Eyes, Ears, & Safety
A patient says, “I can hear you, but I can’t understand what you’re saying.” This is most consistent with a problem in which part of sensory processing?
Perception/interpretation of sound
Name one major risk factor for skin breakdown.
immobility, poor nutrition, moisture, incontinence, decreased sensation, poor perfusion, advanced age
What are the 4 classic local signs of inflammation?
Redness, warmth, swelling, pain
Which arthritis is more strongly associated with autoimmune inflammation: osteoarthritis or rheumatoid arthritis?
Rheumatoid arthritis
What is the most important assessment after giving an opioid?
Respiratory status
What is the most important teaching point for patients to prevent hearing loss over time?
Avoid prolonged loud noise exposure / use hearing protection
A red area over the sacrum that is intact skin and non-blanchable is what stage pressure injury?
Stage 1
A patient has fever, tachycardia, elevated WBC, and purulent drainage from a wound. Is this more consistent with local infection or systemic infection?
Systemic infection (with a local source)
A patient with gout should be taught to report sudden severe pain in which area commonly?
Great toe / first metatarsophalangeal joint
A patient reports pain 8/10 but is drowsy and difficult to arouse after IV opioid medication. What is the priority concern?
Opioid over-sedation / respiratory depression
An older adult says, “My vision is worse at night and I need more light to read.” Is this always an emergency?
No — can be a normal age-related sensory change
A patient has a heel wound with full-thickness skin loss and visible subcutaneous fat, but no bone/tendon exposed. What stage?
Stage 3
A patient with suspected infection has a WBC of 18,500. Is this expected, low, or elevated?
Elevated
A patient taking immunosuppressive therapy for rheumatoid arthritis has a temperature of 100.8°F. Why is this more concerning than in a healthy adult?
Immunosuppression increases infection risk and may blunt normal immune response
Which common opioid side effect should the nurse proactively prevent in most hospitalized patients?
Constipation
A client with hearing impairment is being discharged. What is the BEST nursing action to improve communication and safety at home?
Teach correct use of hearing assistive devices and verify understanding with return demonstration
A bedridden patient has a pressure injury and now has new foul drainage, increased warmth, redness, and worsening pain. What complication should the nurse suspect?
Wound infection / possible cellulitis
A patient with suspected infection has a fever of 103.1°F, chills, tachycardia, and confusion. What is the priority nursing action?
Recognize worsening systemic infection and escalate care / notify provider rapidly
Which intervention is priority during an acute gout flare?
A. Encourage joint overuse to prevent stiffness
B. Promote rest, pain control, and anti-inflammatory treatment
C. Begin aggressive range-of-motion exercises immediately
D. Increase high-purine foods for healing
B
Which patient should the nurse assess FIRST after receiving analgesia?
A. Pain 6/10 but awake and talking
B. Respiratory rate 8/min and hard to arouse
C. Nausea after oral hydrocodone
D. Mild itching after morphine
B
A patient suddenly reports new unilateral eye pain and decreased vision after an eye procedure. What should the nurse do FIRST?
Report immediately / urgent evaluation
Which patient should the nurse see FIRST?
A. Stage 1 pressure injury with intact skin
B. Chronic venous ulcer with stable drainage
C. Sacral wound with fever, confusion, and hypotension
D. Dry skin tears on both forearms
C
A patient is admitted with C. diff. What infection control measure is MOST important?
Contact precautions + soap and water hand hygiene
A patient with rheumatoid arthritis on immune suppression develops fever, fatigue, and a new cough. What is the priority nursing concern?
Infection risk related to immunosuppression
A patient with chronic pain says, “I don’t want to take pain medicine because I’m afraid of addiction.” What is the BEST nursing response?
A therapeutic teaching response such as:
“Let’s talk about your concerns. When pain medication is used appropriately and monitored, we can often manage pain safely while reducing risk.”