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You as the nurse is discussing the diagnostic finding about a terminal illness with the patient, he states “Why God has forsaken me?” What should your response be?
“This is a difficult time for you. I can stay or if you want I can call the hospital chaplain.”
How do you collect urine specimen from a patient with a indwelling catheter?
Patient had an abdominal surgery 12hours ago, patient’s temperature 100F, what intervention should you do first?
Patient has left hemiplegia, he develops unilateral vision syndrome, what is the best nursing intervention?
Provide care on the right side.
Clean around the urinary meatus with wipes the refrigerate urine.
Female client scheduled for discharge,few hours before discharge patient states that there is a knife and she can use it to harm herself. What is the nursing intervention?
Inform the MD about the statement.
You are providing an elderly patient a bed bath, patient states that he is sad because of the death of her wife six months ago, what will be your best response?
An 82 y/o patient was admitted for fractured right hip, foot board was placed. What is the purpose for this intervention?
Stabilizing a client for laryngectomy and left radial neck dissection and tracheostomy was placed.In what position should the patient be placed?
A patient who had CABG surgery with a sapheads (?) vein for grafting, patient also has DM. What will be your nursing diagnosis?
Patient has osteoporosis. She asks the nurse to explain how bone loss can be prevented by promoting bone formation?
Patient with thrombocytopenia, what will be the intervention to prevent bleeding?
9y/o patient was diagnosed with DM, what symptoms would the parents like to report to the doctor?
Patient taking food via NG tube, what intervention is best to prevent diarrhea?
Patient has colon resection days ago and is straining at stool, as a nurse you observed spillage of serous drainage and appearance of the bowel on the skin, what would you call this?
Elderly patient 45y/o to be screened for prostate cancer, what is the test for this?
Patient experiences muscle fatigue on lower extremities?
Removing personal protective equipment, what needs to be removed first?
Ambulatory patient with indwelling catheter is scheduled for a shower, what will you do?
Patient had small bowel resection 3 days ago; he is complaining of calf pain on dorsiflexion,what does it mean?
What would be a symptom for liver cirrhosis that needs immediate action?
Patient with body spica complains of severe nausea, what would be the nursing intervention?
Which one of the patient needs an oral suction?
Bone marrow aspiration, where is it done?
Which one of the following patient is at risk for developing breast cancer?
Purpose of incentive spirometer?
Nurse preparing a patient for a mammogram, what instruction should you tell the patient?
Patient with foley cath needs to take a shower?
Nurse is giving o2via nasal cannula; she heard a hissing sound, what should the nurse do next?
Location of the prostate gland.
What are the steps in emptying a large amount of serous drainage from a Hemovac?
For a patient with nasal cannula, what needs to be protected?
A male pre-op patient who has signed the consent but tells you he is afraid to go through the surgery, what will be your nursing intervention?
(????) As a nurse disconnects an NG tube for a low intermittent suction, the patient has just received his medications, what should the nurse do?
Right atrium > right ventricle> pulmonary semilunar valve> left atrium> mitral valve> left ventricle.
As a nurse you know that skin turgor changes with age, what should be part of your nursing care for the patient?
You as a nurse enters the patient’s room for a sterile dressing change, you noticed that he is gurgling (?? Bubbly sound while breathing), what should you do first?
A patient is scheduled for a CABG procedure, as a nurse you know that the main purpose of this procedure for cardiac process is to?
Home visits for an elderly patient who had an eye surgery 24hrs ago, what action should you do if the patient states that “I am feeling good and I need to clean the house.”
You as a nurse observed that the dressing is soaking in sero-sanguineous 6hrs post-op and the drainage container/vac is empty, what should you do?
Number one symptom for an immunosuppressed patient?
Planning a group activity, what intervention needs to have priority first?
Doctor is considering donating the organs of a comatose patient, if the family declined to go through with it what should you do?
Patient is being transferred from CCU 3 days ago after an MI, what most significant factor is noted in the history of the patient for the rehab?
As a nurse you are making an occupied bed, you placed the patient on a left side lying position,the patient is experiencing orthopnea, and what should you do?
Patient diagnosed with DM, he states that he has an increased thirst. What physiologic mechanism must take place to control the symptom?
As a nurse providing oral care for a patient who is unconscious, you position the patient laterally using basins, what is the next thing to do?
A nurse offers to change an indwelling catheter, what is the intervention to prevent urinary tract infection?
Keep the tubing and the bedside drainage off the floor.
An adolescent female with acute leukemia states that she is having heavy menstrual flow. What is the next intervention?
Using an incentive spirometer post-op from inguinal hernia, what is the wrong way?
A patient has an AV fistula on the left arm. You are observing the CAN who was assigned to check the bp placing the bp cuff directly above the knee. Where is the best position to place the cuff?
As a nurse giving abed bath to a client, to promote the client’s recovery what is the best action?
Observing a patient on a Na restriction diet, she is drinking herbal tea, she is using salt substitute so add taste to her breakfast. What other way could you teach the patient about her diet?
(???) Patient with a chronic medical condition tells you that no ???, nurse action would be?
Patient is diagnosed with terminal cancer, she voices “The doctor told me that I have cancer and have a short life” what will be your response?
An 82y/o patient has bilateral cataracts, to enhance reading ability what would be the best intervention?
In providing care to prevent tonic-clonic seizure for the patient, hat can you assign the UAP?
At the patient’s room the doctor tells the nurse to trim the toenails of the DM patient’s toes. What will you do?
A diabetic patient is hyperventilating with Kaussmaul’s breathing pattern, what will you do?
You are teaching the patient with double barrel (2 opening) colostomy to replace his bag to know if it fits properly what instructions need to be implemented?
While preparing morphine sulfate, the patient states that he thinks he is constipated, what should you implement?
Patient with cholethiasis (?), which desert is best for the patient to eat?
Patient is experiencing muscle sprain on the ankle, what will be the nursing intervention?
Patient had fractured tibia and fibula, to promote comfort, what position would you place the patient?
Assisting patient out of bed, what is the nursing intervention?
Elderly patient with right total hip replacement. During the change of shift report , it state that the patient is having pain intolerant. What should you do?
As a nurse you observed that there is a bleeding in a client’s IV site, the nurse apply dressing to stop bleeding, what will be the next step?
Providing care for a patient with condom catheter?
Immobility due to stroke, what is the intervention to prevent contractures?
Elderly patient must increase intake of fluid, what could be your intervention?
Patient with pulmonary embolism with heparin protocol, you were asked to decrease the infusion pump. What should you do?
Patient with migraine headaches asked you what foods should be avoided to prevent attacks.
A patient post-op with total laryngectomy 2 days ago transferred from CCU to med surg. What measures to stop the patient’s anxiety?
A patient is admitted in post-op after lobectomy, as prescribed there is 20 cm water pressure suction, it has tidaling and bubbling. What action needs to be done?
Mastectomy incision is healing well but patient refuses to look at the incision site. What will be your intervention?
A nurse is caring fora patient who is newly diagnosed with DM, what are the early signs that the patient is experiencing hypoglycemia?
Following CVA, a patient is having difficulty swallowing, what need to be at the bedside?
Patient on skeletal traction has returned for closed reduction of ???, two after returning, patient complains of pain on the affected area and there are bluish discoloration, what should you do?
A 48 y/o female is undergoing chemotherapy for breast cancer; she asked about her hair falling off and asks if it will grow back. What will be your best response?
Safety when a client is having a seizure
Entering a room of an elderly client and finding a patient slumping on the corner with no sign of life.What will you do?
New mom try to breastfeed the baby, it became uncomfortable because there’s too much milk,what will be the intervention?
Epidural anesthesia,what do you need to watch for?
LVN uses 2 hands for fundal massages; one is to place on top and the other at the bottom to?
Postpartum client receives a rubella vaccine, what is it for?
New mom,breast-feeding, engagement
Woman in labor has genital herpes and had used Zovirax, what will be the nursing intervention?
Where does conception happen?
Caring for the first time postpartum patient?
Following vaginal delivery, patient complains of cramping after breast-feeding the baby, why?
LVN change of shift report, which one needs to get immediate attention?
Position when placing a speculum?
An LVN is collecting a urine specimen from a patient and states that she is menstruating. What should the LVN do?
Routine prenatal test.
Patient on active labor at L&D, she has a 6y/o boy at home:
Patient complains of heartburn, what triggers it? What kind of food was eaten?
Patient who is 2 days postpartum who migrated from Ethiopia but can speak English, what should the nurse do before the delivery?
Clear liquid diet fora patient who had abdominal hysterectomy post-op.
Antepartal clinic, patient came in who is 6 weeks pregnant. What are the signs?
Birth control method for a new mom who is breast feeding states that she does not need it, what will be your best response?
Explaining to a new mom about the fontanelles:
Infant skin taste salty, what test to take to diagnose cystic fibrosis?
Observation on a 10day old infant, what needs to be reported immediately?
Mom complaining about child having a fever and rash, what’s the best nursing intervention?
Child who has eczema?
Well baby check, mom states that the infant (1 y/o) is still not taking solid yet. What could become the problem?
An adolescent with appendicitis, what will you do if the pain subsides?
An adolescent patient had a tonsillectomy states “I am too weak to feed myself”, what is happening with him?
Child with diaper rash:
Activity to provide a4 y/o child who is on bed rest?
24hr old newborn vitals, what should a nurse report to the charge nurse immediately?
Pre-op teaching for a 12 y/o child:
Child says “Mine,mine”, what stage is this?
Patient with meningitis has ICP, early s/s of ICP:
A 2y/o boy in reference to Croup develops tachypnea and resting stridor?
Child separation anxiety, before and after surgery;
Put things in order-taking tympanic temperature.
- Apply probe cover first
- Ask mom for help
- Remove the wax or clean external meatus
- Point the thermometer anterior
What is the weight of a 6 month old child in kg if the weight at birth is 605lbs?
Toddler post-op from tonsillectomy refuses to eat, what intervention should you take for this particular situation?
1 ½ y/o child admitted for cleft palette surgery. Mom asks why is there an elbow restraint,what is the best response?
Itching in the cast?
The mom of a 2 ½ y/o child is concerned that her child does not play with other children, what will be your response?
Child with glomerulonephritis, what is the plan of care?
A teaching should be performed to a 5 y/o child for vaginal cream administration, what will be the best position?
A 2 y/o child refuses to take her medication PO, what will be your intervention?
Upon admission of a newborn, why is it recommended to take the temperature rectally?
A 3 y/o child has an acute otitis media, where does it occur?
A newborn is choking and turning blue (cyanotic) with a first sip of water, he may have a tracheoesophageal fistula. MD orders a chest x-ray, what is the nursing intervention?
School age child with AIDS, exposed to chicken pox, as a nurse what should the other family members do?
Mom that has a 22month old child that has RSV, she has another younger child and an older sibling. What action to reinforce the parent?
A 6 month old child who has bronchiolitis admitted to the hospital, what is the s/s that the patient is having respiratory distress?
A 6 y/o child diagnosed with sickle cell anemia, as a nurse which intervention is important to teach the parents to prevent the symptoms?
24 hour old infant in the nursery that regurgitates and turns blue, what should you do?
A 2 y/o child’s mom asked if the child is ready to toilet train, what training should you provide?
Newborn breastfeeding weighs 1oz at birth, loss weight to 7lbs, what should the nurse do?
Infant is placed in Pavlik harness with subluxation (???) for congenital hip replacement, what could be one of the nursing priorities for the care of this patient?
Lethargic 1hr old infant, in what order should you perform the assessment?
During AM rounds, you notice a patient with OCD in the day room repeatedly washing the top of the table, what should you do?
Patient who is schizophrenic has hallucinations and states that he is hearing voices, what will be your response?
Patient who has Alzheimer’s disease and ask “Where is my mom?” what kind of response would you give your patient?
A patient refuses toeat and says that somebody is planning a plot to kill and poison him?
An adult female withdiagnosis of depression, after each therapy the patient has more energy givingher things away. How would you approach the patient?
Elderly patient has adiagnosis of Alzheimer; you noticed that he is opening the emergency exit, whatis the intervention?
You observe a clientwith a schizophrenia sitting alone and quietly, what actions should you do?
Patient refuses totake his antipsychotic meds, he wanders to the other client’s room, what shouldyou do?
Doctor prescribedRisperidal for an elderly patient with dementia and has been spitting andswearing and shows resistance for his hygiene, what should be the response orthe effect of the medication?
A 33 y/o patient ofchronic major depression that recently stopped taking his medication, whatshould you tell the patient?
Elderly patient withbleeding disorder and has a history of drinking problems states “I only drinkoccasionally (???). What defense mechanism is the patient showing?
What kind of problemshould a nurse expect from a patient who has severe depression?
Patient placed on awrist restraints, patient was severely agitated and disoriented. After a fewhours the patient has fallen asleep. What needs to be assessed?
You noticed anagitated patient watching TV and talking to an empty chair, what should you do?
Adult male clientssay that somebody is trying to get into his files, patient insist that an alarmsystem needs to be installed in his house, the patient is experiencing what?
Patient with paranoiaadmitted at the mental health unit, he went straight at the corner of the room.What should you do first?
A college studentstates that his friend is hearing voices that says “Kill, kill, kill”, whatshould be the intervention?
A 75 y/o client hasAlzheimer’s disease, now admitted to extended care, what intervention need tobe implemented?
As a nurse contactedthe doctor over the phone regarding the patient’s change of status, the doctorgot upset…. How would you respond?
Routes of medicationfastest to slowest:
Eye shield applied toright eye, which way to tape?
Elderly patient withDM states “my finger is sore” reuses accucheck, what do you document?
Patient has DM, 1cmmulcer on big toe, dusky color, what do you do?
IV cath lying on bedsheet, what do you document?
Patient has essentialHTN, temp 99, respiration 26, and coronary artery disease, what do you assessfor?
Patient has fever,slowly decreasing, rank activities in order first to last:
24hr past and doctorhas not signed telephone order, what do you do?
Epogen givensubcutaneously to patient with renal failure. Why?
Need to givemedication, patient unresponsive, has no wrist band, what do you do?
Giving low volumehypertonic cleansing enema, patients holds for 5mins before defecating, what doyou do?
1000 ml cleansingenema, after 500ml is administered patient says “stop”, what do you do?
Patient has type 2DM, unresponsive verbally, says doesn’t feel well, what do you do?
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