You are admitting a patient that has an area of non-blanchable erythema on their sacrum. How would you document this pressure injury within the electronic health record? 

A patient states, “I can hear a crunching or grating sound when I kneel.” She also states that “it is very difficult to get out of bed in the morning because of stiffness and pain in my joints.” The nurse would document this finding as…?

How many ml of cough syrup to be given PO are in this syringe?  

The nurse calls the doctor with an SBAR report on the patient in room 7433. The doctor doesn’t feel this situation is urgent but would like the nurse to get started with drawing lab work and blood cultures and then start the patient on Cefazolin 2g IV q8H. He will be at the hospital in about 10-15 minutes as he is coming from the clinic.  What is the nurse’s best response?

The doctor writes an order for a medication. The nurse notes the order says to administer 12.5 mg PO. Pharmacy dispenses the nurse with 6.25 mg tablets. How many tablets will the nurse administer and what medication administration right is the nurse assessing?

A patient was admitted 1 day ago with a diagnosis of COPD. The patient is now having shortness of breath with a respiratory rate of 26, a pulse rate of 108, and a SPO2 of 92%. Which piece of data will the nurse use for “R” when using SBAR?

68 y/o male is experiencing 10/10 chest pain. The patient is ordered to receive a nitroglycerin tablet to be administered under the tongue. What route is this medication administered?

The nurse is caring for a patient who is at risk for infection. Which action by the nurse indicates correct understanding about standard precautions? (Select all that apply)

38 y/o patient states they are in pain after having surgery on a broken femur and alerts the nurse at 7 p.m. The nurse asks the patient when the pain started, to describe the pain, and the pain level on a scale of 0-10, and also assesses the patient’s cast and bandages. The patient states the pain started about an hour ago, it is a throbbing pain, and rates their pain 8 on a scale of 0-10. The bandages and cast appear to be within normal limits for a post-surgical patient.  The nurse checks the orders which state the patient can have morphine 10 mg tablet PO every 4 to 6 hours PRN pain and the last dose of medication was 2 p.m.  The nurse administered Morphine 10 mg tablet at 7:05 p.m. Documentation of patient concern including description and pain scale, nurse’s assessment, and administration of the medication was completed.  At 7:45 p.m. the nurse checks with the patient to re-assess their pain. The patient states the morphine was helpful and their pain level is now down to a “3” on the 0-10 scale. The nurse also documents this.  This is an example of what process?

In which order will the nurse use the nursing process steps during the clinical decision-making process? 1. Evaluating goals2. Assessing patient needs3. Planning priorities of care4. Determining nursing diagnoses5. Implementing nursing interventions