Signs and Symptoms
After a surgical procedure, a patient starts complaining of swelling, pain, warmth, and discoloration in one calf. Using clinical judgment, what would the nurse believe is causing these signs and symptoms?
Deep Vein Thrombosis (DVT)
The nurse is preparing a patient with dysphagia for lunch. Which interventions should be
performed before the patient eats?
A. Position the patient upright for meals
B. Provide the food and liquid consistency ordered for the patient
C. Encourage the patient to eat slowly
D. Monitor for coughing or voice changes while eating
An experienced nurse and a new graduate nurse are caring for a confused older adult who gets out of bed and wanders. The preceptor intervenes when observing which action by the graduate nurse?
a. raising all four side rails to keep the patient in bed
b. performing documentation in the patient's room
c. suggesting obtaining a patient "sitter"
d. Using the bed alarm to alert staff that the patient is leaving the bed
a. raising all four side rails to keep the patient in bed
Name one aspect of care that may be influenced by a patient's cultural preferences.
Examples include dietary practices, personal space, eye contact, touch, family involvement, and communication preferences.
True or False: Body mechanics improve control and do make unsafe lifting safe.
False
Body mechanics improve control; they do not make unsafe lifting safe.
The nurse is assessing a patient who received intravenous (IV) morphine. The patient is
difficult to arouse and with a respiratory rate of 7 breaths/minute. Which medication should
the nurse anticipate administering?
Naloxone
Patient complains of feeling like their bladder is full and that they aren't able to void everything from their bladder. Using clinical judgment, what does the nurse suspect is causing these signs and symptoms?
Urinary incontinence
A nurse is teaching a postmenopausal patient who experiences urine leakage when coughing
and sneezing. Which intervention should the nurse recommend?
Perform pelvic floor (Kegel) exercises
A community health nurse is providing education on child safety. Who does the nurse identify as at highest risk for choking and suffocation?
a. A toddler playing with his older brother's wooden blocks
b. A 4-year-old eating yogurt and strawberries for lunch
c. An infant sleeping in the prone position
d. A 3-year-old drinking a glass of juice
c. An infant sleeping in the prone position
Infants should be placed on their backs to sleep. A young child may place small or loose parts in the mouth. Anything that will fit through the average toilet paper roll is not safe for a toddler. A 3-year-old and a 4-year-old drinking juice and eating yogurt are developmentally appropriate.
The nurse is teaching an older adult about reducing their fall risk at home. Which actions
should the nurse include in the teaching plan for the patient?
A. Remove clutter from walking paths in the home.
B. Install grab bars in the bathroom
C. Use adequate lighting in hallways and stairways.
D. Keep electrical cords out of walking paths.
Regular movement and supported joint positions reduce progressive shortening and fixed loss of joint motion.
Contracture Prevention
Name two nonpharmacologic interventions that may help promote comfort for a patient experiencing pain.
Examples include repositioning, relaxation techniques, guided breathing, reducing environmental stimuli, and applying heat or cold when appropriate and safe.
The patient starts experiencing sudden dyspnea, chest discomfort that worsens with deep breathing, hemoptysis, lightheadedness, and a rapid, irregular heartbeat. Using clinical judgment, what is causing these symptoms?
Pulmonary Embolism (PE)
A client receiving enteral feeding develops abdominal distention and vomiting. What should the nurse do?
Stop the feeding and assess the client. Follow facility protocols and notify the appropriate healthcare professional about concerning findings.
A nurse working in a pediatrician's office receives calls from parents whose children have ingested a toxic substance from under the sink. How will the nurse advise the parents?
Call poison control before attempting any home remedies
A patient states, “My family uses traditional remedies when we are sick, and they help make
healthcare decisions.” What action should the nurse take?
Assess beliefs and preferences about traditional remedies and family participation
During a transfer, the client bears weight through both legs while staff use a gait belt at the trunk to steady balance without lifting the client by the belt.
Staff Guidance or stabilization
A nurse is caring for a patient receiving an IV heparin infusion for a deep vein thrombosis (DVT). Which assessment finding requires the nurse to take immediate action?
a. aPTT is within the prescribed therapeutic range.
b. Platelet count decreases from 220,000 to 85,000
c. Patient reports mild discomfort at the IV insertion site
d. Patient's heart rate is 82 beats/ minute
b. Platelet count decreases from 220,000 to 85,000
Rationale: A significant platelet decrease may indicate heparin-induced thrombocytopenia (HIT), a serious complication that can cause life-threatening thrombosis. The nurse should stop the heparin infusion, notify the provider immediately, and anticipate further evaluation and an alternative anticoagulant as prescribed.
Pt is experiencing dizziness, lightheadedness, visual changes, weakness, and faintness when standing. Using clinical judgment, what does the nurse believe is causing these signs and symptoms?
Orthostatic Hypotension
Why is monitoring intake and output important for a patient at risk for fluid imbalance?
It provides information about fluid intake and losses, supports evaluation of fluid status, and helps identify changes that may require further assessment.
A nurse is teaching parents in a parenting class about the use of car seats and restraints for infants and children. What should be the focus of this education?
Most US states mandate the use of infant care seats and carriers when transporting a child in a motor vehicle.
A patient avoids eye contact while speaking with the nurse. What should the nurse consider?
Eye contact preferences can vary across cultures and individuals. The nurse should avoid assumptions and assess the patient's communication preferences.
During turning, the client bends the knee, reaches for the bedrail, and moves the trunk toward the side of the bed while staff remain available to support the remainder of the turn.
Client-generated movement
A nurse is caring for a patient taking apixaban (Eliquis) for atrial fibrillation. Which patient statement requires immediate follow-up?
a. "I use a soft-bristled toothbrush.'
b. "I have noticed black, tarry stools this morning."
c. "I take my medication at the same time each day."
d. "I try to avoid activities that could cause injury."
b. "I have noticed black, tarry stools this morning."
Rationale: Black, tarry stools may indicate gastrointestinal bleeding, a serious adverse effect of apixaban. The nurse should promptly assess the patient, notify the provider, and arrange urgent evaluation. Severe bleeding or signs of instability require emergency intervention.
A patient has had persistent vomiting and diarrhea. The nurse notes decreased urine output, dizziness, and tachycardia. What is the priority nursing concern?
Possible fluid volume deficit with impaired perfusion. The nurse should promptly assess the patient, monitor relevant findings, and communicate concerns for appropriate intervention.
Why should feeding be stopped when a client develops persistent pocketing, recurrent coughing, and a wet or gurgly voice?
May indicate that food or liquid is not clearing safely and is moving toward the airway.
A school nurse is teaching about adolescent safety to students entering high school. What will the nurse include in the discussion about the major causes of death in this group? List 3.
1. Drowning
2. Suicide
3. Motor Vehicle Accidents (MVC)
4. Guns and Weapons
5. Inhalation and ingestion
A patient declines a particular meal because it conflicts with their dietary practices. What is the most appropriate nursing approach?
Respectfully assess the patient's dietary preferences and nutritional needs, communicate with dietary services and the care team, and collaborate on appropriate alternatives.
During an established activity progression, the client reports dizziness and dimmed vision immediately after standing. Which nursing response is appropriate?
Assist the client to sit, reassess the response, and hold further progression.
A nurse is caring for a patient who has been taking ibuprofen daily for chronic back pain. Which finding is most concerning for a potential adverse effect of NSAID use?
A. The patient reports mild nausea after taking the medication.
B. The patient reports decreased urine output and swelling in the ankles.
C. The patient reports improved pain control.
D. The patient reports mild stiffness after waking up.
B. The patient reports decreased urine output and swelling in the ankles.
Rationale: NSAIDs can reduce blood flow to the kidneys, potentially causing kidney injury and fluid retention. Decreased urine output and ankle swelling require prompt assessment and notification of the healthcare provider.
A: Mild nausea can occur with NSAID use, although persistent or severe symptoms need evaluation.
B: Correct. These findings may indicate impaired kidney function and fluid retention.
C: Improved pain control is an expected therapeutic effect.
D: Morning stiffness may occur with musculoskeletal conditions.