and CORRECT Answers
A pt presses the call bell and requests pain medication for a severe headache. To assess the
quality of the pt. Pain, which approach should the nurse use? - Correct Answer- Ask the
patient to describe the pain
The nurse is wearing personal protective equipment while caring for a pt. When exiting the
room, which PPE should be removed first? - Correct Answer- Gloves
An older pt is brought to the ED with a sudden onset of confusion that occurred after
experiencing a fall at home. The daughter, who has power of attorney, has brought the client's
prescriptions. Which information should the nurse provide first when reporting to the
healthcare provider using SBAR communication? - Correct Answer- Increasing confusion of
the pt.
A pt tells the nurse about working out with a personal trainer and swimming three times a
week in an effort to lose weight and sleep better. The pt states that it still is taking hours to
fall asleep at night. Which action should the nurse implement? - Correct Answer- Ask the pt
for a description of the exercise schedule that is being followed
2 days prior to discharge from the rehab facility, the nurse is teaching a pt who is recovering
from Guillain-Barre syndrome about home. Which actions should the nurse include when
providing discharge teaching to the pt and spouse? SATA - Correct Answer- -review safe
transfer strategies
-develop a nutritional plan
-help identify community support
The nurse implements a tertiary prevention program for type 2 diabetes in a rural health
clinic. Which outcome indicates that the program was effective? - Correct Answer- pt who
develop disease complications promptly received rehabilitation
The nurse has received funding to design a health promotion project for African American
women who are at risk for developing breast cancer. Which resource is most important in
designing this program? - Correct Answer- participation of community leaders in planning
the program
, A pt with multiple injuries is being treated in the burn trauma unit just hours after the injuries
occurred. The healthcare provider instructs the nurse to avoid auto contamination when
performing dressing changes. Which intervention is most important for the nurse to
implement? - Correct Answer- use gown, mask, and gloves with dressing changes
A pt is recovering in the critical care unit following a cardiac cath. IV nitro and heparin are
infusing. The pt is sedated but responds to instructions. After changing positions, the pt
complains of pain at the right groin insertion site. What action should the nurse implement? -
Correct Answer- Stimulate the pt to take deep breaths
Prior to obtaining a trapeze bar for a pt with limited mobility, which pt assessment is most
important for the nurse to obtain? - Correct Answer- upper body muscle strength
While the nurse is assessing an older pt fall risk, the pt reports living at home alone and never
falling. Which action should the nurse take? - Correct Answer- Continue to obtain pt data
needed to complete the fall risk survey
The nurse is feeding an older adult who was admitted with aspiration pneumonia. The pt is
weak and begins coughing while attempting to drink through a straw. Which intervention
should the nurse implement? - Correct Answer- Teach coughing and deep breathing exercises
The nurse is teaching the pt about home care after surgery for an ileal conduit placement.
When reviewing the information, which statement should the nurse recognize as needing
additional education? - Correct Answer- Empty the pouch when it is half full.
A 12 week gestation is admitted to the antepartum unit with a dx of hyperemesis gravidarum.
Which action is most important for the nurse to implement? - Correct Answer- initiate
prescribed IV fluids
A pt with dyspnea is being admitted to the medical unit. To best prepare for the pt arrival, the
nurse should ensure that the pt bed is in which position? - Correct Answer- Picture with the
bed sitting up
A pt who is scheduled for a bronchoscopy in the morning is anxious and asking the nurse
numerous questions about the procedure. In preparing the pt for the procedure, which
intervention has the highest priority? - Correct Answer- Instruct pt to write down questions