All practice questions

A nurse is caring for a client who underwent a left above-the-knee amputation 48 hours ago. The client reports mild discomfort in the residual limb and requests to be repositioned. Which of the following nursing actions is most appropriate to promote comfort and prevent musculoskeletal complications?

A clinic nurse is developing a health maintenance plan for a 50-year-old female client who has a body mass index (BMI) of $31 \text{ kg/m}^2$ and a family history of type 2 diabetes. The client currently reports feeling healthy and has no physical complaints. Which of the following secondary prevention screenings should the nurse include in the client's plan of care? (Select all that apply.)

A nurse is caring for a client in the active phase of dying. The client begins to exhibit loud, gurgling respiratory secretions. The client's family members are at the bedside, visibly distressed, and state, "Please help, they are choking!" Arrange the following nursing actions in the priority order they should be performed.

A young adult client arrives at an outpatient primary care clinic. While in the reception area, the client begins pacing rapidly, hyperventilating, and clutching their chest. Suddenly, the client attempts to push through the staff-only doors, shouting, "I need help right now, I am suffocating!" What is the priority nursing action?

An 82-year-old client with advanced Alzheimer's disease and a history of dysphagia is admitted for the treatment of aspiration pneumonia. During the night shift, the client experiences a sudden onset of severe agitation, repeatedly attempts to dislodge a peripheral intravenous (IV) catheter, and demonstrates an inability to remain in bed. To promote the client's basic care and comfort while ensuring safety, which action should the nurse take?

A nurse is managing the care of a client on a physical rehabilitation unit who has a history of substance use disorder. Over the past two days, the client has exhibited manipulative behaviors, such as attempting to pit nursing staff against each other to obtain early doses of PRN analgesics and frequently arguing about unit visitation rules. The nurse is updating the client's care plan to address these behaviors. Which of the following behavioral interventions should the nurse include? Select all that apply.

A client at 35 weeks gestation is receiving a continuous intravenous (IV) infusion of magnesium sulfate for the management of severe preeclampsia. During an hourly assessment, the nurse notes the client is difficult to arouse, has a respiratory rate of $10\text{ breaths/minute}$, and deep tendon reflexes are absent. Which of the following is the priority nursing action?

A client with hepatic cirrhosis is recovering on the medical-surgical unit 30 minutes after a bedside paracentesis, during which 3.5 liters of ascitic fluid was removed. The client suddenly reports feeling dizzy and lightheaded. The nurse assesses a heart rate of 118 bpm, a blood pressure of 86/54 mmHg, and a respiratory rate of 18/min. Which action should the nurse take immediately to reduce the client's risk of severe circulatory compromise?

A triage nurse in the emergency department receives a 26-year-old client who was found unresponsive in a public restroom. The client presents with pinpoint pupils, perioral cyanosis, and a respiratory rate of 5 breaths per minute. A used syringe is visible in the client's pocket. Arrange the following nursing actions in the correct sequential order of priority from first to last.

A nurse is preparing to administer a prescribed intermittent enteral tube feeding to a client. Arrange the following nursing actions in the correct chronological order.

A pediatric oncology unit is providing palliative care to a 15-year-old client with relapsed, refractory leukemia. The client's parents have explicitly requested that the healthcare team withhold the terminal prognosis from their child. During a routine assessment, the adolescent looks directly at the nurse and asks, "Am I dying?" What is the most appropriate initial action by the nurse?

While reviewing the chart of a client hospitalized with severe bilateral pneumonia, the central monitor alarms. The nurse enters the room and observes the client is highly agitated, diaphoretic, and increasingly confused. The client is currently receiving oxygen therapy via a non-rebreather mask at 15 L/min. Current vitals indicate a heart rate of 134 bpm, blood pressure of 84/46 mmHg, respiratory rate of 38 breaths/min, and an oxygen saturation of 84%. A stat arterial blood gas (ABG) is drawn and reports: pH 7.21, PaCO2 68 mm Hg, PaO2 50 mm Hg, and HCO3- 23 mEq/L. Which action is the priority for this client?

A registered nurse in a primary care clinic is conducting a comprehensive health promotion and disease prevention visit for a 60-year-old client. Arrange the following nursing actions in the most appropriate chronological order to maximize the effectiveness of the preventative care plan.

A pediatric nurse is educating new parents about the expected physical development of their child during the first year of life. Arrange the following gross motor milestones in the chronological order that they are typically achieved by an infant, from earliest to latest.

A postoperative client has an order for intravenous pantoprazole. The medication is prepared in a $100\text{ mL}$ bag of $0.9\%$ sodium chloride and needs to be infused over $15\text{ minutes}$. At what rate, in $\text{mL/hr}$, will the nurse set the infusion pump?

A nurse is caring for a client who returned to the medical-surgical unit 1 hour ago following a cardiac catheterization performed via the right femoral artery. Which intervention should the nurse prioritize to reduce the client's risk for a post-procedure complication?

A nurse is admitting a client who is a practicing Seventh-day Adventist for an elective surgical procedure. During the admission assessment, the client appears visibly anxious and states, "I just realized my surgery is scheduled for this Saturday morning." Which of the following is the priority nursing action?

A nurse is caring for an older adult client who has been diagnosed with dysphagia and is preparing to eat a meal. Which basic care actions should the nurse implement to promote comfort and ensure safety? Select all that apply.

A nurse is caring for a client who received an intravenous infusion of a systemic antineoplastic medication 24 hours ago. The client is unexpectedly incontinent of urine, which has heavily saturated the bed linens. Which of the following actions should the nurse take to safely manage this situation? Select all that apply.

A community health nurse is evaluating a 45-year-old client who presents for an initial wellness examination. The client's vital signs are within normal limits, and the client has a body mass index (BMI) of $28 \text{ kg/m}^2$. Although currently asymptomatic, the client expresses anxiety regarding a paternal history of premature myocardial infarction. When implementing the care plan, which action by the nurse represents the most appropriate secondary prevention health screening measure?