All practice questions

Following the change of shift, the registered nurse evaluates four assigned clients. Which client presentation mandates the nurse's immediate attention?

A nurse is evaluating a 52-year-old client who was admitted 6 hours ago with acute pancreatitis. The client is receiving continuous intravenous fluids and pain medication. Which of the following assessment findings represent the highest clinical priority and require immediate intervention? Select all that apply.

While working on a medical-surgical unit, a nurse assesses a client with moderate dementia who has multiple unexplained, patterned bruises on both shoulders. The client's primary caregiver arrives to visit, at which point the client immediately cowers and becomes highly agitated. The caregiver states, 'You need to tie them down; they are completely out of control today.' Which action should the nurse take to ensure the client's legal rights and safety?

An emergency department nurse is managing a client admitted with severe diabetic ketoacidosis (DKA). The client is lethargic, with a blood pressure of 82/48 mm Hg, heart rate of 128 beats/minute, and Kussmaul respirations. Initial laboratory results reveal a blood glucose of 780 mg/dL (43.3 mmol/L), serum pH of 7.15, and serum potassium of 3.1 mEq/L (3.1 mmol/L). Arrange the following prescribed interventions in the correct chronological sequence of execution from first to last.

A home health nurse is providing care for a 28-year-old client with advanced amyotrophic lateral sclerosis (ALS). The client is fully quadriplegic, dependent on continuous mechanical ventilation, and communicates using an eye-tracking device. The client is alert, fully oriented, and cognitively intact. During the visit, the client types, "My sibling unplugs my ventilator for a few minutes when they get angry with me. Do not tell anyone. If you report this, I will be forced into a state facility, which is worse. I am a competent adult, and I demand you keep this confidential." Which action represents the nurse's legal mandate in this situation?

A registered nurse is managing the care of a 78-year-old client admitted for intravenous antibiotic therapy due to a systemic infection. The client develops acute delirium, repeatedly attempts to remove the intravenous (IV) catheter, and verbally insists on leaving the facility immediately. The client's legally appointed healthcare proxy is at the bedside and demands that the nurse apply bilateral wrist restraints to ensure the necessary medical treatment is completed without interruption. Which action by the nurse represents the legally correct response to this situation?

A 72-year-old client with advanced Parkinson's disease is admitted to a subacute rehabilitation unit following treatment for aspiration pneumonia. During the initial assessment, the nurse observes the client clearing their throat repeatedly after sipping water and experiencing a "freezing of gait" when attempting to stand. The client also struggles to manipulate the buttons on their hospital gown. The client's spouse tearfully states, "I do not know how we will afford the bathroom modifications needed for discharge." Which collaborative action should the nurse prioritize?

An RN on a gastroenterology unit is planning care for a group of clients. Which of the following tasks are appropriate for the RN to delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

During bedside safety checks, a registered nurse gathers the latest assessment data for a group of assigned clients. Which client requires the nurse's immediate attention?

While examining a toddler in the pediatric clinic, the nurse observes multiple distinct cigarette burns on the child's back. The accompanying guardian becomes agitated and begs the nurse not to tell anyone about the injuries. Which of the following is the most appropriate action for the nurse to take?

A nurse case manager is coordinating the discharge of a 10-year-old client who was newly diagnosed with type 1 diabetes mellitus. The client has a pre-existing severe autism spectrum disorder with significant sensory sensitivities. The transition to home requires extensive coordination among the interdisciplinary team. Arrange the nurse's collaborative actions in the most appropriate chronological sequence from first to last.

A nurse on a pediatric unit is reviewing the status of assigned clients. Which of the following client findings require the nurse's immediate intervention? Select all that apply.

A pediatric nurse is coordinating the transition of care for a 10-year-old client who sustained a severe traumatic brain injury and multiple upper extremity fractures in a motor vehicle collision. The client is medically stable but exhibits expressive aphasia, difficulty swallowing liquids, and an inability to perform upper body dressing. Furthermore, the client's parents are expressing extreme distress about their inability to afford the recommended intensive inpatient rehabilitation. Which of the following interdisciplinary team members should the nurse actively involve in this client's care plan? Select all that apply.

A primary nurse on a postpartum unit is collaborating with a licensed practical nurse (LPN/VN) and an unlicensed assistive personnel (UAP) to manage a group of clients. When deciding how to safely distribute the workload, which delegation decision by the primary nurse is most appropriate?

An emergency department charge nurse evaluates a young adult client with a documented severe intellectual disability who arrives from a residential care facility. The client displays extreme agitation, is actively striking out at personnel, and has multiple faded contusions of varying ages on their torso. The accompanying facility employee demands the client be tied down immediately for staff safety and states they will sign all necessary treatment consent forms. Which of the following actions by the nurse are legally required or appropriate? Select all that apply.

While covering for a colleague on a general medical unit, a nurse receives requests to evaluate four different clients. Which client must the nurse attend to first?

A nurse is caring for an oriented adult client who was recently diagnosed with a terminal illness. The client states, "I do not want any further treatments; I just want to be kept comfortable." The client's adult child privately approaches the nurse and says, "You must give my parent the treatments anyway. They do not know what they are saying." Which action by the nurse best demonstrates adherence to the ethical principle of autonomy?

While caring for a postoperative client on the surgical unit, a nurse notes a significant change in the client's condition and calls the covering physician. Organize the nurse's communication statements into the correct sequence based on the standard SBAR interdisciplinary communication tool.

A nurse on a neurological and trauma step-down unit is evaluating the clinical status of multiple assigned clients. Which client presentation requires the nurse's immediate intervention?

The charge nurse on a neurology step-down unit is planning assignments for the upcoming shift. The staffing mix includes a core unit registered nurse (RN), an RN floating from a general medical-surgical unit, a licensed practical nurse (LPN/VN), and an unlicensed assistive personnel (UAP). Which client assignment is the safest and most appropriate?