During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next?

During the primary survey of a patient with severe leg trauma, the nurse observes that the patient’s left pedal and posterior tibial pulses are absent and the entire leg is swollen. Which action will the nurse take next?

After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in the plan of care?

A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should

A 19-yr-old patient is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate giving

A patient who has experienced blunt abdominal trauma during a motor vehicle collision is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of

A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). The nurse determines that discharge teaching has been effective when the patient makes which statement?

A 22-yr-old patient who experienced a drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period?

When planning the response to the potential use of smallpox as a biological weapon, the emergency department (ED) nurse manager will plan to obtain adequate quantities of

When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87° F (30.6° C), which finding indicates that the nurse should discontinue active rewarming?

When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question by the nurse should be first?

A patient arrives in the emergency department (ED) several hours after taking “25 to 30” acetaminophen (Tylenol) tablets. Which action will the nurse plan to take?

A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, “I had a temperature of 103.9° F (39.9° C) at home.” The nurse’s first action should be to

The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment?

The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?

Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first?

A patient arrives in the emergency department (ED) after topical exposure to powdered lime at work. Which action should the nurse take first?

An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. The patient’s core temperature is 105.4° F (40.8° C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. The nurse will plan to

An unresponsive patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first?

Following an earthquake, patients are triaged by emergency medical personnel and transported to the emergency department (ED). Which patient will the nurse need to assess first?

Family members are in the patient’s room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action should the nurse take next?

A patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action will the nurse plan to take?

The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite?

Which interventions will the nurse plan for a comatose patient who is to begin therapeutic hypothermia (select all that apply)?

The emergency department (ED) nurse is starting therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/LVN) (select all that apply)?

The following four patients arrive in the emergency department (ED) after a motor vehicle collision. In which order should the nurse assess them?

The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?

A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding?

A patient with multiple draining wounds is admitted for hypovolemia. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give this patient related to fluid intake?

A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. Which action is appropriate for the nurse to take?

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective?

A patient with new-onset confusion and hyponatremia is being admitted. When making room assignments, the charge nurse should take which action?

IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take?

A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take?

An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation?

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion?

The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient’s condition has improved?

A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication?

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?

When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient’s food tray?

A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value?

A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is accurate?

The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?

The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient has peripheral edema and shortness of breath. Which assessment should the nurse complete first?

A patient with renal failure who arrives for outpatient hemodialysis is unresponsive to questions and has decreased deep tendon reflexes. Family members report that the patient has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. Which action should the nurse take first?

A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction. The patient complains of anxiety and incisional pain. The patient’s respiratory rate is 32 breaths/min, and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?

Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines and medications delegate to a licensed practical/vocational nurse (LPN/LVN)?

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?

Following a thyroidectomy, a patient complains of “a tingling feeling around my mouth.” Which assessment should the nurse complete?

A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse?

When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately?

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next?

A patient comes to the clinic complaining of frequent, watery stools for the past 2 days. Which action should the nurse take first?

Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter?

After receiving change-of-shift report, which patient should the nurse assess first?

During the admission process, the nurse obtains information about a patient through a physical assessment and diagnostic testing. Based on the data shown in the accompanying figure, which nursing diagnosis is appropriate?

The nurse teaches a patient with chronic bronchitis about a new prescription for Advair Diskus (combined fluticasone and salmeterol). Which action by the patient would indicate to the nurse that teaching about medication administration has been successful?

The nurse teaches a patient how to administer formoterol (Perforomist) through a nebulizer. Which action by the patient indicates good understanding of the teaching?

A patient is scheduled for spirometry. Which action should the nurse take to prepare the patient for this procedure?

Which information will the nurse include in the asthma teaching plan for a patient being discharged?

The emergency department nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective?

A patient seen in the asthma clinic has recorded daily peak flow rates that are 75% of the baseline. Which action will the nurse plan to take next?

The nurse teaches a patient who has asthma about peak flow meter use. Which action by the patient indicates that teaching was successful?

A young adult patient who denies any history of smoking is seen in the clinic with a new diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should plan to teach the patient about

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which information obtained from the patient would prompt the nurse to consult with the health care provider before administering the prescribed theophylline?

The home health nurse is visiting a patient with chronic obstructive pulmonary disease (COPD). Which nursing action is appropriate to implement for a nursing diagnosis of impaired breathing pattern related to anxiety?

A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which intervention would be most appropriate for the nurse to include in the plan of care?

The nurse interviews a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which information is most specific in confirming a diagnosis of chronic bronchitis?

The nurse teaches a patient about pursed-lip breathing. Which action by the patient would indicate to the nurse that further teaching is needed?

Which finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment?

The nurse is caring for a patient with cor pulmonale. The nurse should monitor the patient for which expected finding?

The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD). How should the nurse determine the appropriate O2 flow rate?

A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on O2 therapy. Which instruction should the nurse include in the discharge teaching?

A patient is receiving 35% O2 via a Venturi mask. To ensure the correct amount of O2 delivery, which action by the nurse is important?

Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. Which intervention should the nurse include in the plan of care?

The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be appropriate for the nurse to include in the plan of care?

A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, “I wish I were dead! I’m just a burden on everybody.” Based on this information, which nursing diagnosis is most appropriate?

A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would support the patient’s ventilation?

A 55-yr-old patient with increasing dyspnea is being evaluated for a possible diagnosis of chronic obstructive pulmonary disease (COPD). When teaching a patient about pulmonary spirometry for this condition, what is the most important question the nurse should ask?

A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care?

A patient in the clinic with cystic fibrosis (CF) reports increased sweating and weakness during the summer months. Which action by the nurse would be most appropriate?

A young adult female patient with cystic fibrosis (CF) tells the nurse that she is considering getting married and wondering about having children. Which initial response by the nurse is best?

A patient with chronic obstructive pulmonary disease (COPD) has coarse crackles throughout the lung fields and a chronic, nonproductive cough. Which nursing intervention will be most effective?

The nurse provides dietary teaching for a patient with chronic obstructive pulmonary disease (COPD) who has a low body mass index (BMI). Which patient statement indicates that the teaching has been effective?

Which instruction should the nurse include in an exercise teaching plan for a patient with chronic obstructive pulmonary disease (COPD)?

The nurse completes an admission assessment on a patient with asthma. Which information given by patient is indicates a need for a change in therapy?

The nurse takes an admission history on a patient with possible asthma who has new-onset wheezing and shortness of breath. Which information may indicate a need for a change in therapy?

A patient newly diagnosed with asthma is being discharged. The nurse anticipates including which topic in the discharge teaching?

A patient with cystic fibrosis (CF) has blood glucose levels that are consistently between 180 to 250 mg/dL. Which nursing action will the nurse plan to implement?

The nurse assesses a patient with a history of asthma. Which assessment finding indicates that the nurse should take immediate action?

A patient who has been experiencing an asthma attack develops bradycardia and a decrease in wheezing. Which action should the nurse take first?

A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment should the nurse complete first?

Which assessment finding in a patient who has received omalizumab (Xolair) is most important to report immediately to the health care provider?

The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. The results for which patient will require the most rapid action by the nurse?

Which nursing action for a patient with chronic obstructive pulmonary disease (COPD) could the nurse delegate to experienced unlicensed assistive personnel (UAP)?

The clinic nurse makes a follow-up telephone call to a patient with asthma. The patient reports having a baseline peak flow reading of 600 L/min, and the current peak flow is 420 L/min. Which action should the nurse take first?

The nurse reviews the medication administration record (MAR) for a patient having an acute asthma attack. Which medication should the nurse administer first?

The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first?

Which finding in a patient hospitalized with bronchiectasis is most important to report to the health care provider?

A patient with asthma has a personal best peak expiratory flow rate (PEFR) of 400 L/min. When explaining the asthma action plan, the nurse will teach the patient that a change in therapy is needed when the PEFR is less than ___ L/minute