During clinical experience, the student nurse is assigned a patient scheduled to undergo
numerous treatments. The student decides it is not possible to complete all the needed
treatments n the time scheduled for this clinical day. The student nurse consults with the
clinical instructor to: - answer Prioritize
The instructor has suggested that the student nurse could improve organizational skills
and manage time better by scheduling selected nursing activities in the daily
assignment. Which activity should be scheduled? - answer Administering medications
A nurse is assigned to care for five patients. The nurse is concerned about the ability to
care for this many patient. The nurse needs to - answer prioritize the needs of the
patients and determine the sickest patient
The nurse is receiving a phone order from a health care provider. How will the nurse
make sure that the provider's order is received without error? - answer Repeat the
order, write the order verbatim, and read it back to the provider
The nurse receives report on an assigned group of patients. Which patient would the
nurse assess first? - answerA hypertensive patient complaining of severe midsternum
pain
What are critical points to communicate during a shift report or hand-off
communication? - answerPatient name, current physical status, activities that have
contributed to current status, problems that have occurred during the shift, nursing care
to address problems, and a readback or response
The nurse calls a physician to come to the unit to assess a patient. Which of the
following is most effective telephone communication by the nurse? - answerThis is
Sheila Ryan on 4100 calling regarding your patient, Mr Samuels. His BP has dropped
from 130/90 at 8 am to 100/70 at 10 am. His pulse has risen from 80 to 100, and he
seems restless. He received his 8 am Cardizem.
A nurse has received report on assigned patients and is prioritizing their care. Which of
the following patients should the nurse assess first? - answerA patient who has just
returned from surgery and has saturated his dressing
A nurse has been assigned the following patients. Which patient is a priority to assess
first? - answerA patient with pneumonia and o2 saturation of 88%
, A nurse is working with a nurse aide to care for a group of patients. Which of the
following activities would be inappropriate to delegate to the nurse aide? -
answerProviding discharge instructions to a patient
Which information shown in the accompanying figure about a patient who has just
arrived in the emergency department is MOST urgent for the nurse to communicate to
the health care provider?
Assessment: bp 110/69, p 98, brisk cap refill, multiple ecchymosis on arms
CBC: Hgb 10.6 Hct 30% WBC 9,000 Platelets 19,500
Patient hx: occasional aspirin use, abd pain x1 wk, large, dark stool this morning -
answerplatelet count
A patient who has been receiving a heparin infusion and warfarin for DVT is diagnosed
with heparin-induced thrombocytopenia when her platelet level drops to 110,000. Which
action will the nurse include in the plan of care? - answerDiscontinue heparin and flush
intermittent IV lines using normal saline
The patient is brought to the emergency department after a motor vehicle accident. The
patient is diagnosed with internal bleeding. The nurse's primary concern is to monitor for
- answerperfusion
Which nursing observation would indicate that the nurse hold the medication warfarin? -
answerAn INR of 4.8
A student nurse is studying clinical judgment theories and is working with Tanner's
Model of Clinical Judgment. The student nurse can generalize the process as - answera
reflective process where the nurse notices, interprets, responds, and reflects in action
A nursing instructor is talking about care coordination with nursing students. The
instructor stresses which of the following to the students concerning care coordination?
- answerCollaboration is a big part of care coordination
A nurse is working on a medical-surgical unit and receives a phone call from a physician
who would like to give orders for a new patient. What should the nurse do to make the
telephone order safer for the patient? - answerAccept the order and perform a "read
back"
Write down the telephone order as it is being given
A nurse has received an abnormal result on a critical test for an assigned patient. The
nurse has been trying to reach the resident for 20 minutes but has been unsuccessful.
What should be done to ensure the best care for the patient? - answerContinue to
provide care for the patient and document all actions in the medical record
Page the attending physician
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