Reduction of Risk Potential

The nurse is caring for a 55-year-old female patient who is scheduled for a Venous Doppler examination. Which of the following instructions will likely be on the patient instruction sheet?

The nurse is caring for a 34-year-old G1P0 patient in her 30th week of gestation. The patient is having an episode of painless vaginal bleeding and is hemodynamically stable. Which assessment does the nurse anticipate for the physician to order?

A patient comes into the emergency department who has just been in a head-on collision and is unconscious. Which of the following requires the nurse’s immediate attention?

Which of the following events requires immediate intervention by the nurse while teaching a nursing student how to administer PRBCs?

Which of the following statements by a patient indicates that they understand the nurse’s teaching about having an IVC (inferior vena cava) filter placed?

You are the charge nurse of a psychiatric floor that has one free bed. Which of the following psychiatric patients would you anticipate most needing to be placed on your floor?

The nurse is providing pre-procedure education to a patient prior to surgery requiring general anesthesia. Which question by the patient indicates a need for further teaching?

Which is the best indicator of the effectiveness of the treatment plan for a patient with type 2 diabetes mellitus?

The nurse is caring for a client following a diagnostic liver biopsy. Which interventions does the nurse include in the plan of care? Select all that apply.

The 18-year-old female patient presents to a women’s health clinic following unprotected sexual intercourse one week ago. Per the patient’s report, she has painful lesions on her genitals. On physical exam, the nurse notes blisters and ulcerations on the patient’s labia minora and vulva. The nurse anticipates testing will reveal which microorganism to explain this patient’s symptoms?

The patient presents to the urgent care clinic with a hand laceration sustained while using pruning shears in the garden. Which vaccine is most important for this patient?

A client with a history of severe diarrhea presents to the emergency department. Vital signs reveal a respiratory rate of 36 breaths per minute, heart rate 110 bpm, and blood pressure 90/60 mm Hg. Arterial blood gas results include: pH 7.30, PaCO2 29 mm Hg, PaO2 100 mm Hg, and HCO3- 21 mEq/L. How does the nurse interpret these findings?

A client admitted with status asthmaticus requires endotracheal intubation and mechanical ventilation. Which intervention decreases the client’s risk for ventilator-associated pneumonia?

Which central venous access site is preferred in an adult with normal kidney function to reduce the risk for central line-associated bloodstream infection?

The patient presents with diffuse maculopapular rash, fever, myalgia, arthralgia and headache. The patient reports several tick bites after hiking two weeks ago, which prompts the provider to suspect Rocky Mountain spotted fever (RMSF). Which test confirms the diagnosis?

The patient presents to the emergency department with a probable cervical spinal cord injury following a diving accident one hour ago. The nurse anticipates this patient’s labs will most likely show which of the following acid-base disturbances?

The nurse is preparing to remove a patient’s chest tube. Which instruction does the nurse give the patient?

The patient is receiving a transfusion of packed red blood cells. After 30 minutes, the patient complains of intense itching and flank pain. Upon assessment, the nurse notes a fever and tachycardia. Which of the following is the next best step in management?

The nurse is caring for a patient with blood type A+, who requires a transfusion of packed red blood cells. The nurse receives a unit of blood from the blood bank that is labeled AB -. Which of the following is the best course of action for the nurse to take?

An alert patient requires a nasogastric (NG) tube for abdominal decompression. The tube is placed to the appropriate depth, but the nurse is unable to hear a rush of air when auscultating over the patient’s stomach and cannot aspirate gastric contents for pH testing. Which of the following is the most appropriate next course of action?

The patient has been diagnosed with hemochromatosis. Which of the following lab values could be used to monitor for complications of the disease? Select all that apply.

The patient presents with severe fatigue, joint pain, and bronzed skin. Based on these findings, the nurse prepares the patient for which of the following diagnostic test(s)?

A patient with hemochromatosis has just undergone a liver biopsy to assess for cirrhosis. For which complication must the nurse be vigilant in the hours following the procedure?

The nurse is supervising a student nurse in the care of a patient following a percutaneous liver biopsy. The student nurse instructs the patient to lie on his left side following the procedure. Which response by the nurse is most appropriate?

The nurse is reviewing the chart of a patient scheduled to undergo a percutaneous liver biopsy in 2 hours. Which of the following characteristics, if present in the patient’s chart, would prompt the nurse to contact the provider immediately?

The patient is diagnosed with Kawasaki disease. Which of the following tests should the nurse anticipate for this patient to assess for complications of this condition?

The patient is brought to the emergency department following a fire in his home. The nurse notes that the patient has singed facial hair and soot on his face. He is mildly tachypneic, his lung sounds are clear and equal, and the nurse notes pronounced stridor. His oxygen saturation is 90% on room air. Patient also complains of a sore throat and severe pain in his arms and hands, which have about 50% of their area covered by burns. Which of the following is the next best step in management?

A teenager collapsed in the heat following a particularly strenuous football practice. Upon presentation to the emergency department, the patient complains of severe muscle pain and weakness. Rhabdomyolysis is suspected. Which of the following laboratory tests will confirm the diagnosis because it is the most sensitive and specific?

The nurse is performing an electrocardiogram on a patient with rhabdomyolysis. The patient asks the nurse what the rationale is for this test, since he is young and has no cardiac history. Which of the following responses by the nurse is most appropriate?

A septic patient begins to ooze blood from around intravenous cannulation sites and from the gums. The patient’s urine has turned from concentrated yellow to brown. Upon further assessment, the nurse notes the patient’s right calf is swollen, red, and painful. The nurse anticipates which laboratory abnormalities in this patient? Select all that apply.

A 28-year-old female who is 12-weeks pregnant is concerned about her baby having a neural tube defect. Which of the following prenatal tests does the nurse anticipate?

The nurse is reviewing the results of a chromosomal microarray. The results are significant for a chromosomal abnormality in which a single amino acid has been altered. Which of the following terms should the nurse use to describe this abnormality?

A neonate is born at full term to a mother who did not receive prenatal care. The neonate required moderate resuscitation at birth. Upon assessment, the nurse notes poor muscle tone, a protruding tongue, low nasal bridge, and low-set ears. A loud continuous “machine-like” heart murmur is heard. The patient requires 85% FiO2 to maintain an oxygen saturation above 90%. Which of the following tests is the next best diagnostic step in the management of this patient?

The nurse is assessing an infant and notes epicanthal folds, a low nasal bridge, low-set ears, simian palmar creases, and a protruding tongue. Which of the following results does the nurse most likely expect from the patient’s chromosomal microarray?

A female neonate is born at full term to a mother with late prenatal care. Upon assessment, the nurse notes swelling of the neonate’s feet, a webbed neck, and widely-spaced nipples. Upper extremity pulses are bounding, but lower extremity pulses are barely felt. The nurse anticipates which karyotype result for this neonate?

During prenatal testing, a fetus is found to have a 47,XXY karyotype. Which of the following statements by the nurse is most accurate?

The nurse is assigned to care for a neonate who is born with a chromosomal abnormality. The nurse is reviewing the cytogenetic location of the chromosomal defect for this patient. The results state the patient has a deletion at 14q21. Which of the following is the correct interpretation of this result?

The nurse is assisting with genetic counseling for a couple in which the mother has a rare autosomal dominant condition, and the father does not have the condition. Which of the following statements by the nurse is most accurate?

The nurse is caring for a child who has been diagnosed with cystic fibrosis, which the nurse knows is an autosomal recessive condition. What are the most likely genotypes of this patient’s healthy parents? C is the healthy allele and c is the disease allele.

A 32-year-old African American male presents with sudden onset severe jaundice and fatigue. A detailed history revealed a recent dietary change of eating fava beans for the first time. The nurse anticipates genetic testing will reveal which of the following conditions?

The 42-year-old male patient presents with the following arterial blood gas results: pH = 7.29, PCO2 = 40 mmHg, HCO3- = 15 mmol/L. Additional laboratory results are significant for a sodium of 154 mEq/L, chloride of 120 mmol/L, a glucose of 245 mg/dL, albumin of 4 g/dL. Which of the following is the most accurate interpretation of these results?

The nurse is attempting to interpret the arterial blood gas results of an adult male patient with metabolic acidosis who has a bicarbonate (HCO3-) level of 18. Using the Winter formula, determine the expected pCO2 that would indicate this patient is compensating for the metabolic acidosis. Enter your answer using a whole number.

The patient is found to have 4 g/dL protein in the 24-hour urine collection. This result indicates which condition? 

A child has been diagnosed with nephrotic syndrome. Which of the following life-threatening complications of this condition should the nurse be vigilant about?

The nurse is assigned to care for a patient scheduled to undergo a lumbar puncture. Which of the following signs or symptoms, if present in the patient’s chart, would prompt the nurse to question the order?

An immunocompromised patient has suspected meningitis. Antiviral and antibiotic medications have been ordered but the lumbar puncture is on hold until the patient can undergo a computed tomography (CT) scan. Which of the following actions by the nurse is most appropriate?

The nurse is caring for a morbidly obese patient that requires a lumbar puncture. The physician is having trouble identify surface landmarks. Which of the following is the best body position for this procedure to ensure patient safety?

The nurse is assigned to a patient who presents to the emergency department with a severe headache. Upon physical assessment, the patient’s heart rate is 114 bpm, temperature is 38.2[Symbol]C (100.8[Symbol]F), and the blood pressure is 149/93 mmHg. Which of the following questions by the nurse is most important?

The nurse is assisting with a lumbar puncture and obtains a point-of-care (POC) blood glucose level of 72 mg/dL following the procedure. The cerebrospinal fluid (CSF) glucose level is 47 mg/dL. How does the nurse interpret this result for the CSF glucose level?

The nurse is assisting with a lumbar puncture (LP) and obtains a point-of-care (POC) blood glucose level of 72 mg/dL following the procedure. The cerebrospinal fluid (CSF) glucose level is 28 mg/dL. How does the nurse interpret this result for the CSF glucose level?