All practice questions

Following a spontaneous vaginal delivery complicated by a retained placenta requiring manual extraction, a client is transferred to the postpartum unit. Several hours into the shift, the unlicensed assistive personnel (UAP) records the client's vital signs: temperature 98.8°F (37.1°C), blood pressure 112/74 mm Hg, heart rate 116 beats per minute, and respirations 18 per minute. The UAP informs the registered nurse that the client appears to be resting quietly with her eyes closed. Which intervention is the most appropriate next step for the registered nurse?

An individual recovering from a severe motor vehicle collision is experiencing intensive care unit (ICU) delirium. The client continuously grasps at their arterial line and endotracheal tube despite family presence, frequent reorientation, and concealment of the tubing. The provider prescribes bilateral soft wrist restraints. Which action represents the safe and appropriate management of these devices by the nurse?

A client with severe delirium is aggressively attempting to pull out their central venous catheter. After all non-pharmacological alternatives have been exhausted, the healthcare provider prescribes bilateral soft wrist restraints to prevent injury. Arrange the following nursing actions for initiating these restraints in the correct chronological order.

A nurse is collecting an obstetrical history from a client admitted to the labor and birth unit. The client reports the following history:

- Currently pregnant with twins.
- Delivered a viable male infant at $39$ weeks of gestation, who is now $5$ years old and healthy.
- Delivered viable female twins at $34$ weeks of gestation, both of whom are now $3$ years old and healthy.
- Experienced a spontaneous abortion at $10$ weeks of gestation.
- Delivered a stillborn fetus at $22$ weeks of gestation.

Using the GTPAL system, calculate the number that represents the client's "Preterm" (P) deliveries. Record your answer as a whole number.

A nurse is riding in a crowded hospital elevator when two clinicians enter and begin loudly discussing a specific client's surgical complications, mentioning the client by name. Arrange the following actions the nurse should take in the correct chronological sequence, from first to last.

A registered nurse is monitoring an unlicensed assistive personnel (UAP) who is providing morning care to a client isolated for active pulmonary tuberculosis. Which observed action by the UAP requires immediate intervention by the nurse?

A nurse working on a maternal-newborn unit receives the change-of-shift report for four assigned clients. Which of the following clients should the nurse assess first?

An alert and oriented adult client is diagnosed with metastatic pancreatic cancer. The client's adult child privately approaches the nurse and states, "Please do not tell my parent about the cancer. It will destroy their hope, and they will just give up." Which of the following actions should the nurse take? Select all that apply.

A healthcare team is managing the care of a client newly admitted with profound weakness and a high risk for falls. To maintain a safe environment and prevent injury, which specific action should the nurse assign to the unlicensed assistive personnel (UAP)?

A hospital activates its Emergency Operations Plan (EOP) in response to a mass casualty incident involving a suspected aerosolized biological agent (inhalational anthrax) at a local stadium. The facility is immediately overwhelmed with hundreds of victims seeking rapid evaluation and treatment. Which action by the nursing staff demonstrates a correct understanding of disaster response protocols?

Match each clinical client scenario to the appropriate transmission-based precaution category required for their care.

A nursing supervisor is evaluating unit assignments and isolation protocols. Select the correct transmission-based precaution and required personal protective equipment (PPE) for each of the following patient presentations.

A public health nurse is monitoring a client recently diagnosed with active pulmonary tuberculosis. The client states, 'I am stopping the prescribed antibiotics because they cause severe nausea. I forbid you from notifying the health department or my employer, as it will ruin my career. You are ethically bound to protect my privacy.' Which action should the nurse take?

A gravid client at 39 weeks gestation is undergoing a trial of labor after cesarean (TOLAC) while receiving a continuous intravenous oxytocin infusion. The client suddenly cries out, reporting an intense, sharp pain in the lower abdomen that radiates to the right shoulder. The nurse notes that the previously established pattern of regular uterine contractions has abruptly ceased. The fetal heart rate tracing immediately shifts from a baseline of 145 beats/min to a prolonged deceleration of 70 beats/min. The client's current vital signs are: blood pressure 82/45 mm Hg, heart rate 136 beats/min, and respiratory rate 26 breaths/min. Which of the following actions should the nurse perform first?

An older adult client with acute hypoxemic respiratory failure is receiving noninvasive positive pressure ventilation (BiPAP) in the step-down unit. The client is confused, agitated, and continuously attempts to remove the facial mask and pull at their continuous intravenous infusion line. After documented failure of alternative measures, including family presence, frequent reorientation, and a bed alarm, the healthcare provider prescribes bilateral soft wrist restraints. When implementing this safety measure, which actions must the registered nurse include in the plan of care? Select all that apply.

A catastrophic chemical leak at a nearby manufacturing plant has resulted in dozens of exposed workers who are currently self-transporting to the local community hospital. The triage nurse receives radio confirmation that these individuals have bypassed field decontamination. What is the correct chronological sequence of actions the nurse must take to manage this crisis? Arrange the following steps from first to last.

The charge nurse on a maternity unit is reviewing assessment data and ongoing care for several clients. Which of the following clinical findings or situations require the nurse's immediate intervention? Select all that apply.

During a routine prenatal visit, a pregnant client at 35 weeks of gestation is resting flat on her back on the examination table. She suddenly reports feeling dizzy, severely nauseated, and lightheaded. The nurse observes that her skin is noticeably pale and diaphoretic. Which action should the nurse take first?

A registered nurse is participating in the resuscitation of a client in cardiac arrest. During the emergency, the nurse realizes that another client requires a time-sensitive capillary blood glucose check. To ensure the task is completed and recorded promptly, the nurse verbally provides their electronic health record (EHR) password to an unlicensed assistive personnel (UAP), instructing the UAP to obtain the glucose reading and document it using the nurse's login credentials. Which statement accurately describes the legal and ethical implications of the nurse's action?

A nurse is evaluating a client at 40 weeks of gestation who is in active labor. Shortly after the spontaneous rupture of membranes, the electronic fetal monitor displays sudden, severe variable decelerations. During a subsequent vaginal examination, the nurse palpates a soft, pulsating mass in the vaginal vault. Which of the following actions should the nurse take immediately?