All practice questions

A client with severe alcohol withdrawal syndrome is experiencing tactile hallucinations and repeatedly attempting to pull out their continuous bladder irrigation (CBI) catheter. After alternative de-escalation measures have failed, the primary healthcare provider prescribes bilateral soft wrist restraints. Arrange the following nursing actions in the correct chronological order.

An emergency department nurse is establishing a plan of care for a client admitted with a history of tonic-clonic seizures and a current upper respiratory infection. Which safety measures should the nurse implement to prevent injury during a potential seizure event? Select all that apply.

A community health nurse is conducting a home visit for a family that recently welcomed a newborn. The parents express frustration regarding sudden behavioral changes in their older children. The 2-year-old has begun throwing daily temper tantrums and refusing to eat previously favored foods. The 6-year-old has developed frequent stomach aches before school, though recent pediatric physical examinations were normal. Based on the principles of developmental stages and family transitions, which of the following nursing interpretations and corresponding anticipatory guidance is most appropriate?

An outpatient triage nurse is reviewing the electronic health records of several clients scheduled for health maintenance visits today. Based on current evidence-based guidelines, which of the following clients require immediate scheduling or referral for a specific secondary prevention health screening? Select all that apply.

A client on the cardiac step-down unit requires a continuous intravenous infusion of procainamide to manage ventricular ectopy. The healthcare provider's prescription is for $2 \text{ mg/min}$. The available premixed solution contains $2 \text{ g}$ of procainamide in $500 \text{ mL}$ of $5\%$ dextrose in water. Calculate the required infusion rate in $\text{mL/hr}$.

A registered nurse on a medical-surgical unit is coordinating the informed consent process for several clients scheduled for surgical procedures. Which of the following nursing actions regarding informed consent demonstrate safe and effective care? (Select all that apply.)

A nurse is planning care for a client who is admitted with active pulmonary tuberculosis and a concurrent *Clostridioides difficile* infection. Which of the following actions by the nurse indicate appropriate application of standard and transmission-based precautions? (Select all that apply)

A triage nurse in a pediatric acute care clinic is evaluating a 14-year-old client diagnosed with a severe complication of a sexually transmitted infection (STI). The client is highly distressed and pleads, "Please do not tell my parents how I got sick. In our culture, this brings immense shame, and they will force me to leave home. I contracted it from my 22-year-old stepbrother who lives with us." The jurisdiction allows minors to consent to STI treatment without parental notification. Which of the following is the most appropriate action for the nurse to take?

A nurse is coordinating the discharge plan for a client who underwent intermaxillary fixation (wired jaw) for complex facial fractures. The client has a history of opioid use disorder, is currently experiencing persistent nausea, and writes on a bedside whiteboard, "I have no money for those special nutritional shakes, and I am terrified of what will happen if I throw up." Which interdisciplinary collaborative action is the highest priority for the nurse to implement?

A nurse in an urgent care clinic evaluates a 24-year-old client with a profound intellectual disability who is brought in by a residential group home caregiver for a forearm laceration. During the physical assessment, the nurse discovers faded, rope-like ligature marks around both of the client's ankles. The caregiver states, "They always scratch their ankles intensely when they get upset." The client is rocking back and forth and whimpering softly. What is the priority legal responsibility of the nurse in this situation?

A 54-year-old client with chronic hepatitis C has just arrived at the medical-surgical unit after undergoing a percutaneous liver biopsy. The client is alert and reports mild discomfort at the biopsy site. Initial vital signs are stable, with a blood pressure of 118/78 mm Hg, heart rate of 82 beats per minute, and oxygen saturation of 98% on room air. Which of the following actions is the priority to minimize the client's risk of immediate post-procedure complications?

A transitional care nurse is finalizing the self-care maintenance protocol for a 74-year-old client recovering from a severe exacerbation of chronic obstructive pulmonary disease (COPD). The client has a baseline of mild cognitive decline and will receive daily assistance from a home health unlicensed assistive personnel (UAP). Which components of the self-care plan demonstrate safe and effective nursing practice? (Select all that apply.)

A client with left-sided hemiparesis following a stroke is receiving assistance with morning activities. Which actions demonstrate correct principles of basic care, comfort, and mobility for this client? Select all that apply.

A nurse is preparing an SBAR (Situation, Background, Assessment, Recommendation) report for interdisciplinary rounds regarding a client recovering from a craniotomy for a right frontal lobe tumor. The client exhibits left-sided hemiparesis and has severe baseline rheumatoid arthritis in the unaffected right hand. The nurse's assessment notes continuous coughing when drinking thin liquids, food pocketing in the left buccal cavity, and an inability to firmly grasp standard silverware. Which statement by the nurse represents the most appropriate "Recommendation" to the interdisciplinary team?

A hematopoietic stem cell transplant recipient with an absolute neutrophil count (ANC) of $150 \text{ cells}/\mu\text{L}$ develops sudden, copious, foul-smelling liquid stools. The provider suspects an infectious enterocolitis, and stool polymerase chain reaction (PCR) assays are pending. As the clinical team coordinates the client's ongoing care, which of the following interventions are appropriate for this specific presentation? Select all that apply.

A nurse discovers a small fire in a client's wastebasket. In which order should the nurse perform the following actions? Arrange the steps from first to last.

An interdisciplinary team is reviewing the case of a client admitted for osteomyelitis who has a documented history of severe substance use disorder. During the shift, the client becomes visibly agitated, accurately states the current date and location, and loudly declares the intention to leave the facility immediately before receiving the next scheduled dose of intravenous antibiotics. The client's visiting sibling insists the nursing staff must keep the client hospitalized against their will. Which nursing interventions demonstrate compliance with legal rights and responsibilities? Select all that apply.

A nurse is assessing a client who is receiving intravenous morphine via a patient-controlled analgesia (PCA) pump following orthopedic surgery. Upon entering the room, the nurse observes that the client is somnolent, has a respiratory rate of 8 breaths/min, and an oxygen saturation of 87% on room air. Which of the following immediate actions should the nurse take? Select all that apply.

A client is transferred back to the medical unit following a percutaneous liver biopsy. The nurse is assisting the client into bed. To minimize the risk of post-procedure hemorrhage, which position should the nurse place the client in?

A client presents to the clinic following a sudden, traumatic workplace incident. The client is pacing rapidly, wringing their hands, and states, "I cannot think straight. I am going to lose my mind!" The client's respiratory rate is 32 breaths per minute. Which of the following is the priority nursing intervention?