All practice questions

The nursing team is developing a care plan for a client recovering from a traumatic brain injury. To minimize the risk of dangerous elevations in intracranial pressure (ICP), which specific actions are appropriate to implement? Select all that apply.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) through a central venous catheter (CVC). During an intravenous tubing change, the client suddenly grasps their chest and reports severe shortness of breath. The client's oxygen saturation drops rapidly to 85%. Suspecting a central line-associated air embolism, which of the following immediate actions should the nurse take? (Select all that apply.)

A nurse is caring for an older adult client who returned to the medical unit one hour ago following a percutaneous liver biopsy. The client reports a strong urge to void and requests assistance to walk to the bathroom. Which nursing intervention is the most appropriate?

A nurse is caring for a client with acute delirium who is experiencing severe sensory overload. The client is highly agitated, attempting to climb over the bed rails, and shouting at shadows on the wall while the room's television is blaring. In what order should the nurse prioritize the following interventions? Arrange the actions from first (highest priority) to last (lowest priority).

A nurse is caring for a client with cardiogenic shock and metabolic acidosis who currently has a single peripheral intravenous (IV) line. The client is receiving a continuous IV infusion of $8.4\%$ sodium bicarbonate at $50\text{ mL/hr}$. The healthcare provider prescribes a new continuous IV infusion of dopamine at $5\text{ mcg/kg/min}$. The client weighs $176\text{ lbs}$. The pharmacy dispenses dopamine $400\text{ mg}$ diluted in $250\text{ mL}$ of $5\%$ dextrose in water (D5W). Based on this prescription, which of the following actions is the most appropriate for the nurse to take?

A nurse is caring for an older adult client with end-stage heart failure who has recently transitioned to comfort measures only. The client is minimally responsive, exhibits Cheyne-Stokes respirations, and has mottling of the lower extremities. The client's family is at the bedside and expresses distress about the breathing pattern. Which nursing actions are appropriate? Select all that apply.

A clinic nurse is preparing to conduct an intimate partner violence (IPV) screening for a young adult client who arrived at the healthcare facility with their spouse. Arrange the following nursing actions in the correct sequence to safely and effectively perform the screening.

While preparing a specimen for transport, an outpatient clinic nurse accidentally drops a glass sputum collection container from a client with suspected active pulmonary tuberculosis. The jar shatters, spilling the specimen across the exam room floor. Which action should the nurse take first?

A nurse is preparing to change a two-piece ostomy appliance for a client with a newly established descending colostomy. In which order should the nurse perform the following actions? Arrange the steps from first to last.

A nurse in an outpatient clinic is speaking with the parents of a 4-year-old client who was recently diagnosed with type 1 diabetes mellitus. The parents report that the child becomes extremely distressed before each insulin injection, stating that the shots are a punishment for being 'bad'. Which of the following actions should the nurse advise the parents to take?

A community health nurse is establishing a health promotion and disease prevention plan for a 70-year-old client who has recently relocated to the area. The client reports a sedentary lifestyle, new-onset occasional urinary incontinence, and has a 30-pack-year smoking history, though they quit 5 years ago. Which nursing action demonstrates the correct application of a secondary prevention strategy for this client?

A nurse is reviewing the medical record of a client who is scheduled for a computed tomography (CT) scan with intravenous (IV) iodinated contrast. Which finding is the most critical to report to the healthcare provider prior to the procedure?

An older adult client with advanced Parkinson's disease and acute pancreatitis is receiving continuous enteral nutrition through a nasojejunal tube. The client suddenly becomes highly restless, pulls at the bedsheets, and attempts to climb over the side rails. Which nursing action demonstrates the most appropriate approach to this client's basic care and comfort?

A nurse is preparing to safely transfer a client who has generalized weakness from the bed to a wheelchair. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence from first to last.

A client has recently passed away on a medical-surgical unit. The provider has pronounced the death and confirmed that an autopsy is not indicated. The family is currently waiting in the lounge to view the body. Arrange the following post-mortem care actions in the correct chronological sequence.

The nursing team is planning care for four infants recently admitted to the newborn nursery. Which infant should the registered nurse assess FIRST?

While completing evening rounds on a behavioral health unit, a nurse observes a client clenching their fists, breathing rapidly, and shouting obscenities at another staff member. The nurse recognizes that the client is experiencing acute agitation. In what order should the nurse implement the following interventions? Arrange the actions from first to last.

A nurse is preparing to administer a prescribed dose of intravenous (IV) phenytoin to a client who is experiencing active seizure activity. The client has a single peripheral IV line with a continuous infusion of $5\%$ dextrose in water (D5W). Which of the following is the most appropriate action for the nurse to take?

A client who recently experienced sudden and total vision loss following a traumatic injury is admitted to a surgical step-down unit. During the first night, the client becomes acutely agitated, attempts to remove the intravenous (IV) catheter, and shouts, "Who is in here? What are you doing to me?" Which action should the nurse take first?

A nurse is preparing to enter the room of a client who has disseminated herpes zoster and is on airborne and contact precautions. In what order should the nurse don the required personal protective equipment (PPE)? Arrange the following steps in the correct sequence.