All practice questions

An older adult client is admitted to the medical-surgical unit with generalized weakness, poor oral intake, and frequent episodes of fecal incontinence. The client occasionally exhibits periods of confusion and is currently bed-bound. Which interventions should the nurse include in the client's plan of care to promote comfort and prevent skin breakdown? Select all that apply.

A registered nurse is caring for an older adult client with hepatic encephalopathy who is highly agitated, confused, and repeatedly attempting to climb over the bed rails. The client is receiving continuous intravenous (IV) fluids and has an active Clostridioides difficile infection requiring contact precautions. Which action by the nurse is the MOST appropriate priority intervention to prevent client injury?

A nurse is caring for a 65-year-old client who is receiving an intravenous infusion of alteplase (rtPA) for an acute ischemic stroke. Thirty minutes into the infusion, the client reports a sudden, severe headache, becomes intensely nauseous, and exhibits a new unilateral pupillary dilation. To reduce the risk of catastrophic neurological deterioration, arrange the following nursing actions in the correct priority order from first to last.

A registered nurse is caring for a laboring client at 39 weeks of gestation. While observing the external fetal monitor, the nurse notes abrupt decreases in the fetal heart rate from a baseline of 140/min to 105/min, lasting approximately 20 seconds before rapidly returning to baseline. These decreases are V-shaped and occur inconsistently, often independent of uterine contractions. Based on these findings, what is the priority nursing intervention?

A nurse is caring for an older adult client who was recently admitted with bacterial pneumonia and has suddenly developed acute delirium. The client is highly restless, disoriented to place, and repeatedly attempts to climb over the bed rails. The client's visiting family member expresses intense concern and insists that physical restraints be applied immediately to prevent a fall. Which action should the nurse take first?

A clinical team is preparing a unit to receive a direct admission from an outpatient clinic. The client has a history of night sweats and hemoptysis, and a chest radiograph shows upper lobe cavitary lesions. Additionally, the clinic report notes a heavily draining sacral wound that recently cultured positive for Methicillin-resistant Staphylococcus aureus (MRSA). Which of the following infection control interventions should the receiving nurse implement? Select all that apply.

A clinical nurse educator is observing staff members delivering care on a medical-surgical unit. Which observation requires the educator to intervene immediately to prevent client injury?

A nurse preceptor is observing a newly graduated registered nurse (RN) implement infection control measures on a medical-surgical unit. Which of the following actions by the new RN demonstrate correct application of standard and transmission-based precautions? Select all that apply.

An infection control nurse is reviewing the electronic health records of newly admitted clients to ensure appropriate transmission-based protocols are active. Correlate each client's specific clinical presentation with the precise isolation requirements necessary for their care.

A nurse is caring for a client in active labor whose membranes have just spontaneously ruptured. Upon visual inspection of the perineum, the nurse observes a portion of the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?

A client is brought to the emergency department experiencing a severe panic attack. The client is visibly anxious, diaphoretic, and breathing rapidly at a rate of 34 breaths per minute. Which of the following arterial blood gas (ABG) values would the nurse anticipate for this client? Select all that apply.

The nurse receives a client who has just returned to the nursing unit following a diagnostic cardiac catheterization performed via the right femoral artery. Which of the following positioning interventions is most important for the nurse to implement to reduce the risk of postoperative bleeding?

A nurse is preparing to assist a client who has dysphagia and right-sided facial weakness with a meal. Arrange the following nursing actions in the correct chronological sequence to ensure safe oral intake and prevent aspiration. All options must be used.

A nurse assumes care for a postoperative client who just arrived from the surgical recovery room after an exploratory laparotomy. The client has an active Vancomycin-resistant Enterococcus (VRE) infection in the peritoneal cavity and multiple surgical drains in place. Which of the following actions should the nurse implement? Select all that apply.

A nurse is preparing to administer a prescribed intravenous (IV) antibiotic intermittent infusion (piggyback) to a client who is currently receiving a continuous IV infusion of 0.9% sodium chloride. Which of the following is the priority nursing action before initiating the antibiotic infusion?

An intensive care nurse is caring for a hemodynamically unstable client who has a triple-lumen central venous catheter. The current continuous intravenous (IV) infusions are:

* Proximal port: Total parenteral nutrition (TPN)
* Medial port: 0.45% sodium chloride with 20 mEq/L of potassium chloride at 75 mL/hr
* Distal port: Propofol emulsion for continuous sedation

The client's mean arterial pressure abruptly drops to 54 mmHg. The healthcare provider prescribes an immediate 500 mL IV bolus of 0.9% sodium chloride and a continuous infusion of norepinephrine. Which action demonstrates the safest administration of these new prescriptions?

An obstetric nurse is evaluating the electronic fetal monitoring strip of a gravida 2, para 1 at 39 weeks of gestation. The tracing displays gradual, symmetric decreases in the fetal heart rate that perfectly align with the beginning, peak, and end of each uterine contraction. Which of the following is the most appropriate action for the nurse to take?

A nurse is caring for a client weighing $80\text{ kg}$ who is admitted with acute decompensated heart failure. The client is receiving a continuous intravenous infusion of milrinone at $0.5\text{ mcg/kg/min}$ via a single patent 20-gauge peripheral IV line in the left forearm.

The client's respiratory status acutely worsens, with oxygen saturation dropping to 84% on room air and severe bilateral crackles present on auscultation. The healthcare provider prescribes a stat dose of furosemide $1\text{ mg/kg}$ IV push.

The available furosemide vial concentration is $10\text{ mg/mL}$. Facility policy mandates that IV furosemide must not be administered faster than $20\text{ mg/min}$ to prevent ototoxicity.

After multiple unsuccessful attempts to establish a second peripheral IV line by the vascular access team, which of the following is the most appropriate action by the nurse?

An older adult client with a history of heart failure is prescribed daily oral digoxin and furosemide. During the morning rounds, the client reports a new onset of loss of appetite, mild nausea, and seeing a 'yellowish haze' around the lights in the room. Which of the following actions should the nurse take first?

A nurse is receiving shift report for a group of clients on the postpartum unit. Which client should the nurse assess first?