All practice questions

A charge nurse is auditing the electronic health records of four clients who are currently placed in physical restraints. Which documented scenario represents a violation of safety and regulatory standards, requiring IMMEDIATE intervention by the charge nurse?

A critical care nurse is preparing for the arrival of a client transferring from a skilled nursing facility. The transfer report indicates the client has a multidrug-resistant *Acinetobacter baumannii* wound infection and is exhibiting hemoptysis with suspected pulmonary tuberculosis. Which of the following actions should the nurse incorporate into the plan of care? Select all that apply.

A charge nurse on a cardiovascular step-down unit is evaluating the clinical status of multiple clients after receiving the morning shift report. Which of the following client findings indicate an acute deterioration that requires immediate intervention? Select all that apply.

A nurse is performing an assessment on an alert and oriented 32-year-old client in an outpatient clinic. The nurse notes various stages of bruising on the client's torso. The client confides that their domestic partner caused the injuries but explicitly begs the nurse, "Please do not involve the police or tell anyone else. I am afraid of what will happen if they find out." Which of the following actions best demonstrates the nurse's adherence to confidentiality and legal guidelines?

An alert and oriented adult client is admitted to the medical-surgical unit with a severe bacterial infection. The client repeatedly refuses to take the prescribed oral antibiotics, stating, "I do not believe in taking synthetic medications." The client's spouse privately hands the nurse a cup of pudding and says, "Just crush the pill and hide it in here. He needs this medicine to get better." Which action by the nurse demonstrates the most appropriate ethical practice?

A client who underwent thyroid ablation with a high-dose oral unsealed radioactive iodine (I-131) solution three hours ago experiences sudden, severe nausea. The client vomits a large volume of fluid onto the floor and their hospital gown. As the primary nurse responding to the isolation room, which sequence of actions represents the safest and most appropriate management of this hazardous incident?

A nurse is managing the care of an ambulatory older adult client with moderate Alzheimer's disease who is hospitalized for dehydration. The client is receiving continuous intravenous (IV) fluids, appears agitated, frequently paces the hallway, and repeatedly pulls at the IV tubing. The client's family has just left for the evening. Which intervention should the nurse implement first to prevent injury and maintain the IV line?

A charge nurse on a medical step-down unit is evaluating the management of a highly restless client who requires bilateral soft wrist restraints to protect a radial arterial line. Which observation by the charge nurse indicates that the assigned registered nurse (RN) is providing safe and appropriate care?

An acute care nurse is preparing to enter the airborne infection isolation room of a client with suspected severe acute respiratory syndrome (SARS) who also requires contact precautions due to excessive infectious secretions. Arrange the following steps for donning personal protective equipment (PPE) in the correct sequence from first to last.

After a sudden influx of admissions to the telemetry unit, the healthcare team must reassign several client care activities. The team consists of a registered nurse (RN) and an unlicensed assistive personnel (UAP). Which of the following tasks is most appropriate for the RN to safely delegate to the UAP?

A client recovering from a bowel resection develops post-operative delirium and continuously attempts to remove their nasogastric tube and surgical dressings. After less restrictive safety measures have proven ineffective, the healthcare provider prescribes bilateral soft wrist restraints. Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.

A client is admitted to the intensive care unit with sepsis-induced encephalopathy. The client is restless, confused, and repeatedly attempting to remove a newly placed central venous catheter. After unsuccessful trials of a bedside sitter and catheter concealment, the healthcare provider prescribes bilateral soft wrist restraints. Which action by the nurse is correct regarding the management of these restraints?

A charge nurse is supervising a newly licensed registered nurse (RN) who is caring for a 45-year-old client experiencing severe alcohol withdrawal syndrome. The client develops acute hyperactive delirium, begins experiencing terrifying visual hallucinations, and aggressively swings a metal intravenous (IV) pole at the nursing staff. After security is called and the client is safely secured in four-point physical restraints, the newly licensed RN discusses the immediate plan of care. Which of the following statements by the newly licensed RN indicates a critical knowledge deficit requiring immediate correction by the charge nurse?

During interdisciplinary rounds, the healthcare team is discussing the care of a client with a confirmed diagnosis of active pulmonary tuberculosis who recently developed frequent, watery diarrhea that tested positive for Clostridioides difficile toxin. Which interventions should the registered nurse implement to ensure appropriate infection control? Select all that apply.

A nurse assumes care for four clients on an adult medical-surgical unit. Based on the principles of prioritization, arrange the clients in the order they should be assessed, from highest priority to lowest priority.

During a routine community health screening event, a registered nurse evaluates several pediatric clients across various age cohorts. Which client presentation represents a pathological deviation from expected developmental transitions, necessitating an immediate referral for early intervention?

A registered nurse enters a client's room and finds the client lying on the floor near the bathroom. The client states, 'I slipped and fell on my way to the toilet.' Arrange the following nursing interventions in the correct sequence of priority, from first to last.

A nurse on a medical-surgical unit is caring for a client who is scheduled for a below-the-knee amputation the following morning due to severe vascular complications. The client is pacing the room, crying, and states, 'I cannot live with half a leg. I will never be able to do anything for myself again. My life is essentially over.' Which of the following responses by the nurse is the most therapeutic?

A client is admitted to the neurology unit after a moderate cerebrovascular accident (CVA), resulting in right-sided hemiparesis. The client's adult child and spouse are present in the room. The child approaches the nurse privately in the hallway and states, 'My mother is completely overwhelmed and in denial about the extent of his deficits. You must tell her that he requires transfer to an inpatient rehabilitation facility instead of returning home.' Which response by the nurse demonstrates an understanding of therapeutic family dynamics?

A 55-year-old client is admitted to the medical unit for treatment of a severe diabetic foot ulcer. The electronic health record indicates a history of alcohol use disorder, with the client's last alcoholic drink consumed approximately 60 hours ago. During the initial shift assessment, the nurse observes that the client has coarse bilateral hand tremors, profound diaphoresis, and new-onset disorientation to place. Current vital signs are: blood pressure 162/98 mmHg, heart rate 124 bpm, respiratory rate 24/min, and temperature 99.8°F (37.7°C). Which action is the highest priority for the nurse to take?