Basic Care and Comfort

The nurse is supervising a patient who recently had a right hip replacement while she moves from sitting to standing with a walker. Which action would prompt the nurse to correct the patient?

The patient states, “I’m so embarrassed. I won’t feel like I have to pee for hours, then all of a sudden it hits me. I often can’t make it to the bathroom in time.” The nurse uses which term to document this patient’s report?

The patient complains of leaking urine with exercise, laughing, and sneezing. Which term does the nurse use to document this report?

The patient reports urinary incontinence when laughing or sneezing. Which education does the nurse provide the patient?

The parents bring a previously toilet trained 3-year-old patient to the clinic reporting regular fecal incontinence. Which assessment is the priority?

Which interventions does the nurse include in the patient’s care plan to decrease the risk for incontinence-associated dermatitis? Select all that apply.

Which intervention is most important to preventing dermatitis in the patient who is incontinent following a recent cervical spinal cord injury?

The patient with severe fatigue and muscle wasting due to acquired immunodeficiency syndrome (AIDS) is experiencing pain. Which nonpharmacological therapy is most appropriate to include in this patient’s treatment plan?

A patient with chronic anxiety has been learning to manage stress with progressive relaxation therapy. He tells the nurse, “I just don’t think this is working. I feel the muscle tension so much worse now.” Which response by the nurse is most appropriate?

Which assessment indicates the patient with chronic pain is meditating effectively?

Which statement by the nurse is correct when preparing a patient for meditation therapy?

The patient has requested to try electroacupuncture for chronic pain. Which of the following, if part of the patient’s past medical history, would prompt the nurse to contact the provider to have the order discontinued?

Place the steps of therapeutic touch in the correct order.

The patient who is bedridden, incontinent of urine, and requires multiple blankets to stay warm is at risk for hypothermia due to which methods of heat loss? Select all that apply.

An elderly patient requests hotter water during the bath. Which action by the nurse is most appropriate?

The patient with a broken arm in a plaster cast requests to take a shower. Which response by the nurse is most appropriate?

The nurse is assisting a patient with diabetic neuropathy with daily hygiene practices. Which of the following is most important to ensure safety for the patient?

An adolescent patient admitted to the hospital with anorexia nervosa is experiencing extreme fatigue. Which nursing intervention is most appropriate for providing hygiene care for this patient?

The patient appears to be fatiguing before daily bathing and grooming is finished. Which action by the nurse is most appropriate?

The nurse encourages the patient who works the night shift to hang blackout curtains in the bedroom to promote sleep. The nurse makes this recommendation based on an understanding of which physiologic process?

From which stage of non-REM sleep is it most difficult to wake?

The nurse is providing discharge teaching to a new mother. Which of the following statements about the neonate’s sleep patterns is correct?

The parent of a two-year-old tells the nurse, “Every night, bedtime is a struggle. My child never wants to go to sleep.” Which response by the nurse is most appropriate?

The patient tells the nurse, “I fall asleep easily but wake up during the night and can’t go back to sleep.” Which question by the nurse is most helpful in determining the cause of the patient’s difficulty sleeping?

Which substance in milk promotes sleep, making it a popular bedtime drink?

The nurse is counseling a patient on sleep hygiene practices. Which food or drink, if selected by the patient prior to bedtime, indicates the teaching was effective?

The nurse is instructed to assess the patient’s postvoid urine residual volume. Which is the best method by the nurse to perform this task?

The nurse is providing preoperative teaching to a patient with bladder cancer who will have an orthotopic neobladder created. Which statement by the nurse is most appropriate?

The nurse informs a patient with a postvoid residual volume that straight catheterization must be performed to fully empty the patient’s bladder. Which rationale is most appropriate for the nurse to provide for this intervention?

The nurse is supervising the care of a patient with a urinary catheter by an unlicensed assistive personnel (UAP). Which action by the UAP would prompt the nurse to intervene immediately?

The nurse is reviewing a patient’s intake and output and notes the patient’s output has dropped drastically over the past 12 hours. Which intervention does the nurse perform first?

A patient complains of constipation. Which instruction should the nurse give first?

The nurse is teaching the patient about dietary modifications that enhance bowel regularity. Which food, if selected by the patient, indicate a need for further teaching?

The nurse enters the patient’s room and notes the head of bed is at a 65-degree angle. The nurse is concerned about which type of tissue injury related to this positioning?

The nurse instructs the patient with stress incontinence to perform pelvic floor exercises. Which type of muscle contraction occurs during pelvic floor exercises?

A patient who is immobilized following a motor vehicle accident is at risk for which imbalance?

The nurse is teaching a patient how to walk with a cane following a cerebrovascular accident that left the patient with right-sided weakness. Which action by the patient indicates the teaching was effective?

The patient reports being hungry prior to the breakfast tray delivery. When the nurse checks on the patient an hour after the tray was delivered, the nurse notes the patient has not eaten any of the food. Which initial nursing action is most appropriate? 

Which exercise is appropriate for the patient who has a Glasgow Coma Scale of 4?

The patient tells the nurse, “I really didn’t expect acupuncture to decrease my pain, but it actually did! Why did it work?” The nurse bases the response on which theory of pain control?

Release of which neurotransmitters in the brain and spinal cord leads to increased nociception? Select all that apply.

The urine output of a 40-year-old male patient with a urethral catheter has decreased from 80 mL/h to 15 mL/h. Which action should the nurse take first?

The patient has sustained a spinal cord injury at the level of C8. The nurse plans care to include teaching about the use of which adaptive device?

The nurse is supervising the care of a diabetic patient with stomach cancer. After surgery, the patient is placed on total parenteral nutrition (TPN). Which information does the nurse provide the nursing student about the TPN?

The patient with tears of the right medial meniscus asks the nurse about the use of therapeutic massage. Which response by the nurse is appropriate?

Which patient is most at risk for developing a decubitus ulcer?

Which explanation of the mechanism of action of the cutaneous stimulation method in reducing pain is correct?

The nurse is admitting a patient who is being transferred from a nursing home who has been bedridden for the past two months. The nurse anticipates the patient will have which electrolyte disturbances?

The nurse is providing dietary education for a patient with chronic alcoholism complicated by iron deficiency anemia and Wernicke encephalopathy. Which statement by the patient indicates a need for further teaching?

The provider orders that the patient transition to a full liquid diet. Which new item is the patient now allowed to have?