ABC'S
A nurse is caring for a patient who suddenly becomes unresponsive. Which assessment should the nurse perform FIRST?
A. Check the patient's blood glucose
B. Assess the patient's airway
C. Obtain a full set of vital signs
D. Assess the patient's pupils
Assess the patient's airway
A trauma patient arrives after a high-speed MVC. He is unresponsive and has gurgling respirations. What is the nurse's PRIORITY intervention?
Airway!!!
A nurse is caring for a patient who reports feeling short of breath. Which action represents the ASSESSMENT phase of the nursing process?
A. Administer oxygen at 2 L/min
B. The patient's oxygen saturation is 88%
C. Teach the patient pursed-lip breathing
D. Evaluate whether oxygen therapy improved the patient's condition
the patient's oxygen saturation is 88%
A patient refuses a prescribed medication after the nurse explains its purpose, benefits, and potential risks. Which ethical principle is demonstrated when the nurse respects the refusal?
Autonomy
A nurse is caring for a patient who is scheduled for surgery. Who is primarily responsible for explaining the procedure, risks, benefits, and alternatives to the patient?
The provider performing the procedure
A patient is experiencing severe shortness of breath and has an oxygen saturation of 82%. What is the nurse's PRIORITY intervention?
Apply oxygen
A trauma patient has severe external bleeding from the femoral region. What should the nurse do FIRST?
Apply direct pressure to control hemorrhage
A patient reports, "My pain is a 9 out of 10." What type of assessment data is this?
Subjective
A patient asks the nurse, "Did my test results come back?" The nurse knows the results are available but has not yet discussed them with the patient. What ethical principle should guide the nurse's communication?
Veracity
A patient is about to sign a consent form but states, "I don't understand what this procedure is for." What should the nurse do?
Stop the process and notify the provider
Which patient should the nurse assess FIRST?
A. Patient with a blood pressure of 150/88 mmHg
B. Patient reporting pain of 7/10
C. Patient with new-onset stridor
D. Patient requesting assistance to the bathroom
Patient with new-onset strido
A patient with severe trauma has a blood pressure of 78/44 mmHg, heart rate of 138/min, cool clammy skin, and delayed capillary refill. What is the most likely problem?
Hemorrhagic shock
A patient has a respiratory rate of 30/min, oxygen saturation of 86%, and reports difficulty breathing. Which nursing diagnosis is most appropriate?
Impaired gas exchange
A nurse has four patients who all require pain medication. The nurse administers medications based on each patient's clinical need rather than personal preference. Which ethical principle is demonstrated?
Justice
Which patient is most likely able to provide their own informed consent?
A competent adult who understands the procedure
A patient begins choking while eating and is unable to speak or cough effectively. What should the nurse do FIRST?
A. Give the patient water
B. Encourage the patient to cough
C. Perform abdominal thrusts
D. Place the patient in bed
Perform abdominal thrusts
During the trauma primary survey, what is the purpose of the "D" in ABCDE?
Disability/neurologic assessment
Which action represents the PLANNING phase of ADPIE?
Developing a goal
A nurse encourages a patient to participate in physical therapy because it will improve strength and mobility. Which ethical principle is demonstrated?
Beneficence
A patient is scheduled for a procedure requiring informed consent. The patient speaks very little English. What should the nurse do?
Use a qualified medical interpreter
A patient with a GUNSHOT wound has a blood pressure of 78/42 mmHg and heart rate of 132/min. What is the priority nursing intervention?
Establish/maintain IV access and prepare for fluid resuscitation, STOP THE ACUTE BLEED
Find and treat life threats during the primary survey. Don't wait for imaging to treat an obvious immediate threat in an unstable patient. TRUE OR FALSE
True
Which outcome is written correctly?
A. Patient will feel better
B. Nurse will monitor blood pressure
C. Patient will maintain a blood pressure below 140/90 mmHg by the end of the shift
D. Administer antihypertensive medication
Patient will maintain a blood pressure below 140/90 mmHg by the end of the shift
A nurse checks a patient's allergy history before administering an antibiotic. Which ethical principle is demonstrated?
Nonmaleficence
Which information is generally included as part of informed consent?
Risks, benefits, alternatives, and what the procedure involves