Breathing is Kinda Important
A patient's SpO2 drops to 89% on room air. What is the FIRST nursing intervention before calling the provider?
Reposition to high Fowler's (HOB 45-90°) and encourage deep breathing. Check probe placement.
A patient's sodium is 128 mEq/L. Name the imbalance.
Hyponatremia.
A confused patient can't make decisions. Who legally makes medical decisions for them?
The person holding a Healthcare Power of Attorney (HCPOA) or designated healthcare proxy.
A post-op patient on clear liquids asks for ice cream and cream of wheat. Your response?
Both are not allowed. Clear liquids = water, broth, gelatin, popsicles, and clear juices (apple, grape, cranberry) only.
You ask a patient their name, where they are, and today's date. What is this assessment formally called?
Orientation x3 — person, place, and time. Document objectively (e.g., 'oriented to person and place, not to time').
After a blood flashback in your IV catheter, what is the NEXT step before connecting the IV tubing?
Advance the plastic catheter off the needle into the vein, withdraw needle, then flush with NS to confirm patency.
A patient has C. diff. What precautions are required?
Contact precautions (gown + gloves).
A patient feels 'empty inside' and has lost interest in things they used to enjoy. What symptoms does this describe?
depression
Why can't you just 'crank up the O2' on a COPD patient?
COPD patients may rely on hypoxic drive. They already have too much CO2 and do not need more Oxygen. High O2 can suppress breathing. Target SpO2 88-92%.
BUN is 35 and creatinine is 2.4. What organ do these labs reflect?
Kidneys.
A nurse makes a medication error and doesn't document it. What are the legal consequences?
It is a falsification of records. Can create you to lose your license or employment termination.
A patient on a low-sodium diet is secretly salting their food. What are your priority nursing interventions?
Educate on sodium risks (BP, fluid retention), involve dietitian, notify provider, document. Respect autonomy while promoting safety.
A patient's pupils are 'PERRLA.' What does the acronym stand for.
Pupils Equal, Round, Reactive to Light and Accommodate.
A patient receiving IV KCl 40 mEq/100 mL over 1 hour reports severe burning. What is NEVER acceptable?
NEVER give IV KCl as IV push — it causes immediate cardiac arrest.
Your patient is in a negative pressure room for what type of Isolation?
Airborne.
A patient paces the hall, wrings their hands, and says 'I can't stop worrying.' How do you correctly document this?
Objective: pacing and hand-wringing observed. Subjective: patient's exact quote in quotation marks. Diagnosis: Anxiety.
A patient is in acute respiratory distress — tripod position, accessory muscle use, SpO2 88%. Name your FIRST two priority actions.
1) Call for help / activate rapid response. 2) Apply O2 and elevate HOB immediately.
A patient on warfarin has an INR of 4.8. What does an INR of 4.8 indicate?
Risk for Bleeding. INR 4.8 = supratherapeutic, high bleed risk.
A home care patient has multiple unexplained bruises and seems afraid of their caregiver. What is your legal obligation?
Mandatory reporting to Adult Protective Services (APS). Reasonable suspicion is enough — proof is NOT required.
A patient is on TPN. Name three nursing assessments specific to TPN you must perform every shift.
1) Blood glucose monitoring. 2) Central IV site assessment for infection. 3) Strict I&O and daily weight.
A patient who was alert at the start of your shift is now confused and pulling at their IV. What is your FIRST action?
Check ABCs, vital signs, and blood glucose immediately. Worry about hypoxia. Acute mental status change = emergency until ruled out.
An IV site is swollen, cool, and pale with increased pump pressure. Name the complication.
Infiltration.
A patient is admitted with shingles. What precautions are required?
contact
A grieving widow says she's sleeping poorly and crying every day and asks if something is wrong with her. How do you respond therapeutically?
Normalize grief using Kubler-Ross. Distinguish from depression. Assess for suicidal ideation. Involve counseling. Avoid false reassurance.
What is the purpose of incentive spirometry, and how often should it be performed post-op?
Prevents atelectasis and pneumonia. 10 reps every 1-2 hours while awake, sitting upright.
Labs: K+ 6.4, Na+ 128, HCO3 18, pH 7.28. What is the priority concern?
K+ 6.4 = hyperkalemia
A patient asks you to witness their will during your shift. What do you do?
Decline — witnessing a legal document creates conflict of interest.
A patient with dysphagia is ordered nectar-thick liquids. What happens if it isn't followed?
Leads to aspiration. Non-compliance risks aspiration pneumonia, airway obstruction, death.
A patient's right arm drifts downward when extended. What test is this and what does it mean?
Positive pronator drift — suggests left hemisphere lesion (stroke). Activate stroke protocol immediately.
A PICC line patient has a temp of 38.9°C and redness at the insertion site. What complication is this possibly known as?
CLABSI.
You're inserting a urinary catheter. Name two things that maintain sterile technique.
Maintain: sterile gloves, keep field above waist.
A psychiatric patient says 'I have a plan to hurt myself when I get home.' What type of disclosure?
Suicidal ideation WITH a plan
A patient on a 15L non-rebreather mask still has SpO2 of 86%. What is the next O2 delivery step and what sign means imminent respiratory failure?
Escalate to High Flow Nasal Cannula or BiPAP. Imminent failure: altered mental status + SpO2 <90% on high-flow O2.
ABG: pH 7.48, PaCO2 30, HCO3 24. Name the disturbance?
Respiratory alkalosis.
A nurse pulled to an unfamiliar unit gets an assignment outside their competency. What is the correct action?
Notify supervisor of the competency gap, request orientation or preceptor, and document the concern. Do not abandon patients.
Albumin is 2.8 g/dL and prealbumin is 14 mg/dL. Interpret both values and state your nursing actions.
Both low (albumin normal 3.5-5.0; prealbumin normal 15-35 mg/dL) = protein malnutrition. Consult dietitian, encourage protein, notify provider.
A patient has a GCS of 7. What does GCS measure, what does score 7 mean, and what intervention is standard?
Eye (1-4) + Verbal (1-5) + Motor (1-6). GCS 7 = Brain Injury. Standard intervention: intubation to protect the airway.
Ten minutes into a blood transfusion, a patient develops fever, rigors, hypotension, and flank pain. What is your FIRST action?
STOP the transfusion.
What type of isolation would you use for Influenza?
droplet
A patient with schizophrenia says the TV sends them personal messages and their neighbor is poisoning their food. Describe your therapeutic response.
Do NOT argue. Acknowledge fear: 'I can see you're frightened.' Assess safety, check med compliance.