All practice questions

A triage nurse in the emergency department is evaluating four newly arrived clients in the waiting area. Which client requires the most immediate implementation of transmission-based precautions and placement in an isolation room?

A nurse is preparing to draw a blood specimen from a client's multi-lumen central venous catheter (CVC). A continuous intravenous infusion of 0.9% sodium chloride is currently running through a different lumen of the catheter. Arrange the following steps in the correct chronological order to obtain the blood sample safely and prevent laboratory result contamination.

A nurse is evaluating the electronic fetal monitor tracing for a client in active labor. The nurse notes recurrent, abrupt decreases in the fetal heart rate that drop below the baseline and have no consistent relationship with the onset of uterine contractions. Which of the following actions should the nurse perform? Select all that apply.

A registered nurse is providing care for a group of clients on a medical-surgical unit, including an older adult client experiencing acute delirium who is receiving continuous intravenous (IV) therapy. Which of the following actions by the nurse demonstrate appropriate accident, error, and injury prevention? (Select all that apply.)

A charge nurse at a medical center receives a telephone call from an individual claiming that an explosive device has been placed in the facility. Arrange the following actions the nurse should take in the correct chronological sequence. All options must be used.

A nurse is preparing to transfer a client with right-sided hemiparesis from the bed to a wheelchair. To prevent falls and ensure client safety, arrange the following nursing actions in the correct sequence.

A client arrives unannounced at a community health clinic after being heavily splashed with organophosphate pesticides at a local agricultural site. The client is exhibiting excessive salivation, diaphoresis, and severe muscle twitching. Arrange the following emergency response actions in the correct sequential order from first to last.

A nurse is developing a plan of care for a client who recently sustained a severe traumatic brain injury and is at high risk for increased intracranial pressure (ICP). Which of the following basic care and comfort interventions should the nurse include? Select all that apply.

A critical care nurse is preparing to initiate a continuous IV infusion of dobutamine for a client with severe heart failure. The healthcare provider has prescribed dobutamine at $5 \text{ mcg/kg/min}$. The client weighs $198 \text{ lb}$. The medication is supplied as dobutamine $500 \text{ mg}$ in $250 \text{ mL}$ of 5% dextrose in water (D5W). At what rate, in $\text{mL/hr}$, should the nurse set the IV infusion pump? (Record your answer using one decimal place.)

A 68-year-old client is 24 hours post-operative following an open cholecystectomy. The client has been guarding the abdomen and is reluctant to use the incentive spirometer due to incisional pain. The nurse notes shallow respirations at $26$ breaths/min and an oxygen saturation ($SpO_2$) of $89\%$ on room air. A newly drawn arterial blood gas (ABG) reveals the following: pH $7.29$, $PaCO_2$ $56$ mmHg, $HCO_3^-$ $24$ mEq/L, and $PaO_2$ $62$ mmHg. Which immediate action should the nurse implement to reduce the risk of further physiological deterioration?

During morning rounds, a nurse notes that a client has an active peripheral venous catheter infusing lactated Ringer's solution at $100\text{ mL/hr}$. The pharmacy has just delivered a newly prescribed dose of intravenous ceftriaxone. Which action represents the most critical safety step the nurse must perform prior to connecting the medication?

A client is admitted to the emergency department in status epilepticus. The healthcare provider prescribes a loading dose of phenytoin 1,000 mg intravenously STAT. The client has a single 20-gauge peripheral intravenous (IV) catheter, which is currently infusing a primary solution of 5% Dextrose in Water (D5W) at 100 mL/hr. Which sequence of actions by the nurse demonstrates safe administration of this medication?

An electrical fire erupts in the main supply room of a busy telemetry unit. The staff has already rescued the clients in immediate danger and contained the fire by closing the heavy fire doors. The incident commander now orders a complete horizontal evacuation of the remaining unit. To ensure the safest and most efficient clearance of the area, which client should the nursing staff evacuate NEXT?

A registered nurse is coordinating the care of a critically ill client who was just admitted with suspected bacterial meningitis and septic shock. The client is confused, hemodynamically unstable, and receiving a continuous intravenous (IV) infusion of norepinephrine via a central venous catheter. Which of the following actions should the nurse implement to prevent accidents, errors, and injuries? (Select all that apply.)

A nurse is planning care for a client who sustained deep partial-thickness burns to the anterior neck, bilateral axillae, and chest 24 hours ago. The client is experiencing severe discomfort and persistently requests to rest in a curled, fetal position with multiple pillows placed under the head and knees. Which nursing action is the most appropriate to ensure physiological integrity while managing the client's basic care?

A registered nurse is directing care for a client who is actively symptomatic with a Clostridioides difficile infection. Which instruction is most appropriate for the nurse to give to the unlicensed assistive personnel (UAP) assigned to help with the client's morning care?

A nurse is performing an initial assessment on a neonate exactly 1 minute after birth. The neonate presents with a heart rate of 142 beats per minute, a vigorous cry, active spontaneous movement of all extremities, a strong cough and sneeze during nasal suctioning, and a completely pink trunk with blue hands and feet. Calculate the neonate's 1-minute Apgar score.

A client with a deep vein thrombosis is receiving a continuous intravenous (IV) infusion of heparin through a single-lumen peripheral IV catheter. The healthcare provider prescribes a new order for intermittent IV vancomycin to treat a concurrent soft tissue infection. Which action by the nurse is most appropriate?

A massive derailment of a high-speed commuter train has resulted in a surge of critically injured casualties arriving at the emergency department. The hospital has activated its emergency operations plan to manage the sudden influx of victims. The charge nurse on a medical-surgical unit is instructed to evaluate current inpatients for safe, early discharge to rapidly expand bed capacity. Which of the following clients should the nurse recommend for immediate discharge? Select all that apply.

A staff nurse is caring for a client with acute delirium who is continuously attempting to pull out their continuous bladder irrigation (CBI) catheter. The nurse determines that physical safety devices may be necessary to prevent injury. Which action must the nurse take first before applying physical restraints?