All practice questions

A community health nurse is conducting a home visit to evaluate the self-care practices and health literacy of an older adult client who has type 2 diabetes mellitus and a history of mild dysphagia. The client employs an unlicensed assistive personnel (UAP) for assistance with basic activities of daily living. Which observations or statements by the client indicate a correct understanding of safe self-care management? Select all that apply.

Immediately following a percutaneous liver biopsy, an older adult client is transferred to the medical-surgical unit. The client reports mild discomfort near the insertion site and suddenly exhibits new-onset restlessness. Which intervention is the most appropriate action for the nurse to implement?

A nurse is preparing to administer a scheduled intravenous (IV) push medication into a client's continuous primary IV fluid infusion. To prevent a potentially life-threatening complication, which action must the nurse perform immediately prior to administration?

A client admitted with acute decompensated heart failure is receiving a continuous intravenous infusion of milrinone. The healthcare provider prescribes a one-time dose of intravenous furosemide $40\text{ mg}$ to manage worsening pulmonary edema. The client currently has a single peripheral intravenous access site. After consulting the facility's drug reference, the nurse notes that furosemide and milrinone are incompatible. Which of the following is the most appropriate action for the nurse to take?

A nurse is monitoring a client who is 4 hours post-operative following abdominal surgery. Which clinical finding should the nurse identify as an early indicator of hypovolemic shock?

Following a prolonged transcontinental flight, a traveler is brought to the urgent care clinic reporting sudden, sharp chest pain and severe shortness of breath. Initial assessment reveals a heart rate of 122 beats per minute, a blood pressure of 98/80 mmHg, and a respiratory rate of 32 breaths per minute. Arterial blood gas (ABG) analysis on room air demonstrates a $pH$ of 7.54, $PaCO_2$ of 26 mmHg, $PaO_2$ of 54 mmHg, and $HCO_3^-$ of 23 mEq/L. Which physiological adaptations accurately reflect this client's current presentation? (Select all that apply)

A clinic nurse is developing a self-care teaching plan for a 72-year-old client with rheumatoid arthritis who is experiencing significant bilateral hand stiffness and pain. Which action or instruction should the nurse include in the client's plan of care to best promote independence?

A telemetry unit nurse is monitoring a client who has a long-standing history of chronic obstructive pulmonary disease. The client was admitted yesterday with a severe lower respiratory tract infection. During the current assessment, the nurse observes that the client is somnolent and only responds to painful stimuli. The respiratory rate has dropped from 26 to 9 breaths per minute. The most recent arterial blood gas analysis reveals a pH of $7.21$, a PaCO $_2$ of $78$ mmHg, an HCO $_3^-$ of $29$ mEq/L, and a PaO $_2$ of $54$ mmHg. Based on these findings, which of the following is the most appropriate initial action?

A 42-year-old client is being monitored in the neuro-intensive care unit following a severe traumatic brain injury. The client is sedated and mechanically ventilated. Current assessment findings include an intracranial pressure (ICP) of 26 mm Hg, a blood pressure of 170/65 mm Hg, and a heart rate of 52 beats/min. The latest arterial blood gas (ABG) results are: pH 7.28, PaCO2 58 mm Hg, PaO2 94 mm Hg, and HCO3 24 mEq/L. Which intervention should the nurse prioritize to reduce the client's risk for further neurological deterioration?

A client in the active phase of labor is receiving an intravenous oxytocin infusion to augment uterine contractions. While monitoring the client, the nurse observes that the fetal heart rate gradually decreases, with the lowest point of the deceleration occurring consistently after the peak of each uterine contraction. The fetal heart rate slowly returns to baseline after the contraction ends. Which of the following is the priority nursing action?

While managing the care of a critically ill client diagnosed with severe sepsis, the nurse monitors for the complication of acute respiratory distress syndrome (ARDS). Which specific assessment findings signify that the client has entered the early stages of this pulmonary complication? Select all that apply.

A nurse is managing the care of an older adult client who is receiving continuous enteral nutrition via a nasogastric tube. As part of the client's pressure injury prevention plan, the nurse must reposition the client into a flat, lateral recumbent position. Which action is the most appropriate?

A nurse is caring for a client who is two days postoperative following an open exploratory laparotomy. The client coughs forcefully and reports a sudden "popping" sensation in the abdomen. The nurse assesses the surgical site and observes an evisceration. In which order should the nurse perform the following actions to reduce the client's risk of complications? Arrange the actions in chronological order from first to last.

A multidisciplinary team is providing care on a specialized infectious disease unit. The registered nurse (RN) is planning task distribution for the upcoming shift. Which action is most appropriate to assign to the unlicensed assistive personnel (UAP)?

A client on a neurology unit is recovering from a traumatic brain injury and becomes highly disoriented during the night. The client repeatedly tries to pull out a continuous intravenous infusion line and an indwelling urinary catheter. After diversionary activities and frequent monitoring fail to ensure client safety, the healthcare provider orders bilateral soft wrist restraints. Which intervention should the nurse implement regarding the use of this safety device?

A nurse accidentally drops a specimen tube, resulting in a small blood spill on the floor of the clinical utility room. Arrange the following actions in the correct sequence for safely cleaning up this biohazardous material.

An obstetric triage nurse is admitting a client in the late third trimester of pregnancy who reports a sudden onset of painless, bright red vaginal bleeding. Which intervention should the nurse prioritize?

An oncology nurse is planning care for four assigned clients after receiving the morning handoff report. Based on the principles of prioritization, arrange the clients in the order the nurse should assess them, from first to last.

A psychiatric-mental health nurse is conducting an individual session with a 15-year-old client admitted for major depressive disorder. The adolescent reveals that a household member has been physically abusing them. The client becomes highly anxious and states, "Please do not tell anyone. I thought everything we talked about was protected by confidentiality laws." Which action should the nurse take?

An emergency department nurse is developing a plan of care for a newly admitted client who has a severe *Clostridioides difficile* infection and presents with a diffuse, crusted vesicular rash confirmed to be disseminated herpes zoster. Which of the following transmission-based precaution interventions should the nurse implement? Select all that apply.