All practice questions

A charge nurse on an oncology unit is reviewing infection control practices for a client who is 14 days post-allogeneic hematopoietic stem cell transplant and has newly developed a localized dermatomal rash confirmed as herpes zoster (shingles). Which of the following actions by the healthcare team are appropriate? Select all that apply.

A healthcare provider orders haloperidol $5\text{ mg}$ intramuscularly for an agitated adult client. The pharmacy dispenses a multi-dose vial labeled haloperidol $2\text{ mg/mL}$. How many $\text{ mL}$ should the nurse draw up to administer the correct dose? Record your answer using one decimal place.

An older adult client is placed on strict bed rest due to severe generalized weakness and fragile skin. Which nursing action is most appropriate to promote comfort and prevent skin breakdown?

A client with multiple sclerosis is admitted with an acute exacerbation, experiencing severe lower extremity spasticity, profound weakness, and functional incontinence. The healthcare provider prescribes strict bed rest. The nurse is updating the plan of care to promote optimal basic care, comfort, and safety. Which of the following interventions should the nurse include? Select all that apply.

A nurse is providing care for a client recovering from a traumatic brain injury who is becoming increasingly restless and repeatedly attempting to pull out their enteral feeding tube. To ensure client safety while following the legal and ethical principle of least restrictive interventions, arrange the following nursing actions in the correct sequence from first to last.

While assuming care for a client with advanced hepatic cirrhosis who recently underwent a large-volume paracentesis, the nurse evaluates the client's current status. The procedure notes indicate that $4$ liters of ascitic fluid were removed. Which assessment finding is the most critical indicator of a developing physiological complication that requires immediate intervention?

A nurse is caring for a client who was admitted to the medical unit with a 3-day history of severe, persistent diarrhea. Based on this clinical presentation, which acid-base imbalance is the client at greatest risk of developing?

A nurse is evaluating a 64-year-old client who is 12 hours postoperative following a massive bowel resection with the creation of a colostomy. The client is receiving continuous intravenous fluids and has a nasogastric (NG) tube connected to low intermittent wall suction. Which of the following assessment findings represent a high-risk physiological complication requiring the nurse's immediate intervention? Select all that apply.

A $65$-year-old client is receiving a continuous intravenous (IV) infusion of diltiazem at $15 \text{ mg/hr}$ through a single-lumen peripherally inserted central catheter (PICC) for the management of atrial fibrillation. The client suddenly becomes lethargic and diaphoretic. The nurse assesses a heart rate of $32 \text{ beats/min}$ and a blood pressure of $72/40 \text{ mmHg}$. The healthcare provider prescribes atropine $1 \text{ mg}$ IV push STAT. The client has no other IV access. Which sequence of actions is the safest and most appropriate for the nurse to administer the prescribed atropine?

A client with a history of heart failure is admitted to the progressive care unit. During the night shift, the client suddenly awakens with severe dyspnea, a productive cough with frothy pink sputum, and an oxygen saturation of 84% on room air. The nurse observes profound jugular venous distention and hears diffuse coarse crackles upon auscultation. Arrange the following nursing actions in the correct order of priority from first to last.

A nurse is developing a plan of care for an older adult client who is bedbound, has a continuous peripheral IV infusion, and occasionally experiences urinary incontinence. The client's family reports that the client has suddenly become much more confused over the past 24 hours. Which of the following nursing actions should the nurse include in the plan of care? Select all that apply.

At the start of the night shift on a specialized neurovascular unit, a registered nurse is distributing clinical tasks among the healthcare team, which includes a licensed practical nurse (LPN/VN) and an unlicensed assistive personnel (UAP). Which of the following assignments represent safe and appropriate delegation? Select all that apply.

A nurse has completed wound care for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) of the lower extremity and influenza. The client is appropriately placed on contact and droplet precautions. The nurse is currently wearing an isolation gown, a surgical mask, a face shield, and clean gloves. Arrange the following steps for removing (doffing) the personal protective equipment in the correct chronological sequence to prevent self-contamination.

Upon receiving a prescription for a loading dose of intravenous phenytoin, a nurse evaluates a client's vascular access. The client currently has a single peripheral catheter with 5% dextrose in water (D5W) infusing at 75 mL/hr. Which sequence of actions ensures safe delivery of the antiepileptic?

A nurse is delegating care tasks to an unlicensed assistive personnel (UAP) for a client who is receiving continuous enteral tube feedings, wears bilateral sequential compression devices (SCDs), and is on contact precautions for a Clostridioides difficile infection. Which instruction provided by the nurse to the UAP is appropriate?

A client is admitted to the neurotrauma unit following a complete spinal cord injury at the C5 level. Several hours after admission, the nurse assesses the client and finds a blood pressure of 82/46 mm Hg, a heart rate of 44 beats/minute, and warm, flushed skin on the extremities. Based on these clinical findings, which intervention should the nurse anticipate as the highest priority?

A 65-year-old individual with a documented history of severe alcohol dependence and combat-related post-traumatic stress disorder is receiving treatment for acute pancreatitis. Exactly 48 hours after admission, the individual's behavior drastically changes. They begin pacing the corridor, sweating profusely, and displaying coarse bilateral hand tremors. The individual suddenly shouts, "The food here is laced with poison! I am leaving right now!" and aggressively steps toward the unit's exit doors.

What is the priority nursing intervention to safely manage this situation?

A client is receiving continuous gastric suctioning via a nasogastric tube following abdominal surgery. Based on the physiological loss of gastric secretions, which acid-base imbalance should the nurse monitor for in this client?

A client is admitted to the intensive care unit with suspected Neisseria meningitidis infection and is initially placed on standard and droplet precautions. The client's respiratory status rapidly deteriorates, necessitating an emergent endotracheal intubation. Which combination of personal protective equipment (PPE) must the nurse wear while assisting the healthcare provider with this procedure?

A client with right-sided hemiparesis requires assistance moving from the bed to a sitting position in a wheelchair. In which order should the nurse perform the following actions to safely complete this transfer?