A hospice nurse who has become close to a terminally ill patient is presented in
the home when the patient dies and feels saddened and tearful as the family
members begin to cry. Which action should the nurse take at this time?
Cry along with the patient's family members
The son of a dying patient tells the nurse, "Mother doesn't respond any more
when I visit, I don't think she knows that I am here". Which response by the nurse
is appropriate?
"Withdrawal can be a normal response in the process of dying."
A patient who was involved in a motor vehicle crash has had a tracheostomy
placed to allow for mechanical ventilation. How should the nurse interpret the
following arterial blood gas results: pH 7.48, paO2 32 mmHG, and HCO3 25
mEq/L?
Respiratory Alkalosis
An older adult patient receiving iso-osmolar continuous enteral nutrition develops
restlessness, agitation, and weakness. Which laboratory result should the nurse
report to the health care provider immediately?
Na 154 mEq/L (154 mmo/L)
A patient undergoing an emergency appendectomy has been using St. Johns
wart to prevent depression. Which complication should the nurse expect in the
post anesthesia care unit?
Increased anesthesia recovery time
A patient who takes a diuretic and a B-blocker to control blood pressure is
scheduled for breast reconstruction surgery. Which patient information is most
important to communicate to the health care provider before surgery?
Serum potassium 3.2 mEq/L
,While in the holding area, a patient revels to the nurse that his father had a high
fever immediately after surgery. What action by the nurse is a priority?
Alert the anesthesia care provider of the family member's reaction to surgery.
A patient in surgery receives a neuromuscular blocking agent as an adjunct to
general anesthesia. Which in the post anesthesia care unit (PACU). What
assessment finding is most important for the nurse to report?
Weak chest movement
A patient who has begun to awaken after 30 minutes in the post anesthesia care
unit (PACU) is restless and shouting at the nurse. The patient's oxygen
saturation is 96%, and recent laboratory results are all normal. Which action by
the nurse is most appropriate?
Assess for bladder distension
A patient who is just waking up after having hip replacement surgery is agitated
and confused. Which action should the nurse take first?
Check the oxygen (O2) saturation
On admission to the burn unit, a patient with an approximate 25% total body
surface area (TBSA) burn has the following initial laboratory results: Hct 58%,
Hgb 18.2 mg/dL (172 d/L), Serum K+ 4.9 mEq/L (4.8 mmol/L and serum Na+
1345 mEq/L (135 mmo/L). Which of the following prescribed actions should be
the nurse's priority?
Increasing the rate of the ordered IV solution
A patient with severe burns has crystalloid fluid replacement ordered using the
Parkland formula. The initial volume of fluid to be given in the first 24 hrs. Is
30,000 mL. The initial rate of administration is 1875, L/hr. After the first 8 hours,
what rate should the nurse infuse the IV fluids?
938 mL/hr.
A patient arrives in the emergency department with facial and chest burns
caused by a house fire. Which actions should the nurse take first?
, Auscultate for breath sounds
Which nursing action is a priority for a patient who has suffered a burn injury
while working on an electrical power line?
Stabilize the cervical spine
The nurse is caring for a patient who has a right-sided chest tube after a right
lower lobectomy. Which nursing action can the nurse delegate to the unlicensed
assistive personnel (UAP)?
document the amount of drainage every 8 hours.
A patient who has had chest pain for several hours is admitted with a diagnosis
of rule out acute myocardial infarction (AMI). Which laboratory test is most
specific for the nurse to monitor in determining whether the patient has had an
AMI?
Cardiac-specific troponin
Which electrocardiographic (ECG) change by a patient with chest pain is most
important for the nurse to report rapidly to the health care provider?
St-segment elevation
Which assessment finding in a patient admitted with acute decompensated heart
failure) ADHF) requires the most immediate action by the nurse?
O2 saturation of 88%
After receiving change -of-shift report on a heart failure unit, which patient should
the nurse assess first?
Patient who is taking digoxin and has a potassium level of 3.1 mEq/L.
A patient with supraventricular tachycardia who is alert and has a blood pressure
of 110/66 mmHg is being prepared for cardioversion. Which action should the
nurse take?
Give a sedative before cardioversion is implemented.
the home when the patient dies and feels saddened and tearful as the family
members begin to cry. Which action should the nurse take at this time?
Cry along with the patient's family members
The son of a dying patient tells the nurse, "Mother doesn't respond any more
when I visit, I don't think she knows that I am here". Which response by the nurse
is appropriate?
"Withdrawal can be a normal response in the process of dying."
A patient who was involved in a motor vehicle crash has had a tracheostomy
placed to allow for mechanical ventilation. How should the nurse interpret the
following arterial blood gas results: pH 7.48, paO2 32 mmHG, and HCO3 25
mEq/L?
Respiratory Alkalosis
An older adult patient receiving iso-osmolar continuous enteral nutrition develops
restlessness, agitation, and weakness. Which laboratory result should the nurse
report to the health care provider immediately?
Na 154 mEq/L (154 mmo/L)
A patient undergoing an emergency appendectomy has been using St. Johns
wart to prevent depression. Which complication should the nurse expect in the
post anesthesia care unit?
Increased anesthesia recovery time
A patient who takes a diuretic and a B-blocker to control blood pressure is
scheduled for breast reconstruction surgery. Which patient information is most
important to communicate to the health care provider before surgery?
Serum potassium 3.2 mEq/L
,While in the holding area, a patient revels to the nurse that his father had a high
fever immediately after surgery. What action by the nurse is a priority?
Alert the anesthesia care provider of the family member's reaction to surgery.
A patient in surgery receives a neuromuscular blocking agent as an adjunct to
general anesthesia. Which in the post anesthesia care unit (PACU). What
assessment finding is most important for the nurse to report?
Weak chest movement
A patient who has begun to awaken after 30 minutes in the post anesthesia care
unit (PACU) is restless and shouting at the nurse. The patient's oxygen
saturation is 96%, and recent laboratory results are all normal. Which action by
the nurse is most appropriate?
Assess for bladder distension
A patient who is just waking up after having hip replacement surgery is agitated
and confused. Which action should the nurse take first?
Check the oxygen (O2) saturation
On admission to the burn unit, a patient with an approximate 25% total body
surface area (TBSA) burn has the following initial laboratory results: Hct 58%,
Hgb 18.2 mg/dL (172 d/L), Serum K+ 4.9 mEq/L (4.8 mmol/L and serum Na+
1345 mEq/L (135 mmo/L). Which of the following prescribed actions should be
the nurse's priority?
Increasing the rate of the ordered IV solution
A patient with severe burns has crystalloid fluid replacement ordered using the
Parkland formula. The initial volume of fluid to be given in the first 24 hrs. Is
30,000 mL. The initial rate of administration is 1875, L/hr. After the first 8 hours,
what rate should the nurse infuse the IV fluids?
938 mL/hr.
A patient arrives in the emergency department with facial and chest burns
caused by a house fire. Which actions should the nurse take first?
, Auscultate for breath sounds
Which nursing action is a priority for a patient who has suffered a burn injury
while working on an electrical power line?
Stabilize the cervical spine
The nurse is caring for a patient who has a right-sided chest tube after a right
lower lobectomy. Which nursing action can the nurse delegate to the unlicensed
assistive personnel (UAP)?
document the amount of drainage every 8 hours.
A patient who has had chest pain for several hours is admitted with a diagnosis
of rule out acute myocardial infarction (AMI). Which laboratory test is most
specific for the nurse to monitor in determining whether the patient has had an
AMI?
Cardiac-specific troponin
Which electrocardiographic (ECG) change by a patient with chest pain is most
important for the nurse to report rapidly to the health care provider?
St-segment elevation
Which assessment finding in a patient admitted with acute decompensated heart
failure) ADHF) requires the most immediate action by the nurse?
O2 saturation of 88%
After receiving change -of-shift report on a heart failure unit, which patient should
the nurse assess first?
Patient who is taking digoxin and has a potassium level of 3.1 mEq/L.
A patient with supraventricular tachycardia who is alert and has a blood pressure
of 110/66 mmHg is being prepared for cardioversion. Which action should the
nurse take?
Give a sedative before cardioversion is implemented.
