All practice questions

A nurse is administering a prescribed intravenous (IV) push medication into a client's continuous IV infusion line. Immediately after injecting the medication into the Y-site, the nurse observes a cloudy, white precipitate forming in the IV tubing. What is the nurse's immediate priority action?

A nurse enters a client's room and observes smoke and visible flames coming from a wastebasket near the client's bed. Arrange the following immediate actions in the correct priority sequence.

A nurse is preparing to collect a sterile urine specimen for a culture and sensitivity test from a client who has a closed indwelling urinary catheter system. In which order should the nurse perform the following actions to reduce the risk of infection and ensure an accurate diagnostic sample? Arrange the steps from first to last.

A nurse is caring for a client who is exhibiting severe respiratory depression with a respiratory rate of 8 breaths per minute following an opioid overdose. Which of the following arterial blood gas (ABG) results should the nurse most likely expect to find?

A nurse is preparing to administer a dissolved oral medication through a client's established nasogastric (NG) tube. To reduce the risk of complications, in what order should the nurse perform the following actions? Arrange the steps from first to last.

An older adult client is receiving basic care on a medical-surgical unit following a cerebrovascular accident (CVA). The client exhibits right-sided hemiplegia and moderate dysphagia. Which of the following nursing interventions should be included in the client's daily care regimen? (Select all that apply.)

A client with a seizure disorder has a continuous intravenous (IV) infusion of 5% dextrose in water (D5W) running through a peripheral catheter. The nurse needs to administer a scheduled dose of IV phenytoin. What is the most appropriate technique for the nurse to administer this medication through the existing access?

A critically ill client is mechanically ventilated via an oral endotracheal tube. The morning arterial blood gas (ABG) analysis reveals a pH of 7.28, PaCO2 of 62 mm Hg, HCO3- of 26 mEq/L, and PaO2 of 70 mm Hg. The client suddenly exhibits profound diaphoresis, restless movements, and begins biting the endotracheal tube. Which intervention should the nurse implement first to mitigate the risk of further physiological deterioration?

A major commercial train derailment has resulted in a mass casualty incident (MCI), causing a sudden influx of critically injured trauma clients at a local hospital. The hospital administrator has activated the Emergency Operations Plan (EOP) to surge capacity. The charge nurse on a medical-telemetry unit is evaluating current clients for immediate discharge to free up inpatient beds. Which of the following clients should the nurse recommend for safe discharge? Select all that apply.

During a routine intrapartum assessment of a client at 40 weeks of gestation, the nurse analyzes the continuous electronic fetal monitor tracing. The baseline fetal heart rate is 135 beats/min with moderate variability. The nurse notes that the fetal heart rate gradually decreases to 125 beats/min simultaneously with the onset of each uterine contraction, and returns to baseline exactly as the contraction ends. Which of the following is the most appropriate action by the nurse?

A clinical nurse educator is auditing isolation practices and staff interventions across a medical-surgical floor. Which observed actions by the nursing staff indicate adherence to appropriate transmission-based precautions? Select all that apply.

A nurse is evaluating a client with an acute exacerbation of chronic obstructive pulmonary disease (COPD) who is undergoing a spontaneous breathing trial (SBT) via a T-piece. To reduce the risk of cardiopulmonary collapse and extubation failure, which assessment findings require the nurse to immediately terminate the trial and resume mechanical ventilation? Select all that apply.

A client with cervical cancer is undergoing internal radiation therapy (brachytherapy) with a temporary sealed radioactive implant. While performing a routine assessment, the nurse discovers that the radioactive implant has become dislodged and is lying on the client's bed sheets. Which immediate action should the nurse take to prevent radiation injury?

A nurse is caring for an adult client who is receiving a massive blood transfusion protocol (6 units of packed red blood cells over the past 3 hours) due to severe gastrointestinal hemorrhage. The nurse assesses the client for potential physiological complications of the rapid, massive transfusion. Which of the following assessment findings require immediate intervention by the nurse? Select all that apply.

A nurse is managing the care of an older adult client who is receiving continuous enteral nutrition via a nasogastric (NG) tube. The client has become restless and requires a linen change as well as a sacral skin assessment. Which of the following nursing actions is most appropriate?

A nurse is caring for a client with a history of chronic heart failure who is receiving a transfusion of packed red blood cells (PRBCs) at a rate of $120 \text{ mL/hr}$. Approximately forty-five minutes into the infusion, the client suddenly reports shortness of breath. The nurse's assessment reveals a bounding heart rate of $112 \text{ bpm}$, blood pressure of $178/96 \text{ mmHg}$, jugular venous distention, and new-onset bibasilar crackles. The client's temperature remains unchanged at $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$). Which of the following sequences of actions is the priority for the nurse?

A nurse is caring for a client with a mechanical small bowel obstruction who has been receiving continuous nasogastric (NG) decompression for three days. The client suddenly reports a new onset of severe, unrelenting abdominal pain. The healthcare provider orders an arterial blood gas (ABG) analysis, which reveals the following results: pH 7.28, PaCO2 36 mm Hg, and HCO3- 15 mEq/L. Based on these findings, which conclusion should the nurse draw?

A nurse is caring for a 78-year-old client admitted with community-acquired pneumonia and a history of severe chronic obstructive pulmonary disease (COPD). The client suddenly becomes highly restless, disoriented, and repeatedly attempts to remove their nasal cannula. Current vital signs are: Heart Rate 114 bpm, Blood Pressure 148/86 mm Hg, and Respiratory Rate 28 breaths/min. An arterial blood gas (ABG) drawn 15 minutes ago reveals a pH of 7.28, PaCO2 of 65 mm Hg, PaO2 of 57 mm Hg, and HCO3 of 28 mEq/L. To reduce the risk of further physiological deterioration, which action should the nurse take first?

A young adult client with type 1 diabetes mellitus is admitted to the emergency department with a blood glucose level of 450 mg/dL. The nurse suspects the client is experiencing diabetic ketoacidosis (DKA). Which assessment findings and laboratory values should the nurse expect? Select all that apply.

Following a bronchoscopy utilizing topical throat anesthesia, a client is resting in the observation area and requests a glass of water. Which specific nursing assessment must be completed first to ensure the client's safety?