All practice questions

While monitoring a client receiving an infusion of packed red blood cells, the nurse notes the client suddenly develops chills, dyspnea, and flank pain. Arrange the following nursing actions in the correct priority sequence to mitigate further physiological risk.

A nurse is assessing a client who underwent a bedside thoracentesis 1 hour ago to drain a large pleural effusion. To reduce the risk of a life-threatening complication, which assessment finding requires the most immediate intervention by the nurse?

A client receiving a continuous intravenous infusion of unfractionated heparin at $1,500\text{ units/hr}$ through a dedicated 20-gauge peripheral catheter suddenly reports a severe "thunderclap" headache and exhibits unequal pupils. The nurse immediately stops the infusion pump due to suspected intracranial hemorrhage. The healthcare provider prescribes stat intravenous protamine sulfate. What is the most critical action the nurse must take to safely utilize the existing vascular access for the antidote administration?

While managing the care of a client recovering from a recent left total hip replacement (posterior approach), the nurse must implement specific positioning and safety measures. Which action by the nurse is correct?

While caring for a laboring client whose amniotic membranes ruptured two hours ago, the nurse evaluates the electronic fetal heart rate tracing. The nurse observes abrupt, U-shaped decreases in the fetal heart rate that fall 30 to 40 beats per minute below the baseline. These decreases do not have a consistent relationship to the timing of uterine contractions and typically last 20 to 40 seconds before rapidly returning to baseline. Which action should the nurse take first?

A charge nurse is observing a newly licensed nurse prepare to care for a client who has suspected active pulmonary tuberculosis and a sacral wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which statements by the newly licensed nurse indicate a correct understanding of the required precautions? (Select all that apply.)

During bedside rounds on an orthopedic unit, the charge nurse observes a newly hired nurse preparing to assist a client onto a bedpan. The client had a left total hip arthroplasty (posterior surgical approach) two days ago. Which action by the newly hired nurse demonstrates the safest technique for this procedure?

To promote hemostasis and prevent bleeding complications after a percutaneous liver biopsy, the healthcare team must ensure the client maintains a specific resting posture. Which positioning strategy is correct for this client during the immediate post-procedure period?

A clinical team is providing hygiene and mobility support for a bedfast client who exhibits new-onset urinary incontinence and a localized, non-blanchable redness over the sacral area. Which interventions are appropriate for this client? Select all that apply.

A nurse is caring for a 62-year-old client who underwent a cardiac catheterization via the right femoral artery 2 hours ago for the evaluation of ischemic heart disease. Which of the following nursing actions will reduce the client's risk for post-procedure complications? Select all that apply.

A nurse is evaluating a 48-hour-old newborn prior to discharge. The newborn's birth weight was $3,500\text{ g}$, and the current weight is $3,255\text{ g}$. Calculate the newborn's percentage of body weight loss. Enter only the numeric value.

An adult client is admitted to the gastroenterology unit and requires continuous total parenteral nutrition (TPN). The TPN is infusing through a single-lumen peripherally inserted central catheter (PICC). The client has a new prescription for a scheduled intravenous (IV) dose of pantoprazole. Which action should the nurse take to safely administer the medication?

A nurse is preparing to administer a scheduled dose of intravenous (IV) piggyback ceftriaxone to a client admitted with pneumonia. The client currently has a continuous IV infusion of parenteral nutrition (PN) running at $75\text{ mL/hr}$ through a central venous catheter. Which action must the nurse prioritize first?

A hospital's emergency response plan is activated due to a confirmed tornado warning in the immediate vicinity. A nurse is caring for a critically ill client who is mechanically ventilated and cannot be safely moved from their room, which contains a large exterior window. Which action is the most appropriate for the nurse to take to protect this client?

A client hospitalized with severe cellulitis requires scheduled doses of intravenous vancomycin. The client has an active, continuous heparin drip running via a dedicated single-lumen peripheral catheter. Which of the following nursing actions are necessary for safe administration and monitoring? Select all that apply.

Match each client's clinical presentation to the appropriate transmission-based isolation precautions required for their care.

An emergency medical response team arrives at the site of an overturned commuter bus on a major highway. The designated triage nurse begins evaluating victims using the adult START (Simple Triage and Rapid Treatment) algorithm. Which victim should the nurse classify as requiring IMMEDIATE (Red tag) care?

A nurse is caring for a client with decompensated liver cirrhosis who has just undergone a therapeutic paracentesis with the removal of $6.5$ liters of ascitic fluid. Thirty minutes after the procedure, the client reports feeling lightheaded. The puncture site dressing is dry and intact.

Current arterial blood gas (ABG) on room air:
pH: $7.49$
PaCO $_2$: $30$ mmHg
PaO $_2$: $88$ mmHg
HCO $_3^-$: $23$ mEq/L

Which of the following is the priority nursing action to reduce the client's risk of a severe physiological complication?

A rapid response nurse is managing a client who experienced a severe extravasation of a continuous norepinephrine infusion from a peripheral intravenous catheter. Following the facility's extravasation management protocol, the primary health care provider prescribes phentolamine mesylate $0.15\text{ mg/kg}$ to be infiltrated subcutaneously around the ischemic site.

The client weighs $191.4\text{ lbs}$.

The pharmacy dispenses phentolamine in lyophilized vials, which the nurse reconstitutes to yield a concentration of $5\text{ mg/mL}$.

The protocol mandates that the exact calculated phentolamine dose must be further diluted with $0.9\%$ sodium chloride to achieve a final total syringe volume of $12\text{ mL}$ prior to administration.

How many milliliters ($\text{mL}$) of $0.9\%$ sodium chloride must the nurse draw up to mix with the phentolamine? Record your answer to the nearest tenth.

A client with severe sepsis is receiving a continuous intravenous (IV) infusion of norepinephrine at $0.05\text{ mcg/kg/min}$ through the proximal lumen of a double-lumen central venous catheter (CVC). The healthcare provider orders an intermittent IV infusion of piperacillin/tazobactam $3.375\text{ g}$ diluted in $100\text{ mL}$ of normal saline to be administered over $30\text{ minutes}$. A drug reference indicates that piperacillin/tazobactam is physically incompatible with norepinephrine. Which of the following is the most appropriate action by the nurse?