Assessment
. Mr. Carter arrives sitting upright and states, “I cannot catch my breath.” Which assessment should the practical nurse complete first?
A. Ask about bowel habits
B. Check oxygen saturation and respiratory effort
C. Review the menu tray
D. Measure calf circumference
B. Check oxygen saturation and respiratory effort
. Which finding best supports fluid volume excess?
A. Dry mucous membranes and poor skin turgor
B. Crackles, edema, and weight gain
C. Flat neck veins and thirst
D. Concentrated urine only
B. Crackles, edema, and weight gain
The patient’s oxygen tubing is connected, but the flowmeter reads 0 L/min. What should the nurse do first?
A. Turn oxygen to the prescribed flow rate and reassess SpO2
B. Remove the nasal cannula permanently
C. Document refusal
D. Give oral fluids
A. Turn oxygen to the prescribed flow rate and reassess SpO2
. Which finding shows the oxygen intervention is effective?
A. SpO2 rises to ordered target and patient speaks in full sentences
B. Patient has increased retractions
C. Cyanosis worsens
D. PaCO2 continues rising with decreased LOC
A. SpO2 rises to ordered target and patient speaks in full sentences
which information belongs in “Situation”?
A. “I am calling because Mr. Carter’s SpO2 is 86% and he is newly confused.”
B. Full childhood history
C. Insurance information
D. Lunch preference
A. “I am calling because Mr. Carter’s SpO2 is 86% and he is newly confused.”
. The nurse notes nasal flaring, accessory muscle use, and inability to speak full sentences. Which action is priority while staying within PN role expectations?
A. Place the patient in high Fowler’s position and notify the RN/provider
B. Offer a high-fiber snack
C. Clamp the IV tubing
D. Encourage the patient to ambulate to the bathroom
A. Place the patient in high Fowler’s position and notify the RN/provider
Which statement is an assessment cue, not an intervention?
A. Patient reports shortness of breath at rest
B. Place patient in high Fowler’s
C. Teach pursed-lip breathing
D. Notify provider using SBAR
A. Patient reports shortness of breath at rest
Which instruction best teaches pursed-lip breathing?
A. “Breathe in through your nose and slowly exhale through puckered lips.”
B. “Hold your breath as long as possible.”
C. “Breathe rapidly through your mouth.”
D. “Lie flat and cough continuously.”
A. “Breathe in through your nose and slowly exhale through puckered lips.”
Which teaching should the nurse include for home oxygen safety?
A. No smoking near oxygen equipment
B. Store oxygen beside open flames
C. Use oil-based products on cannula area
D. Increase liter flow whenever anxious
A. No smoking near oxygen equipment
which information belongs in “Background”?
A. COPD, CKD, BPH, current oxygen and IV fluid orders
B. Recommendation for ECG only
C. Nurse’s opinion without data
D. Room decorations
A. COPD, CKD, BPH, current oxygen and IV fluid orders
. The patient has COPD and is ordered oxygen at 2 L/min by nasal cannula. Which finding shows the nurse should continue close respiratory monitoring?
A. SpO2 92% with less dyspnea
B. Respiratory rate 18/min and even
C. New confusion with SpO2 86%
D. Warm dry skin
C. New confusion with SpO2 86%
Which nursing diagnosis is priority based on dyspnea, low SpO2, and abnormal ABG?
A. Impaired gas exchange
B. Risk for loneliness
C. Deficient diversional activity
D. Readiness for enhanced nutrition
A. Impaired gas exchange
. The nurse prepares the patient for a urine culture. Which action is correct?
A. Use sterile specimen collection technique according to facility policy
B. Collect from the drainage bag after it hangs overnight
C. Mix stool into the urine cup
D. Leave the specimen unlabeled
A. Use sterile specimen collection technique according to facility policy
Which action is appropriate when collecting a 24-hour urine specimen?
A. Discard the first void, then collect all urine for 24 hours
B. Save only the first urine of the day
C. Mix stool and urine together
D. Keep specimen unlabeled at bedside
A. Discard the first void, then collect all urine for 24 hours
which information belongs in “Assessment”?
A. Respiratory rate, SpO2, lung sounds, urine output, potassium result
B. “Come now” only
C. Unrelated family story
D. Meal percentage only
A. Respiratory rate, SpO2, lung sounds, urine output, potassium result
. Which oxygen device provides the most precise FiO2 for a patient who requires controlled oxygen delivery?
A. Venturi mask
B. Simple face mask
C. Nonrebreather mask
D. Nasal cannula
A. Venturi mask
Which goal is most measurable?
A. Patient will feel better soon
B. Patient will maintain SpO2 at or above provider-ordered target within 30 minutes of interventions
C. Nurse will do all care quickly
D. Patient will have normal labs someday
B. Patient will maintain SpO2 at or above provider-ordered target within 30 minutes of interventions
. A BMP shows sodium 128 mEq/L. Which symptom should the nurse monitor for?
A. Confusion and seizures
B. Bright red urine
C. Improved concentration only
D. Constipation only
A. Confusion and seizures
. Which bowel elimination teaching is safest for a patient with constipation and fluid restriction?
A. Follow prescribed fluid limits while increasing allowed fiber and activity
B. Drink unlimited fluids despite restriction
C. Take multiple laxatives daily without provider guidance
D. Avoid ambulation
A. Follow prescribed fluid limits while increasing allowed fiber and activity
which statement is the best “Recommendation”?
A. “Please evaluate him now; do you want an ECG, repeat ABG/BMP, and changes to oxygen or IV fluids?”
B. “Everything is fine.”
C. “I will check next week.”
D. “The patient likes pillows.”
A. “Please evaluate him now; do you want an ECG, repeat ABG/BMP, and changes to oxygen or IV fluids?”
Which nursing action is safest when using oxygen therapy?
A. Apply petroleum jelly to nares
B. Keep oxygen away from open flames and sparks
C. Remove humidification from all oxygen devices
D. Tape oxygen tubing tightly around the neck
B. Keep oxygen away from open flames and sparks
Which planned intervention is best for impaired gas exchange?
A. Cluster care, high Fowler’s, oxygen as ordered, monitor SpO2, encourage pursed-lip breathing
B. Restrict all fluids without an order
C. Remove oxygen during meals
D. Delay provider notification until end of shift
A. Cluster care, high Fowler’s, oxygen as ordered, monitor SpO2, encourage pursed-lip breathing
Which provider order should the PN question for this patient with potassium 5.9 mEq/L?
A. Repeat potassium level
B. Continuous cardiac monitoring
C. Potassium chloride supplement
D. ECG
C. Potassium chloride supplement
. Which cue best indicates possible bowel obstruction rather than simple constipation?
A. Mild straining
B. Severe abdominal distention, vomiting, absent bowel sounds
C. Hard stool after low fiber intake
D. Infrequent walking
B. Severe abdominal distention, vomiting, absent bowel sounds
The diagnostic blood test panel commonly used to monitor sodium, Potassium, Bun, and creatinine is?
Basic Metabolic Panel ( BMP)