.
Semi-Fowler's with slight flexion of the hips and knees.
A nurse is caring for a patient who has a chest tube connected to a water-seal drainage system. The nurse observes continuous bubbling in the water-seal chamber. What does this finding most likely indicate?
Normal functioning of the drainage system.
A leak in the drainage system.
The patient has a pneumothorax.
The patient is ready for chest tube removal.
A nurse is caring for a patient who is receiving mechanical ventilation. The high-pressure alarm on the ventilator keeps sounding. What is the nurse's most appropriate initial action?
Increase the set tidal volume.
Suction the patient's airway.
Decrease the sensitivity of the alarm.
Administer a neuromuscular blocking agent.
A nurse is caring for a patient who is receiving a blood transfusion. Ten minutes after the transfusion begins, the patient reports chills and back pain. What is the nurse's most appropriate first action?
Slow down the rate of the transfusion.
Administer acetaminophen as prescribed.
Stop the blood transfusion immediately.
A nurse is caring for a patient who is scheduled for an electroencephalogram (EEG). Which of the following instructions should the nurse provide to the patient before the procedure?
You will need to lie completely still during the recording.
You should avoid caffeine for 24 hours before the test.
You will receive a mild sedative to help you relax.
You should eat a heavy meal before the test to prevent hunger.
A nurse is caring for a patient who has a deep vein thrombosis (DVT) in the left leg and is receiving a continuous infusion of heparin. Which of the following nursing interventions is most important to prevent a pulmonary embolism (PE)?
Applying sequential compression devices (SCDs) to both legs.
Encouraging the patient to ambulate frequently.
Monitoring the patient for signs and symptoms of a PE.
Elevating the patient's left leg on pillows.
A nurse is teaching a patient with newly diagnosed type 2 diabetes mellitus about foot care. Which of the following instructions should the nurse include in the teaching plan?
You should inspect your feet daily for any cuts, blisters, or redness.
It's acceptable to walk barefoot at home to improve circulation.
You should cut your toenails in a rounded fashion to prevent ingrown nails.
Soak your feet in warm water daily for at least 30 minutes to keep them clean.
A nurse is providing discharge teaching to a patient prescribed warfarin (Coumadin). Which of the following statements by the patient indicates a need for further teaching?
I should avoid eating large amounts of leafy green vegetables.
I will take my medication at the same time every day.
I will report any signs of unusual bleeding or bruising to my doctor.
I can take aspirin or ibuprofen for headaches as needed.
A nurse is teaching a patient about self-administration of insulin. Which of the following statements indicates the patient understands how to rotate injection sites?
I will inject my insulin in the same spot on my abdomen every day.
I will rotate injection sites within the same general body area, like my abdomen, before moving to another area.
I will inject my insulin into my arm one day, then my thigh the next day, and then my abdomen the day after.
I should always inject insulin into my dominant arm to ensure better absorption.
A nurse is caring for a patient who has a nasogastric (NG) tube inserted for gastric decompression. Which of the following findings would indicate that the NG tube is functioning effectively?
The patient reports feeling nauseous and bloated.
There is continuous gastric drainage in the collection container.
The patient's abdomen becomes increasingly distended.
The patient has frequent episodes of vomiting.
A nurse is teaching a patient about a low-sodium diet. The nurse should advise the patient to limit or avoid which of the following foods?
Canned soup
Fresh fruit
Unsalted nuts
Steamed vegetables
A nurse is preparing to administer medications through a nasogastric (NG) tube. After checking for tube placement, what is the nurse's next most appropriate action?
Mix all medications together and administer them simultaneously.
Flush the NG tube with 30 mL of water.
Administer each medication separately, flushing with water between each medication.
Administer the medications by pushing them quickly through the tube.
