#1
Which condition is a potential complication of immobility in bedridden patients?
Hypertension
Pneumonia
Hyperglycemia
Urinary incontinence
#2
Which nursing intervention is appropriate for a patient with impaired skin integrity?
Applying lotion to dry skin
Massaging reddened areas
Applying heat to the affected area
Implementing a turning schedule and using pressure-relieving devices
#3
Which nursing intervention is appropriate for a patient experiencing chest pain?
Administering pain medication as ordered
Instructing the patient to ignore the pain
Encouraging the patient to rest
Assessing vital signs and contacting the healthcare provider
#4
What is the priority nursing action for a patient with acute respiratory distress?
Providing emotional support
Administering oxygen therapy
Offering pain relief
Contacting the family
#5
Which laboratory result requires immediate action for a patient on warfarin therapy?
INR of 2.5
PT of 15 seconds
PTT of 40 seconds
INR of 5.0
#6
What is the priority nursing action for a patient admitted with diabetic ketoacidosis?
Monitoring blood glucose levels every 12 hours
Encouraging fluid intake
Administering regular insulin via IV infusion
Encouraging a high-carbohydrate diet
#7
Which action is essential when caring for a patient with a chest tube drainage system?
Milking the tubing to facilitate drainage
Clamping the tubing during ambulation
Keeping the drainage system below the level of the chest
Emptying the drainage system every 24 hours
#8
Which assessment finding requires immediate intervention for a patient receiving continuous enteral feeding?
Presence of bowel sounds
Residual volume greater than 100 mL
Regular bowel movements
Gastric pH of 2
#9
What is the priority nursing intervention for a patient experiencing a seizure?
Restraining the patient's movements
Placing a soft object in the mouth to prevent tongue biting
Ensuring a patent airway and protecting the patient from injury
Administering antiepileptic medication
#10
Which assessment finding requires immediate intervention in a patient with a nasogastric tube?
Presence of bowel sounds
Clear drainage from the NG tube
Coughing during tube insertion
Abdominal distension and absent bowel sounds
#11
What is the priority nursing intervention for a patient with a central venous catheter experiencing signs of infection?
Administering analgesics for pain relief
Applying a warm compress to the catheter site
Removing the catheter immediately
Obtaining cultures from the catheter and initiating antibiotic therapy as ordered
#12
Which intervention is essential to prevent ventilator-associated pneumonia in a mechanically ventilated patient?
Administering prophylactic antibiotics
Limiting oral care
Maintaining the head of the bed at 30 to 45 degrees
Encouraging deep breathing exercises every 4 hours
#13
What is the priority nursing intervention for a patient experiencing anaphylaxis?
Administering an antihistamine
Administering a corticosteroid
Administering epinephrine
Monitoring vital signs
#14
What is the priority nursing intervention for a patient experiencing a hypertensive crisis?
Administering a beta-blocker
Initiating IV fluid administration
Administering an angiotensin-converting enzyme (ACE) inhibitor
Administering IV antihypertensive medication as ordered