Wondershare

PDFelement
Wondershare
PDFelement
 Wondershare
PDFelement

Screen 1 of 6

The nurse in the emergency department (ED) is caring for a 78-year-old female client. Select the 4 client findings that require immediate follow-up.

Nurses’ Notes 1. vital signs

1000: Client was brought to the ED by the client’s adult child due to increased 2. lung sounds
shortness of breath this morning. The adult child reports that the client has
been running a fever for the past few days and has started to cough up 3. capillary refill
greenish mucus and to complain of soreness throughout the body. Client
was hospitalized for issues with atrial fibrillation 6 days ago. History of 4. client orientation
hypertension. Vital signs: T 101.1° F (38.4° C), P 92, RR 22, BP 152/86,
pulse oximetry reading 94% on oxygen at 2 L/min via nasal cannula.
On assessment, the client’s breathing appears slightly labored, and coarse 5. radial pulse characteristics
crackles (rales) are noted in the bilateral lung bases. Skin slightly cool to
touch and pale pink in tone; pulses 3+ and irregular. Capillary refill is 3 6. characteristics of the cough
seconds. Client is alert and oriented to person, place, and time. The adult
child states, “Sometimes it seems like my parent is confused.” Peripheral
venous access device (VAD) placed in right forearm.

©2021 NCSBN. All rights reserved. Page 2/64

 Wondershare
PDFelement

Screen 2 of 6

The nurse in the emergency department (ED) is caring for a 78-year-old female client. For each client finding below, click to specify if the finding is consistent
with the disease process of pneumonia, a urinary tract infection (UTI),
or influenza. Each finding may support more than 1 disease process.
Nurses’ Notes

Urinary Tract
1000: Client was brought to the ED by the client’s adult child due to increased Client Findings Pneumonia Influenza
Infection
shortness of breath this morning. The adult child reports that the client has
been running a fever for the past few days and has started to cough up fever
greenish mucus and to complain of soreness throughout the body. Client
was hospitalized for issues with atrial fibrillation 6 days ago. History of confusion
hypertension. Vital signs: T 101.1° F (38.4° C), P 92, RR 22, BP 152/86,
pulse oximetry reading 94% on oxygen at 2 L/min via nasal cannula. body soreness
On assessment, the client’s breathing appears slightly labored, and coarse
cough and sputum
crackles (rales) are noted in the bilateral lung bases. Skin slightly cool to
touch and pale pink in tone; pulses 3+ and irregular. Capillary refill is 3 shortness of breath
seconds. Client is alert and oriented to person, place, and time. The adult
child states, “Sometimes it seems like my parent is confused.” Peripheral
venous access device (VAD) placed in right forearm. Note: Each column must have at least 1 response option selected.

©2021 NCSBN. All rights reserved. Page 3/64

 Wondershare
PDFelement

Screen 3 of 6

The nurse in the emergency department (ED) is caring for a 78-year-old female client. Complete the following sentence by choosing from the list of options.

The client is at highest risk for developing Select…

Nurses’ Notes

1000: Client was brought to the ED by the client’s adult child due to increased
shortness of breath this morning. The adult child reports that the client has
been running a fever for the past few days and has started to cough up
greenish mucus and to complain of soreness throughout the body. Client
was hospitalized for issues with atrial fibrillation 6 days ago. History of
hypertension. Vital signs: T 101.1° F (38.4° C), P 92, RR 22, BP 152/86,
pulse oximetry reading 94% on oxygen at 2 L/min via nasal cannula.
On assessment, the client’s breathing appears slightly labored, and coarse
crackles (rales) are noted in the bilateral lung bases. Skin slightly cool to
touch and pale pink in tone; pulses 3+ and irregular. Capillary refill is 3
seconds. Client is alert and oriented to person, place, and time. The adult
child states, “Sometimes it seems like my parent is confused.” Peripheral
venous access device (VAD) placed in right forearm.

©2021 NCSBN. All rights reserved. Page 4/64

 Wondershare
PDFelement

Screen 3 of 6

The nurse in the emergency department (ED) is caring for a 78-year-old female client. Complete the following sentence by choosing from the list of options.

The client is at highest risk for developing Select…

Nurses’ Notes
Select…
stroke
1000: Client was brought to the ED by the client’s adult child due to increased
shortness of breath this morning. The adult child reports that the client has hypoxia
been running a fever for the past few days and has started to cough up
dysrhythmias
greenish mucus and to complain of soreness throughout the body. Client
was hospitalized for issues with atrial fibrillation 6 days ago. History of a pulmonary embolism
hypertension. Vital signs: T 101.1° F (38.4° C), P 92, RR 22, BP 152/86,
pulse oximetry reading 94% on oxygen at 2 L/min via nasal cannula.
On assessment, the client’s breathing appears slightly labored, and coarse
crackles (rales) are noted in the bilateral lung bases. Skin slightly cool to
touch and pale pink in tone; pulses 3+ and irregular. Capillary refill is 3
seconds. Client is alert and oriented to person, place, and time. The adult
child states, “Sometimes it seems like my parent is confused.” Peripheral
venous access device (VAD) placed in right forearm.

©2021 NCSBN. All rights reserved. Page 5/64

 Wondershare
PDFelement

Screen 4 of 6

The nurse in the emergency department (ED) is caring for a 78-year-old female client. The nurse has reviewed the Nurses’ Notes from 1200.

For each potential nursing intervention, click to specify whether the

Nurses’ Notes intervention is indicated or not indicated for the care of the client.

1000: Client was brought to the ED by the client’s adult child due to increased
shortness of breath this morning. The adult child reports that the client has
been running a fever for the past few days and has started to cough up Client Findings Indicated Not Indicated
greenish mucus and to complain of soreness throughout the body. Client
was hospitalized for issues with atrial fibrillation 6 days ago. History of Prepare the client for defibrillation.
hypertension. Vital signs: T 101.1° F (38.4° C), P 92, RR 22, BP 152/86,
pulse oximetry reading 94% on oxygen at 2 L/min via nasal cannula. Place client in a semi-Fowler’s
On assessment, the client’s breathing appears slightly labored, and coarse position.
crackles (rales) are noted in the bilateral lung bases. Skin slightly cool to
Request an order to increase
touch and pale pink in tone; pulses 3+ and irregular. Capillary refill is 3
seconds. Client is alert and oriented to person, place, and time. The adult the oxygen flow rate.
child states, “Sometimes it seems like my parent is confused.” Peripheral Request an order to insert an
venous access device (VAD) placed in right forearm. additional peripheral VAD.
Request an order to administer
1200: Called to bedside by the adult child who states that the client “isn’t acting
an intravenous fluid bolus.
right.” On assessment, client is difficult to arose, pale, and diaphoretic.
Vital signs: P 112, RR 32, BP 90/62, pulse oximetry reading 91% on 2 L/min
of oxygen via nasal cannula. Note: Each row must have 1 response option selected.

©2021 NCSBN. All rights reserved. Page 6/64

 Wondershare
PDFelement

Screen 5 of 6

The nurse in the emergency department (ED) is caring for a 78-year-old female client. The nurse has reviewed the Orders from 1215.

Click to highlight the orders that the nurse should consider a priority.
Nurses’ Notes

1000: Client was brought to the ED by the client’s adult child due to increased Orders
shortness of breath this morning. The adult child reports that the client has
been running a fever for the past few days and has started to cough up 1215:
greenish mucus and to complain of soreness throughout the body. Client
was hospitalized for issues with atrial fibrillation 6 days ago. History of • insert an indwelling urethral catheter
hypertension. Vital signs: T 101.1° F (38.4° C), P 92, RR 22, BP 152/86, • vancomycin 1 g, IV, every 12 hours
pulse oximetry reading 94% on oxygen at 2 L/min via nasal cannula.
On assessment, the client’s breathing appears slightly labored, and coarse • computed tomography (CT) scan of the chest
crackles (rales) are noted in the bilateral lung bases. Skin slightly cool to • 0.9% sodium chloride (normal saline) 500 mL, IV, once
touch and pale pink in tone; pulses 3+ and irregular. Capillary refill is 3
seconds. Client is alert and oriented to person, place, and time. The adult • laboratory tests: blood culture and sensitivity (C & S), complete
child states, “Sometimes it seems like my parent is confused.” Peripheral blood count (CBC), arterial blood gas (ABG)
venous access device (VAD) placed in right forearm.

1200: Called to bedside by the adult child who states that the client “isn’t acting
right.” On assessment, client is difficult to arose, pale, and diaphoretic.
Vital signs: P 112, RR 32, BP 90/62, pulse oximetry reading 91% on 2 L/min
of oxygen via nasal cannula.

©2021 NCSBN. All rights reserved. Page 7/64

 Wondershare
PDFelement

Screen 5 of 6

The nurse in the emergency department (ED) is caring for a 78-year-old female client. The nurse has reviewed the Orders from 1215.

Click to highlight the orders that the nurse should consider a priority.
Nurses’ Notes

1000: Client was brought to the ED by the client’s adult child due to increased Orders
shortness of breath this morning. The adult child reports that the client has
been running a fever for the past few days and has started to cough up 1215:
greenish mucus and to complain of soreness throughout the body. Client
was hospitalized for issues with atrial fibrillation 6 days ago. History of • insert an indwelling urethral catheter
hypertension. Vital signs: T 101.1° F (38.4° C), P 92, RR 22, BP 152/86, • vancomycin 1 g, IV, every 12 hours
pulse oximetry reading 94% on oxygen at 2 L/min via nasal cannula.
On assessment, the client’s breathing appears slightly labored, and coarse • computed tomography (CT) scan of the chest
crackles (rales) are noted in the bilateral lung bases. Skin slightly cool to • 0.9% sodium chloride (normal saline) 500 mL, IV, once
touch and pale pink in tone; pulses 3+ and irregular. Capillary refill is 3
seconds. Client is alert and oriented to person, place, and time. The adult • laboratory tests: blood culture and sensitivity (C & S), complete
child states, “Sometimes it seems like my parent is confused.” Peripheral blood count (CBC), arterial blood gas (ABG)
venous access device (VAD) placed in right forearm.

1200: Called to bedside by the adult child who states that the client “isn’t acting
right.” On assessment, client is difficult to arose, pale, and diaphoretic.
Vital signs: P 112, RR 32, BP 90/62, pulse oximetry reading 91% on 2 L/min
of oxygen via nasal cannula.

©2021 NCSBN. All rights reserved. Page 8/64

 Wondershare
PDFelement

Screen 6 of 6 Screen 6 of 6

The nurse in the emergency department (ED) is caring for a 78-year-old female client. For each assessment finding, click to specify if the finding indicates
that the client’s condition has improved, not changed, or worsened.
Nurses’ Notes Orders

1000: Client was brought to the ED by the client’s adult child due to increased Assessment Findings Improved Not Changed Worsened
shortness of breath this morning. The adult child reports that the client has
been running a fever for the past few days and has started to cough up pale skin tone
greenish mucus and to complain of soreness throughout the body. Client
was hospitalized for issues with atrial fibrillation 6 days ago. History of respirations, 36
hypertension. Vital signs: T 101.1° F (38.4° C), P 92, RR 22, BP 152/86,
pulse oximetry reading 94% on oxygen at 2 L/min via nasal cannula. blood pressure, 118/68
On assessment, the client’s breathing appears slightly labored, and coarse pulse oximetry
crackles (rales) are noted in the bilateral lung bases. Skin slightly cool to reading 91%
touch and pale pink in tone; pulses 3+ and irregular. Capillary refill is 3
seconds. Client is alert and oriented to person, place, and time. The adult client interacting with
child states, “Sometimes it seems like my parent is confused.” Peripheral adult child at bedside
venous access device (VAD) placed in right forearm.

1200: Called to bedside by the adult child who states that the client “isn’t acting Note: Each row must have 1 response option selected.
right.” On assessment, client is difficult to arose, pale, and diaphoretic.
Vital signs: P 112, RR 32, BP 90/62, pulse oximetry reading 91% on 2 L/min
of oxygen via nasal cannula.

©2021 NCSBN. All rights reserved. Page 9/64

 Wondershare
PDFelement

Screen 6 of 6 Screen 6 of 6

The nurse in the emergency department (ED) is caring for a 78-year-old female client. For each assessment finding, click to specify if the finding indicates
that the client’s condition has improved, not changed, or worsened.
Nurses’ Notes Orders

Assessment Findings Improved Not Changed Worsened

1215:
• insert an indwelling urethral catheter pale skin tone
• vancomycin 1 g, IV, every 12 hours
respirations, 36
• computed tomography (CT) scan of the chest
blood pressure, 118/68
• 0.9% sodium chloride (normal saline) 500 mL, IV, once
pulse oximetry
• laboratory tests: blood culture and sensitivity (C & S), complete reading 91%
blood count (CBC), arterial blood gas (ABG)
client interacting with
adult child at bedside

Note: Each row must have 1 response option selected.

©2021 NCSBN. All rights reserved. Page 10/64

 Wondershare
PDFelement

Screen 1 of 6

The nurse in the emergency department (ED) is caring for a 17-year-old male client. Which of the following assessment findings require immediate follow-up?
Select all that apply.
History and Laboratory
Nurses’ Notes Vital Signs
Physical Results
1. lung sounds

2. shoulder pain
Body System Findings
3. laboratory results
denies shortness of breath; reports discomfort in
Pulmonary the lower left side of chest when taking a deep 4. productive cough
breath
reports feeling abdominal fullness and is 5. abdominal assessment findings
Gastrointestinal
occasionally nauseated
sustained an injury to the left rib cage after being 6. pulse, respirations, and blood pressure
struck by a mechanically pitched baseball in a
batting cage last week; reports intermittent pain 7. temperature and pulse oximetry reading
in the left shoulder rated 6/10 on the Numerical
Musculoskeletal
Rating Scale and feels light-headed; significant
bruising to the shoulder; history of an orthoscopic
repair to the left shoulder for a torn rotator cuff
last year
client has not felt well enough to attend baseball
Psychosocial
practice since the injury

©2021 NCSBN. All rights reserved. Page 11/64

 Wondershare
PDFelement

Screen 1 of 6

The nurse in the emergency department (ED) is caring for a 17-year-old male client. Which of the following assessment findings require immediate follow-up?
Select all that apply.
History and Laboratory
Nurses’ Notes Vital Signs
Physical Results
1. lung sounds
Emergency Department
2. shoulder pain
Day 1
3. laboratory results

0900: Client appears pale and slightly diaphoretic. Large amount of bruising 4. productive cough
noted along the left torso and over the left upper quadrant (LUG) of
the abdomen. Tenderness, guarding, and dullness to percussion noted
on abdominal assessment. Slightly diminished breath sounds noted 5. abdominal assessment findings
in the left lung fields on auscultation; client has a productive cough.
Electrocardiogram (ECG) shows normal sinus rhythm. 6. pulse, respirations, and blood pressure

7. temperature and pulse oximetry reading

©2021 NCSBN. All rights reserved. Page 12/64

 Wondershare
PDFelement

Screen 1 of 6

The nurse in the emergency department (ED) is caring for a 17-year-old male client. Which of the following assessment findings require immediate follow-up?
Select all that apply.
History and Laboratory
Nurses’ Notes Vital Signs
Physical Results
1. lung sounds

2. shoulder pain
Emergency Department
Day 1
3. laboratory results
0900
T 97.8° F (36.6° C) 4. productive cough

P 116 5. abdominal assessment findings

RR 24
6. pulse, respirations, and blood pressure
BP 90/50
7. temperature and pulse oximetry reading
Pulse oximetry reading 98% on room air

©2021 NCSBN. All rights reserved. Page 13/64

 Wondershare
PDFelement

Screen 1 of 6

The nurse in the emergency department (ED) is caring for a 17-year-old male client. Which of the following assessment findings require immediate follow-up?
Select all that apply.
History and Laboratory
Nurses’ Notes Vital Signs
Physical Results
1. lung sounds

Emergency 2. shoulder pain

Department
Day 1 3. laboratory results
Laboratory Test and Reference Range 0900
4. productive cough
white blood cell (WBC) count
19,000/mm 3
Adult/child > 2 years: 5,000–10,000/mm3 5. abdominal assessment findings
(19 x 109/L)
(5–10 x 109/L)

hemoglobin (Hgb) 6. pulse, respirations, and blood pressure

Male: 14–18 g/dL
9 g/dL 7. temperature and pulse oximetry reading
(140–180 g/L)
(90 g/L)
Female: 12–16 g/dL
(120–160 g/L)

hematocrit (HCT)
Male: 42%–52%
27%
(0.42–0.52)
(0.27)
Female: 37%–47%
(0.37–0.47)

©2021 NCSBN. All rights reserved. Page 14/64

 Wondershare
PDFelement

Screen 2 of 6

The nurse in the emergency department (ED) is caring for a 17-year-old male client. Which of the following issues is the client at risk of developing?
Select all that apply.
History and Laboratory
Nurses’ Notes Vital Signs
Physical Results
1. stroke

2. hemothorax
Body System Findings
3. bowel perforation
denies shortness of breath; reports discomfort in
Pulmonary the lower left side of chest when taking a deep 4. splenic laceration
breath
reports feeling abdominal fullness and is 5. pulmonary embolism
Gastrointestinal
occasionally nauseated
sustained an injury to the left rib cage after being 6. abdominal aortic aneurysm
struck by a mechanically pitched baseball in a
batting cage last week; reports intermittent pain
in the left shoulder rated 6/10 on the Numerical
Musculoskeletal
Rating Scale and feels light-headed; significant
bruising to the shoulder; history of an orthoscopic
repair to the left shoulder for a torn rotator cuff
last year
client has not felt well enough to attend baseball
Psychosocial
practice since the injury

©2021 NCSBN. All rights reserved. Page 15/64

 Wondershare
PDFelement

Screen 3 of 6

The nurse in the emergency department (ED) is caring for a 17-year-old male client. Complete the following sentence by choosing from the list of options.

History and Laboratory The nurse should first address the client’s Select…
Nurses’ Notes Vital Signs
Physical Results

Body System Findings

denies shortness of breath; reports discomfort in

Pulmonary the lower left side of chest when taking a deep
breath
reports feeling abdominal fullness and is
Gastrointestinal
occasionally nauseated
sustained an injury to the left rib cage after being
struck by a mechanically pitched baseball in a
batting cage last week; reports intermittent pain
in the left shoulder rated 6/10 on the Numerical
Musculoskeletal
Rating Scale and feels light-headed; significant
bruising to the shoulder; history of an orthoscopic
repair to the left shoulder for a torn rotator cuff
last year
client has not felt well enough to attend baseball
Psychosocial
practice since the injury

©2021 NCSBN. All rights reserved. Page 16/64

 Wondershare
PDFelement

Screen 3 of 6

The nurse in the emergency department (ED) is caring for a 17-year-old male client. Complete the following sentence by choosing from the list of options.

History and Laboratory The nurse should first address the client’s Select…
Nurses’ Notes Vital Signs
Physical Results Select…
abdominal pain
respiratory status
Body System Findings laboratory results
denies shortness of breath; reports discomfort in
Pulmonary the lower left side of chest when taking a deep
breath
reports feeling abdominal fullness and is
Gastrointestinal
occasionally nauseated
sustained an injury to the left rib cage after being
struck by a mechanically pitched baseball in a
batting cage last week; reports intermittent pain
in the left shoulder rated 6/10 on the Numerical
Musculoskeletal
Rating Scale and feels light-headed; significant
bruising to the shoulder; history of an orthoscopic
repair to the left shoulder for a torn rotator cuff
last year
client has not felt well enough to attend baseball
Psychosocial
practice since the injury

©2021 NCSBN. All rights reserved. Page 17/64

 Wondershare
PDFelement

Screen 4 of 6

The nurse in the emergency department (ED) is caring for a 17-year-old male client. The nurse has reviewed the Nurses’ Notes from 1000.

History and Laboratory For each potential order, click to specify whether the potential order is
Nurses’ Notes Vital Signs indicated or not indicated for the client.
Physical Results

Emergency Department
Potential Orders Indicated Not Indicated
Day 1
intravenous fluids
0900: Client appears pale and slightly diaphoretic. Large amount of bruising
serum type and screen
noted along the left torso and over the left upper quadrant (LUG) of the
abdomen. Tenderness, guarding, and dullness to percussion noted
on abdominal assessment. Slightly diminished breath sounds noted chest percussion therapy
in the left lung fields on auscultation; client has a productive cough.
Electrocardiogram (ECG) shows normal sinus rhythm. insertion of a nasogastric (NG) tube

administration of prescribed pain

1000: Client diagnosed with a splenic laceration and a left-sided hemothorax medication
per the physician.

Note: Each row must have 1 response option selected.

©2021 NCSBN. All rights reserved. Page 18/64

 Wondershare
PDFelement

Screen 5 of 6

The nurse in the emergency department (ED) is caring for a 17-year-old male client. The nurse has reviewed the Nurses’ Notes from 1030.

History and Laboratory Which of the following actions should the nurse take?
Nurses’ Notes Vital Signs
Physical Results Select all that apply.
Emergency Department
1. Mark the surgical site.
Day 1
2. Provide the client with ice chips.

0900: Client appears pale and slightly diaphoretic. Large amount of bruising 3. Perform a medication reconciliation.
noted along the left torso and over the left upper quadrant (LUG) of the
abdomen. Tenderness, guarding, and dullness to percussion noted 4. Obtain consent for surgery from the client.
on abdominal assessment. Slightly diminished breath sounds noted
in the left lung fields on auscultation; client has a productive cough.
Electrocardiogram (ECG) shows normal sinus rhythm. 5. Insert a peripheral venous access device (VAD).

6. Inform the client about the risks and benefits of the surgery.
1000: Client diagnosed with a splenic laceration and a left-sided hemothorax
per the physician.
7. Assess the client’s previous experience with surgery
1030: Client referred for immediate surgery. and anesthesia.

8. Ask the client’s parents to wait in the waiting room while the
plan of care is discussed with the client.

©2021 NCSBN. All rights reserved. Page 19/64

 Wondershare
PDFelement

Screen 6 of 6

The nurse in the emergency department (ED) is caring for a 17-year-old male client. The nurse has reviewed the Progress Notes from 0800.

History and Laboratory Click to highlight the findings below that indicate a worsening of
Nurses’ Notes Vital Signs the client’s status.
Physical Results

Progress Notes
Body System Findings

denies shortness of breath; reports discomfort in Day 3:

Pulmonary the lower left side of chest when taking a deep
breath 0800: Client is postoperative day 3 after a splenectomy and is
reports feeling abdominal fullness and is able to ambulate in the corridor 3 or 4 times daily with
Gastrointestinal minimal assistance. Client has clear breath sounds a
occasionally nauseated
left-sided chest tube in place attached to a closed-chest
sustained an injury to the left rib cage after being
drainage system. Tidaling of the water chamber noted on
struck by a mechanically pitched baseball in a
deep inspiration. Client refuses to use the incentive
batting cage last week; reports intermittent pain
spirometer, stating it causes left-sided chest pain. Client
in the left shoulder rated 6/10 on the Numerical
Musculoskeletal is using prescribed patient-controlled analgesia (PCA) device
Rating Scale and feels light-headed; significant
maximally every hour and continues to have intermittent
bruising to the shoulder; history of an orthoscopic
nausea and vomiting. Adequate urine output. Abdominal
repair to the left shoulder for a torn rotator cuff
surgical incision site with dressing is clean, dry, and intact
last year
with no erythema, edema, or drainage.
client has not felt well enough to attend baseball
Psychosocial
practice since the injury

©2021 NCSBN. All rights reserved. Page 20/64

 Wondershare
PDFelement

Screen 6 of 6

The nurse in the emergency department (ED) is caring for a 17-year-old male client. The nurse has reviewed the Progress Notes from 0800.

History and Laboratory Click to highlight the findings below that indicate a worsening of
Nurses’ Notes Vital Signs the client’s status.
Physical Results

Progress Notes
Body System Findings

denies shortness of breath; reports discomfort in Day 3:

Pulmonary the lower left side of chest when taking a deep
breath 0800: Client is postoperative day 3 after a splenectomy and is
reports feeling abdominal fullness and is able to ambulate in the corridor 3 or 4 times daily with
Gastrointestinal minimal assistance. Client has clear breath sounds a
occasionally nauseated
left-sided chest tube in place attached to a closed-chest
sustained an injury to the left rib cage after being
drainage system. Tidaling of the water chamber noted on
struck by a mechanically pitched baseball in a
deep inspiration. Client refuses to use the incentive
batting cage last week; reports intermittent pain
spirometer, stating it causes left-sided chest pain. Client
in the left shoulder rated 6/10 on the Numerical
Musculoskeletal is using prescribed patient-controlled anaglesia (PCA) device
Rating Scale and feels light-headed; significant
maximally every hour and continues to have intermittent
bruising to the shoulder; history of an orthoscopic
nausea and vomiting. Adequate urine output. Abdominal
repair to the left shoulder for a torn rotator cuff
surgical incision site with dressing is clean, dry, and intact
last year
with no erythema, edema, or drainage.
client has not felt well enough to attend baseball
Psychosocial
practice since the injury

©2021 NCSBN. All rights reserved. Page 21/64

 Wondershare
PDFelement

Screen 1 of 6

The nurse in the emergency department (ED) is caring for a 41-year-old male client.

Click to highlight the findings below that would require follow-up.

Nurses’ Notes

1100: Client reports nausea, loss of appetite, vomiting, fever, and constipation
for the past 2 weeks and abdominal pain rated 7/10 on the Numerical
Rating Scale for 1 week. Client states, “The abdominal pain started after
my 7-year-old child accidentally kicked me in the stomach.” Client plays
soccer with the child once a week. Vital signs: T 103.4° F (39.7° C),
P 92, RR 22, BP 130/86, pulse oximetry reading 98% on room air. No
significant past medical or surgical history. Body mass index (BMI) of 32.
Drinks alcohol only during social occasions, usually 3 beverages.
Smokes cigarettes during social occasions.

©2021 NCSBN. All rights reserved. Page 22/64

 Wondershare
PDFelement

Screen 1 of 6

The nurse in the emergency department (ED) is caring for a 41-year-old male client.

Click to highlight the findings below that would require follow-up.

Nurses’ Notes

1100: Client reports nausea, loss of appetite, vomiting, fever, and constipation
for the past 2 weeks and abdominal pain rated 7/10 on the Numerical
Rating Scale for 1 week. Client states, “The abdominal pain started after
my 7-year-old child accidentally kicked me in the stomach.” Client plays
soccer with the child once a week. Vital signs: T 103.4° F (39.7° C),
P 92, RR 22, BP 130/86, pulse oximetry reading 98% on room air. No
significant past medical or surgical history. Body mass index (BMI) of 32.
Drinks alcohol only during social occasions, usually 3 beverages.
Smokes cigarettes during social occasions.

©2021 NCSBN. All rights reserved. Page 23/64

 Wondershare
PDFelement

Screen 2 of 6

The nurse in the emergency department (ED) is caring for a 41-year-old male client. For each assessment finding below, click to specify if the finding is consistent
with the disease process of bowel obstruction, appendicitis, or ruptured
spleen. Each finding may support more than 1 disease process.
Nurses’ Notes
Bowel Ruptured
Emergency Department Assessment Findings Obstruction Appendicitis Spleen
1100: Client reports nausea, loss of appetite, vomiting, fever, and constipation
for the past 2 weeks and abdominal pain rated 7/10 on the Numerical appetite
Rating Scale for 1 week. Client states, “The abdominal pain started after pain level
my 7-year-old child accidentally kicked me in the stomach.” Client plays
soccer with the child once a week. Vital signs: T 103.4° F (39.7° C), bowel pattern
P 92, RR 22, BP 130/86, pulse oximetry reading 98% on room air. No
significant past medical or surgical history. Body mass index (BMI) of 32. gastrointestinal symptoms
Drinks alcohol only during social occasions, usually 3 beverages.
Smokes cigarettes during social occasions.
Note: Each column must have at least 1 response option selected.

©2021 NCSBN. All rights reserved. Page 24/64

 Wondershare
PDFelement

Screen 3 of 6

The nurse in the emergency department (ED) is caring for a 41-year-old male client. Select the 3 complications the client is at risk for developing.

Nurses’ Notes
1. anemia
Emergency Department
2. peritonitis
1100: Client reports nausea, loss of appetite, vomiting, fever, and constipation
for the past 2 weeks and abdominal pain rated 7/10 on the Numerical
Rating Scale for 1 week. Client states, “The abdominal pain started after 3. septic shock
my 7-year-old child accidentally kicked me in the stomach.” Client plays
soccer with the child once a week. Vital signs: T 103.4° F (39.7° C), 4. hypovolemia
P 92, RR 22, BP 130/86, pulse oximetry reading 98% on room air. No
significant past medical or surgical history. Body mass index (BMI) of 32.
5. dysrhythmias
Drinks alcohol only during social occasions, usually 3 beverages.
Smokes cigarettes during social occasions.
6. cardiac arrest

©2021 NCSBN. All rights reserved. Page 25/64

 Wondershare
PDFelement

Screen 4 of 6

The nurse in the emergency department (ED) is caring for a 41-year-old male client. The nurse has reviewed the Nurses’ Notes from 1130.

For each potential intervention, click to specify whether the

Nurses’ Notes intervention is indicated or not indicated for the client.

Emergency Department
1100: Client reports nausea, loss of appetite, vomiting, fever, and constipation Potential Orders Indicated Not Indicated
for the past 2 weeks and abdominal pain rated 7/10 on the Numerical
Rating Scale for 1 week. Client states, “The abdominal pain started after clear liquid diet
my 7-year-old child accidentally kicked me in the stomach.” Client plays
soccer with the child once a week. Vital signs: T 103.4° F (39.7° C), soapsuds enema
P 92, RR 22, BP 130/86, pulse oximetry reading 98% on room air. No
significant past medical or surgical history. Body mass index (BMI) of 32.
Drinks alcohol only during social occasions, usually 3 beverages. heating pad to abdomen
Smokes cigarettes during social occasions.
abdominal girth measurements
1130: Notified primary health care provider about client status. Awaiting orders.
abdominal computed tomography
(CT) scan

Note: Each row must have 1 response option selected.

©2021 NCSBN. All rights reserved. Page 26/64

 Wondershare
PDFelement

Screen 5 of 6

The nurse in the emergency department (ED) is caring for a 41-year-old male client. The nurse has reviewed the Nurses’ Notes from 1230, 1245, 1400, and 1415
and the Diagnostic Results from 1230 and 1445.
Diagnostic
Nurses’ Notes Complete the following sentences by choosing from the lists of options.
Results

Emergency Department The nurse should insert Select…

1100: Client reports nausea, loss of appetite, vomiting, fever, and constipation
for the past 2 weeks and abdominal pain rated 7/10 on the Numerical It would be a priority for the nurse to request a
Rating Scale for 1 week. Client states, “The abdominal pain started after prescription for an Select…
my 7-year-old child accidentally kicked me in the stomach.” Client plays
soccer with the child once a week. Vital signs: T 103.4° F (39.7° C), The nurse should prepare the client for surgery within Select…
P 92, RR 22, BP 130/86, pulse oximetry reading 98% on room air. No
significant past medical or surgical history. Body mass index (BMI) of 32.
Drinks alcohol only during social occasions, usually 3 beverages.
Smokes cigarettes during social occasions.

1130: Notified primary health care provider about client status. Awaiting orders.

1230: Client transported to radiology department for abdominal computed

tomography (CT) scan.

1245: 20-gauge peripheral venous access device (VAD) inserted into the left
hand. VAD site patent without signs of infiltration. 0.9% sodium chloride
(normal saline) infusing at 75 mL/hr.

1400: Client reports sudden relief of abdominal pain. Vital signs: T 102.5° F
(39.2° C), P 110, RR 20, BP 125/86.

1415: Primary health care provider notified about client status. Order received
for an additional abdominal CT scan. Client transported to radiology
department.

©2021 NCSBN. All rights reserved. Page 27/64

 Wondershare
PDFelement

Screen 5 of 6

The nurse in the emergency department (ED) is caring for a 41-year-old male client. The nurse has reviewed the Nurses’ Notes from 1230, 1245, 1400, and 1415
and the Diagnostic Results from 1230 and 1445.
Diagnostic
Nurses’ Notes Complete the following sentences by choosing from the lists of options.
Results

Abdominal CT scan The nurse should insert Select…

1230: Acute gangrenous appendix with calcified appendicolith.
It would be a priority for the nurse to request a
1445: Free intraperitoneal fluid noted consistent with a ruptured appendix. prescription for an Select…

The nurse should prepare the client for surgery within Select…

©2021 NCSBN. All rights reserved. Page 28/64

 Wondershare
PDFelement

Screen 5 of 6

The nurse in the emergency department (ED) is caring for a 41-year-old male client. The nurse has reviewed the Nurses’ Notes from 1230, 1245, 1400, and 1415
and the Diagnostic Results from 1230 and 1445.
Diagnostic
Nurses’ Notes Complete the following sentences by choosing from the lists of options.
Results

Abdominal CT scan The nurse should insert Select…

1230: Acute gangrenous appendix with calcified appendicolith. Select…
It would be a priority for the nurse to request a
a rectal tube
1445: Free intraperitoneal fluid noted consistent with a ruptured appendix. prescription for an Select…
a nasogastric (NG) tube Select…
The nurse should prepare an theindwelling
client for surgery
urethral within Select…
catheter

©2021 NCSBN. All rights reserved. Page 29/64

 Wondershare
PDFelement

Screen 5 of 6

The nurse in the emergency department (ED) is caring for a 41-year-old male client. The nurse has reviewed the Nurses’ Notes from 1230, 1245, 1400, and 1415
and the Diagnostic Results from 1230 and 1445.
Diagnostic
Nurses’ Notes Complete the following sentences by choosing from the lists of options.
Results

Abdominal CT scan The nurse should insert Select…

1230: Acute gangrenous appendix with calcified appendicolith.
It would be a priority for the nurse to request a
1445: Free intraperitoneal fluid noted consistent with a ruptured appendix. prescription for an Select…
Select…
The nurse should prepare the client for surgery within Select…
analgesic medication
antipyretic medication
anti-infective medication

©2021 NCSBN. All rights reserved. Page 30/64

 Wondershare
PDFelement

Screen 5 of 6

The nurse in the emergency department (ED) is caring for a 41-year-old male client. The nurse has reviewed the Nurses’ Notes from 1230, 1245, 1400, and 1415
and the Diagnostic Results from 1230 and 1445.
Diagnostic
Nurses’ Notes Complete the following sentences by choosing from the lists of options.
Results

Abdominal CT scan The nurse should insert Select…

1230: Acute gangrenous appendix with calcified appendicolith.
It would be a priority for the nurse to request a
1445: Free intraperitoneal fluid noted consistent with a ruptured appendix. prescription for an Select…

The nurse should prepare the client for surgery within Select…
Select…
6 hours
8 hours
24 hours

©2021 NCSBN. All rights reserved. Page 31/64

 Wondershare
PDFelement

Screen 6 of 6

The nurse in the emergency department (ED) is caring for a 41-year-old male client. The nurse has reviewed the Nurses’ Notes from 1800, 2030, and 2230.

Diagnostic Which of the following findings would indicate the client is progressing
Nurses’ Notes as expected? Select all that apply.
Results

Emergency Department 1. clear liquid diet

1100: Client reports nausea, loss of appetite, vomiting, fever, and constipation for the past 2 weeks
2. boardlike abdomen
and abdominal pain rated 7/10 on the Numerical Rating Scale for 1 week. Client states, “The
abdominal pain started after my 7-year-old child accidentally kicked me in the stomach.” Client
plays soccer with the child once a week. Vital signs: T 103.4° F (39.7° C), P 92, RR 22, BP 3. rebound tenderness
130/86, pulse oximetry reading 98% on room air. No significant past medical or surgical history.
Body mass index (BMI) of 32. Drinks alcohol only during social occasions, usually 3 beverages.
Smokes cigarettes during social occasions.
4. incentive spirometry use

1130: Notified primary health care provider about client status. Awaiting orders. 5. diminished bowel sounds
1230: Client transported to radiology department for abdominal computed tomography (CT) scan.
6. performance of leg exercises
1245: 20-gauge peripheral venous access device (VAD) inserted into the left hand. VAD site patent
without signs of infiltration. 0.9% sodium chloride (normal saline) infusing at 75 mL/hr.

1400: Client reports sudden relief of abdominal pain. Vital signs: T 102.5° F (39.2° C), P 110, RR 20,
BP 125/86.

1415: Primary health care provider notified about client status. Order received for an additional
abdominal CT scan. Client transported to radiology department.

1800: Client transported to the operating room for an open appendectomy.

Medical-Surgical Unit

2030: Client transported back to the medical-surgical unit.

2230: Client performing coughing and deep-breathing exercises every hour while awake with
the incentive spirometer. Performing postoperative leg exercises every hour while awake.
Nasogastric (NG) tube removed. Drinking clear liquids. Abdomen boardlike with diminished
bowel sounds in all quadrants. Rebound tenderness present.

©2021 NCSBN. All rights reserved. Page 32/64

 Wondershare
PDFelement

Screen 1 of 6

The nurse in the outpatient clinic is caring for a 38-year-old female client. The nurse has collected data from the client.

Which of the following findings require immediate follow-up?

Progress Notes
Select all that apply.
Clinic Visit 1. vertigo
Day 1
1300: Client reports pain in left ear for the past 2 days. Experienced pain in the 2. appetite
same ear last month but was able to tolerate the pain and self-treat with
over-the counter (OTC) medications. Client is febrile with small amount of 3. vomiting
cerumen observed in left ear canal. Prescribed azithromycin 500 mg, p.o.,
today, then 250 mg, p.o., daily for 4 days. 4. headache
Day 13
5. bowel sounds
0900: Client returns to clinic reporting that left ear pain was reduced after
completing azithromycin treatment, but it recurred 3 days ago. Yesterday,
6. cardiac rhythm
client observed drops of blood on pillow case. Reports bile-colored emesis
last evening after eating dinner. Reports having no oral intake today. Client
states, “I have not had an appetite for over a week.” Client is febrile and
experiencing dizziness, vertigo, and tenderness over the left mastoid
process. Purulent drainage observed in the left ear canal. Tympanic
membrane is dull and bulging on otoscopic examination. Client reports
decreased hearing in the left ear and onset of a headache. Abdomen soft
with hypoactive bowel sounds. Last bowel movement was yesterday of
formed, brown stool. Sinuses, chest, and throat clear without congestion.
12-lead electrocardiogram (ECG) reveals normal sinus rhythm.

©2021 NCSBN. All rights reserved. Page 33/64

 Wondershare
PDFelement

Screen 2 of 6

The nurse in the outpatient clinic is caring for a 38-year-old female client. The nurse has reviewed the collected data with the registered nurse.

Which of the following complications is the client at risk for experiencing?

Progress Notes
Select all that apply.
Clinic Visit 1. leukopenia
Day 1
1300: Client reports pain in left ear for the past 2 days. Experienced pain in the 2. paralytic ileus
same ear last month but was able to tolerate the pain and self-treat with
over-the counter (OTC) medications. Client is febrile with small amount of 3. fluid imbalance
cerumen observed in left ear canal. Prescribed azithromycin 500 mg, p.o.,
today, then 250 mg, p.o., daily for 4 days. 4. injury from falling
Day 13
5. venous thrombosis
0900: Client returns to clinic reporting that left ear pain was reduced after
completing azithromycin treatment, but it recurred 3 days ago. Yesterday,
client observed drops of blood on pillow case. Reports bile-colored emesis
last evening after eating dinner. Reports having no oral intake today. Client
states, “I have not had an appetite for over a week.” Client is febrile and
experiencing dizziness, vertigo, and tenderness over the left mastoid
process. Purulent drainage observed in the left ear canal. Tympanic
membrane is dull and bulging on otoscopic examination. Client reports
decreased hearing in the left ear and onset of a headache. Abdomen soft
with hypoactive bowel sounds. Last bowel movement was yesterday of
formed, brown stool. Sinuses, chest, and throat clear without congestion.
12-lead electrocardiogram (ECG) reveals normal sinus rhythm.

©2021 NCSBN. All rights reserved. Page 34/64

 Wondershare
PDFelement

Screen 3 of 6

The nurse in the outpatient clinic is caring for a 38-year-old female client. The nurse has collaborated with the registered nurse.

Complete the following sentence by choosing from the list of options.

Progress Notes
The client is at highest risk for developing Select…
Clinic Visit
Day 1
1300: Client reports pain in left ear for the past 2 days. Experienced pain in the
same ear last month but was able to tolerate the pain and self-treat with
over-the counter (OTC) medications. Client is febrile with small amount of
cerumen observed in left ear canal. Prescribed azithromycin 500 mg, p.o.,
today, then 250 mg, p.o., daily for 4 days.
Day 13
0900: Client returns to clinic reporting that left ear pain was reduced after
completing azithromycin treatment, but it recurred 3 days ago. Yesterday,
client observed drops of blood on pillow case. Reports bile-colored emesis
last evening after eating dinner. Reports having no oral intake today. Client
states, “I have not had an appetite for over a week.” Client is febrile and
experiencing dizziness, vertigo, and tenderness over the left mastoid
process. Purulent drainage observed in the left ear canal. Tympanic
membrane is dull and bulging on otoscopic examination. Client reports
decreased hearing in the left ear and onset of a headache. Abdomen soft
with hypoactive bowel sounds. Last bowel movement was yesterday of
formed, brown stool. Sinuses, chest, and throat clear without congestion.
12-lead electrocardiogram (ECG) reveals normal sinus rhythm.

©2021 NCSBN. All rights reserved. Page 35/64

 Wondershare
PDFelement

Screen 3 of 6

The nurse in the outpatient clinic is caring for a 38-year-old female client. The nurse has collaborated with the registered nurse.

Complete the following sentence by choosing from the list of options.

Progress Notes
The client is at highest risk for developing Select…
Clinic Visit
Select…
Day 1
meningitis
1300: Client reports pain in left ear for the past 2 days. Experienced pain in the
same ear last month but was able to tolerate the pain and self-treat with otosclerosis
over-the counter (OTC) medications. Client is febrile with small amount of Ménière disease
cerumen observed in left ear canal. Prescribed azithromycin 500 mg, p.o.,
today, then 250 mg, p.o., daily for 4 days.
Day 13
0900: Client returns to clinic reporting that left ear pain was reduced after
completing azithromycin treatment, but it recurred 3 days ago. Yesterday,
client observed drops of blood on pillow case. Reports bile-colored emesis
last evening after eating dinner. Reports having no oral intake today. Client
states, “I have not had an appetite for over a week.” Client is febrile and
experiencing dizziness, vertigo, and tenderness over the left mastoid
process. Purulent drainage observed in the left ear canal. Tympanic
membrane is dull and bulging on otoscopic examination. Client reports
decreased hearing in the left ear and onset of a headache. Abdomen soft
with hypoactive bowel sounds. Last bowel movement was yesterday of
formed, brown stool. Sinuses, chest, and throat clear without congestion.
12-lead electrocardiogram (ECG) reveals normal sinus rhythm.

©2021 NCSBN. All rights reserved. Page 36/64

 Wondershare
PDFelement

Screen 4 of 6

The nurse in the outpatient clinic is caring for a 38-year-old female client. The nurse has reviewed the Progress Notes from 0930 and 1000 and the
History and Physical findings and is contributing to the client’s plan of care.
History and
Progress Notes Which of the following health care orders should the nurse anticipate?
Physical
Select all that apply.
Clinic Visit
Day 1 1. lumbar puncture
1300: Client reports pain in left ear for the past 2 days. Experienced pain in the
same ear last month but was able to tolerate the pain and self-treat with 2. indwelling urethral catheter
over-the counter (OTC) medications. Client is febrile with small amount of
cerumen observed in left ear canal. Prescribed azithromycin 500 mg, p.o., 3. airborne isolation precautions
today, then 250 mg, p.o., daily for 4 days.
Day 13 4. culture and sensitivity (C & S) testing of ear drainage

0900: Client returns to clinic reporting that left ear pain was reduced after 5. psychiatric consultation for evaluation of abnormal grief
completing azithromycin treatment, but it recurred 3 days ago. Yesterday,
client observed drops of blood on pillow case. Reports bile-colored emesis
last evening after eating dinner. Reports having no oral intake today. Client 6. computed tomography (CT) scan of the head and left ear
states, “I have not had an appetite for over a week.” Client is febrile and
experiencing dizziness, vertigo, and tenderness over the left mastoid
process. Purulent drainage observed in the left ear canal. Tympanic
membrane is dull and bulging on otoscopic examination. Client reports
decreased hearing in the left ear and onset of a headache. Abdomen soft
with hypoactive bowel sounds. Last bowel movement was yesterday of
formed, brown stool. Sinuses, chest, and throat clear without congestion.
12-lead electrocardiogram (ECG) reveals normal sinus rhythm.

0930: Client transferred to hospital for further evaluation and treatment.

Medical-Surgical Unit

1000: Client admitted for recurring otitis media and worsening of symptoms.

©2021 NCSBN. All rights reserved. Page 37/64

 Wondershare
PDFelement

Screen 4 of 6

The nurse in the outpatient clinic is caring for a 38-year-old female client. The nurse has reviewed the Progress Notes from 0930 and 1000 and the
History and Physical findings and is contributing to the client’s plan of care.
History and
Progress Notes Which of the following health care orders should the nurse anticipate?
Physical
Select all that apply.
Body System Findings
1. lumbar puncture
alert and oriented to person, place, and time;
Neurological
uncomfortable and becoming irritable
2. indwelling urethral catheter
Eye, Ear, Nose, and admitted for recurring otitis media and worsening
Throat (EENT) symptoms 3. airborne isolation precautions
vital signs: RR 18, pulse oximetry reading 97% on room
Pulmonary air; lung sounds clear bilaterally; quit smoking cigarettes 4. culture and sensitivity (C & S) testing of ear drainage
3 years ago after a bacterial pneumonia infection
vital signs: T 100.6° F (38.1° C), P 110, BP 107/72; first 5. psychiatric consultation for evaluation of abnormal grief
heart sound (S1) and second heart sound (S2) heard on
Cardiovascular
auscultation; peripheral pulses 2+; experiencing vertigo 6. computed tomography (CT) scan of the head and left ear
and headache
weight loss of 12 lb (5.5 kg) in 2 weeks; reported
Gastrointestinal experiencing anorexia for the past week; nausea and
vomiting once yesterday
Musculoskeletal generalized weakness

Genitourinary voided 450 mL of amber-colored urine

Immunological past anaphylactic reactions to penicillin and cefotaxime

married, lives with spouse and children; states, “The last
time I was in a hospital was when my 11-year-old child
Pyschosocial died 2 years ago”; reports that the oldest child of 3 was
hit by a motor vehicle and died; states, “It was very sad.
My faith got me through it.”

©2021 NCSBN. All rights reserved. Page 38/64

 Wondershare
PDFelement

Screen 5 of 6

The nurse in the outpatient clinic is caring for a 38-year-old female client. The nurse has reviewed the Progress Notes from 1000 and 1600, the
Diagnostic Results from 1100 and 1300, and the Laboratory Results from
History and Diagnostic Laboratory 0830, all from Day 14, and is implementing the client’s plan of care.
Progress Notes
Physical Results Results
For each potential nursing intervention, click to specify whether the
Clinic Visit
intervention is indicated or not indicated for the postoperative care of
Day 1
the client.
1300: Client reports pain in left ear for the past 2 days. Experienced pain in the same ear
last month but was able to tolerate the pain and self-treat with over-the counter (OTC)
medications. Client is febrile with small amount of cerumen observed in left ear canal.
Prescribed azithromycin 500 mg, p.o., today, then 250 mg, p.o., daily for 4 days.
Potential Nursing Interventions Indicated Not Indicated
Day 13
0900: Client returns to clinic reporting that left ear pain was reduced after completing azithromycin Keep the client supine for 24 hours.
treatment, but it recurred 3 days ago. Yesterday, client observed drops of blood on pillow
case. Reports bile-colored emesis last evening after eating dinner. Reports having no Assess for bleeding from the left ear.
oral intake today. Client states, “I have not had an appetite for over a week.” Client is
febrile and experiencing dizziness, vertigo, and tenderness over the left mastoid process. Administer antiemetics to prevent
Purulent drainage observed in the left ear canal. Tympanic membrane is dull and bulging vomiting.
on otoscopic examination. Client reports decreased hearing in the left ear and onset of
a headache. Abdomen soft with hypoactive bowel sounds. Last bowel movement was Reinforce the importance of coughing
yesterday of formed, brown stool. Sinuses, chest, and throat clear without congestion. to clear the airway.
12-lead electrocardiogram (ECG) reveals normal sinus rhythm.

0930: Client transferred to hospital for further evaluation and treatment. Note: Each row must have at least 1 response option selected.

Medical-Surgical Unit
1000: Client admitted for recurring otitis media and worsening symptoms.

Day 14
1000: Client transferred to preoperative suite for scheduled mastoidectomy.
1600: Client transferred from postanesthesia care unit (PACU). Tolerated surgery without
complications. Returned to medical-surgical unit in stable condition.

©2021 NCSBN. All rights reserved. Page 39/64

 Wondershare
PDFelement

Screen 5 of 6

The nurse in the outpatient clinic is caring for a 38-year-old female client. The nurse has reviewed the Progress Notes from 1000 and 1600, the
Diagnostic Results from 1100 and 1300, and the Laboratory Results from
History and Diagnostic Laboratory 0830, all from Day 14, and is implementing the client’s plan of care.
Progress Notes
Physical Results Results
For each potential nursing intervention, click to specify whether the
Day 14 intervention is indicated or not indicated for the postoperative care of
Lumbar puncture the client.

1100: Cerebral spinal fluid negative for infection.

Potential Nursing Interventions Indicated Not Indicated
Computed tomography (CT) scan of the head and left ear
Keep the client supine for 24 hours.
1300: Negative for lesions or abscess. Inflammation of left mastoid bone.
Large fluid collection noted in inner ear and middle ear.
Assess for bleeding from the left ear.

Administer antiemetics to prevent

vomiting.
Reinforce the importance of coughing
to clear the airway.

Note: Each row must have at least 1 response option selected.

©2021 NCSBN. All rights reserved. Page 40/64

 Wondershare
PDFelement

Screen 5 of 6

The nurse in the outpatient clinic is caring for a 38-year-old female client. The nurse has reviewed the Progress Notes from 1000 and 1600, the
Diagnostic Results from 1100 and 1300, and the Laboratory Results from
History and Diagnostic Laboratory 0830, all from Day 14, and is implementing the client’s plan of care.
Progress Notes
Physical Results Results
For each potential nursing intervention, click to specify whether the
intervention is indicated or not indicated for the postoperative care of
Day 14 the client.
Laboratory Test and Reference Range 0830
Potential Nursing Interventions Indicated Not Indicated
left ear drainage specimen for culture and
sensitivity (C & S) pending
negative Keep the client supine for 24 hours.

Assess for bleeding from the left ear.

Administer antiemetics to prevent

vomiting.
Reinforce the importance of coughing
to clear the airway.

Note: Each row must have at least 1 response option selected.

©2021 NCSBN. All rights reserved. Page 41/64

 Wondershare
PDFelement

Screen 6 of 6

The nurse in the outpatient clinic is caring for a 38-year-old female client. The nurse has reviewed the Progress Notes from 1400 and has reinforced
teaching with the client.
History and Diagnostic Laboratory
Progress Notes For each of the statements made by the client, click to specify whether the
Physical Results Results
Clinic Visit statement indicates an understanding or no understanding of the discharge
Day 1 teaching provided.
1300: Client reports pain in left ear for the past 2 days. Experienced pain in the same ear last month
but was able to tolerate the pain and self-treat with over-the counter (OTC) medications. Client is
No
febrile with small amount of cerumen observed in left ear canal. Prescribed azithromycin 500 mg, Client Statements Understanding
p.o., today, then 250 mg, p.o., daily for 4 days. Understanding
Day 13 “I should avoid blowing my nose.”
0900: Client returns to clinic reporting that left ear pain was reduced after completing azithromycin
treatment, but it recurred 3 days ago. Yesterday, client observed drops of blood on pillow case. “I will experience some permanent
Reports bile-colored emesis last evening after eating dinner. Reports having no oral intake today.
hearing loss.”
Client states, “I have not had an appetite for over a week.” Client is febrile and experiencing
dizziness, vertigo, and tenderness over the left mastoid process. Purulent drainage observed “I should check with my physician
in the left ear canal. Tympanic membrane is dull and bulging on otoscopic examination. Client
before I travel by air again.”
reports decreased hearing in the left ear and onset of a headache. Abdomen soft with hypoactive
bowel sounds. Last bowel movement was yesterday of formed, brown stool. Sinuses, chest, and “I will stop taking the anti-infective as
throat clear without congestion. 12-lead electrocardiogram (ECG) reveals normal sinus rhythm.
soon as I no longer have ear pain.”
0930: Client transferred to hospital for further evaluation and treatment. “I should not shampoo my hair until
Medical-Surgical Unit
my physician instructs me to do so.”

1000: Client admitted for recurring otitis media and worsening symptoms.
Note: Each row must have 1 response option selected.
Day 14
1000: Client transferred to preoperative suite for scheduled mastoidectomy.
1600: Client transferred from postanesthesia care unit (PACU). Tolerated surgery without complications.
Returned to medical-surgical unit in stable condition.

Day 15
1400: Discharged client to home with postsurgical instructions. Follow-up appointment scheduled
in 1 week.

©2021 NCSBN. All rights reserved. Page 42/64

 Wondershare
PDFelement

Screen 1 of 6

The nurse in the long-term care facility is caring for a 19-year-old client. The nurse has collected data from the client.

History and Laboratory Which of the following would require immediate follow-up?
Nurses’ Notes Vital Signs
Physical Results Select all that apply.

1. pulse
1100: Client has piloerection on the arms and legs and diaphoresis on the
forehead. Client is wearing new, low-top athletic shoes purchased by 2. respirations
the client’s parents instead of prescribed foot splints. During abdominal
palpation, a semi-firm mass is noted in the left lower quadrant (LLQ). 3. diaphoresis
Bladder is nonpalpable.
4. piloerection

5. blood pressure

6. serum blood glucose result

7. wearing low-top athletic shoes

©2021 NCSBN. All rights reserved. Page 43/64

 Wondershare
PDFelement

Screen 1 of 6

The nurse in the long-term care facility is caring for a 19-year-old client. The nurse has collected data from the client.

History and Laboratory Which of the following would require immediate follow-up?
Nurses’ Notes Vital Signs
Physical Results Select all that apply.

1. pulse

Body System Findings 2. respirations

spinal cord injury at C4 from a gunshot injury 2 3. diaphoresis

Neurological
years ago; uses sip-and-puff wheelchair
receiving pressure-controlled portable 4. piloerection
Pulmonary
mechanical ventilation, tracheostomy
Endocrine diabetes mellitus (type 1) 5. blood pressure

family lives 3 hours away from the facility and 6. serum blood glucose result
sends the client designer clothing and gifts once
Psychosocial a month; friends have not visited the client in 1.5
7. wearing low-top athletic shoes
years; client prefers to sit in room alone rather
than interact with other residents

©2021 NCSBN. All rights reserved. Page 44/64

 Wondershare
PDFelement

Screen 1 of 6

The nurse in the long-term care facility is caring for a 19-year-old client. The nurse has collected data from the client.

History and Laboratory Which of the following would require immediate follow-up?
Nurses’ Notes Vital Signs
Physical Results Select all that apply.

1. pulse

1100 2. respirations
99.0° F
T 3. diaphoresis
(37.2° C)
P 56 4. piloerection
RR 18
5. blood pressure
BP 192/102
6. serum blood glucose result
97% on
Pulse oximetry
mechanical
reading 7. wearing low-top athletic shoes
ventilation

©2021 NCSBN. All rights reserved. Page 45/64

 Wondershare
PDFelement

Screen 1 of 6

The nurse in the long-term care facility is caring for a 19-year-old client. The nurse has collected data from the client.

History and Laboratory Which of the following would require immediate follow-up?
Nurses’ Notes Vital Signs
Physical Results Select all that apply.

1. pulse
Laboratory Test and Reference Range 0900
2. respirations
serum glucose, 2-hour postprandial
140 mg/dL 3. diaphoresis
0–50 years: < 140 mg/dL
(7.8 mmol/L)
(< 7.8 mmol/L)
4. piloerection

5. blood pressure

6. serum blood glucose result

7. wearing low-top athletic shoes

©2021 NCSBN. All rights reserved. Page 46/64

 Wondershare
PDFelement

Screen 2 of 6

The nurse in the long-term care facility is caring for a 19-year-old client. The nurse has reviewed the collected data from the Nurses’ Notes at 1115
with the registered nurse.
History and Laboratory
Nurses’ Notes Vital Signs Drag each word choice from below to fill in each blank in the
Physical Results
following sentence.

1100: Client has piloerection on the arms and legs and diaphoresis on the The nurse should recognize that the client is potentially experiencing
forehead. Client is wearing new, low-top athletic shoes purchased by Word Choice and Word Choice
the client’s parents instead of prescribed foot splints. During abdominal
palpation, a semi-firm mass is noted in the left lower quadrant (LLQ).
Bladder is nonpalpable.

1115: Intermittent urethral catheterization was performed, and 400 mL of clear Word Choices
yellow urine was obtained. Client has facial flushing and foul-smelling
liquid stool leaking from the anus. Semi-firm mass is still present in the an infection
LLQ of the abdomen.
urinary retention

a fecal impaction

autonomic dysreflexia

©2021 NCSBN. All rights reserved. Page 47/64

 Wondershare
PDFelement

Screen 3 of 6

The nurse in the long-term care facility is caring for a 19-year-old client. The nurse has reviewed the Nurses’ Notes from 1130 and has collaborated
with the registered nurse.
History and Laboratory
Nurses’ Notes Vital Signs Complete the following sentence by choosing from the lists of options.
Physical Results

The nurse should recognize that the client is most likely

1100: Client has piloerection on the arms and legs and diaphoresis on the experiencing Select…
forehead. Client is wearing new, low-top athletic shoes purchased by
the client’s parents instead of prescribed foot splints. During abdominal
palpation, a semi-firm mass is noted in the left lower quadrant (LLQ).
Bladder is nonpalpable.

1115: Intermittent urethral catheterization was performed, and 400 mL of clear

yellow urine obtained. Client has facial flushing and foul-smelling liquid
stool leaking from the anus. Semi-firm mass is still present in the LLQ of
the abdomen.

1130: Client reports a headache rated 10/10 on the Numerical Rating Scale
and blurred vision.

©2021 NCSBN. All rights reserved. Page 48/64

 Wondershare
PDFelement

Screen 3 of 6

The nurse in the long-term care facility is caring for a 19-year-old client. The nurse has reviewed the Nurses’ Notes from 1130 and has collaborated
with the registered nurse.
History and Laboratory
Nurses’ Notes Vital Signs Complete the following sentence by choosing from the lists of options.
Physical Results

The nurse should recognize that the client is most likely

1100: Client has piloerection on the arms and legs and diaphoresis on the experiencing Select…
forehead. Client is wearing new, low-top athletic shoes purchased by Select…
the client’s parents instead of prescribed foot splints. During abdominal
an infection
palpation, a semi-firm mass is noted in the left lower quadrant (LLQ).
Bladder is nonpalpable. autonomic dysreflexia

1115: Intermittent urethral catheterization was performed, and 400 mL of clear an abdominal aneurysm
yellow urine obtained. Client has facial flushing and foul-smelling liquid
stool leaking from the anus. Semi-firm mass is still present in the LLQ of
the abdomen.

1130: Client reports a headache rated 10/10 on the Numerical Rating Scale
and blurred vision.

©2021 NCSBN. All rights reserved. Page 49/64

 Wondershare
PDFelement

Screen 4 of 6

The nurse in the long-term care facility is caring for a 19-year-old client. The nurse is contributing to the client’s plan of care.

History and Laboratory For each potential nursing intervention, click to specify whether the
Nurses’ Notes Vital Signs
Physical Results intervention is indicated or not indicated for the client.

1100: Client has piloerection on the arms and legs and diaphoresis on the Potential Nursing Interventions Indicated Not Indicated
forehead. Client is wearing new, low-top athletic shoes purchased by
the client’s parents instead of prescribed foot splints. During abdominal Place the client in the left lateral
palpation, a semi-firm mass is noted in the left lower quadrant (LLQ). position.
Bladder is nonpalpable.
Remove the client’s low-top
1115: Intermittent urethral catheterization was performed, and 400 mL of clear athletic shoes.
yellow urine obtained. Client has facial flushing and foul-smelling liquid Inform the client that the Credé
stool leaking from the anus. Semi-firm mass is still present in the LLQ of method will be performed.
the abdomen. Request a prescription for an over-
the-counter (OTC) laxative.
1130: Client reports a headache rated 10/10 on the Numerical Rating Scale
and blurred vision.
Note: Each row must have 1 response option selected.

©2021 NCSBN. All rights reserved. Page 50/64

 Wondershare
PDFelement

Screen 5 of 6

The nurse in the long-term care facility is caring for a 19-year-old client. The nurse is implementing the client’s plan of care.

History and Laboratory Select 2 actions the nurse should take.

Nurses’ Notes Vital Signs
Physical Results

1. Request a prescription for hydralazine.

1100: Client has piloerection on the arms and legs and diaphoresis on the
forehead. Client is wearing new, low-top athletic shoes purchased by 2. Place the client in Trendelenburg’s position.
the client’s parents instead of prescribed foot splints. During abdominal
palpation, a semi-firm mass is noted in the left lower quadrant (LLQ). 3. Check the client’s blood pressure every 30 minutes.
Bladder is nonpalpable.
4. Apply lubricant to gloved fingers to remove fecal impaction.
1115: Intermittent urethral catheterization was performed, and 400 mL of clear
yellow urine obtained. Client has facial flushing and foul-smelling liquid
stool leaking from the anus. Semi-firm mass is still present in the LLQ of 5. Inform the client that a magnetic resonance imaging (MRI)
the abdomen. scan will be performed.

1130: Client reports a headache rated 10/10 on the Numerical Rating Scale
and blurred vision.

©2021 NCSBN. All rights reserved. Page 51/64

 Wondershare
PDFelement

Screen 6 of 6

The nurse in the long-term care facility is caring for a 19-year-old client. The nurse has reviewed the Nurses’ Notes from 1145 and 1200 and the
Vital Signs from 1145 and is assisting to evaluate the client’s status.
History and Laboratory
Nurses’ Notes Vital Signs For each data collection finding, click to specify whether the finding
Physical Results
indicates that the client’s status has worsened or is unchanged.

1100: Client has piloerection on the arms and legs and diaphoresis on the
forehead. Client is wearing new, low-top athletic shoes purchased by Data Collection Findings Worsened Unchanged
the client’s parents instead of prescribed foot splints. During abdominal
palpation, a semi-firm mass is noted in the left lower quadrant (LLQ). pulse
Bladder is nonpalpable.
respirations
1115: Intermittent urethral catheterization was performed, and 400 mL of clear
yellow urine obtained. Client has facial flushing and foul-smelling liquid
blood pressure
stool leaking from the anus. Semi-firm mass is still present in the LLQ of
the abdomen.
tonic-clonic seizures
1130: Client reports a headache rated 10/10 on the Numerical Rating Scale
and blurred vision.
Note: Each row must have 1 response option selected.
1145: Elevated the head of the client’s bed and removed the client’s low-
top athletic shoes. Requested a prescription for digital fecal impaction
removal and lidocaine lubricant.

1200: Client is having tonic-clonic seizures, so the client has been placed in
side-lying position.

©2021 NCSBN. All rights reserved. Page 52/64

 Wondershare
PDFelement

Screen 6 of 6

The nurse in the long-term care facility is caring for a 19-year-old client. The nurse has reviewed the Nurses’ Notes from 1145 and 1200 and the
Vital Signs from 1145 and is assisting to evaluate the client’s status.
History and Laboratory
Nurses’ Notes Vital Signs For each data collection finding, click to specify whether the finding
Physical Results
indicates that the client’s status has worsened or is unchanged.

1100 1145
Data Collection Findings Worsened Unchanged
99.0° F 98.9° F
T
(37.2° C) (37.2° C) pulse
P 56 47
respirations
RR 18 17
blood pressure
BP 192/102 223/115
97% on 96% on tonic-clonic seizures
Pulse oximetry
mechanical mechanical
reading
ventilation ventilation
Note: Each row must have 1 response option selected.

©2021 NCSBN. All rights reserved. Page 53/64

 Wondershare
PDFelement

Example 1

The home-health nurse is caring for a 2-month-old client. Drag words from the choices below to fill in each blank in the
following sentence.
Nurses’ Notes The nurse should anticipate that the physician will instruct the parent to

Weekly Visit 1 Word Choice and Word Choice

1000: Client is sleepy. Parent reports that the client breast-feeds on demand
approximately 8 times daily. Weight is below the 5th percentile at 7 lb
(3.2 kg). Physician notified.
Word Choices
Weekly Visit 2
1030: Client is alert but irritable. Parent reports that the client breast-feeds fortify the breast milk
on demand, fluctuating from 6 to 8 times daily. Weight is below the 5th
percentile at 6 lb 9 oz (3.0 kg), with a 6.3% weight loss. Parent is visibly
upset after viewing client’s current weight. Physician notified. complete a feeding log
Weekly Visit 3
0900: Client is lethargic. Parent reports that the client is still breast-feeding on feed the client formula for
demand, fluctuating from 6 to 8 times daily. Weight remains below the 5th 2 weeks
percentile at 6 lb 2 oz (2.8 kg), with a 12.5% total weight loss. Physician
contacted; awaiting orders. increase the parent’s
caloric intake

consult a pediatric surgeon for

placement of a gastrostomy tube

©2021 NCSBN. All rights reserved. Page 54/64

 Wondershare
PDFelement

Example 2

The nurse in the emergency department (ED) is caring for a 10-day-old client. Which of the following diagnostic procedures should the nurse anticipate
the physician would order? Select all that apply.
Flow Sheet
1. barium enema

1000 1400 1800 2. abdominal x-ray

Intake 480 mL (formula) 60 mL (formula) 60 mL (formula)
3. abdominal ultrasound
Output 3 small yellow stools 40 mL (emesis) 40 mL (emesis)
4. complete metabolic panel
Nurses’ Notes
1000: Parent reports that the client has been vomiting after drinking each bottle 5. esophagogastroduodenoscopy (EGD)
of formula. Parent estimates the client is vomiting half of each bottle with
each feeding. Client triaged. Vital signs: T 97.7° F (36.5° C), P 124,
RR 30.

1400: Client experienced projectile vomiting 30 minutes after drinking 60 mL of

formula. Anterior fontanel is soft and flat. Bowel sounds are hyperactive.

1800: Client experienced projectile vomiting 30 minutes after drinking 60 mL of

formula. Abdomen is distended. Client is crying and inconsolable.

©2021 NCSBN. All rights reserved. Page 55/64

 Wondershare
PDFelement

Example 1

The nurse in the pediatric unit is caring for a 6-month-old client. The nurse is reviewing the client’s assessment data to prepare the
client’s plan of care.
Nurses’ Notes Complete the diagram by dragging from the choices below to specify
what condition the client is most likely experiencing, 2 actions the
nurse should take to address that condition, and 2 parameters the
0800: Client admitted with increased irritability and a leaking gastrostomy
nurse should monitor to assess the client’s progress.
feeding tube, which was placed 2 weeks ago for failure to thrive. The
feeding tube insertion site, which is on the left side of the abdomen, is
covered with a dressing that is saturated with old formula. On removal of Action to Take Parameter to Monitor
the dressing, the skin surrounding the feeding tube site is erythematous
and flaking. At the insertion site, a small amount of thick, yellow drainage Condition Most Likely
is noted, and the feeding tube is loose. Peripheral pulses are weak; Experiencing
capillary refill is 3 seconds. Extremities are cool to the touch. Client is
intermittently pulling at the tube and scratching at the site. Parent reports Action to Take Parameter to Monitor
giving the client acetaminophen last night before bedtime, but the client
was still intermittently waking and irritable throughout the night. Parent
attempted to feed the client through the feeding tube 8 hours ago. Vital Actions to Take Potential Conditions Parameters to Monitor
signs: temporal T 100.6° F (38.1° C), P 171, RR 42, BP 74/62, pulse
oximetry reading 97% on room air. Parent has a history of a penicillin
allergy. change the site dressing refeeding syndrome stool output

infection of the gastrostomy

request a wound consultation skin integrity
tube site

obtain an electrocardiogram normal gastrostomy tube site

feeding tolerance
(ECG). findings

request a bolus of
intolerance to gastrostomy
intravenous 0.9% sodium vital signs every 30 minutes
tube feedings
chloride (normal saline)

reassure the parent that the

parent’s ability to administer
site findings are the normal
a tube feeding
progression of healing

©2021 NCSBN. All rights reserved. Page 56/64

 Wondershare
PDFelement

Example 2

The nurse in the emergency department (ED) is caring for a 79-year-old female client. The nurse is reviewing the client’s assessment data to prepare the
client’s plan of care.
History and Laboratory Complete the diagram by dragging from the choices below to specify
Nurses’ Notes
Physical Results what condition the client is most likely experiencing, 2 actions the
nurse should take to address that condition, and 2 parameters the
nurse should monitor to assess the client’s progress.
1215: Client presents with right-sided ptosis and facial drooping, right-sided
hemiparesis, and expressive aphasia. Client’s adult child reports that the
client recently had influenza. On assessment, skin is warm and dry. Lung Action to Take Parameter to Monitor
sounds are clear; apical pulse is irregular. Bowel sounds are active in
all quadrants. Client is incontinent of urine 2 times in the ED; adult child Condition Most Likely
reports that the client is typically continent of urine. Capillary refill of 3 Experiencing
seconds. Peripheral pulses palpable, 2+. Vital signs: T 97.5° F (36.4° C);
Action to Take Parameter to Monitor
P 126, RR 18, BP 188/90, pulse oximetry reading 90% on room air.

Actions to Take Potential Conditions Parameters to Monitor

Administer oxygen at
Bell’s palsy urine output
2 L/min via nasal cannula.

Request a prescription for

hypoglycemia temperature
an oral corticosteroid.

Insert a peripheral venous

ischemic stroke neurologic status
access device (VAD).

Obtain a urine specimen

for urinalysis and culture urinary tract infection (UTI) serum glucose level
and sensitivity (C & S).

Request an order for 50%

electrocardiogram (ECG)
dextrose in water to be
rhythm
administered intravenously.

©2021 NCSBN. All rights reserved. Page 57/64

 Wondershare
PDFelement

Example 2

The nurse in the emergency department (ED) is caring for a 79-year-old female client. The nurse is reviewing the client’s assessment data to prepare the
client’s plan of care.
History and Laboratory Complete the diagram by dragging from the choices below to specify
Nurses’ Notes
Physical Results what condition the client is most likely experiencing, 2 actions the
nurse should take to address that condition, and 2 parameters the
nurse should monitor to assess the client’s progress.
Body System Findings
Action to Take Parameter to Monitor
Neurological history of a stroke 2 years ago
Condition Most Likely
history of hypertension; atrial fibrillation; Experiencing
Cardiovascular
hyperlipidemia
Action to Take Parameter to Monitor
Gastrointestinal history of gastrointestinal bleeding 2 months ago

Endocrine history of diabetes mellitus (type 2) for 30 years

Actions to Take Potential Conditions Parameters to Monitor
Immunological influenza 3 weeks ago
Administer oxygen at
Bell’s palsy urine output
2 L/min via nasal cannula.

Request a prescription for

hypoglycemia temperature
an oral corticosteroid.

Insert a peripheral venous

ischemic stroke neurologic status
access device (VAD).

Obtain a urine specimen

for urinalysis and culture urinary tract infection (UTI) serum glucose level
and sensitivity (C & S).

Request an order for 50%

electrocardiogram (ECG)
dextrose in water to be
rhythm
administered intravenously.

©2021 NCSBN. All rights reserved. Page 58/64

 Wondershare
PDFelement

Example 2

The nurse in the emergency department (ED) is caring for a 79-year-old female client. The nurse is reviewing the client’s assessment data to prepare the
client’s plan of care.
History and Laboratory Complete the diagram by dragging from the choices below to specify
Nurses’ Notes
Physical Results what condition the client is most likely experiencing, 2 actions the
nurse should take to address that condition, and 2 parameters the
nurse should monitor to assess the client’s progress.
Laboratory Test and Reference Range 1215

random serum glucose Action to Take Parameter to Monitor

76 mg/dL
Elderly 60–90 years 82–115 mg/dL
(4.2 mmol/L) Condition Most Likely
(4.6–6.4 mmol/L)
Experiencing
Action to Take Parameter to Monitor

Actions to Take Potential Conditions Parameters to Monitor

Administer oxygen at
Bell’s palsy urine output
2 L/min via nasal cannula.

Request a prescription for

hypoglycemia temperature
an oral corticosteroid.

Insert a peripheral venous

ischemic stroke neurologic status
access device (VAD).

Obtain a urine specimen

for urinalysis and culture urinary tract infection (UTI) serum glucose level
and sensitivity (C & S).

Request an order for 50%

electrocardiogram (ECG)
dextrose in water to be
rhythm
administered intravenously.

©2021 NCSBN. All rights reserved. Page 59/64

 Wondershare
PDFelement

Example 1

The nurse in the surgical unit is caring for a 50-year-old male client. The nurse is contributing to the client’s plan of care.

Select the 3 potential nursing interventions the nurse should anticipate

Nurses’ Notes Vital Signs
for the care of the client.

Preoperative Unit 1. Pad the client’s side rails.

0800: Awaiting thyroidectomy for thyroid cancer. No acute distress noted. Alert
and oriented to person, place, time, and situation. Vital signs stable. Skin 2. Place the client on telemetry.
is warm and dry. Palpable thyroid gland noted. Lung sounds clear to
auscultation bilaterally. Abdomen soft with diminished bowel sounds in all 3. Monitor serum calcium levels.
4 quadrants. Peripheral venous access device (VAD) established with a
20-gauge cannula to client’s right hand per the registered nurse. Client 4. Remind the client to avoid flexion of the neck.
has been NPO since midnight. Denies having any allergies. History of
hypertension and myopia.
5. Keep a tracheostomy tray at the client’s bedside.
Postanesthesia Care Unit
6. Place several boxes of sterile dressings in the client’s room.
1130: Indwelling urethral catheter was inserted in the operating room; no
complications during surgery. Client arouses readily. Appropriate when
awake, follows commands. Surgical site pain rated 3/10 to 4/10 on the
Numerical Rating Scale, and reports that the throat is sore. Lactated
Ringer’s solution infusing at 125 mL/hr. Preparing to transfer the client to
the surgical unit, report given.

Surgical Unit

1200: Arouses easily and appropriately while alert. Taking ice chips for
dry mouth without coughing. Neck dressing dry and intact. Head is
supported by pillows. Indwelling urethral catheter draining yellow urine
free from sediment. Client is requesting analgesia for incisional pain
rated 6/10 on the Numerical Rating Scale. Informed the client that
morphine may be administered intravenously. Intravenous fluids infusing
at 125 mL/hr.

©2021 NCSBN. All rights reserved. Page 60/64

 Wondershare
PDFelement

Example 1

The nurse in the surgical unit is caring for a 50-year-old male client. The nurse is contributing to the client’s plan of care.

Select the 3 potential nursing interventions the nurse should anticipate

Nurses’ Notes Vital Signs
for the care of the client.

1. Pad the client’s side rails.

Preoperative Postanesthesia Surgical Unit 2. Place the client on telemetry.

Unit Care Unit 1200
0800 1130 3. Monitor serum calcium levels.

T 98.7° F (37.1° C) 97.5° F (36.4° C) 98.7° F (37.1° C) 4. Remind the client to avoid flexion of the neck.
P 108 88 94
5. Keep a tracheostomy tray at the client’s bedside.
RR 16 18 16
6. Place several boxes of sterile dressings in the client’s room.
BP 138/84 121/82 116/78
Pulse 97% on oxygen
oximetry 99% on room air at 2 L/min via 96% on room air
reading nasal cannula

©2021 NCSBN. All rights reserved. Page 61/64

 Wondershare
PDFelement

Example 1

The nurse in the pediatric unit is caring for a 16-year-old client. The nurse is reviewing the collected client data to assist with preparing
the client’s plan of care.
History and Complete the diagram by dragging from the choices below to specify
Nurses’ Notes Vital Signs
Physical what condition the client is most likely experiencing, 2 actions the
nurse should take to address that condition, and 2 parameters the
nurse should monitor to assess the client’s progress.
1600: Client is transferred from the emergency department (ED) to the pediatric
unit via wheelchair, admitted, and accompanied by the parent. Client
reports experiencing frequent nausea, vomiting, anorexia, periumbilical Action to Take Parameter to Monitor
and right lower quadrant (RLQ) abdominal pain rated 8/10 on the
Numerical Rating Scale. States, “The pain began around 4 o’clock this Condition Most Likely
morning, and then I started to throw up.” Respirations are shallow. Skin Experiencing
and mucous membranes are dry. Posture is stooped, mood and affect
Action to Take Parameter to Monitor
are irritable. Last meal was approximately 20 hours ago.

Actions to Take Potential Conditions Parameters to Monitor

Request an order to
appendicitis rectal bleeding
administer corticosteroids.

Prepare to reinforce teaching

ulcerative colitis growth restriction
about insulin administration.

Prepare the client for a

new onset diabetes mellitus
computed tomography (CT) sudden pain relief
(type 1)
scan of the abdomen.

Reinforce teaching about

regional enteritis (Crohn’s
the importance of folic acid complete blood count (CBC)
disease)
supplementation.

Ensure peripheral venous

glycosylated hemoglobin
access device (VAD) for fluid
(HgbA1C) every 3 months
and electrolyte correction.

©2021 NCSBN. All rights reserved. Page 62/64

 Wondershare
PDFelement

Example 1

The nurse in the pediatric unit is caring for a 16-year-old client. The nurse is reviewing the collected client data to assist with preparing
the client’s plan of care.
History and Complete the diagram by dragging from the choices below to specify
Nurses’ Notes Vital Signs
Physical what condition the client is most likely experiencing, 2 actions the
nurse should take to address that condition, and 2 parameters the
nurse should monitor to assess the client’s progress.

1600
Action to Take Parameter to Monitor
T 99.2° F (37.3° C)
Condition Most Likely
P 102 Experiencing
RR 20 Action to Take Parameter to Monitor

BP 100/58
Pulse oximetry Actions to Take Potential Conditions Parameters to Monitor
98% on room air
reading
Request an order to
appendicitis rectal bleeding
administer corticosteroids.

Prepare to reinforce teaching

ulcerative colitis growth restriction
about insulin administration.

Prepare the client for a

new onset diabetes mellitus
computed tomography (CT) sudden pain relief
(type 1)
scan of the abdomen.

Reinforce teaching about

regional enteritis (Crohn’s
the importance of folic acid complete blood count (CBC)
disease)
supplementation.

Ensure peripheral venous

glycosylated hemoglobin
access device (VAD) for fluid
(HgbA1C) every 3 months
and electrolyte correction.

©2021 NCSBN. All rights reserved. Page 63/64

 Wondershare
PDFelement

Example 1

The nurse in the pediatric unit is caring for a 16-year-old client. The nurse is reviewing the collected client data to assist with preparing
the client’s plan of care.
History and Complete the diagram by dragging from the choices below to specify
Nurses’ Notes Vital Signs
Physical what condition the client is most likely experiencing, 2 actions the
nurse should take to address that condition, and 2 parameters the
nurse should monitor to assess the client’s progress.

Body System Findings

Action to Take Parameter to Monitor
multiple episodes of streptococcal pharyngitis
Eye, Ear, Nose, and Condition Most Likely
throughout school-age years; tonsillectomy at 8
Throat (EENT) Experiencing
years old
menarche at 12 years old; last menstrual period 3 Action to Take Parameter to Monitor
Reproductive
weeks ago

Actions to Take Potential Conditions Parameters to Monitor

Request an order to
appendicitis rectal bleeding
administer corticosteroids.

Prepare to reinforce teaching

ulcerative colitis growth restriction
about insulin administration.

Prepare the client for a

new onset diabetes mellitus
computed tomography (CT) sudden pain relief
(type 1)
scan of the abdomen.

Reinforce teaching about

regional enteritis (Crohn’s
the importance of folic acid complete blood count (CBC)
disease)
supplementation.

Ensure peripheral venous

glycosylated hemoglobin
access device (VAD) for fluid
(HgbA1C) every 3 months
and electrolyte correction.

©2021 NCSBN. All rights reserved. Page 64/64