Nursing Assessments
What is the difference between subjective and objective data during a patient interview?
What is subjective data is the patient’s experience (e.g., pain), and objective data is observable or measurable (e.g., vital signs)?
What simple environmental changes can significantly reduce the fall risk in hospitalized patients?
What is lowering the bed to the lowest position and ensuring the call light is within reach?
A nurse encourages a patient to make their own choices about care and supports independence. What concept is the nurse demonstrating?
What is promoting autonomy?
A nurse teaches a group about healthy eating. Which message should the nurse emphasize about portion sizes?
What is to fill half the plate with fruits and vegetables (slightly more veggies) and half the plate with protein and grains as well as a side of low fat dairy?
A nurse makes a medication error. What should the nurse do first?
What is take accountability by notifying the healthcare provider and document the error in the patient’s record?
A patient complains of bloating and nausea and has a firm abdomen. What should the nurse consider as a possible cause?
What is fecal impaction or bowel obstruction?
A nurse is preparing to administer medications to a patient who has a history of allergic reactions to certain medications. How should the nurse ensure patient safety while administering the prescribed medication?
What is reviewing the patient’s allergy history, confirming with the patient before administering, and checking for any potential drug interactions or contraindications?
A nurse is assessing a pediatric patient with developmental delays. Which nursing theorist’s framework could the nurse use to guide this assessment and intervention?
What is using Erik Erikson’s psychosocial development theory to understand the child’s stage of development and offer age-appropriate interventions?
A nurse is communicating with a patient who has difficulty speaking. Which method is best for effective communication?
What is using a communication board or pictures to help the patient express their needs?
Which electrolyte imbalance is commonly associated with prolonged diarrhea and needs close monitoring?
What is hypokalemia?
A patient with a fever and confusion is at high risk for dehydration. What signs should the nurse look for to assess the patient’s hydration status?
What is checking for dry mouth, poor skin turgor, and low urine output?
The nurse should encourage fluid intake and notify the provider if dehydration is suspected.
A nurse is caring for a diabetic patient whose blood glucose has dropped below 70 mg/dL. What immediate action should the nurse take, and what long-term adjustments could be made to prevent future occurrences?
What is providing 15 grams of fast-acting carbohydrate (e.g., juice or glucose tablets) and reassessing the blood glucose after 15 minutes?
Long-term, the nurse should review the patient’s medication regimen, meal timing, and daily glucose monitoring.
A nurse is caring for a patient and focuses on providing comfort and care. Which nursing theorist's work is this approach most aligned with?
What is Florence Nightingale, who emphasized cleanliness, comfort, and the environment in patient care?
A patient with low health literacy nods during teaching but seems confused. What should the nurse do next?
What is pause the teaching, assess understanding with open-ended questions, and adjust methods accordingly?
What is notify the healthcare provider and document the error in the patient’s record?
What is witnessing the patient’s signature and ensuring they understand the procedure and risks involved?
A patient presents with severe diarrhea for the past 48 hours. The nurse notes a blood pH of 7.32, a PaCO2 of 38 mmHg, and a bicarbonate (HCO3) level of 14 mEq/L. What acid-base imbalance is most likely present?
What is metabolic acidosis, likely due to the loss of bicarbonate through diarrhea?
A nurse is managing a patient who is at high risk for deep vein thrombosis (DVT) after surgery. What preventative measures should the nurse prioritize to ensure patient safety?
What is encouraging early ambulation, using sequential compression devices (SCDs), and administering prescribed anticoagulants, along with monitoring for signs of DVT (swelling, redness, warmth)?
Who is Dorthea Dix, Clara Barton, and Lillian Wald and their contributions to nursing?
What is:
Dorothea Dix: Advocated for the mentally ill and served as Superintendent of Army Nurses during the Civil War.
Clara Barton: Served as a nurse during the Civil War and later founded the American Red Cross and brought aid to soldiers and disaster victims.
Lillian Wald: Founded the Henry Street Settlement and is known as the mother of public health nursing.
A nurse is talking with an older adult who is taking calcium supplements. The patient reports constipation. What should the nurse recommend?
What is to increase fluids and fiber in the diet while continuing calcium supplementation?
A nurse is caring for a patient with chronic kidney disease and a phosphorus level of 5.8 mg/dL. What type of medication might the nurse expect to administer, and what is the goal?
What is a phosphate binder, to reduce phosphorus levels and prevent bone and cardiovascular complications?
A patient with an ileostomy is reporting skin irritation around the stoma site. What could be the cause of the irritation, and how should the nurse intervene?
What is an improper fitting of the stoma appliance or leakage of stool, causing skin irritation?
The nurse should assess the fit of the appliance, cleanse the area, and ensure the patient knows how to maintain skin integrity around the stoma.
A patient with kidney disease has high phosphorus levels. What should the nurse do first to address this?
What is administering phosphate binders as prescribed?
The nurse should monitor lab results and ensure the patient is taking medications as directed.
A nurse is working with a patient who has expressed fear of undergoing a complex surgical procedure. How can the nurse apply Hildegard Peplau’s theory of interpersonal relationships to address the patient’s concerns?
What is using a therapeutic nurse-patient relationship to help the patient verbalize fears, educate them about the procedure, and establish trust through clear communication and support?
A nurse is providing discharge teaching to a patient with hypertension. What factors should the nurse assess to ensure the patient will follow the instructions for home care?
What is assessing the patient’s health literacy, understanding of the condition, ability to afford medications, and support system, and providing written instructions in a simple, clear format?
You’re caring for four patients. Based on their conditions and lab values, who do you assess first?
Patient A: Complains of leg cramps; potassium is 3.1 mEq/L.
Patient B: Confused and irritable; sodium is 128 mEq/L.
Patient C: Reports tingling around the mouth and fingers; calcium is 7.9 mg/dL.
Patient D: Weakness and irregular heartbeat; potassium is 6.2 mEq/L.
What is Patient D, because hyperkalemia can cause life-threatening cardiac dysrhythmias and requires immediate intervention such as cardiac monitoring and possible medication administration?