All practice questions

Following a diagnostic spinal tap, a client is transported back to the clinical unit. The client is alert and reports a dull ache near the lumbar insertion site. To promote client comfort and minimize the risk of procedural complications, which of the following actions should the nurse take?

A nurse is caring for a client admitted to the emergency department with a severe asthma exacerbation. Initially, the client was tachypneic with a respiratory rate of 34 breaths/min, and the initial arterial blood gas (ABG) revealed a pH of 7.50, PaCO2 of 28 mm Hg, and PaO2 of 72 mm Hg. Two hours after receiving continuous nebulized bronchodilators and intravenous corticosteroids, the client remains diaphoretic, is using accessory muscles to breathe, and has significantly diminished breath sounds bilaterally. A repeat ABG shows a pH of 7.38, PaCO2 of 42 mm Hg, and PaO2 of 64 mm Hg. Based on these findings, which of the following is the most accurate interpretation of the client's condition and the priority nursing action?

A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes into the transfusion, the client reports sudden chills, severe lower back pain, and shortness of breath. Arrange the following nursing interventions in the correct priority sequence from first to last.

An older adult client with severe chronic obstructive pulmonary disease (COPD) is admitted for acute hypercapnic respiratory failure and requires continuous bilevel positive airway pressure (BiPAP). The client becomes intensely agitated, repeatedly attempting to remove the BiPAP mask and grasp at an indwelling arterial line. The healthcare provider prescribes bilateral soft wrist restraints and PRN intravenous lorazepam for severe agitation. Which intervention should the nurse implement to best maintain client safety?

A client is admitted to the inpatient medical unit with severe abdominal cramping and frequent watery stools. Laboratory results confirm an active Clostridioides difficile (C. diff) infection. Which of the following infection control measures should the nurse implement? Select all that apply.

A critically ill client admitted with diabetic ketoacidosis (DKA) has a serum potassium level of $2.8$ mEq/L. The healthcare provider prescribes an intravenous infusion of $20$ mEq potassium chloride (KCl) in $100$ mL of $0.9\%$ sodium chloride to be administered over $1$ hour. The client has a double-lumen central venous catheter (CVC) in the right internal jugular vein. A continuous regular insulin infusion is actively running through the distal lumen. Which of the following actions should the nurse take regarding the potassium chloride administration? (Select all that apply.)

A nurse receives the shift report for a group of assigned clients on a medical-surgical trauma unit. Which client requires the nurse's immediate assessment and intervention?

A nurse is providing care for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache. Upon assessment, the nurse notes profuse diaphoresis on the client's face and neck, severe facial flushing, a blood pressure of 218/114 mm Hg, and a heart rate of 52 beats/min. The client has an indwelling urinary catheter in place. Arrange the following nursing interventions in the correct order of priority, from first to last.

An interdisciplinary team is conducting rounds on a medical-surgical unit housing clients with various infectious diseases. Which of the following observed practices indicate correct adherence to transmission-based precautions? Select all that apply.

A nurse is caring for a client admitted 12 hours ago with severe acute pancreatitis. The client's current assessment reveals pale, diaphoretic skin and a total urine output of 25 mL over the past two hours. Current vital signs are: blood pressure 84/50 mm Hg, heart rate 136 beats/min, and respiratory rate 28 breaths/min. Arterial blood gas (ABG) results show a pH of 7.28, PaCO2 of 31 mm Hg, and HCO3- of 15 mEq/L. What is the priority nursing action?

A nurse is evaluating a client who was intubated and placed on mechanical ventilation $2$ hours ago for acute respiratory failure. Current assessment findings include a heart rate of $132$ bpm, blood pressure of $86/52$ mm Hg, and cool, pale extremities. The latest arterial blood gas (ABG) results are pH $7.26$, $PaCO_2$ $62$ mm Hg, $HCO_3^-$ $25$ mEq/L, and $PaO_2$ $58$ mm Hg. Based on these assessment findings, which of the following clinical judgments and nursing actions are appropriate? Select all that apply.

A nurse assumes care for a client with severe Crohn's disease who is malnourished and receiving Total Parenteral Nutrition (TPN) via a peripherally inserted central catheter (PICC). The client's current vital signs are stable, and the continuous infusion is running on an electronic pump. Which of the following nursing actions must be included in the client's plan of care? Select all that apply.

The registered nurse (RN) is managing care delivery on an acute neurovascular step-down unit. Which task assignment demonstrates adherence to the principles of safe delegation?

A registered nurse (RN) on a neurology step-down unit is assigning tasks for the upcoming shift. The nursing team includes the RN, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP). Which of the following tasks are appropriate for the RN to delegate? Select all that apply.

The nurse is preparing to administer a large-volume cleansing enema to an adult client. Arrange the following procedural steps in the correct chronological order.

While receiving total parenteral nutrition (TPN) through a single-lumen peripherally inserted central catheter (PICC), a client suddenly develops a high fever. The healthcare provider prescribes an immediate dose of intravenous ceftriaxone. What is the most appropriate action for the nurse to take?

A registered nurse (RN) enters a preoperative staging area to witness the surgical consent signature for a 65-year-old client scheduled for a pacemaker insertion. The client's spouse and an unlicensed assistive personnel (UAP) are present. The RN notes the client is acutely lethargic and disoriented, which the spouse reports began shortly after the client received a preoperative dose of intravenous midazolam. The surgeon is waiting to proceed and requests the RN to witness the signature immediately so the surgical schedule is not delayed. Which actions by the RN are appropriate in this situation? (Select all that apply.)

A registered nurse on a medical-surgical unit receives the morning handoff report for four assigned clients. In which order should the nurse assess these clients? Arrange the clients from highest priority (first) to lowest priority (last).

A client is preparing for discharge following a 4-week hospitalization for severe Guillain-Barré syndrome. While the client's respiratory function is now stable, they exhibit significant residual weakness in their intrinsic hand muscles, preventing them from grasping eating utensils or manipulating buttons on clothing. The client's spouse expresses feeling overwhelmed about managing these daily care tasks at home and states, 'I do not know how we will afford all the special tools the doctor said we might need.' Which interdisciplinary collaboration action by the nurse is the most appropriate?

A registered nurse (RN) and an unlicensed assistive personnel (UAP) are working together on a nephrology unit. Which of the following client care activities is most appropriate for the RN to delegate to the UAP?