LEGAL PROOF
A nurse administers an IV opioid medication to a patient reporting severe postoperative pain. Which action should the nurse take?
A. Document the medication when completing the end-of-shift summary.
B. Document the medication immediately after administration.
C. Ask the oncoming nurse to document the medication.
D. Document the medication before administering it.
B. Document the medication immediately after administration.
Which nursing action occurs during the working phase of the nurse–patient relationship?
A. Establishing the initial agreement between the nurse and patient
B. Identifying problems and developing possible solutions with the patient
C. Introducing the patient to members of the healthcare team
D. Reviewing the relationship and preparing the patient for discharge
B. Identifying problems and developing possible solutions with the patient
A nurse is developing a teaching plan for a patient newly diagnosed with diabetes mellitus. Which action best demonstrates patient-focused teaching?
A. Use the same standardized teaching plan provided to every patient.
B. Begin by assessing the patient’s current knowledge, priorities, and preferred learning methods.
C. Present all information about diabetes during one teaching session.
D. Ask the patient’s family to decide what information the patient should receive.
B. Begin by assessing the patient’s current knowledge, priorities, and preferred learning methods.
An older adult is admitted to the medical unit after falling at home. Which finding places the patient at the greatest immediate risk for another fall?
A. The patient wears reading glasses.
B. The patient reports dizziness when standing.
C. The patient prefers to sleep with the door closed.
D. The patient eats meals at different times each day.
B. The patient reports dizziness when standing.
A patient has arrived in the post anesthesia care unit following abdominal surgery. Which perioperative phase is the patient experiencing?
A. Preoperative
B. Intraoperative
C. Postoperative
D. Preprocedural
C. Postoperative
An older adult reports increasing difficulty walking because of pain and stiffness in both knees. Which factor most directly affects this patient’s mobility?
A. Age-related changes in vision
B. Decreased joint movement caused by arthritis
C. Increased respiratory secretions
D. Decreased short-term memory
B. Decreased joint movement caused by arthritis
. Which action should the nurse not take when correcting an error in a paper patient record?
A. Draw a single line through the incorrect information.
B. Write “mistaken entry” according to facility policy.
C. Erase the incorrect information so it cannot be read.
D. Add the nurse’s initials and the date or time of the correction.
C. Erase the incorrect information so it cannot be read.
A patient newly diagnosed with cancer states, “I am frightened about what will happen to my family.” Which response by the nurse best demonstrates empathy?
A. “You should try to remain positive for your family.”
B. “I understand exactly how you feel.”
C. “It sounds as though you are worried about how this illness will affect your family.”
D. “Many patients with cancer experience the same concerns.”
C. “It sounds as though you are worried about how this illness will affect your family.”
A patient states, “I know I need to change my diet, but I am not ready to give up every food I enjoy.” Which response by the nurse best demonstrates negotiation?
A. “You must follow the prescribed diet exactly.”
B. “Let us identify one dietary change that is important to you and feels manageable.”
C. “I will ask the dietitian to make the decisions for you.”
D. “We can discuss your diet again when you are more motivated.”
B. “Let us identify one dietary change that is important to you and feels manageable.”
A hospitalized patient is confused and repeatedly attempts to get out of bed without assistance. Which intervention should the nurse implement first?
A. Apply bilateral wrist restraints.
B. Place the bed in the lowest position and activate the bed alarm.
C. Raise all four side rails.
D. Administer a sedating medication.
B. Place the bed in the lowest position and activate the bed alarm.
Which action should the nurse NOT perform when obtaining informed consent for surgery?
A. Verify that the patient is signing voluntarily.
B. Witness the patient’s signature according to facility policy.
C. Explain the surgical risks, benefits, and alternatives to the patient.
D. Notify the surgeon if the patient has unanswered questions.
C. Explain the surgical risks, benefits, and alternatives to the patient.
A patient has remained on bed rest for several days. Which finding requires the nurse’s immediate intervention?
A. Decreased appetite
B. Difficulty sleeping at night
C. Unilateral calf warmth and swelling
D. Decreased interest in recreational activities
C. Unilateral calf warmth and swelling
The nurse is writing a SOAP progress note for a patient experiencing shortness of breath. Which information belongs in the Assessment section?
A. “I feel like I cannot catch my breath.”
B. Respiratory rate 28/min with oxygen saturation of 89%.
C. Impaired gas exchange related to ventilation-perfusion imbalance.
D. Apply oxygen and notify the healthcare provider.
C. Impaired gas exchange related to ventilation-perfusion imbalance.
Which nursing action best demonstrates positive regard?
A. Correcting a patient each time the patient expresses an unrealistic concern
B. Treating the patient as a person with value and dignity without unnecessary labeling
C. Sharing personal experiences so the patient will view the nurse as a friend
D. Agreeing with every decision the patient makes
B. Treating the patient as a person with value and dignity without unnecessary labeling
A patient needs to learn how to change a sterile dressing before discharge. Which teaching method is most appropriate?
A. Provide a lecture about the principles of wound healing.
B. Demonstrate the procedure and then have the patient perform a return demonstration.
C. Ask the patient to read the dressing-change instructions independently.
D. Show the patient photographs of different wound types.
B. Demonstrate the procedure and then have the patient perform a return demonstration.
. A patient with confusion repeatedly pulls at an IV catheter. Which action should the nurse take before requesting a restraint prescription?
A. Apply a restraint temporarily and notify the provider afterward.
B. Attempt alternatives such as reorientation, distraction, and concealing the tubing.
C. Ask a family member to authorize the use of restraints.
D. Administer a sedative to prevent the patient from touching the catheter.
B. Attempt alternatives such as reorientation, distraction, and concealing the tubing.
The perioperative team pauses immediately before making the surgical incision. What is the primary purpose of this time-out?
A. Confirm the patient’s postoperative discharge plan.
B. Verify the correct patient, procedure, and surgical site.
C. Determine whether the patient requires additional pain medication.
D. Confirm that the patient’s family has been notified.
B. Verify the correct patient, procedure, and surgical site.
Which patient action demonstrates active range of motion?
A. The nurse moves the patient’s ankle through dorsiflexion and plantar flexion.
B. The physical therapist moves the patient’s shoulder while the patient relaxes.
C. The patient independently bends and straightens the knees.
D. The nurse supports the patient’s arm through the entire exercise.
C. The patient independently bends and straightens the knees.
Which nursing entry is the most objective?
A. “Patient appears angry and uncooperative.”
B. “Patient is experiencing severe anxiety.”
C. “Patient paced in the hallway and stated, ‘I cannot sit still.’”
D. “Patient behaved inappropriately toward the nursing staff.”
C. “Patient paced in the hallway and stated, ‘I cannot sit still.’”
A patient tells the nurse, “Nothing has felt right since I came home from the hospital.” Which response uses the therapeutic technique of seeking clarification?
A. “Why do you think you feel that way?”
B. “Everything will begin to feel normal soon.”
C. “Can you explain what you mean when you say that nothing feels right?”
D. “Let us discuss the medications you are taking.”
C. “Can you explain what you mean when you say that nothing feels right?”
After teaching a patient about a newly prescribed medication, which statement by the nurse best uses the teach-back method?
A. “Do you understand everything I explained?”
B. “Please repeat the information exactly as I presented it.”
C. “Tell me how you will take this medication when you are at home.”
D. “Read the medication handout and sign that you received it.”
C. “Tell me how you will take this medication when you are at home.”
A nurse discovers a fire in a wastebasket inside a patient’s room. Which action should the nurse take first?
A. Activate the fire alarm.
B. Close the patient’s door.
C. Remove the patient from immediate danger.
D. Attempt to extinguish the fire.
C. Remove the patient from immediate danger.
A patient arrives in the postanesthesia care unit following general anesthesia. Which assessment is the nurse’s priority?
A. Surgical pain
B. Airway patency
C. Urinary output
D. Incisional drainage
B. Airway patency
Two nurses are preparing to move a dependent patient from the bed to a stretcher. Which action demonstrates correct body mechanics?
A. Keep the feet close together while lifting.
B. Bend forward at the waist to reach across the bed.
C. Hold the patient away from the nurses’ bodies during movement.
D. Position the feet shoulder-width apart and bend at the hips and knees.
D. Position the feet shoulder-width apart and bend at the hips and knees.
Which information should the nurse include when transferring a patient to another nursing unit? Select all that apply.
A. Current assessment findings
B. Recent changes in the patient’s condition
C. Personal opinions about the patient’s family
D. Medications recently administered
A. Current assessment findings
B. Recent changes in the patient’s condition
D. Medications recently administered
A patient awaiting surgery states, “I am afraid I will not wake up afterward.” Which response would not be therapeutic?
A. “Tell me more about what concerns you most.”
B. “You should not worry; everything will be fine.”
C. “You appear frightened about the anesthesia.”
D. “I will stay with you while we discuss your concerns.”
B. “You should not worry; everything will be fine.”
Which information should the nurse document after completing a patient-teaching session? Select all that apply.
A. The subject matter taught
B. The nurse’s opinion about the patient’s intelligence
C. The patient’s response to the teaching
D. The method used to evaluate learning
A. The subject matter taught
C. The patient’s response to the teaching
D. The method used to evaluate learning
A nurse discovers that a patient received twice the prescribed dose of an opioid and is difficult to arouse. Which actions should the nurse take? Select all that apply.
A. Assess the patient’s respiratory status and level of consciousness.
B. Document in the medical record that the adverse event report was completed.
C. Document the patient’s assessment and care in the medical record.
D. Complete an adverse event report according to facility policy.
A. Assess the patient’s respiratory status and level of consciousness.
C. Document the patient’s assessment and care in the medical record.
D. Complete an adverse event report according to facility policy.
A nurse is receiving a patient in the post anesthesia care unit. Which assessments should the nurse perform? Select all that apply.
A. Airway patency and respiratory function
B. Return of sensory and motor function
C. Ability to tolerate oral fluids
D. Surgical drainage and evidence of bleeding
A. Airway patency and respiratory function
B. Return of sensory and motor function
D. Surgical drainage and evidence of bleeding
The nurse teaches a patient with left-leg weakness how to use a cane. Which action by the patient demonstrates correct technique?
A. Holds the cane in the left hand and moves the right leg first
B. Holds the cane in the right hand and advances it with the left leg
C. Holds the cane in the left hand and advances it with the left leg
D. Holds the cane in either hand and moves the stronger leg first
B. Holds the cane in the right hand and advances it with the left leg