Activity, Exercise, Immobility
A postoperative patient has been on bedrest for 48 hours. Which nursing intervention is the priority to reduce the patient's risk for developing a deep vein thrombosis? SATA
A. Restrict oral fluids
B. Encourage leg exercises and early ambulation
C. Massage the patient's calves every 2 hours
B. Encourage leg exercises and early ambulation
A nurse is caring for an older adult who requires assistance with bathing. Which nursing intervention best promotes the patient's independence?
A. Complete the entire bath for the patient to conserve energy.
B. Encourage the patient to wash areas they can safely reach while assisting with difficult areas.
C. Delay hygiene until family members arrive.
B. Encourage the patient to wash areas they can safely reach while assisting with difficult areas.
A patient suddenly becomes restless and anxious following abdominal surgery. Which assessment should the nurse perform first?
A. Assess bowel sounds.
B. Assess oxygen saturation.
C. Assess pedal pulses.
B. Assess oxygen saturation.
Which patient assessment finding best indicates fluid volume deficit?
A. Bounding pulses
B. Weight gain of 4 lb overnight
C. Dry mucous membranes and tachycardia
D. Jugular vein distention
C. Dry mucous membranes and tachycardia
A patient reports difficulty sleeping in the hospital because staff enter the room frequently throughout the night. Which nursing intervention is most appropriate?
A. Administer a sedative every night.
B. Cluster nursing care to allow longer uninterrupted sleep.
C. Encourage daytime naps every hour.
D. Turn the lights on during assessments.
B. Cluster nursing care to allow longer uninterrupted sleep.
A postoperative patient reports pain as 8/10, but their vital signs are within normal limits. What is the nurse's best action? SATA
A. Explain that severe pain always causes elevated vital signs.
B. Administer the prescribed pain medication based on the patient's report.
C. Delay pain medication until the vital signs increase.
D. Reassess the pain in 30 minutes.
B. Administer the prescribed pain medication based on the patient's report.
A nurse prepares to transfer a patient from the bed to a chair. Which assessment finding requires the nurse to obtain additional assistance before moving the patient?
A. The patient reports mild pain rated 3/10.
B. The patient weighs 110 kg and has left-sided weakness.
C. The patient wears compression stockings.
B. The patient weighs 110 kg and has left-sided weakness.
A patient with diabetes asks the nurse to trim their toenails during a bath. What is the nurse's best response?
A. Trim the nails straight across.
B. Soak the feet before trimming.
C. Explain that a podiatrist should perform diabetic nail care.
D. Trim only the thickened toenails.
C. Explain that a podiatrist should perform diabetic nail care.
The nurse is caring for a patient receiving oxygen by nasal cannula. Which finding requires immediate intervention?
A. Dry nasal mucosa.
B. Oxygen saturation of 96%.
C. The patient removes the oxygen while eating.
D. Respiratory rate of 18/min.
A. Dry nasal mucosa.
A patient receiving IV furosemide develops muscle weakness and an irregular pulse. Which laboratory value should the nurse review first?
A. Sodium
B. Potassium
C. Calcium
D. Magnesium
B. Potassium
A patient reports loud snoring and waking up gasping for air every night. Which disorder does the nurse suspect?
A. Narcolepsy
B. Obstructive sleep apnea
C. Restless leg syndrome
D. Parasomnia
B. Obstructive sleep apnea
The nurse is assessing a patient with chronic osteoarthritis pain. Which question best evaluates the effectiveness of previous pain management?
A. "How long have you had arthritis?"
B. "What treatments have helped control your pain in the past?"
C. "Does your family also have arthritis?"
D. "Would you like stronger pain medication?"
B. "What treatments have helped control your pain in the past?"
A patient recovering from pneumonia suddenly becomes dizzy while ambulating with a gait belt. Which action should the nurse perform first?
A. Return the patient immediately to bed.
B. Guide the patient safely to the floor while protecting the head.
C. Call for a rapid response.
B. Guide the patient safely to the floor while protecting the head.
A patient is preparing for Foley catheter insertion. Which nursing action most effectively reduces the patient's risk for developing a catheter-associated urinary tract infection?
A. Wash only the patient's thighs.
B. Perform thorough perineal care before insertion.
C. Insert the catheter quickly to reduce discomfort.
B. Perform thorough perineal care before insertion.
A mechanically ventilated patient triggers a high-pressure alarm. What should the nurse assess first?
A. Whether the patient needs additional sedation.
B. The ventilator settings.
C. The tubing for kinks or obstruction.
D. The IV infusion rate.
C. The tubing for kinks or obstruction.
A patient has severe vomiting for two days. Which acid-base imbalance does the nurse anticipate?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Metabolic acidosis
C. Metabolic alkalosis
The nurse is assessing a patient with chronic sleep deprivation. Which complication is most concerning? SATA
A. Increased appetite
B. Increased agitation
C. Increased risk for injury due to impaired judgment
D. A&O x 2
B. Increased agitation
C. Increased risk for injury due to impaired judgment
D. A&O x 2
A patient is prescribed morphine following surgery. Thirty minutes after administration, which assessment finding requires immediate intervention? SATA
A. Pain decreased from 8/10 to 4/10.
B. Respiratory rate decreased from 18/min to 8/min.
C. Blood pressure decreased from 138/84 to 95/47.
D. Patient states they feel sleepy.
B. Respiratory rate decreased from 18/min to 8/min.
C. Blood pressure decreased from 138/84 to 95/47.
The nurse cares for four patients on a medical-surgical unit. Which patient is at greatest risk for developing a contracture?
A. A patient receiving passive ROM every shift
B. A patient with a cast who has not moved the affected extremity for several weeks
C. A patient sitting in a chair for meals
B. A patient with a cast who has not moved the affected extremity for several weeks
The nurse is caring for four patients. Which patient should receive hygiene care first?
A. A patient requesting assistance brushing their teeth.
B. A postoperative patient who is incontinent of stool.
C. A patient requesting a warm blanket after a shower.
B. A postoperative patient who is incontinent of stool.
The nurse observes continuous vigorous bubbling in the chest tube water-seal chamber. What is the priority nursing action? SATA
A. Increase suction.
B. Clamp the chest tube.
C. Assess the system for an air leak.
D. Empty the drainage chamber.
C. Assess the system for an air leak.
The nurse reviews laboratory results for four patients. Which patient requires immediate intervention?
A. Potassium 3.9 mEq/L
B. Sodium 140 mEq/L
C. Potassium 6.2 mEq/L with peaked T waves
D. Calcium 9.0 mg/dL
C. Potassium 6.2 mEq/L with peaked T waves
The nurse is planning care for a patient with narcolepsy. Which intervention is the priority?
A. Encourage vigorous exercise before bedtime.
B. Implement safety precautions during activities.
C. Restrict daytime naps completely.
D. Keep lights on throughout the night.
B. Implement safety precautions during activities.
A patient with diabetic neuropathy continues to report burning pain despite scheduled acetaminophen. Which medication would the nurse anticipate the provider prescribing as an adjuvant analgesic?
A. Aspirin
B. Gabapentin
C. Ibuprofen
D. Naloxone
B. Gabapentin
A patient has remained immobile for one week following multiple fractures. Which assessment finding requires immediate intervention? SATA
A. Serum albumin of 3.4 g/dL
B. Urine output of 35 mL/hr
C. Sudden unilateral calf pain and swelling
C. Sudden unilateral calf pain and swelling
A patient recovering from a stroke refuses a bath every morning because of religious beliefs regarding personal hygiene. What is the nurse's best action? SATA
A. Explain hospital policy requires daily bathing.
B. Document noncompliance.
C. Collaborate with the patient to develop a bathing schedule that respects cultural and religious preferences while maintaining hygiene.
D. Notify the provider.
C. Collaborate with the patient to develop a bathing schedule that respects cultural and religious preferences while maintaining hygiene.
A postoperative patient suddenly develops chest pain, dyspnea, tachycardia, and oxygen saturation of 84%. Which nursing action has the highest priority?
A. Obtain a sputum specimen.
B. Place the patient in high Fowler's position and administer oxygen while notifying the provider.
C. Encourage incentive spirometry.
D. Perform hand hygiene
B. Place the patient in high Fowler's position and administer oxygen while notifying the provider.
A patient admitted with heart failure has crackles, jugular vein distention, bilateral edema, and rapid weight gain. Which provider prescription should the nurse question? SATA
A. Daily weights
B. IV antidiuretic
C. Encourage 3 L oral fluids daily
D. Strict intake and output
B. IV antidiuretic
C. Encourage 3 L oral fluids daily
A hospitalized patient with obstructive sleep apnea becomes increasingly drowsy after receiving IV opioids. Which nursing action is the priority?
A. Encourage oral fluids.
B. Apply the patient's CPAP if prescribed and assess respiratory status immediately.
C. Dim the lights to promote sleep.
D. Reassure the patient that drowsiness is expected.
B. Apply the patient's CPAP if prescribed and assess respiratory status immediately.
The nurse is caring for four postoperative patients. Which patient should be assessed first?
A. Patient requesting pain medication rated 7/10
B. Patient who received morphine 20 minutes ago and has a respiratory rate of 7/min
C. Patient requesting a heating pad for chronic back pain
D. Patient reporting pain of 3/10 before physical therapy
B. Patient who received morphine 20 minutes ago and has a respiratory rate of 7/min