All practice questions

A client diagnosed with bacterial pneumonia is prescribed intravenous ceftriaxone. While completing the admission history, the nurse discovers that the client has a documented history of anaphylaxis following amoxicillin administration. Which action is the priority for the nurse to take?

A nurse is providing care for a client who had a right below-the-knee amputation 36 hours ago. The client reports mild discomfort and stiffness in the affected leg. Which nursing action is the most appropriate?

A newly admitted adult client is recovering from a prolonged tonic-clonic seizure. The client has a peripheral venous catheter in the right forearm, which is currently infusing a maintenance solution of 5% dextrose in water at $80\text{ mL/hr}$. The nurse must deliver a stat order of intravenous phenytoin. Which procedural approach ensures safe administration of this medication?

An intensive care nurse evaluates a critically ill client being treated for severe viral pneumonia. Over the past 30 minutes, the client has become increasingly agitated and disoriented. Current vital signs reveal a heart rate of 126 beats/min, a respiratory rate of 34 breaths/min, and a blood pressure of 98/78 mm Hg. Stat arterial blood gas (ABG) analysis on a non-rebreather mask demonstrates a pH of 7.26, $PaCO_2$ of 64 mm Hg, $PaO_2$ of 52 mm Hg, and $HCO_3^-$ of 24 mEq/L. What is the most appropriate action by the nurse to mitigate the risk of immediate cardiorespiratory arrest?

A $72$-year-old client with a history of dysphagia is receiving continuous enteral nutrition via a nasogastric tube. The client suddenly exhibits severe shortness of breath, use of accessory muscles, and a pulse oximetry reading of $84\%$ on room air. A stat arterial blood gas (ABG) analysis shows a pH of $7.26$, PaCO $_2$ of $64$ mm Hg, and HCO $_3^-$ of $24$ mEq/L. The nurse suspects acute pulmonary aspiration. Which of the following immediate interventions should the nurse implement? Select all that apply.

A newly admitted client who recently completed a 14-day course of levofloxacin reports experiencing frequent, watery stools and abdominal cramping. The healthcare provider suspects a *Clostridioides difficile* infection. Which of the following infection control measures must the nurse implement? (Select all that apply.)

A nurse is caring for a client who is receiving intravenous fluids through a central venous catheter. The client suddenly gasps, reports severe chest pain, and becomes extremely short of breath. The nurse notes a heart rate of 124 beats/min, a blood pressure of 82/50 mm Hg, and auscultates a loud, churning "mill-wheel" murmur over the precordium. Suspecting a venous air embolism, arrange the following nursing actions in the correct priority order.

A nurse is assessing a client who is receiving continuous intravenous opioid analgesia. The client is difficult to arouse and has a respiratory rate of 8 breaths per minute. The nurse anticipates the client is developing respiratory acidosis. What arterial blood gas (ABG) findings would confirm this complication? Select all that apply.

An adolescent client is brought to the emergency department after ingesting a toxic amount of acetylsalicylic acid (aspirin) 6 hours ago. The client is confused, diaphoretic, and reports tinnitus. Vital signs are: heart rate 124 beats/min, respiratory rate 34 breaths/min and deep, and blood pressure 102/64 mm Hg. Arterial blood gas (ABG) analysis reveals: pH 7.31, PaCO2 24 mm Hg, HCO3 12 mEq/L, and PaO2 96 mm Hg. Which physiological interpretation and corresponding priority action is most appropriate for this client?

A district school nurse is collaborating with a local health coalition to address the increasing prevalence of childhood obesity. The nurse is tasked with prioritizing a primary disease prevention strategy. Which of the following interventions should the nurse select?

A nurse in the cardiovascular intensive care unit is caring for a client with acute decompensated heart failure. The client weighs $209\text{ lbs}$.

The client is receiving a continuous intravenous infusion of dobutamine. The standard hospital mixture contains $500\text{ mg}$ of dobutamine in $250\text{ mL}$ of $5\%$ dextrose in water (D5W). The infusion pump is currently running at $17.1\text{ mL/hr}$.

The provider's order reads: 'Titrate dobutamine by $1.5\text{ mcg/kg/min}$ every $15\text{ minutes}$ to achieve a cardiac index $\geq 2.2\text{ L/min/m}^2$.'

The latest hemodynamic assessment reveals a cardiac index of $1.8\text{ L/min/m}^2$. The nurse prepares to perform the next titration step according to the protocol.

At what value in $\text{mL/hr}$ will the nurse program the infusion pump for the new dose? (Round the final answer to the nearest tenth.)

An adult client admitted to the medical-surgical unit is currently receiving continuous enteral nutrition through a nasogastric tube. To actively reduce the risk of potential physiological complications associated with this therapy, which intervention is most appropriate for the nurse to implement?

A nurse is managing the care of a client who is receiving continuous total parenteral nutrition (TPN) via a peripherally inserted central catheter (PICC). Which of the following nursing actions are appropriate to include in the client's plan of care? (Select all that apply.)

A nurse is caring for a client with type 2 diabetes mellitus whose morning blood glucose level is $185 \text{ mg/dL}$. The healthcare provider has prescribed $10 \text{ units}$ of regular insulin and $20 \text{ units}$ of NPH insulin to be administered subcutaneously. The nurse is preparing to mix both insulins in a single syringe. Arrange the following steps in the correct sequence for this procedure.

A nurse is caring for a 62-year-old client who is 4 days post-operative following an open colon resection. While the nurse is assisting the client with coughing and deep breathing exercises, the client reports a sudden "popping" sensation in the abdomen. The nurse inspects the surgical site and observes a wound evisceration. Place the following nursing interventions in the correct order of priority to mitigate further physiological risk.

A nurse in an ambulatory care clinic is evaluating a 55-year-old male client who has not visited a healthcare provider in over a decade. The client is currently asymptomatic but reports a strong family history of type 2 diabetes mellitus and colorectal cancer. Which of the following nursing actions are appropriate regarding this client's health promotion and disease prevention plan? Select all that apply.

A nurse is evaluating a client who sustained a massive anterior wall myocardial infarction 24 hours ago. Which of the following clinical findings indicate the client is developing cardiogenic shock? Select all that apply.

A nurse is assessing a client who is 4 hours post-operative following a total thyroidectomy. Which of the following clinical observations and assessment findings require immediate intervention by the nurse? Select all that apply.

A nurse receives handoff report for a client who is 4 hours postpartum following a forceps-assisted vaginal delivery of an 8 lb 12 oz (3.97 kg) neonate. The client reports intense, deep pelvic pain and severe rectal pressure. The previous shift's assessment noted a firm, midline fundus, scant lochia rubra, heart rate of 118 bpm, and blood pressure of 92/58 mm Hg. Which action is the highest priority for the nurse to take?

A client is recovering in the outpatient endoscopy unit after undergoing an esophagogastroduodenoscopy (EGD) with gastric biopsies. The client received intravenous midazolam and fentanyl for moderate sedation. Which assessment finding represents the highest priority physiological risk that the nurse must report immediately?