All practice questions

A nurse on a medical-surgical unit is evaluating the status of four assigned clients. Based on the provided clinical data, which client requires the nurse's immediate intervention?

A public health nurse is conducting a home visit for an older adult client who is the sole caregiver for a spouse with late-stage Alzheimer's disease. The client appears disheveled, paces the room rapidly, and states, 'I am so exhausted I cannot think straight. I left the stove on twice yesterday. I just want to go to sleep and never wake up.' Which action is the nurse's priority?

A community health nurse conducts a home visit for a 45-year-old client with advanced multiple sclerosis who is wheelchair-bound and completely dependent on their spouse for activities of daily living. The nurse observes that the client is wearing soiled clothing, has a strong odor of urine, and has developed unstageable pressure injuries on the sacrum. The spouse states, "I just cannot keep up with all the cleaning and turning anymore; it is entirely too much work." Which actions are appropriate for the nurse to take? Select all that apply.

A nurse is planning care for an 82-year-old client admitted with an acute exacerbation of heart failure. The client has marked lower extremity edema, requires continuous supplemental oxygen, and is on strict bed rest. During the night shift, the client becomes increasingly restless and makes repeated attempts to climb out of bed. Which of the following basic care and safety interventions should the nurse include in the client's plan of care? Select all that apply.

A client on an inpatient psychiatric unit receives a phone call regarding the sudden death of a family member. The client drops the phone, begins pacing the hallway rapidly, hyperventilating, and shouting, "I can't breathe, I'm going to die!" Arrange the following nursing interventions in the correct order of priority. All options must be used.

A nurse is caring for a client with dysphagia who is preparing to eat breakfast. Which positioning action is most appropriate to prevent aspiration?

A nurse in an ambulatory care clinic is communicating with clients who are experiencing various emotional responses to their health conditions. Match each of the nurse's statements to the specific evidence-based therapeutic communication technique it represents.

A client is receiving low continuous nasogastric suction for a small bowel obstruction. The nurse should monitor the client for which primary acid-base imbalance resulting from this therapy?

A nurse is directing the basic care and comfort measures for an 82-year-old client admitted to the medical-surgical unit with severe bilateral pneumonia. The client has a history of mild dementia and is currently experiencing significant dyspnea, generalized fatigue, and an oxygen saturation of 88% on room air. Which of the following nursing actions should the nurse include in the client's plan of care? (Select all that apply)

A nurse in a prenatal clinic is assessing a 26-year-old client at 28 weeks of gestation. The nurse observes yellow and purple bruising on the client's upper arms and neck. The client's partner is present in the examination room, sits between the client and the door, and repeatedly answers questions that the nurse directs at the client. Which of the following is the priority nursing action?

A nurse is caring for a young adult client who was recently diagnosed with multiple sclerosis. The client refuses to participate in physical therapy and tearfully states, "What is the point of trying? My body is just going to completely betray me anyway, and I will end up being a burden to my family." Which of the following nursing responses or actions demonstrate effective therapeutic communication? Select all that apply.

An inpatient psychiatric nurse approaches a client diagnosed with schizophrenia. The client is pacing rapidly in the dayroom, staring intently at an empty corner, and looking terrified. The client points to the corner and shouts, "The demons are telling me that the food here is poisoned! Tell them to be quiet! You can hear them, right?" Which of the following is the most therapeutic response by the nurse?

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

A 68-year-old client is 2 hours post-percutaneous coronary intervention (PCI) utilizing a right femoral artery approach. The arterial sheath was removed 45 minutes ago, and a mechanical compression device is currently in place. The client reports a new onset of vague right lower back and flank pain, accompanied by mild nausea. Over the past 45 minutes, the client's heart rate has progressively increased from 72 to 110 bpm, and the blood pressure has trended from 134/82 mm Hg down to 112/74 mm Hg. The right femoral insertion site is dry, intact, and free of any superficial bleeding or palpable hematoma. Which of the following actions is the priority for the nurse to perform to reduce the risk of severe physiological deterioration?

Following a percutaneous liver biopsy, a client remains on bed rest for post-procedure monitoring. Which specific clinical findings should immediately alert the nurse that this client is developing early hemorrhagic shock? Select all that apply.

A critical care nurse is evaluating a client with a history of acute severe asthma who is undergoing a spontaneous breathing trial (SBT) via a T-piece. Thirty minutes into the trial, the client becomes restless and diaphoretic. The nurse draws an arterial blood gas (ABG) sample, which reveals the following results: pH 7.28, PaCO2 56 mm Hg, PaO2 62 mm Hg, and HCO3- 24 mEq/L. To mitigate the risk of physiological decompensation, which action should the nurse take immediately?

A pediatric intensive care nurse is caring for a child who sustained a severe head injury three weeks ago. The child's parent, who has remained continuously at the bedside, suddenly stands up, forcefully knocks a chair over, and shouts, "You are all doing nothing! I cannot take another second of watching my child like this!" The parent is visibly trembling and pacing rapidly near the client's life-sustaining equipment. Which of the following is the priority nursing action?

A nurse is monitoring a client admitted with blunt abdominal trauma. The nurse suspects the client is actively bleeding internally. Which assessment findings should the nurse recognize as early compensatory signs of hypovolemic shock? (Select all that apply.)

A client is admitted to the behavioral health unit exhibiting symptoms of acute mania, including rapid pacing, loud and pressured speech, and impulsivity. The client continuously attempts to interrupt group sessions and intrudes on other clients' personal space. Which of the following nursing interventions should be included in the initial plan of care? Select all that apply.

A client is recovering on the medical-surgical unit two hours after a diagnostic lumbar puncture. The nurse enters the room and observes the client sitting upright on the edge of the bed. The client reports a severe, throbbing headache that began shortly after sitting up. Vital signs are within baseline limits. Which of the following is the most appropriate initial nursing action to reduce the client's risk for further physiological decompensation?