All practice questions

A client with a complete spinal cord injury at the $T4$ level suddenly reports a severe, throbbing headache, blurred vision, and profound nasal congestion. The client's blood pressure is $218/114$ mm Hg, and the heart rate is $52$ beats/min. To reduce the immediate risk of a catastrophic cerebrovascular complication, which action must the nurse perform first?

A nurse is instructing a client with a right fractured tibia who is non-weight-bearing on how to ascend stairs using axillary crutches. In what order should the nurse teach the client to perform the following actions? Arrange the steps in the correct sequence from first to last.

A localized chemical explosion at a manufacturing plant produces multiple casualties. A nurse on the emergency response team assesses an adult victim found sitting on the ground outside the main blast zone. The client states they are unable to stand up due to severe back pain. The nurse notes a palpable radial pulse, a capillary refill time of 1.5 seconds, and a respiratory rate of 34 breaths per minute. The client is alert and accurately states their name. Based on the START (Simple Triage and Rapid Treatment) algorithm, which triage category should the nurse assign to this client?

While performing an hourly clinical assessment, a critical care nurse evaluates the peripheral intravenous site of a client receiving a continuous norepinephrine infusion. The surrounding skin appears blanched, edematous, and cool to the touch. The client reports intense burning in the arm. Which intervention is the most appropriate initial action?

A nurse is assessing a client who is two days postoperative following a right total knee arthroplasty. The client suddenly becomes severely restless and reports sharp, pleuritic chest pain. Which of the following assessment findings would indicate that the client has developed a pulmonary embolism complicated by obstructive shock? Select all that apply.

A geriatric client with right-sided heart failure and marked dependent edema is receiving inpatient care. The client also has right-sided hemiplegia secondary to a past cerebrovascular event. Over the last few hours, the client has become highly restless and is experiencing new-onset urinary incontinence. Which intervention regarding the client's comfort and care is the most appropriate?

An obstetrical nurse is admitting a multigravida client at 39 weeks of gestation who reports a sudden gush of clear fluid from the vagina while walking in the hospital corridor. Which action must the nurse perform first?

A nurse is preparing to administer an intravenous (IV) push medication that is incompatible with the client's continuous IV fluid infusion. The client has a single peripheral IV access. Arrange the following actions in the correct sequence to safely administer this medication. (Place the first action at the top and the last action at the bottom.)

A nurse is providing care for a client who is 1 day postoperative following a right total hip arthroplasty with a posterior approach. Which nursing action is most appropriate when assisting the client with basic care and mobility?

A nurse is caring for a client admitted with an acute severe asthma exacerbation. Upon admission, the client was anxious and tachypneic with a respiratory rate of 34/min, and auscultation revealed loud, diffuse bilateral wheezing. Two hours later, the nurse notes that the client is now lethargic, the respiratory rate has decreased to 14/min, and breath sounds are markedly diminished. Which of the following arterial blood gas (ABG) results should the nurse anticipate based on the client's current clinical status?

A nurse is caring for a client who is receiving continuous total parenteral nutrition (TPN) via a peripherally inserted central catheter (PICC). Which of the following nursing actions are appropriate for managing this client's parenteral therapy? Select all that apply.

A critically ill adult client is admitted to the intensive care unit with severe diabetic ketoacidosis (DKA). The initial laboratory results indicate a blood glucose level of $715\text{ mg/dL}$, an arterial pH of $7.12$, and a serum potassium level of $3.1\text{ mEq/L}$. To reduce the risk of fatal complications during treatment, arrange the following collaborative interventions in the safest chronological order from first to last.

A nurse is caring for a 68-year-old client admitted 12 hours ago with acute pyelonephritis. The client is currently restless, and the nurse notes their skin is abnormally warm and flushed. Assessment reveals a urine output of 15 mL/hr over the past two hours. Vital signs are:

* Blood pressure: 86/42 mmHg
* Heart rate: 124 bpm
* Respiratory rate: 28 breaths/min
* Temperature: 39.1°C (102.4°F)

An arterial blood gas (ABG) analysis on room air shows: pH 7.31, PaCO2 29 mmHg, HCO3- 14 mEq/L, and PaO2 86 mmHg. Which of the following actions should the nurse perform FIRST?

A nurse is caring for a client who is mechanically ventilated in the intensive care unit following abdominal surgery. The ventilator's high-pressure alarm has been sounding frequently. The client's latest arterial blood gas (ABG) results are provided in the table below:

Which intervention should the nurse implement first to reduce the risk of further physiological decompensation?

A registered nurse is providing care for a client who is receiving a continuous intravenous (IV) heparin infusion to treat a deep vein thrombosis. The healthcare provider prescribes a scheduled dose of IV vancomycin. The client currently has a single peripheral IV access site. Which action by the nurse is essential to ensure client safety and prevent a medical error?

A charge nurse is evaluating a newly licensed nurse who is managing a client 12 hours postoperative following a right total pneumonectomy. No chest tube is present. The client's vital signs are: blood pressure 110/70 mmHg, heart rate 98 bpm, respiratory rate 20/min, and oxygen saturation 94% on 2 L/min via nasal cannula. Which action by the newly licensed nurse requires immediate intervention by the charge nurse to prevent a life-threatening complication?

A registered nurse is preparing to administer a mixed dose of NPH and regular insulin to a client with diabetes mellitus. In what order should the nurse perform the following actions to safely prepare the injection? Arrange the steps in the correct sequence.

A client admitted with a hypertensive emergency is receiving a continuous intravenous infusion of sodium nitroprusside at $3 \text{ mcg/kg/min}$. The client weighs $220 \text{ lbs}$. The medication is supplied as $50 \text{ mg}$ of sodium nitroprusside in $250 \text{ mL}$ of $5\%$ dextrose in water (D5W). Upon assessment, the nurse notes the client's blood pressure has decreased to $86/52 \text{ mmHg}$. The healthcare provider prescribes titrating the infusion rate down to $1 \text{ mcg/kg/min}$. Which action is most appropriate for the nurse to take?

During an environmental safety audit on a medical-surgical unit, the charge nurse evaluates the room setup and care plan for a client admitted with uncontrolled generalized tonic-clonic seizures. Which of the following documented interventions confirm that appropriate injury prevention measures have been implemented? Select all that apply.

A 58-year-old client is being managed in the high-dependency unit for acute necrotizing pancreatitis. Over the past three hours, the nurse notes the client's heart rate has increased from $86$ to $116$ beats/min, and the blood pressure has trended from $134/78$ mm Hg to $112/86$ mm Hg. The client's urine output for the last hour is $15$ mL. The most recent arterial blood gas analysis reveals a pH of $7.31$, PaCO2 of $35$ mm Hg, and HCO3- of $16$ mEq/L. Based on these findings, which immediate risk mitigation action should the nurse prioritize?