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A nurse is calling a provider to report a patient’s change in condition using the SBAR communication framework. Using clinical judgment, which action demonstrates an effective approach to the “B” (Background) component to support accurate decision-making?
A nurse is calling a provider to report a patient’s change in condition using the SBAR communication framework. Using clinical judgment, which action demonstrates an effective approach to the “B” (Background) component to support accurate decision-making?
A patient from a cultural background that values stoicism reports no pain, but their vital signs indicate tachycardia and increased blood pressure. The nurse observes signs of discomfort. What is the most appropriate nursing intervention?
A patient from a cultural background that values stoicism reports no pain, but their vital signs indicate tachycardia and increased blood pressure. The nurse observes signs of discomfort. What is the most appropriate nursing intervention?
A nurse is educating a community group about risk factors for impaired cognition. Which of the following individuals demonstrates the highest risk for developing cognitive impairment?
A nurse is educating a community group about risk factors for impaired cognition. Which of the following individuals demonstrates the highest risk for developing cognitive impairment?
During a health history assessment, a 48-year-old female reports the following:
• Persistent headache occurring daily for the past month
• Blurred vision and occasional dizziness
• A family history of hypertension and stroke
• Increased stress at work and poor sleep quality
Which of the following findings would be considered most abnormal and require immediate intervention?
During a health history assessment, a 48-year-old female reports the following: • Persistent headache occurring daily for the past month • Blurred vision and occasional dizziness • A family history of hypertension and stroke • Increased stress at work and poor sleep quality Which of the following findings would be considered most abnormal and require immediate intervention?
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A new client comes into the office, they can only speak broken sentences but have no issue understanding. Which of the following should the nurse do?
A new client comes into the office, they can only speak broken sentences but have no issue understanding. Which of the following should the nurse do?
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A client comes into the office experience symptoms of hypertension, which of the following are expected findings. Select all that apply.
- Severe Headaches
- Dizziness
- Difficulty Breathing
- Fainting
A client comes into the office experience symptoms of hypertension, which of the following are expected findings. Select all that apply.
- Severe Headaches
- Dizziness
- Difficulty Breathing
- Fainting
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A nurse is assessing a 75 year old client during a routine physical examination. Upon assessing the client, which of the following findings should the nurse report as abnormal?
A nurse is assessing a 75 year old client during a routine physical examination. Upon assessing the client, which of the following findings should the nurse report as abnormal?
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A Nurse is caring for a 72 year old patient who has been admitted to the Emergency Room complaining about shortness of breath. Upon taking the client’s vital signs, the nurse notes that the client’s oxygen saturation is at 90%. The nurse is preparing to assess the client’s respiratory status. Which of the following actions should be a priority that the nurse should take?
A Nurse is caring for a 72 year old patient who has been admitted to the Emergency Room complaining about shortness of breath. Upon taking the client’s vital signs, the nurse notes that the client’s oxygen saturation is at 90%. The nurse is preparing to assess the client’s respiratory status. Which of the following actions should be a priority that the nurse should take?
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The nurse is assessing a client’s cranial nerve function. Which of the following findings would be considered abnormal when testing cranial nerve II (optic nerve)?
The nurse is assessing a client’s cranial nerve function. Which of the following findings would be considered abnormal when testing cranial nerve II (optic nerve)?
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A nurse is caring for a group of clients in a medical-surgical unit. Which of the following clients is at the greatest risk for developing an infection?
A nurse is caring for a group of clients in a medical-surgical unit. Which of the following clients is at the greatest risk for developing an infection?
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The nurse is conducting a cardiovascular assessment on a 60-year-old patient. Which finding should the nurse identify as abnormal and require further investigation?
The nurse is conducting a cardiovascular assessment on a 60-year-old patient. Which finding should the nurse identify as abnormal and require further investigation?
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The nurse is teaching a patient about the risk factors for insomnia. Which patient statement indicates a need for further teaching?
The nurse is teaching a patient about the risk factors for insomnia. Which patient statement indicates a need for further teaching?
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A nurse is promoting smoking cessation to a group of patient. Which statement by a participant indicates they are in the preparation stage of the Transtheoretical Model of Change?
A nurse is promoting smoking cessation to a group of patient. Which statement by a participant indicates they are in the preparation stage of the Transtheoretical Model of Change?
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A nurse is assessing a patient’s respiratory status. Which of the following findings are abnormal? (Select all that apply.)
A. Respiratory rate of 17 bpm
B. Use of accessory muscle during inspiration
C. Oxygen saturation of 97% on room air
D. Crackles in the lung on auscultation
E. Asymmetrical chest expansion during inspiration
A nurse is assessing a patient’s respiratory status. Which of the following findings are abnormal? (Select all that apply.) A. Respiratory rate of 17 bpm B. Use of accessory muscle during inspiration C. Oxygen saturation of 97% on room air D. Crackles in the lung on auscultation E. Asymmetrical chest expansion during inspiration
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A nurse is performing an abdominal assessment on a patient. Which of the following actions should the nurse take first when conducting the assessment?
A nurse is performing an abdominal assessment on a patient. Which of the following actions should the nurse take first when conducting the assessment?
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A nurse educating a client about good sleep hygiene. Which of the following statements by the client indicates a need for further teaching?
A nurse educating a client about good sleep hygiene. Which of the following statements by the client indicates a need for further teaching?
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Which of the following interventions should a nurse prioritize to limit the spread of Clostridioides difficile (C. diff) in a healthcare setting?
Which of the following interventions should a nurse prioritize to limit the spread of Clostridioides difficile (C. diff) in a healthcare setting?
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The nurse is performing a focused musculoskeletal assessment on a patient. Which of the following findings would the nurse identify as abnormal and require further evaluation?
Select all that apply:
A. A smooth, coordinated gait with a symmetric arm swing.
B. Tenderness and swelling over the left knee joint.
C. Full range of motion in all extremities without pain.
D. Muscle strength of 2/5 in the right lower extremity.
E. A slight curvature of the thoracic spine when viewed laterally.
The nurse is performing a focused musculoskeletal assessment on a patient. Which of the following findings would the nurse identify as abnormal and require further evaluation? Select all that apply: A. A smooth, coordinated gait with a symmetric arm swing. B. Tenderness and swelling over the left knee joint. C. Full range of motion in all extremities without pain. D. Muscle strength of 2/5 in the right lower extremity. E. A slight curvature of the thoracic spine when viewed laterally.
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A nurse is caring for a patient who has been prescribed parenteral nutrition (PN) due to severe malnutrition. Which of the following nursing interventions is most important to ensure the safe administration of parenteral nutrition?
A nurse is caring for a patient who has been prescribed parenteral nutrition (PN) due to severe malnutrition. Which of the following nursing interventions is most important to ensure the safe administration of parenteral nutrition?
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A nurse is performing a peripheral neurological assessment on a patient with a history of diabetes mellitus. Which of the following findings is considered normal and should not raise concern?
A nurse is performing a peripheral neurological assessment on a patient with a history of diabetes mellitus. Which of the following findings is considered normal and should not raise concern?
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A nurse is caring for a patient diagnosed with Clostridium difficile (C. difficile) infection in the hospital. The patient is placed in an isolation room. The nurse is reviewing the infection control measures to prevent the transmission of the infection. Which of the following statements best describes the necessary precautions for this patient?
A nurse is caring for a patient diagnosed with Clostridium difficile (C. difficile) infection in the hospital. The patient is placed in an isolation room. The nurse is reviewing the infection control measures to prevent the transmission of the infection. Which of the following statements best describes the necessary precautions for this patient?
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A nurse is conducting a health history assessment on a 55-year-old patient who presents for a routine check-up. The patient reports feeling generally well but has experienced some occasional headaches, difficulty falling asleep, and mild shortness of breath during exercise. Which of the following findings from the health history assessment would be considered abnormal and require further investigation? (Select all that apply.)
A) The patient reports a family history of hypertension, diabetes, and stroke.
B) The patient has a history of smoking 10 cigarettes per day for the past 20 years but quit 5 years ago.
C) The patient states that their blood pressure is normally 130/85 mm Hg.
D) The patient has a mild but chronic cough that occurs mostly in the morning.
E) The patient reports occasional headaches and difficulty falling asleep, but no other recent changes in health.
F) The patient denies any significant weight changes or difficulty with appetite
A nurse is conducting a health history assessment on a 55-year-old patient who presents for a routine check-up. The patient reports feeling generally well but has experienced some occasional headaches, difficulty falling asleep, and mild shortness of breath during exercise. Which of the following findings from the health history assessment would be considered abnormal and require further investigation? (Select all that apply.) A) The patient reports a family history of hypertension, diabetes, and stroke. B) The patient has a history of smoking 10 cigarettes per day for the past 20 years but quit 5 years ago. C) The patient states that their blood pressure is normally 130/85 mm Hg. D) The patient has a mild but chronic cough that occurs mostly in the morning. E) The patient reports occasional headaches and difficulty falling asleep, but no other recent changes in health. F) The patient denies any significant weight changes or difficulty with appetite
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A nurse is caring for a patient diagnosed with Clostridium difficile (C. difficile) infection in the hospital. The patient is placed in an isolation room. The nurse is reviewing the infection control measures to prevent the transmission of the infection. Which of the following statements best describes the necessary precautions for this patient?
A nurse is caring for a patient diagnosed with Clostridium difficile (C. difficile) infection in the hospital. The patient is placed in an isolation room. The nurse is reviewing the infection control measures to prevent the transmission of the infection. Which of the following statements best describes the necessary precautions for this patient?
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A nurse is caring for a 68-year-old patient recently diagnosed with moderate cognitive impairment due to early-stage Alzheimer's disease. The nurse collaborates with the healthcare team to develop a plan of care aimed at minimizing symptoms and improving the patient's quality of life. Which of the following interventions is most appropriate for the nurse to implement as part of the care plan?
A nurse is caring for a 68-year-old patient recently diagnosed with moderate cognitive impairment due to early-stage Alzheimer's disease. The nurse collaborates with the healthcare team to develop a plan of care aimed at minimizing symptoms and improving the patient's quality of life. Which of the following interventions is most appropriate for the nurse to implement as part of the care plan?
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A nurse is assessing the vital signs of a 45-year-old patient who is admitted to the hospital. The following vital signs are recorded:
• Temperature: 37.0°C (98.6°F)
• Heart rate: 88 beats per minute
• Respiratory rate: 22 breaths per minute
• Blood pressure: 118/76 mmHg
• Oxygen saturation: 98% on room air
Which of his vital signs are within the normal range for an adult?
A nurse is assessing the vital signs of a 45-year-old patient who is admitted to the hospital. The following vital signs are recorded: • Temperature: 37.0°C (98.6°F) • Heart rate: 88 beats per minute • Respiratory rate: 22 breaths per minute • Blood pressure: 118/76 mmHg • Oxygen saturation: 98% on room air
Which of his vital signs are within the normal range for an adult?
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The nurse is performing a respiratory assessment on a 45-year-old client. Which of the following findings would the nurse recognize as abnormal?
The nurse is performing a respiratory assessment on a 45-year-old client. Which of the following findings would the nurse recognize as abnormal?
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A nurse is conducting an initial assessment for a client newly admitted to a rehabilitation facility. Which statement best explains the importance of assessing the client’s functional ability in client-centered care?
A nurse is conducting an initial assessment for a client newly admitted to a rehabilitation facility. Which statement best explains the importance of assessing the client’s functional ability in client-centered care?
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A nurse is educating a patient with type 2 diabetes about self-management strategies to improve health outcomes. The patient expresses concern about their ability to manage the condition long-term. Which of the following approaches is most likely to improve the patient's health perception and enhance their self-care behaviors?
A nurse is educating a patient with type 2 diabetes about self-management strategies to improve health outcomes. The patient expresses concern about their ability to manage the condition long-term. Which of the following approaches is most likely to improve the patient's health perception and enhance their self-care behaviors?
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Patient presents to the ED with complaints of hypertension. Which of the findings are abnormal?
Patient presents to the ED with complaints of hypertension. Which of the findings are abnormal?
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A nurse is teaching a client about healthy eating habits. Which of the following dietary choices by the client indicates that the nurse's teaching has been effective?
A nurse is teaching a client about healthy eating habits. Which of the following dietary choices by the client indicates that the nurse's teaching has been effective?
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A nurse is assessing a patients head and neck. Which of the following findings should the nurse report to the provider?
A nurse is assessing a patients head and neck. Which of the following findings should the nurse report to the provider?
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A nurse is assessing a 55 year old client who reports recent feelings of stress and anxiety. The client states, “I have been feeling anxious and tired all the time due to my new job, but I do not know how to fix it,”. Which of the following nursing interventions would be the most appropriate for this client?
A nurse is assessing a 55 year old client who reports recent feelings of stress and anxiety. The client states, “I have been feeling anxious and tired all the time due to my new job, but I do not know how to fix it,”. Which of the following nursing interventions would be the most appropriate for this client?
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A nurse is performing a health assessment on a 65 year old client who reports having occasional shortness of breath and chest discomfort, after walking up the stairs. The nurse notes that the client is a smoker of 25 years, with an oxygen saturation of 91% on room air. Which of the following actions should the nurse take next?
A nurse is performing a health assessment on a 65 year old client who reports having occasional shortness of breath and chest discomfort, after walking up the stairs. The nurse notes that the client is a smoker of 25 years, with an oxygen saturation of 91% on room air. Which of the following actions should the nurse take next?
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A nurse is assessing a client during a routine cardiovascular exam. The findings include:
• Blood Pressure: 160/98 mmHg
• Heart Rate: 102 bpm, regular
• Peripheral Pulses: 2+ bilaterally
• Capillary Refill: 4 seconds
• Auscultation: S1 and S2 present, with a high-pitched murmur at the apex
Which of the following findings should the nurse identify as abnormal?
A nurse is assessing a client during a routine cardiovascular exam. The findings include: • Blood Pressure: 160/98 mmHg • Heart Rate: 102 bpm, regular • Peripheral Pulses: 2+ bilaterally • Capillary Refill: 4 seconds • Auscultation: S1 and S2 present, with a high-pitched murmur at the apex
Which of the following findings should the nurse identify as abnormal?
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A nurse is assessing a client who reports severe abdominal pain rated 8/10 on a numeric pain scale. The client is grimacing, holding their abdomen, and states, "It hurts so much, I can’t eat or sleep." Which of the following is the nurse’s priority intervention?
A nurse is assessing a client who reports severe abdominal pain rated 8/10 on a numeric pain scale. The client is grimacing, holding their abdomen, and states, "It hurts so much, I can’t eat or sleep." Which of the following is the nurse’s priority intervention?
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A nurse is assessing a client who reports shortness of breath. The client's oxygen saturation is 88% on room air. Which of the following is the nurse's priority intervention?
A nurse is assessing a client who reports shortness of breath. The client's oxygen saturation is 88% on room air. Which of the following is the nurse's priority intervention?
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A nurse is assessing a client who was admitted with a head injury sustained in a motor vehicle accident. The client is lethargic, responds to verbal stimuli but falls asleep quickly, and is disoriented to time and place. Which of the following is the nurse's priority intervention?
A nurse is assessing a client who was admitted with a head injury sustained in a motor vehicle accident. The client is lethargic, responds to verbal stimuli but falls asleep quickly, and is disoriented to time and place. Which of the following is the nurse's priority intervention?
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A nurse is assessing a 65-year-old client during a routine examination and detects an irregular radial pulse. Which of the following actions should the nurse prioritize?
A nurse is assessing a 65-year-old client during a routine examination and detects an irregular radial pulse. Which of the following actions should the nurse prioritize?
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A client arrives at the emergency department with signs of a stroke. Which of the following is the priority assessment for the nurse to perform?
A client arrives at the emergency department with signs of a stroke. Which of the following is the priority assessment for the nurse to perform?
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A nurse is caring for a client with increased intracranial pressure (ICP). Which nursing intervention is appropriate to reduce ICP?
A nurse is caring for a client with increased intracranial pressure (ICP). Which nursing intervention is appropriate to reduce ICP?
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A nurse is caring for a client of Asian descent who recently gave birth. The client's family brings her warm soups and advises her to avoid cold foods. Which nursing action demonstrates culturally competent care?
A nurse is caring for a client of Asian descent who recently gave birth. The client's family brings her warm soups and advises her to avoid cold foods. Which nursing action demonstrates culturally competent care?
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A nurse is performing a musculoskeletal assessment on a 55-year-old client. Which of the following findings should the nurse identify as abnormal?
A nurse is performing a musculoskeletal assessment on a 55-year-old client. Which of the following findings should the nurse identify as abnormal?
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A nurse educates nursing students about the long-term health and psychosocial consequences of untreated sleep disorders. Which of the following long-term and psychosocial implications of untreated sleep disorders? Which of the following long-term effects should the nurse emphasize as being most significant?
A nurse educates nursing students about the long-term health and psychosocial consequences of untreated sleep disorders. Which of the following long-term and psychosocial implications of untreated sleep disorders? Which of the following long-term effects should the nurse emphasize as being most significant?
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Tiffany, a student nurse, is performing a health assessment on a 62-year-old patient. During the skin assessment, the nurse notes several common findings associated with aging skin changes. Which of the following findings should the nurse identify as a normal age-related change?
Tiffany, a student nurse, is performing a health assessment on a 62-year-old patient. During the skin assessment, the nurse notes several common findings associated with aging skin changes. Which of the following findings should the nurse identify as a normal age-related change?
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A nurse is caring for an older adult client who reports that they wake up frequently during the night. The nurse should identify which characteristics of older adult sleep patterns might explain the client's frequent awakening?
A nurse is caring for an older adult client who reports that they wake up frequently during the night. The nurse should identify which characteristics of older adult sleep patterns might explain the client's frequent awakening?
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A nurse is caring for a client following an appendectomy who has a postoperative prescription that reads “discontinue NPO status; advance to clear liquid as tolerated”. Which of the following choices should the nurse offer the client?
a. applesauce
b. chicken broth
c. sherbet
d. wheat toast
e. cranberry juice
A nurse is caring for a client following an appendectomy who has a postoperative prescription that reads “discontinue NPO status; advance to clear liquid as tolerated”. Which of the following choices should the nurse offer the client? a. applesauce b. chicken broth c. sherbet d. wheat toast e. cranberry juice
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A nurse is caring for a client who is newly admitted to the unit. Which action should the nurse take to establish a helping relationship with the client?
A nurse is caring for a client who is newly admitted to the unit. Which action should the nurse take to establish a helping relationship with the client?
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A nurse is performing a general survey on a new patient admitted to the hospital. Which of the following findings is most important for the nurse to report to the healthcare provider immediately?
A nurse is performing a general survey on a new patient admitted to the hospital. Which of the following findings is most important for the nurse to report to the healthcare provider immediately?
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A nurse is assessing a client who reports insomnia. Which of the following findings can contribute to the client’s insomnia? (Select all that apply)
a. Irregular schedule
b. Stress
c. Warm bath
d. Alcohol intake
e. Morning walk
A nurse is assessing a client who reports insomnia. Which of the following findings can contribute to the client’s insomnia? (Select all that apply) a. Irregular schedule b. Stress c. Warm bath d. Alcohol intake e. Morning walk
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A 45-year-old woman with a family history of breast cancer undergoes a mammogram as part of her annual screening. Which health promotion strategy is being employed?
A 45-year-old woman with a family history of breast cancer undergoes a mammogram as part of her annual screening. Which health promotion strategy is being employed?
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Which of the following is an example of the Assessment component in the SBAR communication method?
Which of the following is an example of the Assessment component in the SBAR communication method?
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A nurse is caring for a patient who has recently been diagnosed with terminal cancer. The patient expresses feelings of sadness and asks the nurse, "Why is this happening to me?" Which of the following responses by the nurse best demonstrates the use of therapeutic communication?
A nurse is caring for a patient who has recently been diagnosed with terminal cancer. The patient expresses feelings of sadness and asks the nurse, "Why is this happening to me?" Which of the following responses by the nurse best demonstrates the use of therapeutic communication?
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A nurse is preparing to communicate a patient's condition to a physician using the SBAR (Situation, Background, Assessment, Recommendation) format. Which of the following is the appropriate order and content of the SBAR communication?
A nurse is preparing to communicate a patient's condition to a physician using the SBAR (Situation, Background, Assessment, Recommendation) format. Which of the following is the appropriate order and content of the SBAR communication?
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