All practice questions

A $28$-year-old client is admitted to the trauma unit after sustaining a closed pelvic fracture in a motorcycle collision. The nurse is monitoring the client for potential complications. Which of the following assessment findings suggest early physiological decompensation and require immediate intervention? (Select all that apply.)

An adult client is admitted with community-acquired pneumonia and has a continuous peripheral intravenous (IV) infusion of Lactated Ringer's solution running at $125 \text{ mL/hr}$. The healthcare provider prescribes a scheduled dose of intravenous ceftriaxone. Based on pharmacological safety principles, which action should the nurse perform?

A nurse is caring for a client with a T4 spinal cord injury who suddenly reports a severe, pounding headache. Assessment reveals profuse diaphoresis above the level of the injury, a blood pressure of 210/115 mm Hg, and a heart rate of 54 bpm. Arrange the following nursing interventions in the correct priority sequence, from first to last.

An adult client receiving a continuous $0.9\%$ sodium chloride infusion at $75\text{ mL/hr}$ through a single peripheral venous catheter is prescribed a dose of intravenous amphotericin B for a severe fungal infection. Before hanging the antifungal medication, which action must the nurse prioritize to ensure safe administration?

A nurse is assessing a client who has been receiving a continuous intravenous infusion of unfractionated heparin for four days to treat a deep vein thrombosis. The client's most recent laboratory results reveal a platelet count that has decreased from an admission baseline of $240,000/\text{mm}^3$ to $95,000/\text{mm}^3$. The nurse suspects the client is developing heparin-induced thrombocytopenia (HIT). Based on this clinical presentation, which of the following actions should the nurse take? Select all that apply.

A nurse is caring for a client who is 12 hours postoperative following an abdominal surgery and is receiving intravenous morphine via a patient-controlled analgesia (PCA) pump. Which of the following nursing actions are appropriate for the safe administration and monitoring of this therapy? (Select all that apply.)

A nurse is performing a postoperative assessment on a client who is utilizing a patient-controlled analgesia (PCA) pump with morphine following a right total knee arthroplasty. The client is lethargic, difficult to arouse, and has a respiratory rate of 8 breaths per minute with shallow chest excursion. Based on these assessment findings, which arterial blood gas (ABG) result should the nurse anticipate?

An 84-year-old client receiving treatment for a severe lower respiratory tract infection suddenly becomes acutely disoriented and forcefully attempts to remove their intravenous (IV) catheter. The healthcare provider issues a telephone prescription for bilateral soft wrist restraints. Which action by the registered nurse is the highest priority prior to implementing this prescription?

A client with viral encephalitis is experiencing severe delirium and extreme psychomotor agitation. The client abruptly lunges forward and begins forcefully pulling at their femoral arterial sheath. Recognizing an imminent risk for catastrophic hemorrhage, the nurse determines that emergency physical restraints are required. Arrange the following nursing actions in the correct chronological sequence from first to last.

At exactly $1$ minute following a spontaneous vaginal delivery, the attending nurse evaluates the newly born neonate. Assessment reveals an apical heart rate of $96$ beats per minute. The infant exhibits a slow and irregular breathing pattern. Musculoskeletal assessment demonstrates some flexion of the extremities. During the clearing of the airway with a bulb syringe, the neonate displays a grimace. Observation of the skin reveals a pink torso with distinct bluish discoloration of the hands and feet.

Calculate the newborn's $1$-minute Apgar score.

A rapid response team is called to the room of a client who was admitted with fever, night sweats, and a productive cough. The client has pending sputum cultures for Mycobacterium tuberculosis and has suddenly developed severe respiratory distress with active hemoptysis. Which of the following actions should the responding nurses take? Select all that apply.

A client presents to the obstetric clinic for an initial prenatal visit. Her obstetrical history includes a previous miscarriage at $8$ weeks gestation, a live birth of a daughter at $38$ weeks gestation, and a live birth of a son at $35$ weeks gestation. She is currently pregnant. What is the client's gravidity (G) score?

A registered nurse on a neurology step-down unit is developing a care plan for an individual with acute encephalitis who is increasingly agitated and repeatedly attempting to dislodge a central venous catheter. Arrange the following interventions in the correct sequence, from the least restrictive action to the most restrictive measure.

A Level 1 Trauma Center is notified of a multi-vehicle pileup involving a passenger bus and a chemical transport tanker. The facility's emergency operations plan is activated due to a mass casualty incident (MCI) with potential hazardous materials exposure. The emergency department (ED) charge nurse is coordinating the reception of victims.

Which actions by the charge nurse are appropriate? (Select all that apply.)

An adult client on an inpatient behavioral health unit exhibits active violent self-harm behavior, attempting to use broken plastic to inflict deep wounds. After verbal de-escalation and pharmacological interventions prove ineffective, the nurse emergently applies four-point mechanical restraints. Which actions must the nurse include in the client's plan of care? Select all that apply.

A nurse is caring for a gravid client who is progressing through the first stage of labor. Upon reviewing the fetal monitor tracing, the nurse notes a baseline fetal heart rate of 145 beats/min. Additionally, there are periodic, gradual decreases in the fetal heart rate that begin and end in exact alignment with the mother's uterine contractions. Which of the following is the most appropriate nursing action based on these findings?

A nurse is preparing to perform Leopold maneuvers on a pregnant client at $36$ weeks of gestation to assess fetal position and presentation. In what order should the nurse perform the assessment steps? Arrange the actions in the correct sequence.

An infection control nurse conducting a unit audit observes healthcare team members caring for a client placed on both airborne and enteric contact precautions due to suspected pulmonary tuberculosis and a confirmed Clostridioides difficile infection. Which of the following observed actions indicate a breach in infection control protocols that require immediate intervention? Select all that apply.

While coordinating care on a busy acute care unit, a registered nurse observes several activities being performed by the healthcare team. Which observed action poses the greatest immediate risk to client safety and necessitates an urgent intervention?

A nurse is preparing to perform Leopold maneuvers on a pregnant client to determine fetal presentation and position. Place the steps of this assessment in the correct chronological order.