A student nurse is assessing their patient who is NPO due to a recent surgery. The provider comes in the room to see the patient and states that the patient is cleared to start a full liquid diet. What is the best action by the student nurse?

Ensure the patient is safe and leave to get them some water.

Contact dietary to order the patient a full liquid meal.

Request that the provider write the order in the chart.

Record the information in the patient chart.

Answer and Explanation

The Correct Answer is C

A. Ensure the patient is safe and leave to get them some water: The provider’s verbal statement is not an official order. The student nurse must ensure a written order is in place before implementing dietary changes.

B. Contact dietary to order the patient a full liquid meal: The student nurse cannot place orders. They must first verify that the provider has documented the order.

C. Request that the provider write the order in the chart: Orders must be documented in the patient’s medical record before they can be carried out. The student nurse should ensure the provider formally writes the order.

D. Record the information in the patient chart: The student nurse cannot chart an order that has not been officially written by the provider.

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Correct Answer is B

Explanation

A. "Patient with complaints of urinary incontinence." The patient did not report involuntary leakage of urine, which defines incontinence.
B. "Patient reports urinary retention." Urinary retention refers to the inability to completely empty the bladder, which matches the patient's description.
C. "Patient reports urinary frequency." Urinary frequency means voiding frequently (e.g., every 1-2 hours), but the patient described difficulty emptying.
D. "Patient has an enlarged prostate." While an enlarged prostate (BPH) could cause retention, the nurse should not diagnose—only report symptoms.

A. Palpate for pedal pulses. B. Turn the patient every three hours. C. Document the stage 1 pressure injury. D. Elevate bilateral heels.

Correct Answer is A

Explanation

A. Palpate for pedal pulses: Cool skin may indicate poor circulation or ischemia. Checking pedal pulses helps assess blood flow. This step provides essential information about the vascular status of the patient's foot, guiding further interventions.

B. Turn the patient every three hours: Patients on bedrest should be turned every 2 hours, not every 3 hours, to prevent pressure injuries.

C. Document the stage 1 pressure injury: Blistering indicates at least a Stage 2 pressure injury, not Stage 1. The nurse must assess further before staging.

D. Elevate bilateral heels: Once assessment confirms the need, elevating the heels can help reduce pressure and promote circulation, potentially preventing further damage and aiding in the healing process.

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A student nurse is assessing their patient who is NPO due to a recent surgery. The provider comes in the room to see the patient and states that the patient is cleared to start a full liquid diet. What is the best action by the student nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a health history interview, a client tells the nurse that they do not feel that they completely empty the bladder when they void. How would the nurse report this findings to the provider?

Correct Answer is B

Explanation

While bathing a patient who is on bedrest, the nurse notes an area of blistering and hypopigmentation on the patient's right heel. Upon further assessment, the area is also tender and cooler than the surrounding area. What is the next best action by the nurse?

Correct Answer is A

Explanation

A nurse is preparing to bathe a client with dyspnea. Which of the following actions should the nurse plan to take?

A client has developed edema in her lower legs and feet prompting her physician to prescribe furosemide, a diuretic medication. After the client has begun this new medication, what should the nurse anticipate as a normal finding?

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A nurse is providing education to a female patient who has been diagnosed with recurrent urinary tract infections. What statement should the nurse include in the education?

A student nurse is assigned a patient to provide care for throughout the day. Which of the following actions would violate client confidentiality?

A nurse makes a medication error and fills out an incident report. What will the nurse do with the incident report once it is filled out?

The provider has notified the patient and family that the patient will be started on parenteral nutrition. The patient asks if their family can go get them a milk shake since the provider said they could have nutrition. What is the best response by nurse at this time?