Chapter 1: Professional Nursing PracticeNursing Pe

A nurse is assessing a patient admitted with COPD exacerbation. Which finding is the most concerning?

C. SpO₂ 82% on room air

A patient states, “I can’t breathe lying flat,” and the nurse observes the patient sitting upright, using accessory muscles. What type of data is this?

B. Subjective

A patient presents with BP 180/100, headache, blurred vision, and dizziness. Which interpretation is most appropriate?

B. Hypertensive crisis

A patient has blood glucose 48 mg/dL, diaphoresis, tremors, and confusion. What should the nurse conclude?

B. Hypoglycemia

A patient reports chest pain radiating to the left arm, diaphoresis, and nausea. Which hypothesis should be prioritized?

B. Myocardial infarction

A patient with dementia is restless, pulling at their Foley catheter, and yelling for help. Which possible cause is the highest priority?

B. Acute pain or discomfort

A patient with pneumonia has ineffective airway clearance. Which intervention is most appropriate?

B. Provide chest physiotherapy as ordered

A patient with type 2 diabetes is at risk for foot ulcers. Which nursing intervention is best?

B. Inspect feet daily and keep skin moisturized

The nurse receives a new order to start IV antibiotics for sepsis. What is the priority action?

B. Verify allergies before administration

A patient with heart failure has crackles in the lungs and dyspnea. Which intervention should the nurse implement first?

A. Elevate the head of the bed

After administering a bronchodilator, which finding best indicates the intervention was effective?

B. SpO₂ improved from 86% to 95%

A patient received a diuretic for fluid overload. Which finding indicates the medication was effective?

A. Increased urine output

A patient is refusing to eat because they “don’t feel loved” by their family. According to Maslow’s hierarchy, what level of need is being unmet?

C. Belonging

A nurse is planning care for four patients. Which patient need should be addressed first?

B. Patient with SpO₂ 82% on room air

Which intervention addresses the safety and security level of Maslow’s hierarchy?

B. Ensuring the call light is within reach

A nurse is teaching a newly diagnosed diabetic patient about insulin administration. Which level of Maslow’s hierarchy does this address?

C. Physiologic

A patient presents with the following needs. Which should be addressed first? (Select all that Apply)

• A. Severe abdominal pain

• B. Feeling isolated from family

• C. Difficulty breathing

• D. Request for help with prayer

• E. Fear about diagnosis

A & C

A patient designates their daughter to make medical decisions if they become incapacitated. This is an example of:

B. Health care power of attorney

Which statement by a patient indicates the need for further teaching about advance directives?

C. “A health care proxy can make financial decisions for me.”

A nurse is caring for a patient with a DNR order. The patient becomes pulseless and apneic. What action should the nurse take?

C. Provide comfort measures

During the assessment phase, the nurse:

A. Collects subjective and objective data

A patient reports shortness of breath with activity. Pulse oximetry is 88%. What is the most appropriate nursing diagnosis?

C. Ineffective breathing pattern related to impaired gas exchange

A patient has the nursing diagnosis: Ineffective breathing pattern. Which is an appropriate goal?

A. Patient will maintain SpO₂ above 92% with oxygen therapy.

The nurse is performing the implementation phase of ADPIE when:

B. Administering prescribed oxygen

Which statement demonstrates evaluation?

A. “The patient’s SpO₂ remained above 95% after ambulation.”

A nurse identifies that a patient with pneumonia has a fever and thick secretions. Which is the best nursing diagnosis?

A. Impaired gas exchange related to alveolar-capillary changes

Which patient condition represents a collaborative problem requiring both physician and nurse interventions?

C. Hypoglycemia in a patient on insulin therapy

The nurse is caring for four patients. Which patient should be assessed first?

C. Patient with chest pain and diaphoresis

A patient with heart failure is on fluid restriction. Which nursing interventions are appropriate? (Select all that apply.)
A. Offer frequent mouth care
B. Provide ice chips
C. Restrict sodium intake
D. Encourage unlimited water intake
E. Weigh patient daily

A, B, C, E

A patient with pneumonia is receiving IV antibiotics. After 48 hours, the patient’s fever has resolved, SpO₂ is 95%, and lung sounds have improved. What is the nurse’s best action?

C. Continue the current plan of care