Assess This!
The normal range for an adult heart rate is:
What is 60-100 beats per minute?
The single most important routine action for preventing the spread of infection in healthcare settings is:
What is hand hygiene?
The type of communication that involves listening carefully, showing empathy, and focusing on the patient's needs is:
What is therapeutic communication?
The term that describes the process of removing liquid waste from the body through the urinary system is:
What is urinary elimination?
In the Clinical Judgment Measurement Model, the first step in the clinical judgment process is: (include what the nurse does during this step)
What is recognize cues? The nurse collects subjective and objective data, observes nonverbal and environmental cues, filters information, and identifies red flags.
For a healthy adult, the normal range for an oxygen saturation reading is:
What is approximately 95%-100% (Would also take 92%-100%)
Before administering a medication, the nurse compares the patient's ID bracelet with the MAR. Which right of medication administration is the nurse following?
What is the right patient?
A patient says, "I'm really worried about my surgery tomorrow". Out of the following responses, the most therapeutic is:
"Don't worry, everything will be fine"
"Can you tell me more about what is worrying you?"
Include rationale.
What is "Can you tell me more about what is worrying you?" This response encourages the patient to express concerns without offering false reassurance.
The nurse should encourage adequate fluid intake in a patient who has no fluid restrictions because:
What is to help maintain hydration, support normal body functions, and promote kidney and bowel function?
The priority-setting framework which focuses on airway, breathing, and circulation when identifying potentially life-threatening problems is:
What is the ABC framework?
A patient reports pain rated 8/10. The nurse observes that the patient is smiling and talking with a visitor. The nurse's response should be:
What is accept patient's report, assess the pain further, and intervene appropriately?
A nurse enters a patient's room and finds the bed elevated, the call light on the floor, and clutter blocking the walking path. Name two patient safety risks and the appropriate corrections.
What is fall and injury risks? Lower and lock the bed, return the call light within reach, and clear the walking path.
A patient speaks limited English and needs education about a new medication. The best resource for the nurse to use to support accurate communication is:
What is a qualified medical interpreter or facility-approved technology, along with language-appropriate educational materials?
A patient has been on bed rest for several days. Two potential complications of immobility are:
What are pressure injuries, venous thromboembolism, muscle weakness, constipation, and decreased lung expansion.
A patient with diabetes is sweating, trembling, and acting confused. the problem the nurse should suspect is and the first action that should be taken are:
What are hypoglycemia, and immediately assess the patient blood glucose. Provide rapid-acting glucose if the patient is alert and able to swallow safely, following protocol. If the patient cannot swallow safely, use the appropriate emergency treatment and seek assistance as needed.
A patient's respiratory rate increases from 16 to 30 breaths/minute, and the patient appears restless. The nurse's first action should be:
What is assess respiratory status immediately, including work of breathing and oxygen saturation, and intervene or escalate care immediately based on findings?
A patient has a draining wound caused by a suspected infectious organism. The nurse anticipates contact precautions. The steps the nurse should follow before providing care are:
What is follow the isolation precautions, perform hand hygiene, and put on required PPE.
A patient declines a recommended treatment because of a religious belief. The nurse's best response would be:
What is explore the patient's concerns respectfully, provide accurate information, assess understanding, and communicate with the healthcare team while respecting the patient's informed decisions.
An older adult becomes dizzy when standing from a chair. The nurse's first action and the potential problem to be considered are:
What are help the patient sit or lie down safely and assess the patient, the potential problems are orthostatic hypotension and fall risk.
A patient scheduled for surgery reports eating breakfast despite instructions to remain NPO. The nurse's actions should be:
What is notify the surgical/anesthesia team, determine the timing and nature of the intake, and follow their instructions. Do not proceed as though the NPO requirement was met.
The nurse receives report on four patients: one has new confusion, one has pain rated 4/10, one needs assistance with bathing, and one has O2 sats of 84% with shortness of breath. The patient that the nurse should see first is:
What is the patient with O2 sats of 84% and shortness of breath. Rationale: these symptoms suggest potentially life-threatening impaired oxygenation.
A patient at high risk for pressure injuries has limited mobility, urinary incontinence, and poor nutritional intake. The nursing actions that should be prioritized include: (list two)
What are assess skin and risk factors, reposition and offload pressure, manage moisture, support nutrition and hydration, use appropriate pressure-redistributing surfaces?
A patient with newly-diagnosed diabetes says, "My life is over. I will never be able to eat anything I enjoy again." The nurse's best response to support both psychosocial well-being and learning is:
What is acknowledge the patient's feelings, invite them to share concerns, assess readiness to learn, and develop realistic, individualized education about diabetes management and food choices?
A patient recovering from abdominal surgery reports abdominal discomfort, has a distended abdomen, and has not passes stool or flatus. The nurse should assess for: (include what should be reported and why)
What is abdominal findings, bowel sounds, nausea/vomiting, timing of last stool and flatus? Report concerning findings because postoperative ileus or bowel obstruction may be present.
At the beginning of a shift, the nurse identifies four needs: a patient with new chest pain and shortness of breath, a patient requesting pain medication for longstanding back pain, a stable patient needing discharge instructions, and a patient who needs assistance to the bathroom. The patient who should be seen first is: (include your rationale)
Who is the patient with new chest pain and shortness of breath. These may indicate an acute, life-threatening cardiovascular or respiratory problem. Prioritize immediate threats and unstable conditions over routine needs.