#1
Which condition is a potential complication of immobility in bedridden patients?
Pneumonia
ExplanationStagnation of respiratory secretions can lead to pneumonia.
#2
Which nursing intervention is appropriate for a patient with impaired skin integrity?
Implementing a turning schedule and using pressure-relieving devices
ExplanationPrevention of pressure ulcers through proper positioning and support.
#3
Which nursing intervention is appropriate for a patient experiencing chest pain?
Assessing vital signs and contacting the healthcare provider
ExplanationImmediate assessment to identify potential cardiac issues.
#4
What is the priority nursing action for a patient with acute respiratory distress?
Administering oxygen therapy
ExplanationEnsuring adequate oxygenation to support respiratory function.
#5
Which laboratory result requires immediate action for a patient on warfarin therapy?
INR of 5.0
ExplanationIndicates increased risk of bleeding, necessitating adjustment of anticoagulation therapy.
#6
What is the priority nursing action for a patient admitted with diabetic ketoacidosis?
Administering regular insulin via IV infusion
ExplanationTo lower blood glucose levels and address metabolic acidosis.
#7
Which action is essential when caring for a patient with a chest tube drainage system?
Keeping the drainage system below the level of the chest
ExplanationPrevents backflow of fluid and air into the chest cavity.
#8
Which assessment finding requires immediate intervention for a patient receiving continuous enteral feeding?
Residual volume greater than 100 mL
ExplanationIndicates inadequate digestion or absorption, risking aspiration.
#9
Which action is essential for the nurse when caring for a patient with a suspected spinal cord injury?
Immobilizing the head and neck
ExplanationPrevents further damage to the spinal cord and nerves.
#10
Which assessment finding indicates a potential complication in a patient with a nasogastric tube?
Abdominal distension and absent bowel sounds
ExplanationSigns of gastrointestinal dysfunction or obstruction.
#11
Which nursing action is appropriate when caring for a patient with a newly inserted urinary catheter?
Ensuring the catheter bag is kept above the level of the bladder
ExplanationPrevents backflow of urine and reduces risk of infection.
#12
What is the priority nursing intervention for a patient at risk for aspiration?
Elevating the head of the bed to at least 30 degrees during and after meals
ExplanationReduces risk of aspiration by promoting proper swallowing and digestion.
#13
What is the priority nursing intervention for a patient experiencing a seizure?
Ensuring a patent airway and protecting the patient from injury
ExplanationSafety measures to prevent harm during seizure activity.
#14
Which assessment finding requires immediate intervention in a patient with a nasogastric tube?
Abdominal distension and absent bowel sounds
ExplanationIndicative of potential bowel obstruction or other complications.
#15
What is the priority nursing intervention for a patient with a central venous catheter experiencing signs of infection?
Obtaining cultures from the catheter and initiating antibiotic therapy as ordered
ExplanationEarly identification and treatment of infection to prevent systemic complications.
#16
Which intervention is essential to prevent ventilator-associated pneumonia in a mechanically ventilated patient?
Maintaining the head of the bed at 30 to 45 degrees
ExplanationReduces risk of aspiration and improves lung expansion.
#17
What is the priority nursing intervention for a patient experiencing anaphylaxis?
Administering epinephrine
ExplanationCounteracts severe allergic reactions to prevent further complications.
#18
What is the priority nursing intervention for a patient experiencing a hypertensive crisis?
Administering IV antihypertensive medication as ordered
ExplanationTo rapidly lower blood pressure and prevent end-organ damage.
#19
What is the priority nursing intervention for a patient experiencing a hypertensive emergency?
Administering IV vasodilators as ordered
ExplanationTo rapidly reduce blood pressure and prevent complications.
#20
What is the priority nursing intervention for a patient experiencing a hemorrhagic stroke?
Monitoring neurologic status closely
ExplanationEarly detection of neurological deterioration is crucial for timely intervention.
#21
What is the priority nursing intervention for a patient with hypovolemic shock?
Administering IV fluids rapidly
ExplanationTo restore circulating volume and improve tissue perfusion.
#22
What is the priority nursing intervention for a patient with septic shock?
Administering IV antibiotics
ExplanationTo combat the underlying infection and prevent systemic complications.
#23
Which assessment finding requires immediate intervention for a patient receiving intravenous (IV) therapy?
Formation of a blood clot in the IV tubing
ExplanationCan obstruct flow and increase risk of embolism or infection.
#24
What is the priority nursing action for a patient admitted with a suspected stroke?
Assessing and maintaining airway, breathing, and circulation
ExplanationImmediate assessment to prevent further neurological compromise.