All practice questions

A nurse is evaluating the arterial blood gas (ABG) results for a client who is admitted to the medical-surgical unit with a diagnosis of diabetic ketoacidosis. The laboratory report shows a pH of $7.28$, a $\text{PaCO}_2$ of $38\text{ mm Hg}$, and an $\text{HCO}_3^-$ of $15\text{ mEq/L}$. Based on these values, which of the following acid-base imbalances is this client experiencing?

A nurse is caring for a client who has just arrived at the emergency department with diabetic ketoacidosis (DKA). The client is lethargic, displays deep, rapid respirations, and has a blood glucose level of $650$ mg/dL ($36.1$ mmol/L). Arrange the following collaborative and nursing actions in the correct priority sequence.

A nurse manager is coordinating the on-site medical response following a large residential building collapse. While rapidly assessing the victims on the perimeter, the nurse must determine treatment priorities using standard mass casualty triage guidelines. Which individual meets the criteria for a delayed (yellow) triage tag?

A client receiving a packed red blood cell (PRBC) transfusion reports acute lower back pain and sudden shortness of breath. The nurse notes a rapid heart rate and a drop in blood pressure. Arrange the following immediate nursing actions in the correct chronological sequence to manage this severe physiological complication.

A nurse is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, pounding headache, and the nurse notes profuse diaphoresis and a blood pressure of 210/110 mm Hg. Arrange the following nursing interventions in the correct order of priority.

A nurse is caring for a client who was placed in balanced suspension skeletal traction for a right femur fracture 24 hours ago. The client reports severe lower back discomfort and requests assistance with repositioning. Which of the following is the most appropriate action by the nurse?

A healthcare team is managing the recovery of a 60-year-old client who underwent a right total pneumonectomy yesterday for bronchogenic carcinoma. The client's current continuous intravenous (IV) infusion is 0.9% sodium chloride running at 125 mL/hr. During the morning assessment, the nurse records the following clinical parameters:

- Vital Signs: Blood pressure 146/88 mm Hg, heart rate 116 bpm, respiratory rate 28 breaths/min
- Hemodynamics: Central Venous Pressure (CVP) reading is 15 mm Hg
- Arterial Blood Gas (ABG): pH 7.32, PaCO2 56 mm Hg, PaO2 65 mm Hg, HCO3 27 mEq/L
- Auscultation: Fine crackles present in the dependent lobes of the left lung

Based on these findings, which action should the nurse implement immediately to mitigate the risk of a life-threatening complication?

An emergency department nurse is deployed to the site of a partial factory collapse to conduct field triage. According to the START (Simple Triage and Rapid Treatment) algorithm, arrange the following assessment actions in the correct chronological order.

A young adult client is admitted to the intensive care unit with profound lethargy, deep and rapid respirations, and a capillary blood glucose of 680 mg/dL (37.7 mmol/L). The healthcare provider diagnoses severe diabetic ketoacidosis (DKA). Arrange the following nursing interventions in the correct physiological priority order for managing this acute crisis. (Place the most immediate priority action at the top and the final transition action at the bottom).

An individual with acute necrotizing pancreatitis is currently receiving care on a progressive care unit. The client reports excruciating abdominal pain radiating to the back. A recent rhythm check on the central monitor reveals a newly prolonged QT interval. Current hemodynamics include a mean arterial pressure (MAP) of 62 mmHg, a heart rate of 118 beats per minute, and shallow respirations at 28 breaths per minute. Based on these clinical findings, which of the following interventions are critical for the nurse to implement? Select all that apply.

A nurse is evaluating a client who has just returned to the clinical unit following a percutaneous liver biopsy. The client is awake, oriented, and reports mild tenderness at the puncture site on the right side. Vital signs are currently stable. Which of the following nursing actions is the priority to minimize this client's risk for immediate post-procedure complications?

While evaluating a client recovering from a large anterior myocardial infarction in the intensive care unit, the nurse observes new-onset bilateral crackles extending to the mid-lung fields, severe jugular venous distension, and an audible S3 gallop. The client is restless, and their extremities are cool and mottled. Current vital signs include a blood pressure of 82/52 mm Hg, a heart rate of 124 beats/min, and a respiratory rate of 28 breaths/min. Based on these findings, which of the following prescribed interventions is the priority for the nurse to implement?

A community hospital is located in the direct path of an approaching tornado, and the facility's severe weather protocol has been activated. A nurse is working on a third-floor medical-surgical unit with a mix of ambulatory and bedbound clients. Which action should the nurse implement to ensure client safety?

A nurse is caring for a client admitted with a severe urinary tract infection who has been receiving intravenous antibiotics. Over the past two hours, the client has become increasingly restless. The nurse notes the following assessment data:

Baseline Data (On Admission):
Blood pressure: 118/76 mm Hg
Heart rate: 88 beats/minute
Skin: Warm and dry

Current Data:
Blood pressure: 84/52 mm Hg
Heart rate: 126 beats/minute (thready)
Respiratory rate: 28 breaths/minute
Skin: Pale, cool, and clammy to the touch
Arterial Blood Gas (ABG) on room air: pH 7.28, PaCO2 31 mm Hg, HCO3 15 mEq/L, PaO2 89 mm Hg

Which of the following actions should the nurse take immediately to reduce the risk of severe physiological decompensation?

A nurse is managing the basic care and comfort of an older adult client who is 48 hours postoperative following a right above-the-knee amputation. The client reports mild discomfort in the residual limb and requests that it be elevated on a soft pillow. Which of the following nursing actions is the most appropriate?

A nurse is evaluating a client who sustained blunt abdominal trauma in a motor vehicle collision. Which of the following assessment findings should the nurse identify as early indicators of compensatory hypovolemic shock? (Select all that apply.)

An older adult client with advanced dementia and impaired physical mobility is admitted to an acute care unit. The client has poor nutritional intake and is at high risk for skin breakdown. Which interventions should the nurse include in the plan of care to promote basic care and comfort? Select all that apply.

A client receiving continuous total parenteral nutrition (TPN) via a single-lumen peripherally inserted central catheter (PICC) suddenly develops acute pulmonary edema. The client's oxygen saturation drops to $84\%$ on room air, and the nurse auscultates bilateral crackles. The healthcare provider prescribes a stat dose of intravenous furosemide $60\text{ mg}$. The available furosemide concentration is $10\text{ mg/mL}$. Which of the following is the most appropriate action by the nurse?

A client is in the intensive care unit 48 hours after sustaining a severe traumatic brain injury. The nurse assesses the following clinical data:

The client is lethargic and responds only to noxious stimuli. Which of the following is the priority nursing action?

A nurse is preparing to perform a routine sterile dressing change for a client's peripherally inserted central catheter (PICC). To minimize the risk of central line-associated bloodstream infection (CLABSI) and prevent catheter dislodgement, place the following nursing actions in the correct sequential order.