All practice questions

A nurse is receiving handoff report for a client admitted with severe dehydration secondary to confirmed *Clostridioides difficile* (*C. diff*) colitis. The client has experienced six episodes of profuse, watery diarrhea in the past 4 hours. Which transmission-based precautions and nursing interventions should the nurse implement? Select all that apply.

An emergency pediatric nurse is assigned to perform field triage at the scene of a severe multi-vehicle collision involving a school bus. Utilizing the JumpSTART pediatric mass casualty algorithm, the nurse assesses a 6-year-old victim who is unresponsive and not breathing. After the nurse manually opens the airway, the child remains apneic. Which action should the nurse take next?

A nurse is planning care for a client who is $2$ days postoperative following a right total hip arthroplasty (posterior approach). Which positioning intervention should the nurse implement to prevent surgical complications?

A nurse is preparing to obtain a sterile urine specimen for culture and sensitivity from a client who has a continuous indwelling urinary catheter. Arrange the following steps in the correct order to minimize the risk of infection and ensure an accurate sample.

A patient with septic shock, weighing $165\text{ lbs}$, is receiving a continuous intravenous infusion of norepinephrine via a dedicated central venous catheter to minimize the risk of extravasation. The current infusion rate delivers $0.05\text{ mcg/kg/min}$. The patient's mean arterial pressure (MAP) is currently $58\text{ mmHg}$. The hemodynamic titration protocol prescribes increasing the dose by $0.02\text{ mcg/kg/min}$ every $5\text{ minutes}$ until the MAP is $\ge 65\text{ mmHg}$. The medication is supplied as $4\text{ mg}$ of norepinephrine in $250\text{ mL}$ of 5% dextrose in water (D5W). The nurse prepares to initiate the first titration increment. What should the new infusion pump rate be set at in $\text{mL/hr}$? (Round to the nearest tenth)

A nurse is caring for a client with decompensated heart failure who weighs $187\text{ lb}$. The healthcare provider prescribes a continuous IV infusion of dobutamine at $7.5\text{ mcg/kg/min}$. The pharmacy dispenses a premixed IV bag containing dobutamine $500\text{ mg}$ in $250\text{ mL}$ of $5\%\text{ dextrose in water}$. At what rate, in $\text{mL/hr}$, should the nurse set the IV infusion pump? (Record your answer to the nearest tenth.)

A client receiving a transfusion of packed red blood cells (PRBCs) suddenly reports severe lower back pain, chills, and shortness of breath. Suspecting an acute hemolytic transfusion reaction, the nurse must intervene immediately. Arrange the following nursing actions in the correct chronological sequence.

A nurse is conducting a physical assessment on a client who is 2 hours postpartum following a spontaneous vaginal delivery. Which of the following findings should the nurse identify as expected physiological adaptations during this period? Select all that apply.

A registered nurse is planning care for a client admitted with meningococcal meningitis and a stage 3 pressure injury colonized with methicillin-resistant *Staphylococcus aureus* (MRSA). The nurse is reviewing the daily care plan with an unlicensed assistive personnel (UAP). Which of the following statements by the UAP indicate a correct understanding of the required transmission-based precautions and scope of practice? Select all that apply.

An older adult client with advanced Alzheimer's disease is receiving acute care for pneumonia. The client becomes intensely agitated and physically combative during attempts to provide morning hygiene. Which actions should the nurse include in the client's care plan to safely promote basic hygiene and comfort? (Select all that apply.)

A charge nurse is conducting environmental safety rounds on a medical-surgical unit. Which observation involving a client with severe cognitive impairment and a high risk for falls requires immediate intervention to prevent injury?

An older adult client with a history of mild dementia has just returned to the unit following a diagnostic lumbar puncture. The client is restless, repeatedly attempts to sit up in bed, and verbally reports a throbbing headache. Which of the following basic care and comfort interventions should the nurse implement? (Select all that apply.)

A nurse is establishing a basic care regimen for an older adult client who is bedbound with right-sided flaccid paralysis and altered sensory perception due to a recent traumatic brain injury. To optimize comfort, prevent contractures, and protect skin integrity, which combination of nursing actions is most appropriate?

A charge nurse on a medical-surgical unit is evaluating a client with advanced Parkinson's disease who is experiencing acute confusion. The client repeatedly attempts to stand up and walk unassisted, demonstrating an unsteady gait and a high risk for falls. What is the most appropriate initial intervention by the nurse?

A clinical nurse is evaluating a client who underwent an open bowel resection with a temporary colostomy formation $48$ hours ago. The client has a nasogastric (NG) tube connected to low intermittent suction, which has drained $950$ mL of fluid over the past $12$ hours. Which cluster of clinical data indicates the highest risk for a physiological crisis and requires the most immediate intervention?

A nurse is preparing to administer intravenous (IV) ceftazidime to a pediatric client who weighs $24\text{ kg}$. The healthcare provider's prescription is for $50\text{ mg/kg/day}$ administered in $4$ equally divided doses. How many milligrams (mg) should the nurse administer for one single dose?

A radiological dispersion device has detonated at a crowded outdoor festival, causing a mass casualty incident. Numerous victims are arriving at the hospital, prompting the activation of the emergency operations plan for a radiological event. Which of the following actions by the nursing staff are appropriate? Select all that apply.

A nurse is caring for a client with a history of severe chronic obstructive pulmonary disease (COPD) who was admitted for community-acquired pneumonia. The client is currently receiving oxygen at $2 \text{ L/min}$ via nasal cannula. The most recent arterial blood gas (ABG) results reveal a $pH$ of $7.28$, $PaCO_2$ of $64 \text{ mm Hg}$, $HCO_3^-$ of $30 \text{ mEq/L}$, and $PaO_2$ of $56 \text{ mm Hg}$. The client's vital signs are blood pressure $86/54 \text{ mm Hg}$, heart rate $118 \text{ bpm}$, and respiratory rate $28 \text{ breaths/min}$. Which of the following actions should the nurse prioritize to reduce the risk of further physiological decompensation? Select all that apply.

Four clients arrive simultaneously at the emergency department triage desk. Based on the presenting clinical manifestations, which client requires the highest priority for immediate placement in an airborne infection isolation (negative-pressure) room?

A nurse in an outpatient obstetric clinic is evaluating the electronic fetal monitoring tracing of a nonstress test (NST) for a client at 38 weeks of gestation. Over a 20-minute monitoring period, the baseline fetal heart rate is 135 beats per minute. The nurse observes two fetal heart rate accelerations that peak at 155 beats per minute and last for 15 seconds each. There are no decelerations present on the tracing. Which of the following actions should the nurse take based on these findings?