All practice questions

A nurse is caring for a client who requires a transfusion of packed red blood cells (PRBCs) for symptomatic anemia. The client has a single $18$-gauge peripheral intravenous (IV) catheter, which is currently infusing Lactated Ringer's solution at $75 \text{ mL/hr}$. Which of the following is the most appropriate action by the nurse?

During shift report on a progressive care unit, a nurse receives handoff for a client recovering from a massive anterior wall myocardial infarction. The previous shift's documented vital signs were: blood pressure 128/74 mm Hg, heart rate 80 beats/min, and respiratory rate 14/min. Upon initial rounds, the nurse observes the client fidgeting in bed. Vital signs are now: blood pressure 104/86 mm Hg, heart rate 118 beats/min, and respiratory rate 24/min. Which of the following conclusions should the nurse draw from this assessment?

An emergency nurse is evaluating a client with type 1 diabetes mellitus who presents with altered mental status, profound lethargy, and a distinct sweet-smelling breath odor. The client is exhibiting heavily labored respirations with an increased depth at a rate of $34$ breaths per minute. Cardiac monitoring displays sinus tachycardia at $132$ beats per minute, and the non-invasive blood pressure reads $84/44$ mm Hg. Laboratory results indicate a capillary blood glucose of $612$ mg/dL, $\text{pH}$ of $7.15$, $\text{PaCO}_2$ of $23$ mm Hg, and $\text{HCO}_3^-$ of $10$ mEq/L. Which action should the nurse execute immediately?

A clinical nurse leader is evaluating the care plan for an older adult client who is essentially bedbound due to severe generalized deconditioning and has recently developed episodic urinary incontinence. Which interventions are appropriate for the client's basic care and comfort? Select all that apply.

A nurse is caring for a client with a pulmonary embolism who is receiving a continuous intravenous (IV) infusion of unfractionated heparin through a single-lumen peripheral IV catheter. The healthcare provider prescribes a scheduled dose of IV gentamicin to be infused over $60 \text{ minutes}$. A pharmacological reference indicates that heparin and gentamicin are physically incompatible at the Y-site. Which action is most appropriate for the nurse to take?

A client admitted with septic shock is receiving a continuous intravenous infusion of norepinephrine through a single 20-gauge peripheral catheter. The healthcare provider prescribes an intermittent intravenous piggyback of ceftriaxone to be administered immediately. The nurse reviews a drug reference guide and notes that ceftriaxone is incompatible with norepinephrine. Which action should the nurse take?

A client is recovering on the medical-surgical unit shortly after undergoing an exploratory laparotomy and intestinal resection. To promptly detect and mitigate potential postoperative complications, which interventions should the nurse implement? Select all that apply.

A nurse is preparing to administer an intravenous (IV) dose of phenytoin $300\text{ mg}$ to a client with a seizure disorder. The client has a continuous IV infusion of $5\%$ dextrose in water (D5W) infusing at $75\text{ mL/hr}$ through a single peripheral IV catheter. Which of the following is the most appropriate action by the nurse?

A nurse is assessing a client who has experienced severe vomiting and diarrhea for the past 3 days. Which assessment findings indicate the client has developed early compensatory hypovolemic shock? Select all that apply.

A nurse is assessing a 45-year-old client who is 6 hours post-operative following a total thyroidectomy for Graves' disease. Which of the following clinical findings indicate a developing complication that requires IMMEDIATE intervention? Select all that apply.

A client who weighs $165\text{ lb}$ is experiencing prolonged seizure activity. The healthcare provider prescribes an intravenous (IV) loading dose of phenytoin at $15\text{ mg/kg}$. To prevent severe hypotension and cardiac dysrhythmias, institutional policy dictates that IV phenytoin must not be administered faster than $50\text{ mg/min}$.

What is the minimum time, in minutes, required to safely infuse this loading dose? Record your answer using one decimal place.

A nurse is monitoring a client who is 48 hours post-operative following an emergency bowel resection for a perforated diverticulum. The client has become increasingly restless over the past two hours. Which of the following assessment findings should the nurse identify as early (hyperdynamic) indicators of septic shock? Select all that apply.

An older adult client is being monitored in the surgical intensive care unit following an open abdominal aortic aneurysm repair. Over the past hour, the client's urine output has dropped to $15\text{ mL}$. Current vital signs reveal a blood pressure of $86/52\text{ mm Hg}$, a heart rate of $122\text{ beats/minute}$, and a respiratory rate of $26\text{ breaths/minute}$. Recent arterial blood gas results show a pH of $7.31$, a PaCO2 of $34\text{ mm Hg}$, and an HCO3 of $15\text{ mEq/L}$. Which intervention should the nurse implement first?

A client receiving a packed red blood cell (PRBC) transfusion suddenly reports severe lower back pain, chills, and shortness of breath. Suspecting an acute hemolytic transfusion reaction, arrange the following nursing actions in the correct priority order to mitigate further risk to the client.

An 82-year-old client with a long history of severe chronic obstructive pulmonary disease (COPD) is brought to the emergency department for worsening shortness of breath and a productive cough. Which assessment findings should indicate to the nurse that the client is experiencing acute hypercapnic respiratory failure rather than expected chronic baseline changes? (Select all that apply)

A nurse is caring for an adult client who has a serum potassium level of $2.8 \text{ mEq/L}$. The healthcare provider prescribes $40 \text{ mEq}$ of intravenous potassium chloride (KCl) diluted in $100 \text{ mL}$ of $0.9\%$ sodium chloride to be infused over $30 \text{ minutes}$ via a peripheral venous catheter. Which of the following is the priority nursing action?

A nurse is caring for a client who is 24 hours postoperative following an open bowel resection. The client has an intravenous line and an indwelling urinary catheter. Which change in the client's assessment provides the earliest physiological indication of a developing shock state?

A client recovering from an open femoral fracture reduction abruptly develops profound dyspnea, diaphoresis, and reports a feeling of impending doom. Current vital signs are: blood pressure $85/60$ mmHg, heart rate $132$ bpm, respiratory rate $34$ breaths/min, and oxygen saturation $86\%$ on room air. Arterial blood gas (ABG) analysis reveals: pH $7.52$, PaCO $_2$ $28$ mmHg, PaO $_2$ $54$ mmHg, and HCO $_3^-$ $24$ mEq/L. The nurse notes a rapidly narrowing pulse pressure. Which of the following is the highest priority nursing action?

A nurse is preparing a client with cirrhosis for a bedside paracentesis to relieve severe ascites. Which nursing actions are essential to reduce the client's risk for procedural and post-procedural complications? Select all that apply.

A hospitalized client with severe anemia is receiving a transfusion of packed red blood cells. Fifteen minutes after the procedure begins, the client reports acute lower back pain, sudden chills, and a sensation of chest tightness. The telemetry monitor indicates a rapid onset of sinus tachycardia. The nurse immediately halts the transfusion. What is the most critical subsequent action for the nurse to execute?