Management of Care

A 76-year-old man with a history of congestive heart failure suddenly fell on the ground as he was trying to get up from bed. He is conscious but feels dizzy. Which of the following is the best next step?

A 38-year-old unconscious man with a diagnosis of alcohol intoxication is lying on his back in the emergency department. Suddenly he starts vomiting. Which of the following is the best next step?

A 94-year-old woman presents from a long-term care facility with mental status change. Urinalysis is positive for leukocyte esterase and nitrites. Based on these urinalysis results, the nurse can anticipate which of the following orders?

After receiving a dose of antibiotics, a 34-year-old man develops an itchy rash, throat swelling, shortness of breath, lightheadedness, and hypotension. Which of the following is the best next step?

The patient in the emergency room has a traumatic leg wound which has been cleaned and dressed. The nurse enters the room to reassess the wound prior to discharging the patient and notes bright red drainage on the dressing that is increasing in size. Which action does the nurse take first?

A 73-year-old man is brought to the emergency department with complaints of profuse watery diarrhea, 7 to 8 times per day over the last three days. Which of the following is the best next step?

A patient of sound mind is scheduled to undergo a minor surgical procedure in 30 minutes and has just been given a light sedative. The nurse realizes that no consent form has been signed for the procedure. Which action does the nurse take?

A multiple-gunshot victim is brought by EMS to the emergency department, and subsequently expires. Which action by the nurse is completed first?

The Health Insurance Portability and Accountability Act (HIPAA) includes a Privacy Rule, the federal law that covers a client’s protected health information. Which action by the nurse violates the Privacy Rule?

The patient with a terminal illness wishes not to receive heroic measures to prolong her life should her heart stop beating. The nurse encourages the patient to sign which document to ensure her wishes are followed?

A 25-year-old patient presents to the emergency department unconscious following a motor vehicle accident. The nurse is unable to wake the patient and the provider determines the patient requires emergency surgery due to internal bleeding. No emergency contact can be found for the patient. Which of the following is the most appropriate next course of action?

Which of the following are unable to sign their own consent for a surgical procedure?

For which of the following cases is informed consent not required?

The nurse notices that a patient who is scheduled for surgery tomorrow did not yet sign the consent form. The nurse was not in the room when the surgeon explained the procedure to the patient. Which of the following statements is most appropriate for the nurse to make when he/she brings the consent form for the patient to sign?

Which task can be performed by an unlicensed assistive personnel?

The nurse is called to assist with a Jehovah’s Witness involved in a motor vehicle accident brought in by ambulance with multiple traumatic injuries. Which order does the nurse question?

Which term refers to the legal document that grants another person the right to make health care decisions for a person if they lack the ability to make the decisions themselves?

Which patient does the nurse assess first?

The nurse is caring for a patient who cannot read or write. The patient has a surgical procedure tomorrow and needs to give informed consent. Which of the following is the correct role for the nurse to take for obtaining consent from this patient?

The nurse has been caring for a patient who will be discharged home today. Patient has an open wound in his left thigh that has been treated under vacuum. He has advanced COPD and has been requiring oxygen to maintain his oxygen saturation. Patient has been undergoing intravenous antibiotic therapy with vancomycin and piperacillin/tazobactam for a wound infection and has no mobility in his left leg. Which of the following statements is correct concerning the discharge needs of this patient? Select all that apply.

A nurse is discussing a patient’s clinical case with the treating physician and they enter a public hospital elevator. Which action by the colleagues is the most appropriate?

The nurse is caring for a celebrity patient who is suffering from generalized anxiety. Non-treating physicians and nurses have been asking the nurse about the case and clinical notes written by the nurse have been accessed by non-treating healthcare personnel. Which of the following statements are most appropriate regarding the patient’s medical confidentiality?

The nurse is caring for a patient who natively speaks Japanese and speaks English proficiently. The nurse needs to obtain informed consent for a surgical procedure the patient needs urgently. Which action does the nurse take?

A nurse on an inpatient medical unit notices that multiple patients being admitted to the unit from the emergency department are not wearing ID bands. Which of the following is the most appropriate way to address this issue?

The nurse is caring for a patient of apparently sound mind who has a chronic severe wound infection on his forearm. Amputation of the limb below the elbow is the recommended course of treatment for this patient, but he refuses to allow the procedure. Despite an understanding of the risks and benefits of the procedure as well as of refusing the procedure, the patient refuses the amputation. Which management is the most appropriate?

The nurse has received report on four patients at 0700. Which patient should the nurse assess first?

The nurse is a first responder at a mass casualty event. According to the Simple Triage and Rapid Treatment (START) protocol, which patient will receive medical care first?

The nurse is a first responder following a multi-vehicle accident and performs triage on the victims while waiting for further assistance. A person walks up to the nurse with a minor head wound and asks to be treated. Which response by the nurse is appropriate?

The nurse is a first responder following a mass casualty incident and performs triage on these victims while waiting for assistance. List the patients in order they must be treated according to the Simple Triage and Rapid Treatment (START) protocol.

The nurse is working in the emergency department when a mass casualty event occurs. Which patient will the nurse treat first?

A nurse is obtaining health information history of the patients through interviews and physical examination. Which of the following phases of the nursing process is this?

A 17-year-old patient is declared brain dead after a motor vehicle accident in which he sustained a liver laceration, severe subdural hematoma, and high cervical spinal cord injury. The parents have decided to donate their son’s organs. Which statement by the nurse is appropriate?

The patient with end stage renal disease is on the transplant waiting list for a kidney. The nurse is aware this patient’s wait time will depend on which factors? Select all that apply.

Following a motor vehicle accident, an organ donor is declared brain dead and the heart is procured at 0700 on Monday. By what time must the heart be transplanted into the recipient? Enter your number using military time (0000).

Donated lungs from a 28-year-old victim of a motorcycle accident have been procured and have matched to four people. Which patient will receive the lungs?

A 16-year-old is placed on life support following a suicide attempt in which the individual overdosed on acetaminophen. The patient’s mother tells the nurse, “I know she will die from this. I hate that we didn’t find her for hours afterward. I would like her memory to live on as an organ donor. Is it possible to donate my daughter’s organs?” Which response by the nurse is appropriate?

A kidney is procured at 0900 on Monday during a living donation. When is the latest it can be transplanted into the recipient?

A patient in liver failure tells the nurse, “My wife is so selfless; she has offered to donate her liver to me. I can’t let her die for me, though.” Which response by the nurse is most appropriate?

The nurse is compiling research to institute a new evidence-based practice regarding pressure injury prevention and finds a randomized controlled trial from a multi-site healthcare system on the west coast. Which level of evidence does the nurse assign to this source?

The nurse finds a study about a novel anticoagulation therapy tested in mice. Which statement indicates an understanding of this research?

The nurse wishes to decrease ventilator-associated pneumonia rates in the intensive care unit. Which source will provide the best evidence from which to develop a process improvement project?

Which type of study is retrospective?

The nurse is reviewing clinical practice guidelines on central line management in order to create a process improvement project that decreases central-line associated bloodstream infections (CLABSI). Which level of evidence is the nurse using?

Which vital sign reported by the unlicensed assistive personnel (UAP) does the nurse investigate first?

The patient with which assessment is to be treated first in the emergency department?

Which patient does the nurse visit first?

Which assessment requires the most immediate intervention?

Which document delineates the patient’s responsibilities and rights while hospitalized?

Which assessments are considered second priority? Select all that apply

The nurse is the first responder to a multi-car accident on the highway. Which assessment does the nurse make first?