All practice questions

A home health nurse is evaluating a preschool-aged child diagnosed with spastic cerebral palsy. The child's caregivers report severe behavioral frustration during meal times because the child lacks the fine motor control necessary to hold standard dining utensils independently. Which action represents the most appropriate interdisciplinary collaboration to address this specific barrier?

Simultaneous vital sign alerts and assessment data are transmitted to the centralized monitor on an adult medical-surgical unit. Which client presentation dictates the most immediate physical evaluation by the nurse?

The nurse has received the shift report for four assigned clients. In what order should the nurse assess these clients? Arrange the clients from highest priority (first to be assessed) to lowest priority (last to be assessed).

A client who is experiencing confusion keeps attempting to remove their peripheral intravenous (IV) catheter. Which of the following is the most appropriate initial nursing action to protect the IV site?

An RN is distributing clinical tasks for a group of complex clients on a general medical unit. The team matrix consists of the RN, a licensed practical nurse (LPN/VN), and an unlicensed assistive personnel (UAP). To maintain client safety and adhere to the authorized scope of practice, which assignment is most appropriate for the RN to make?

During a shift change report, the nurse learns that an assigned client has a wound culture positive for Vancomycin-Resistant Enterococcus (VRE). What specific infection control measures should the nurse implement for this client? Select all that apply.

A hospitalized client is placed on transmission-based precautions due to suspected active pulmonary tuberculosis and a concurrent, confirmed Clostridioides difficile infection. Which of the following nursing actions are appropriate? Select all that apply.

A registered nurse (RN) is coordinating care for clients on a pediatric hematology/oncology unit with the assistance of a licensed practical/vocational nurse (LPN/VN) and an unlicensed assistive personnel (UAP). Which of the following task delegations by the RN are appropriate? Select all that apply.

A registered nurse is managing the care of several clients on an orthopedic trauma unit and is working with an unlicensed assistive personnel (UAP). Which task is most appropriate for the nurse to delegate to the UAP?

A nurse is preparing the room for a newly admitted client who has a history of frequent, generalized tonic-clonic seizures. Which safety interventions should the nurse implement? Select all that apply.

An emergency department triage nurse is establishing immediate isolation measures for multiple newly arriving clients. Match each client's clinical presentation with the most appropriate transmission-based precaution protocol.

A clinical nurse manager is evaluating staff compliance with information security, client confidentiality, and legal mandates on a medical-surgical unit. Which of the following observed actions demonstrate appropriate adherence to these guidelines? Select all that apply.

A nurse in the pediatric intensive care unit is caring for a 7-year-old child who is intubated following a severe traumatic brain injury sustained in a motor vehicle collision. The child is highly restless and repeatedly attempts to grasp the endotracheal tube. At the bedside, one parent tearfully discloses that the other parent was driving intoxicated when the crash occurred, and begs the nurse to keep this information confidential. Which legally appropriate actions should the nurse implement? Select all that apply.

A nurse on an adult medical-surgical unit is reviewing the electronic health records and morning assessment data for a group of assigned clients. Which of the following client findings require immediate follow-up by the nurse? Select all that apply.

A nurse is reviewing the medication administration record for a client receiving continuous enteral nutrition via a nasogastric tube. The morning prescriptions include liquid acetaminophen, an immediate-release carvedilol tablet, and an extended-release nifedipine tablet. The provider's prescription states to crush all solid medications and administer them via the tube. Which action is the highest priority for the nurse to prevent a critical adverse event?

A pediatric triage nurse in an outpatient clinic is evaluating phone messages left by caregivers. Which client condition requires the most immediate callback and intervention?

During a busy morning shift on a medical-surgical unit, a staff nurse is collaborating with an unlicensed assistive personnel (UAP) to provide client care. Which of the following clinical tasks are appropriate to delegate to the UAP? Select all that apply.

An older adult client with moderate dementia is admitted to the medical-surgical unit. During the night, the client repeatedly wanders out of the room, creating a significant risk for falls. Which initial action should the nurse take to promote client safety?

During a shift on a surgical unit, a nurse receives a radiology report indicating that a small, sterile surgical sponge was inadvertently left inside a client's abdominal cavity during a procedure performed the previous day. The client is alert, oriented, and recovering well. The attending surgeon approaches the nurse and states, 'I will schedule the client for a brief wound washout today to retrieve the sponge. Please do not mention the retained sponge to the client; knowing about this error will only cause unnecessary panic, and I can resolve it safely.' Which of the following responses or actions by the nurse most appropriately upholds the ethical principles of veracity and client advocacy?

A registered nurse is formulating an SBAR (Situation, Background, Assessment, Recommendation) communication for an interdisciplinary care conference regarding a 29-year-old client recovering from severe Guillain-Barré syndrome in an acute rehabilitation unit.

Situation: The client is weaning from nocturnal mechanical ventilation via tracheostomy, receives enteral nutrition via a percutaneous endoscopic gastrostomy (PEG) tube, and exhibits dense bilateral upper extremity weakness with wrist drop.
Background: The client was diagnosed 4 weeks ago and was previously independent. The client has a 2-year-old child at home.
Assessment: The client tolerates a daytime tracheostomy collar but is unable to grasp objects. The client is tearful and expresses overwhelming anxiety regarding future parenting capabilities.
Recommendation: Initiate specific interprofessional collaborations to optimize discharge readiness.

Which of the following recommendations are appropriate for the nurse to include in the interdisciplinary care plan? Select all that apply.