All practice questions

A nurse is caring for a client who was admitted 72 hours ago for a severe respiratory infection. The client suddenly becomes extremely agitated, exhibits profuse diaphoresis, and frantically states, "There are spiders crawling all over the walls!" The client's spouse reports that the client usually drinks a pint of vodka daily but abruptly stopped on the day of admission. Arrange the following nursing actions in the correct prioritized sequence from first to last.

A nurse is caring for a client who is receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes after the infusion begins, the client suddenly reports severe lower back pain, chills, and shortness of breath. What is the priority sequence of nursing actions to minimize the risk of further physiological deterioration? Arrange the steps in the correct chronological order.

A nurse is removing a non-tunneled central venous access device (CVAD) from a client's right subclavian vein. Immediately after the catheter is withdrawn, the client exhibits sudden, severe dyspnea, diaphoresis, and a loud, continuous "churning" murmur over the precordium. To mitigate the risk of fatal hemodynamic collapse, arrange the following nursing actions in the priority order they should be performed. (Place the first action at the top and the last action at the bottom.)

A 15-year-old client is receiving treatment in the emergency department for injuries sustained in a sports accident. The client's divorced parents are arguing loudly in the hallway outside the room regarding the proposed treatment plan, which is visibly upsetting the conscious client. In what order should the nurse perform the following actions to de-escalate the family crisis and establish boundaries? Arrange the nursing actions from first to last.

A nurse is removing a central venous catheter from a client's subclavian vein. Immediately after the catheter is withdrawn, the client suddenly gasps for air, reports sharp chest pain, and becomes severely dyspneic and pale. Suspecting an air embolism, arrange the following nursing actions in the priority order they should be performed to reduce the risk of a fatal cardiopulmonary complication.

A client on a medical-surgical unit is receiving an infusion of packed red blood cells (PRBCs) for symptomatic anemia. Ten minutes after the transfusion begins, the client reports sudden severe lower back pain, dyspnea, and chills. The nurse notes visible flushing and shivering. Place the following nursing interventions in the correct order of priority. (Arrange from first action to last action.)

A nurse is caring for an alert and oriented client with diabetes mellitus who reports feeling shaky and sweaty. The client's capillary blood glucose level is 55 mg/dL. Arrange the following nursing interventions in the correct order of priority.

A nurse is educating a client who has a right fractured tibia and is prescribed non-weight-bearing status. The client is learning to ascend a flight of stairs using axillary crutches. In what order should the nurse instruct the client to perform the following movements?

A registered nurse (RN) on a medical-surgical unit is preparing to delegate the insertion of a straight urinary catheter for a client with acute urinary retention to a licensed practical/vocational nurse (LPN/VN). Arrange the following steps of the delegation process in the correct chronological order according to national delegation guidelines. (Place the first step at the top and the final step at the bottom.)

An older adult client with advanced Alzheimer's disease is admitted for severe dehydration. The client continuously attempts to pull out their peripheral intravenous (IV) line despite the implementation of multiple non-restrictive safety measures. The healthcare provider has prescribed bilateral soft wrist restraints. Arrange the following nursing actions in the correct sequence of execution from first to last.

A client requires a large-volume cleansing enema to relieve severe constipation. In what chronological sequence should the nurse perform the steps of this procedure?

A nurse is preparing to remove a client's non-tunneled percutaneous central venous catheter (CVC). To minimize the risk of an air embolism, in what order should the nurse perform the following actions? Arrange the steps in the correct sequence from first to last.

A critically ill client is admitted to the intensive care unit with a diagnosis of severe diabetic ketoacidosis. Initial laboratory results reveal a serum glucose of $815$ mg/dL ($45.2$ mmol/L), an arterial pH of $7.08$, and a serum potassium of $3.0$ mEq/L ($3.0$ mmol/L). The client exhibits profound lethargy, deep and rapid respirations, and poor skin turgor. Arrange the following therapeutic interventions in the correct physiological priority sequence to safely manage this client's acute decompensation.

A triage nurse in the emergency department receives a client with acute kidney injury secondary to severe rhabdomyolysis. The client reports profound muscle weakness. A STAT 12-lead electrocardiogram reveals absent P waves, a heart rate of $42\text{ bpm}$, and markedly widened QRS complexes. Arrange the following nursing actions in the most appropriate priority order from first to last.

A client is 6 hours post-coronary artery bypass graft (CABG) surgery and is receiving mechanical ventilation. The intensive care nurse notes that the mediastinal chest tube drainage, which had been steadily draining $100\text{ mL/hr}$, has abruptly ceased over the past 45 minutes. The client's blood pressure drops from $115/75\text{ mmHg}$ to $82/64\text{ mmHg}$, heart rate increases from $85\text{ bpm}$ to $128\text{ bpm}$, and central venous pressure (CVP) rapidly rises from $8\text{ mmHg}$ to $19\text{ mmHg}$. Jugular venous distension is visible. The nurse suspects acute cardiac tamponade. Place the following collaborative and nursing actions in the correct priority sequence.

A $34$-year-old client with a known history of Graves' disease is admitted to the progressive care unit exhibiting extreme restlessness, profound diaphoresis, and delirium. Current vital signs reveal a heart rate of $188\text{ beats/min}$, blood pressure of $182/104\text{ mmHg}$, and a core temperature of $40.6^\circ\text{C}$ ($105.1^\circ\text{F}$). The client is diagnosed with a thyrotoxic crisis (thyroid storm). The healthcare provider prescribes several emergent interventions. Arrange the following actions in the correct physiological priority order.

A nurse is caring for a client with a complete $T4$ spinal cord injury. The client suddenly reports a severe, pounding headache and blurred vision. The nurse observes profuse diaphoresis and flushing above the level of the spinal lesion, accompanied by marked pallor and piloerection below the lesion. The client's blood pressure is $220/115$ mmHg and heart rate is $48$ bpm. Place the following nursing interventions in the correct sequence of priority to manage this acute complication.

A nurse is caring for a client who is 4 hours postoperative following a coronary artery bypass grafting (CABG) procedure. The client suddenly exhibits profound hypotension, pronounced jugular venous distention, muffled heart sounds, and a precipitous drop in mediastinal chest tube drainage. Arrange the following nursing actions in the priority order they should be executed.

A registered nurse realizes that an incorrect intravenous (IV) high-alert medication has just been initiated for an adult client. Arrange the following nursing actions in the priority sequence the nurse should perform them to mitigate harm and manage the error.

A nurse working at the emergency department triage desk receives a telephone call from an unknown individual stating that an explosive device has been placed in the hospital. Arrange the following actions in the correct priority sequence the nurse should take according to standard emergency response protocols. (Order from first action to last action)