All practice questions

A nurse is admitting a young adult client who sustained a severe, permanent spinal cord injury three days ago. While staring at the ceiling, the client says to the nurse, "I don't know why the paramedics even bothered to save me. Being paralyzed is worse than being dead." Which of the following is the most therapeutic response by the nurse?

A client in cardiogenic shock is receiving a continuous intravenous (IV) infusion of dopamine through a single-lumen peripheral IV line. The healthcare provider prescribes a stat dose of furosemide $120$ mg IV push for acute pulmonary edema. The facility protocol dictates that furosemide should not be administered faster than $20$ mg/minute to prevent adverse effects. Furosemide is physically incompatible with dopamine. Based on these parameters, which action by the nurse is the safest and most appropriate?

A nurse is planning basic care for an older adult client who is completely bedbound and requires assistance with all activities of daily living. Which interventions should the nurse include in the plan of care to maintain skin integrity and promote comfort? Select all that apply.

The healthcare provider prescribes a $100\text{ mL}$ intravenous piggyback infusion of ceftriaxone to run over $30\text{ minutes}$. At what rate, in $\text{mL/hr}$, will the nurse set the electronic infusion pump? (Record your answer as a whole number).

While managing a client in the intensive care unit who is in profound distributive shock, the nurse notes the client has developed severe, unsafe psychomotor agitation. The client's only vascular access is a single-lumen central venous catheter (CVC) currently infusing norepinephrine at $0.2 \text{ mcg/kg/min}$ to maintain a mean arterial pressure greater than $65 \text{ mm Hg}$. The provider prescribes a stat dose of intravenous (IV) midazolam $2 \text{ mg}$. Which of the following is the safest and most appropriate action for the nurse to take?

A nurse is monitoring a client who is receiving an intravenous (IV) transfusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion begins, the client reports sudden lower back pain and chills. The client's heart rate increases from 82 to 118 beats/min, and blood pressure drops from 124/76 mm Hg to 92/58 mm Hg. Which of the following is the priority nursing action?

A school nurse is caring for a high school student who just witnessed a severe physical altercation between peers in the hallway. The student is pacing rapidly around the health office, demonstrating tachypnea, and shouting, "I am not safe anywhere! They are going to come after me next!" Which of the following is the priority nursing intervention?

A nurse is caring for a client hospitalized with acute pancreatitis related to heavy, daily alcohol consumption. The client reports their last alcoholic beverage was approximately 14 hours ago. During morning rounds, the client is pacing the room continuously, appears highly anxious, and repeatedly demands to leave the facility against medical advice. Current vital signs reveal a heart rate of 112 bpm, blood pressure of 148/92 mm Hg, and mild diaphoresis. Which action is the priority for the nurse to implement?

A 10-year-old child with a cognitive disability is brought to the emergency department by a caregiver. The child has an actively bleeding scalp laceration, and the nurse observes patterned, defensive bruising on the child's forearms. The caregiver's explanation of the injuries is inconsistent with the physical findings. Arrange the following nursing actions in the correct order of priority from first to last.

A nurse is planning care for a 78-year-old client with Parkinson's disease and severe dysphagia who was recently admitted with aspiration pneumonia. The client is receiving continuous enteral feedings via a nasogastric tube and has a highly friable stage 3 sacral pressure injury. Upon assessment, the nurse notes the client is newly confused, restless, and repeatedly grasping at the nasogastric tube. Which comprehensive intervention is the most appropriate for the nurse to implement?

A nurse is assigned to care for a client with a mechanical bowel obstruction who has had a nasogastric (NG) tube connected to low intermittent suction for the past $48$ hours. The client's morning arterial blood gas (ABG) results reveal a pH of $7.52$, a PaCO $_2$ of $42$ mm Hg, and an HCO $_3^-$ of $34$ mEq/L. Which of the following nursing interventions should be implemented to reduce the risk of further physiological complications? Select all that apply.

A nurse is caring for a client who is 1 day postoperative following a total abdominal hysterectomy. Which of the following interventions should the nurse implement to reduce the risk of developing a deep vein thrombosis (DVT)? Select all that apply.

A nurse is preparing to initiate a transfusion of packed red blood cells (PRBCs) for a client with symptomatic anemia. Which intravenous (IV) fluid should the nurse use to prime the blood administration tubing?

A client is received on the medical unit directly after a percutaneous liver biopsy. To mitigate the primary risk associated with this procedure, which positioning strategy must the nurse implement?

A nurse enters the room of a client with a history of severe opioid use disorder and finds the client unresponsive, cyanotic, and exhibiting a respiratory rate of 4 breaths/min with pinpoint pupils. Arrange the following nursing interventions in the correct order of priority, from first to last.

A nurse is caring for a 45-year-old client who is 12 hours postoperative following an extensive small bowel resection for mesenteric ischemia. The client is intubated, receiving mechanical ventilation with a positive end-expiratory pressure (PEEP) of 10 cm $H_2O$, and has a central venous catheter. The nurse is evaluating the client to reduce the risk of potential complications. Which of the following findings or observed nursing actions indicate an imminent risk for physiological decompensation or client harm? Select all that apply.

A nurse is caring for a critically ill client who is experiencing septic shock and new-onset tonic-clonic seizures. The client has a double-lumen central venous catheter (CVC) in place. Lumen one is infusing continuous total parenteral nutrition (TPN), and lumen two is infusing continuous norepinephrine. The healthcare provider prescribes a stat dose of intravenous (IV) push phenytoin. Which of the following actions by the nurse demonstrate safe pharmacological and parenteral management? (Select all that apply)

A nurse is interacting with an older adult client who recently experienced a severe ischemic stroke and is scheduled to transfer to a long-term care facility. The client stares out the window and tearfully states, "I never imagined my life would end up this way. I am losing my home, my garden, and everything I worked for. I will just be sitting in some room waiting for the end." Which of the following responses by the nurse is the most therapeutic?

A nurse is caring for a client who is receiving an infusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion begins, the client reports sudden lower back pain, chills, and shortness of breath. In which order should the nurse perform the following actions? Arrange the actions from first to last.

A home health nurse evaluates a client who provides full-time care for a spouse with advanced Alzheimer's disease. The client exhibits unintended weight loss, a flat affect, and reports chronic insomnia. The client states, "I am completely exhausted, but I cannot let anyone else help. If I don't do every single task myself, my spouse will suffer." Which action should the nurse take first to facilitate effective stress management?