All practice questions

A nurse is caring for a client with cervical cancer who is receiving intracavitary brachytherapy with a sealed radioactive implant. Upon entering the room, the nurse discovers that the radioactive applicator has dislodged and is lying on the bed linens. Which of the following is the priority nursing action?

An 81-year-old client with bulbar amyotrophic lateral sclerosis (ALS) is admitted for treatment of aspiration pneumonia. The client has a newly inserted percutaneous endoscopic gastrostomy (PEG) tube for continuous enteral feeding, a Stage II sacral pressure injury, and exhibits intermittent periods of profound disorientation. Which nursing interventions are appropriate for this client's basic care and comfort? Select all that apply.

An occupational health nurse is developing a comprehensive lifestyle modification plan for a 65-year-old night-shift security guard who has newly diagnosed primary hypertension and a body mass index (BMI) of 31 kg/m². Which of the following nursing interventions are appropriate? Select all that apply.

A nurse is planning care for an older adult client who is on strict bed rest due to severe generalized weakness. Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.

A nurse is removing a non-tunneled central venous access device (CVAD) from a client's right subclavian vein. Immediately after the catheter is withdrawn, the client exhibits sudden, severe dyspnea, diaphoresis, and a loud, continuous "churning" murmur over the precordium. To mitigate the risk of fatal hemodynamic collapse, arrange the following nursing actions in the priority order they should be performed. (Place the first action at the top and the last action at the bottom.)

A 15-year-old client is receiving treatment in the emergency department for injuries sustained in a sports accident. The client's divorced parents are arguing loudly in the hallway outside the room regarding the proposed treatment plan, which is visibly upsetting the conscious client. In what order should the nurse perform the following actions to de-escalate the family crisis and establish boundaries? Arrange the nursing actions from first to last.

A nurse is providing care for a client who has a heavily draining wound infected with methicillin-resistant Staphylococcus aureus (MRSA). When handling the infectious materials, laboratory specimens, and waste in this room, which of the following actions by the nurse are correct? Select all that apply.

A nurse is developing a plan of care for a client who is 2 hours postoperative following a total thyroidectomy. Which of the following nursing actions are appropriate to reduce the risk of postoperative complications? Select all that apply.

A nurse is caring for a client who underwent a percutaneous coronary intervention (PCI) via the right femoral artery 3 hours ago. The client's current vital signs are: blood pressure 104/62 mmHg (baseline 128/78 mmHg) and heart rate 102 bpm (baseline 76 bpm). The client reports new-onset moderate right flank pain. Which of the following is the most appropriate initial nursing action?

A nurse is removing a central venous catheter from a client's subclavian vein. Immediately after the catheter is withdrawn, the client suddenly gasps for air, reports sharp chest pain, and becomes severely dyspneic and pale. Suspecting an air embolism, arrange the following nursing actions in the priority order they should be performed to reduce the risk of a fatal cardiopulmonary complication.

Following a precipitous vaginal birth of a macrosomic newborn, a client is transferred to the postpartum unit. During the initial assessment 45 minutes after delivery, the nurse observes a continuous, steady trickle of bright red vaginal blood. Palpation reveals the uterine fundus is midline and firmly contracted at the level of the umbilicus. The client's heart rate is 118 beats/minute, blood pressure is 90/58 mmHg, and respiratory rate is 22 breaths/minute. The client states, "I feel incredibly dizzy and my mouth is extremely dry." Which action is the highest priority for the nurse to perform?

During the immediate postoperative period following a coronary artery bypass grafting (CABG) procedure, the client's mediastinal chest tube drainage abruptly stops. The client becomes increasingly restless and diaphoresis is noted. Which of the following subsequent clinical findings support a developing complication of cardiac tamponade? Select all that apply.

An occupational health nurse at an industrial manufacturing plant is reviewing proposed employee wellness initiatives for the upcoming quarter. Which of the following activities accurately represent secondary disease prevention measures? Select all that apply.

A client arrives at a community health clinic reporting severe muscle aches, insomnia, stomach cramps, and a constantly runny nose that began early in the morning. During the interview, the nurse observes that the client is highly restless, yawning frequently, and has noticeably dilated pupils. The client insists on receiving a strong antibiotic to treat these "severe flu symptoms." Which response or action by the nurse is the priority?

A client on a medical-surgical unit is receiving an infusion of packed red blood cells (PRBCs) for symptomatic anemia. Ten minutes after the transfusion begins, the client reports sudden severe lower back pain, dyspnea, and chills. The nurse notes visible flushing and shivering. Place the following nursing interventions in the correct order of priority. (Arrange from first action to last action.)

A client is recovering 24 hours post-operatively following an emergency repair of a ruptured abdominal aortic aneurysm. Due to significant intraoperative blood loss, the client required massive fluid and blood product resuscitation. The nurse assesses the client and notes a tensely distended abdomen, a sudden decrease in urine output to 12 mL/hr, and increasing peak inspiratory pressures on the mechanical ventilator. Current hemodynamic monitoring reveals a blood pressure of 84/46 mm Hg, a heart rate of 128 beats/min, and a central venous pressure (CVP) of 18 mm Hg. Which of the following is the nurse's MOST appropriate initial action?

A client hospitalized with a massive pulmonary embolism is receiving a continuous intravenous infusion of unfractionated heparin through a single-lumen peripheral catheter. The client develops a systemic bloodstream infection, and the healthcare provider prescribes an intermittent intravenous infusion of vancomycin to run over 90 minutes. Upon consulting the facility's parenteral drug reference, the nurse notes that heparin and vancomycin are physically incompatible. Which action represents the safest nursing practice in this situation?

An adult client who underwent a diagnostic lumbar puncture four hours ago is now complaining of a severe, throbbing headache that worsens upon sitting. When planning interventions to promote comfort and safety, which action should the nurse implement?

During a routine assessment on the surgical unit, a nurse evaluates a client who underwent an open splenectomy earlier in the day. The client's spouse reports that the client has suddenly become restless and anxious. A review of the electronic health record reveals the following vital sign trends:

The client's urine output for the past hour is 15 mL. Based on these findings, which action is the priority to prevent further physiological deterioration?

A nurse is caring for an alert and oriented client with diabetes mellitus who reports feeling shaky and sweaty. The client's capillary blood glucose level is 55 mg/dL. Arrange the following nursing interventions in the correct order of priority.