All practice questions

A nurse is performing an assessment on a 2-hour-old newborn. Which of the following findings requires immediate intervention by the nurse?

A nurse is developing a plan of care for a client admitted with a persistent cough, night sweats, hemoptysis, and a positive acid-fast bacilli (AFB) sputum smear. Which of the following interventions should the nurse include in the client's care plan? Select all that apply.

A nurse is caring for a client with cardiogenic shock who weighs $85 \text{ kg}$. The healthcare provider prescribes a continuous intravenous (IV) infusion of dopamine at $5 \text{ mcg/kg/min}$. The pharmacy provides an IV bag containing $400 \text{ mg}$ of dopamine mixed in $250 \text{ mL}$ of $5\%$ Dextrose in Water (D5W). At what rate should the nurse set the IV infusion pump in $\text{mL/hr}$? (Record your answer to the nearest tenth.)

A 32-year-old client is admitted to the emergency department following a high-speed motor vehicle collision. The client sustained blunt trauma to the anterior chest. The nurse's initial assessment reveals a blood pressure of 88/54 mm Hg, heart rate of 134 bpm, and respiratory rate of 32 breaths/min. The client's trachea is deviated to the left, and jugular venous distention (JVD) is present despite the head of the bed being elevated to 45 degrees. An arterial blood gas (ABG) analysis on room air shows pH 7.28, PaCO2 56 mm Hg, HCO3 24 mEq/L, and PaO2 58 mm Hg. Which action should the nurse take FIRST?

During the first 4 hours of postoperative care following a radical nephrectomy, a client's physiological parameters begin to shift. The initial postoperative assessment revealed a blood pressure of 138/76 mm Hg and a heart rate of 78 beats/min. The current assessment shows a blood pressure of 116/88 mm Hg, a heart rate of 115 beats/min, and a respiratory rate of 22 breaths/min. In response to these changes, which of the following interventions should the nurse prioritize?

A nurse is planning basic care and comfort measures for a geriatric client who is recovering from a right total hip arthroplasty utilizing a posterior surgical approach. The client reports sacral discomfort from prolonged bed rest, and the nurse must reposition them while mitigating the risk of complications. Which action is the most appropriate?

A 72-year-old client with a history of moderate dementia is hospitalized for treatment of aspiration pneumonia. The client is receiving continuous intravenous (IV) fluids, has a poor appetite, and exhibits increased restlessness, repeatedly pulling at the IV tubing. Which of the following nursing actions are appropriate to promote the client's basic care and comfort? Select all that apply.

An off-duty nurse is the first responder at the scene of a severe multi-vehicle highway collision involving a commuter bus. Using the Simple Triage and Rapid Treatment (START) algorithm, which individual should the nurse classify as "Immediate" (red tag)?

The nurse is reviewing the health records of several clients to determine their risk for acid-base imbalances. Which of the following conditions place a client at high risk for developing respiratory acidosis? Select all that apply.

An emergency department nurse is evaluating a young adult who presented with a severe acute asthma exacerbation. Upon arrival, the client exhibited audible wheezing, prominent intercostal retractions, and a respiratory rate of 36 breaths/min. The baseline arterial blood gas (ABG) results on room air were:

One hour after the administration of continuous nebulized bronchodilators and intravenous corticosteroids, the nurse reassesses the client. The client is now lethargic, the respiratory rate has decreased to 12 breaths/min, and lung sounds are significantly diminished bilaterally with no audible wheezing. The repeat ABG results are:

Which intervention is the most appropriate priority action based on these clinical changes?

An adult client is recovering on the surgical unit 48 hours after undergoing a right above-the-knee amputation. To prevent complications related to immobility and promote optimal physical comfort, which action should the nurse take?

A client is receiving care in the urgent care clinic after experiencing severe, watery diarrhea for the past three days. Based on the significant loss of lower gastrointestinal fluids, which acid-base imbalance should the nurse anticipate?

A community health nurse is assisting at a field triage station established near the epicenter of a major earthquake. Using the START (Simple Triage and Rapid Treatment) algorithm, which of the following non-ambulatory adult casualties should the nurse classify as Immediate (Red tag)? Select all that apply.

A nurse is preparing to administer a prescribed parenteral medication from a glass ampule. Arrange the following actions in the correct chronological order to ensure safe preparation. (Place the first action at the top and the final action at the bottom.)

Match each client's clinical presentation to the correct infection control precautions and room assignment requirement.

A nurse is preparing to administer an intermittent bolus enteral feeding via a nasogastric (NG) tube to an adult client. In what order should the nurse perform the following actions? Arrange the steps in the correct chronological sequence from first to last.

The nurse is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, pounding headache and profuse diaphoresis above the level of the injury. The blood pressure is 198/104 mm Hg and heart rate is 52 beats per minute. Arrange the following nursing interventions in the correct priority order from first to last.

A 68-year-old client with a history of heart failure is admitted for an acute exacerbation and is receiving high-dose intravenous furosemide. During the afternoon assessment, the client appears increasingly lethargic with shallow respirations at a rate of 10 breaths/min. The latest laboratory results reveal a serum potassium level of 2.6 mEq/L. An arterial blood gas (ABG) analysis on room air shows:

$pH$: 7.53
$PaCO_2$: 49 mm Hg
$HCO_3^-$: 35 mEq/L
$PaO_2$: 82 mm Hg

Which immediate action should the nurse take to reduce the client's risk for a life-threatening physiological complication?

A nurse is assessing a client who has been receiving continuous nasogastric (NG) tube suctioning for 48 hours due to a mechanical small bowel obstruction. The client is now reporting severe muscle cramping and tingling in the extremities. The nurse observes that the client's respirations are shallow at a rate of 10 breaths/min. Based on the client's clinical presentation and the physiological effects of gastric fluid loss, which of the following arterial blood gas (ABG) results should the nurse anticipate?

A clinical protocol for unfractionated heparin is being used to manage a client with a recent pulmonary embolism. The client's admission weight is $75 \text{ kg}$. The intravenous (IV) medication bag contains $25,000 \text{ units}$ of heparin mixed in $250 \text{ mL}$ of 0.9% sodium chloride.

At 10:00, the client's activated partial thromboplastin time (aPTT) is reported as $42$ seconds. The client's heparin infusion is currently running at $15 \text{ units/kg/hr}$.

The facility's heparin nomogram includes the following directives:

After administering the required IV bolus, what is the correct new rate for the continuous infusion pump in $\text{mL/hr}$? (Round to the nearest tenth).