All practice questions

An older adult client is prescribed a large-volume cleansing enema to treat severe constipation. Which of the following actions should the nurse take when preparing and administering this intervention?

An emergency department team is treating a client for a hypertensive emergency. The provider prescribes a continuous sodium nitroprusside infusion with instructions to begin at $0.3 \text{ mcg/kg/min}$ and titrate upward by $0.3 \text{ mcg/kg/min}$ every $5 \text{ minutes}$ until the mean arterial pressure (MAP) falls below $100 \text{ mm Hg}$.

The client's admission weight is $231 \text{ lbs}$.
The pharmacy supplies a premixed IV bag containing $50 \text{ mg}$ of sodium nitroprusside in $250 \text{ mL}$ of $5\%$ dextrose in water ($D_5W$).

The nurse initiates the infusion. Because the client's MAP remains consistently above $100 \text{ mm Hg}$ during the initial monitoring period, the nurse performs exactly three protocol-directed upward titrations.

Determine the new IV pump rate in $\text{mL/hr}$ immediately following the third titration. Round your final answer to the nearest whole number.

A nurse is initiating the post-procedure care plan for a client who returned to the medical-surgical unit following a percutaneous liver biopsy. To actively reduce the client's risk for a life-threatening complication, which intervention should the nurse implement?

An emergency department triage nurse evaluates a client who sustained blunt force abdominal trauma in a motor vehicle collision. The nurse suspects the client is entering the compensatory stage of shock. Which of the following assessment findings support this physiological adaptation? Select all that apply.

A nurse is assessing a client who underwent a percutaneous coronary intervention (PCI) via the right femoral artery 2 hours ago. The client suddenly reports a warm, wet sensation in their right groin. The nurse immediately dons clean gloves and observes active arterial bleeding and a rapidly expanding hematoma. Place the following nursing interventions in the correct priority sequence to manage this complication.

A nurse is preparing to remove a client's non-tunneled central venous catheter (CVC). After performing hand hygiene, donning appropriate personal protective equipment (PPE), and removing the old dressing, in what order should the nurse perform the following actions? Arrange the steps from first to last.

A client with severe acute respiratory distress syndrome (ARDS) is mechanically ventilated and requires continuous sedation. The healthcare provider prescribes a propofol infusion at $30 \text{ mcg/kg/min}$. The client weighs $209 \text{ lb}$. The pharmacy dispenses propofol $1,000 \text{ mg}$ in a $100 \text{ mL}$ lipid emulsion. What should the nurse set the infusion pump rate to in $\text{mL/hr}$? Record your answer to the nearest whole number.

While conducting midnight rounds on a medical-surgical unit, a nurse discovers an older adult client who is acutely confused, highly restless, and attempting to climb out of bed. The client was alert and oriented during the previous shift. Which action should the nurse implement first to ensure the client's safety?

A nurse is assessing a client who experienced significant blood loss from a severe laceration. Which assessment findings should the nurse identify as early compensatory signs of hypovolemic shock? Select all that apply.

A nurse is preparing to administer a scheduled bolus enteral feeding via a percutaneous endoscopic gastrostomy (PEG) tube to a client who is receiving long-term nutritional support. Arrange the following nursing actions in the correct sequence.

An intensive care nurse is managing a client in profound cardiogenic shock complicated by severe metabolic acidosis. The client has a single-lumen central venous catheter currently dedicated to a continuous intravenous infusion of norepinephrine at $0.15 \text{ mcg/kg/min}$ to maintain a mean arterial pressure of $62 \text{ mm Hg}$. The healthcare provider gives a STAT prescription for $50 \text{ mEq}$ of intravenous sodium bicarbonate. Which action represents the safest and most appropriate method for the nurse to administer this medication?

The charge nurse is reviewing bed assignments and infection control requirements for several newly admitted clients. Match each client's clinical presentation with the most appropriate isolation room assignment and required personal protective equipment (PPE).

A 62-year-old client has a chest tube connected to a closed water-seal drainage system for the treatment of a right-sided spontaneous pneumothorax. Which assessment findings indicate a developing physiological complication or system malfunction that requires immediate intervention? Select all that apply.

A nurse is instructing a client with right-sided hemiparesis on how to safely ambulate using a single-point cane. Place the following steps of the ambulation sequence in the correct order. (Arrange the items from first to last.)

A registered nurse and an unlicensed assistive personnel (UAP) are preparing to transfer a client with left-sided hemiparesis from the bed to a bedside chair. The client is on contact precautions for a methicillin-resistant *Staphylococcus aureus* (MRSA) wound infection. Which action by the nurse best demonstrates adherence to safety and injury prevention protocols?

A nurse on a medical-surgical unit is caring for a client with a serum potassium level of $2.4 \text{ mEq/L}$. The healthcare provider prescribes an intravenous infusion of $40 \text{ mEq}$ of potassium chloride in $100 \text{ mL}$ of $0.9\% \text{ sodium chloride}$ to be administered over $30 \text{ minutes}$. The client has a patent 20-gauge peripheral intravenous catheter. Which of the following is the priority nursing action?

An older adult client is restricted to bed rest on the surgical unit following a lumbar spinal fusion. When addressing the client's basic care, comfort, and mobility needs, which interventions should the nurse implement? Select all that apply.

A nurse is planning skin integrity and comfort measures for an intubated client with severe acute respiratory distress syndrome (ARDS) who is undergoing therapeutic prone positioning. Which action is the most appropriate to include in the plan of care to protect the client's skin and promote safety?

A telemetry nurse is caring for a client who suddenly develops paroxysmal supraventricular tachycardia (SVT). The client's heart rate is 205 beats/min, and blood pressure is 114/72 mm Hg. The client is alert and reports feeling a "racing heart." The client has a double-lumen central venous catheter (CVC) in the right internal jugular vein. The proximal lumen is infusing continuous normal saline, and the distal lumen is capped. No peripheral intravenous access is available. The healthcare provider is at the bedside and verbally orders, "Administer adenosine 6 mg rapid IV push stat."

What is the most appropriate action by the nurse?

A client is receiving an initial intravenous infusion of vancomycin for a severe soft tissue infection. Fifteen minutes after the infusion begins, the nurse observes that the client's face, neck, and upper chest are intensely red. The client reports feeling dizzy and severely itchy. Current vital signs reveal a blood pressure of $88/54 \text{ mmHg}$ and a heart rate of $118 \text{ beats/min}$. What is the priority nursing action?