A nurse is working on a unit when the fire alarm goes off.  What is the nurse’s highest priority action in the event of a fire?

A new nurse is conducting a patient interview. Which nursing behavior(s) should re-evaluate? (Select all that apply) 

The nurse is auscultating the patient’s lung fields. The nurse hears high-pitched turbulent airflow in the upper airway, which may be indicative of a serious airway obstruction.  What is the nurse hearing?

A nurse is preparing to use the Glasgow Coma Scale to assess a patient’s neurological status.  What should the nurse assess? (Select all that apply)

It is the nurses’ responsibility to evaluate all patients admitted in the hospital for risk of injury.  The nurse assesses mental status, gait, ambulatory aid, history of falls, and any secondary diagnosis.  Which assessment tool is the nurse using?

During a physical assessment, a nurse assesses the 74 year-old patient’s nose.  Which finding should the nurse expect to see with this patient?

A patient admitted to the Intensive Care Unit (ICU) is exhibiting signs of sensory deprivation. Which intervention(s) should the nurse implement? (Select all that apply). 

A mother calls the clinic and tells the nurse her toddler has ingested a household cleaning product. What is the best instruction for the nurse to give the mother?  

It is the nurses’ responsibility to evaluate all patients admitted in the hospital for risk of injury. Which would be the best nursing intervention to prevent injuries in patients?

The nurse is caring for a three year old child.  According to Erikson, how does the nurse identify the child is in the Identity vs. Role Confusion stage of development?