Tüm alıştırma soruları

2933 soru

Soru 2121Soru →

A practical nurse is preparing to obtain a capillary blood glucose measurement for a client with diabetes mellitus. In which order should the nurse perform the following actions to ensure an accurate result and reduce the risk of complications? Arrange the steps from first to last.

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Cevap

The correct sequence is to first verify the client's identity, cleanse the site and allow it to air-dry, puncture the fingertip, wipe away the first drop of blood, and finally apply the second drop of blood to the test strip.
To safely and accurately obtain a capillary blood glucose measurement, the nurse must follow a specific sequence. First, verifying client identity is a mandatory safety standard to prevent errors. Next, cleansing the site and letting it air-dry reduces the risk of infection and prevents chemical interference from the alcohol. Puncturing the lateral aspect of the finger minimizes pain. Wiping away the first drop of blood is a critical step to reduce risk potential, because it contains interstitial fluid and alcohol that can skew results. Finally, testing the newly formed second drop ensures an accurate representation of the client's capillary blood glucose.

Adım Adım Çözüm

1
Identify the foundational safety requirement before any procedure.
Verifying the client's identity using two identifiers is the first step.
This prevents medical errors and ensures the correct client is being tested.
2
Determine the necessary site preparation.
The nurse must cleanse the site with an antiseptic swab and let it air-dry completely.
This reduces the risk of introducing infection and prevents residual alcohol from chemically altering the test result.
3
Identify the correct technique for obtaining the sample.
The side of the fingertip is punctured with a sterile lancet.
The lateral side of the finger pad has fewer nerve endings, minimizing client discomfort.
4
Determine the proper handling of the blood sample.
The nurse must wipe away the first drop of blood with dry gauze.
The first drop contains tissue fluid that can cause a falsely altered glucose reading.
5
Identify the final action for testing.
The second drop of blood is applied to the test strip.
This ensures the glucose monitor reads a pure capillary blood sample.

Anahtar Kavram

Capillary Blood Glucose Specimen Collection Protocol
Soru 2122Soru →

A practical nurse is preparing to administer an intramuscular injection of iron dextran to an adult client diagnosed with severe iron deficiency anemia (hemoglobin 7.2 g/dL). To prevent medication leakage and permanent skin staining, the nurse must use the Z-track method. Arrange the following steps of the Z-track administration technique in the correct chronological order.

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Cevap

The correct sequence for the Z-track method is to first change the needle, then displace the skin laterally, insert the needle and inject slowly, wait 10 seconds, and finally withdraw the needle while immediately releasing the skin.
The Z-track method is a specialized intramuscular injection technique designed to prevent leakage of irritating or staining medications into the subcutaneous tissue. The correct sequence ensures a clean needle enters the skin, the superficial tissues are displaced to create a staggered track, the medication is deposited and given time to disperse in the muscle, and finally, the track is permanently sealed by releasing the skin simultaneously as the needle is withdrawn.

Adım Adım Çözüm

1
Change the needle on the syringe after drawing up the prescribed dose of iron dextran.
The needle shaft entering the client is completely clean.
Prevents tracking of the dark, irritating iron medication through the superficial subcutaneous tissues upon insertion.
2
Use the non-dominant hand to pull the skin and subcutaneous tissue 1 to 1.5 inches laterally from the injection site.
The tissue layers are misaligned.
Prepares the Z-track zigzag pathway required to lock the medication deep within the muscle.
3
Insert the needle at a 90-degree angle and push the plunger slowly to administer the medication.
Medication is deposited into the deep muscle layer.
Intramuscular administration requires a 90-degree angle for proper depth, and slow injection minimizes tissue tearing.
4
Leave the needle inserted in the muscle for 10 seconds after the medication is completely injected.
The medication begins to absorb and disperse.
Prevents the medication from pooling and being forced back up the track upon immediate needle removal.
5
Withdraw the needle smoothly and immediately release the taut skin.
The tissue layers slide back into their original, aligned position.
Closes off the needle track, effectively sealing the irritating iron dextran within the muscle tissue and preventing leakage.

Anahtar Kavram

Pharmacological Therapies
Soru 2123Soru →

A practical nurse is talking with the parent of a 14-year-old client during a community health fair. The parent expresses concern that the adolescent spends significant time grooming, frequently alters their clothing style, and prioritizes peer group activities over family events. Based on expected developmental stages, what is the most appropriate information for the nurse to reinforce?

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Cevap: These actions are typical as the adolescent works to establish a sense of personal identity.

Cevap

These actions are typical as the adolescent works to establish a sense of personal identity.
According to Erikson's theory of psychosocial development, adolescents (typically ages 12 to 18) are in the stage of Identity versus Role Confusion. During this transition, it is entirely normal for teens to become highly focused on their appearance, try out different clothing styles, and rely heavily on their peer group for social validation. These behaviors help them differentiate from their parents and establish a unique personal identity. The practical nurse should reassure the parent that these are expected, healthy developmental milestones.

Adım Adım Çözüm

1
Analyze the client's chronological age and the behaviors reported by the parent.
The client is 14 years old, focusing heavily on physical appearance, changing styles, and prioritizing peer relationships.
Identifying the age helps determine the expected developmental stage according to established psychosocial theories.
2
Correlate the client's age with Erikson's stages of psychosocial development.
A 14-year-old is in the adolescent stage, which corresponds to the core conflict of Identity versus Role Confusion.
Understanding the correct developmental stage allows the nurse to distinguish between normal developmental milestones and abnormal behaviors.
3
Evaluate the parent's specific concerns against the expected milestones for this stage.
Experimenting with styles and prioritizing peer interactions are normal, healthy ways adolescents explore and establish their independent personal identity.
The nurse must reinforce accurate developmental expectations to alleviate unwarranted parental anxiety and support the client's healthy growth.

Anahtar Kavram

Adolescent Psychosocial Development (Identity vs. Role Confusion)
Soru 2124Soru →

A client with end-stage chronic obstructive pulmonary disease (COPD) has just been transitioned to comfort care measures. The client's adult child yells at the practical nurse (PN), "You are all just giving up! There must be another medication you can try!" Which response by the PN is the most therapeutic?

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Cevap: It sounds like you are feeling overwhelmed and upset about this transition.

Cevap

The response that reflects and validates the family member's feelings of being overwhelmed and upset.
The correct answer uses reflection to acknowledge and validate the family member's underlying feelings of being overwhelmed and upset. This technique demonstrates empathy and keeps the lines of communication open, allowing the family member to express their anticipatory grief safely without feeling judged.

Adım Adım Çözüm

1
Analyze the family member's statement and emotional state.
The family member is experiencing anticipatory grief and expressing it through anger and denial.
Recognizing the underlying emotion is essential for selecting an appropriate therapeutic response.
2
Evaluate the options against therapeutic communication principles.
The correct response uses reflection and empathy. Other options are defensive, use 'why' questions, or inappropriately attempt to categorize the grief.
Validating feelings encourages open communication and builds trust without being dismissive or argumentative.

Anahtar Kavram

Therapeutic communication and anticipatory grief
Soru 2125Soru →

During morning rounds on the orthopedic unit, a practical nurse evaluates a client who underwent a right total knee arthroplasty (TKA) earlier today. To promote safety and optimal joint recovery, which basic care and comfort measures must the nurse incorporate into the plan of care? Select all that apply.

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Cevap: Position a rolled towel under the right lower leg and ankle to suspend the heel off the bed.; Maintain the operative knee in a neutral, extended position while the client is resting.; Apply a prescribed continuous cold therapy wrap around the right knee.; Encourage the client to perform ankle pumping exercises on both legs hourly while awake.

Cevap

The correct interventions are: positioning a rolled towel under the ankle, maintaining the knee in an extended position, applying cold therapy, and encouraging the client to perform ankle pumping exercises.
Safe basic care following a total knee arthroplasty focuses on preventing contractures, promoting circulation, and ensuring skin integrity. Maintaining the knee in a neutral, extended position ensures the joint heals without a flexion contracture. Placing a rolled towel under the ankle suspends the vulnerable heel off the mattress to prevent pressure ulcers. Ankle pumping exercises engage calf muscles to promote venous return and prevent deep vein thrombosis. Applying a prescribed cold therapy wrap effectively decreases postoperative edema and provides localized pain relief.

Adım Adım Çözüm

1
Identify the surgical procedure and its specific postoperative risks.
The client had a right total knee arthroplasty (TKA). Primary risks include knee flexion contractures, deep vein thrombosis (DVT), postoperative edema, and pressure ulcers.
Understanding the specific complications of a TKA guides the selection of safe positioning and comfort measures.
2
Evaluate each intervention for its effect on joint mobility and venous return.
Keeping the knee extended prevents contractures. Ankle pumping promotes venous return. Pillows under the knee or using a knee gatch cause flexion and popliteal compression, which are unsafe.
Postoperative positioning must balance immediate client comfort with the prevention of long-term immobility complications.
3
Evaluate each intervention for basic skin care and pain management.
Suspending the heel prevents skin breakdown. Cold therapy effectively manages pain and swelling.
Basic care involves protecting skin integrity and utilizing non-pharmacological comfort strategies.

Anahtar Kavram

Postoperative Basic Care and Proper Positioning for Total Knee Arthroplasty
Tahmini Süre:1m 30s
Soru 2126Soru →

A client who underwent a lumbar laminectomy the previous day requires morning care. To ensure safety and comfort, which actions should the practical nurse incorporate into the care plan? Select all that apply.

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Cevap: Turn the client as a single unit using the logrolling method.; Place a pillow between the client's knees when lying on their side.; Maintain the client's spinal alignment when assisting with bed mobility.

Cevap

The correct actions include turning the client as a single unit, placing a pillow between the knees when side-lying, and maintaining spinal alignment during mobility.
Following a lumbar laminectomy, the primary goal of basic care is to maintain the spine in a neutral position to facilitate healing and prevent injury. Logrolling, keeping a pillow between the legs to prevent hip rotation, and generally maintaining strict spinal alignment are all essential, safe practices that accomplish this goal.

Adım Adım Çözüm

1
Identify the surgical procedure and its implications for basic care.
The client had a lumbar laminectomy, meaning the lower spine requires strict alignment and protection from stress.
Understanding the anatomical site of surgery dictates safe mobility and positioning.
2
Evaluate each intervention for its effect on spinal alignment.
Logrolling, using a pillow between the knees, and general spinal alignment protect the back. High-Fowler's position and twisting put dangerous stress on the lumbar region.
Nursing actions must prevent complications and promote healing.

Anahtar Kavram

Postoperative spinal precautions and proper positioning
Soru 2127Soru →

A client who is observing a religious month of daytime fasting is discussing lifestyle choices for weight management with the practical nurse. The client states, "I tend to overeat heavy, fried foods during the evening meal after fasting all day." Which response by the nurse is most appropriate?

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Cevap: Let us explore some traditional foods you enjoy and discuss ways to prepare them using less oil.

Cevap

The most appropriate response is to explore the client's traditional food preferences and discuss healthier preparation methods.
The correct response is therapeutic, culturally respectful, and safely within the scope of a practical nurse. It focuses on gathering more data about the client's preferences and reinforcing previous teaching about healthy cooking methods, which supports the client's lifestyle choices without undermining their religious practices.

Adım Adım Çözüm

1
Analyze the client's statement and the context of religious fasting.
The client is experiencing a challenge with lifestyle modifications (overeating fried foods) while adhering to cultural or religious practices.
Understanding the contextual barriers is essential for providing culturally competent care and reinforcing appropriate lifestyle choices.
2
Evaluate the nursing responses based on therapeutic communication, cultural sensitivity, and scope of practice.
Responses asking 'why' or dismissing the cultural practice are inappropriate. Formulating a new comprehensive plan is out of the practical nurse's scope.
Eliminating options that violate communication principles or scope of practice isolates the correct intervention.
3
Select the response that supports the client therapeutically and remains within the practical nursing scope.
The correct response involves data collection (exploring preferences) and reinforcing education (healthier preparation), which respects the client's culture and adheres to the practical nurse's role.
This approach empowers the client to make healthier lifestyle choices without compromising their religious observances.

Anahtar Kavram

Culturally Competent Care and Scope of Practice in Lifestyle Modifications
Soru 2128Soru →

A practical nurse (PN) is observing a client who is receiving continuous enteral tube feedings. The client suddenly begins coughing forcefully and appears dyspneic. Arrange the following nursing actions in the priority order the PN should perform them.

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Cevap

The correct sequence is to first stop the feeding, then position the client, check respiratory status, and finally notify the RN.
In any acute respiratory event during a continuous feeding, the immediate priority is to stop the feeding to prevent further aspiration. Next, the airway must be protected by positioning the client appropriately. Once the immediate threat is mitigated, the nurse gathers data on the client's respiratory status to determine the severity of the event. Finally, the nurse reports the findings and actions to the RN.

Adım Adım Çözüm

1
Stop the continuous enteral feeding pump.
Further risk of aspiration is immediately halted.
According to the airway, breathing, circulation (ABC) priority framework, removing the source of airway compromise is the most critical first action.
2
Position the client on their side or in high Fowler's position.
The airway is cleared and protected.
This positioning utilizes gravity to prevent aspiration of any remaining fluids in the oropharynx.
3
Check the client's oxygen saturation level and count the respiratory rate.
The client's clinical status is evaluated.
Data collection determines the severity of the respiratory compromise and guides further interventions.
4
Notify the registered nurse (RN).
Higher-level care is initiated.
The PN must report acute changes in condition to the RN for potential modifications to the plan of care.

Anahtar Kavram

Airway and breathing prioritization during continuous enteral feeding complications
Soru 2129Soru →

A 45-year-old client on a medical unit is prescribed antibiotic ear drops for an acute outer ear infection. Which of the following techniques should the practical nurse use when administering this medication?

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Cevap: Pull the client's pinna upward and backward before instilling the drops.

Cevap

The practical nurse should pull the pinna upward and backward to straighten the ear canal for an adult client.
For clients older than 3 years of age and adults, the ear canal is straightened by gently pulling the pinna upward and backward. This essential anatomical adjustment ensures the medication flows deeply into the ear canal to treat the infection effectively.

Adım Adım Çözüm

1
Identify the age of the client.
The client is 45 years old (an adult).
Ear drop administration techniques differ based on whether the client is an adult or a child under 3 years old.
2
Determine the correct anatomical maneuver to straighten the ear canal for this age group.
The pinna must be pulled upward and backward.
In adults, pulling the pinna upward and backward aligns the ear canal so that the medication can reach the affected area effectively.
3
Evaluate the other administration safety principles.
Medication should be room temperature and the client should be side-lying.
These steps prevent adverse vestibular reactions (vertigo) and ensure the medication remains in the ear.

Anahtar Kavram

Otic Medication Administration in Adults
Soru 2130Soru →

During morning rounds, a client is scheduled to receive a daily dose of levothyroxine 75 mcg75\text{ mcg} PO. The practical nurse accesses the automated dispensing cabinet and retrieves a scored tablet labeled 0.15 mg0.15\text{ mg}. Upon seeing the prepared medication, the client remarks, 'I always take a pink pill for my thyroid, but this one is white. Is there a mistake?' Which action should the practical nurse take next?

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Cevap: Withhold the medication and perform a complete verification of the prescription, the medication label, and the dosage calculation.

Cevap

The practical nurse should withhold the medication and perform a complete verification of the prescription, the medication label, and the dosage calculation.
When a client questions a medication's appearance or dosage, it is a critical safety alert. The practical nurse must immediately withhold the medication and re-verify the original prescription, the pharmacy label, and the dosage calculation to ensure the 'right drug' and 'right dose' before proceeding.

Adım Adım Çözüm

1
Listen to the client's concern regarding the medication's appearance.
The client actively questions the color of the pill, indicating it differs from their usual home medication.
Client statements about unfamiliar medications are a primary safeguard against medication administration errors.
2
Withhold the scheduled medication.
The administration is safely paused.
The nurse must never administer a medication when there is an unresolved question about its identity or dosage.
3
Re-verify the medication rights.
The prescription, MAR, medication label, and dosage calculation are checked again.
This confirms whether the medication provided is correct (e.g., a generic substitution) or if a dispensing error occurred.

Anahtar Kavram

Safe medication administration and client advocacy
Soru 2131Soru →

A practical nurse (PN) is evaluating a client two hours after a percutaneous liver biopsy. Which assessment finding requires immediate notification to the registered nurse (RN)?

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Cevap: A heart rate of 115 beats/min and a blood pressure of 88/56 mm Hg

Cevap

The finding of a heart rate of 115 beats/min and a blood pressure of 88/56 mm Hg requires immediate reporting to the RN.
The correct answer identifies tachycardia and hypotension as early signs of hypovolemic shock. Hemorrhage is a major life-threatening complication of a liver biopsy. These vital signs demand immediate escalation to the registered nurse to prevent further decompensation.

Adım Adım Çözüm

1
Analyze the client's recent procedure.
The client underwent a percutaneous liver biopsy, a procedure with a high risk of hemorrhage because the liver is extremely vascular.
Identifying the specific procedure helps anticipate the most dangerous potential complications.
2
Evaluate each assessment finding against expected post-procedure outcomes.
Mild referred pain, slight temperature elevation, and a dry spot of blood are expected or non-emergent findings. The elevated heart rate and low blood pressure indicate cardiovascular compromise.
Differentiating between expected benign findings and signs of clinical deterioration is essential for prioritizing nursing care.
3
Determine the priority action based on the findings.
The abnormal vital signs indicate early hypovolemic shock, requiring immediate escalation to the registered nurse or healthcare provider.
Early intervention in shock prevents severe client harm and potential mortality.

Anahtar Kavram

Early recognition of hypovolemic shock following vascular procedures
Soru 2132Soru →

An older adult resident in a long-term care facility suddenly becomes withdrawn, disoriented to time, and begins pacing the hallway aimlessly. The resident's documented baseline status is alert, oriented, and highly engaged in daily social activities. Which action should the practical nurse take first?

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Cevap: Obtain a full set of vital signs and perform a focused assessment to identify potential acute illnesses

Cevap

The correct action is to obtain a full set of vital signs and perform a focused assessment to identify potential acute illnesses.
Sudden changes in cognition, such as acute confusion, disorientation, or agitation in an older adult, are hallmark signs of delirium rather than normal aging. Delirium is often triggered by an acute, reversible physiological issue such as an infection, dehydration, or medication adverse effect. The practical nurse must prioritize data collection by obtaining vital signs and completing a focused assessment to identify the physiological root cause.

Adım Adım Çözüm

1
Identify the change in the client's baseline neurological and behavioral status.
The client has transitioned from alert, oriented, and socially engaged to suddenly disoriented, withdrawn, and pacing.
Recognizing acute changes from a client's baseline is essential for early clinical intervention in the older adult population.
2
Differentiate between normal age-related changes and acute pathological processes.
The sudden onset of confusion and disorientation indicates acute delirium, not normal aging or dementia.
In older adults, delirium is frequently an atypical presentation of an underlying physiological issue, such as a urinary tract infection, dehydration, or hypoxia.
3
Select the priority nursing intervention based on the clinical findings.
The nurse must prioritize gathering objective physical data to help identify the root cause of the delirium.
Collecting a full set of vital signs and performing a focused physical assessment is the critical first step to ensure patient safety and guide further medical treatment.

Anahtar Kavram

Atypical Presentation of Illness in Older Adults (Delirium)
Tahmini Süre:1m 0s
Soru 2133Soru →

An older adult client is recovering on the surgical unit 1212 hours after a transurethral resection of the prostate (TURP) with ongoing continuous bladder irrigation (CBI). While performing a focused assessment, the practical nurse (PN) notes several clinical changes. Which of the following findings represent emergent complications that must be immediately reported to the registered nurse (RN)? Select all that apply.

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Cevap: The client demonstrates a sudden, new-onset inability to state their location or the current year.; The client's apical pulse gradually rises to 108108 beats per minute with a simultaneous blood pressure reading of 94/5694/56 mmHg.; The morning laboratory report indicates a serum sodium concentration of 120120 mEq/L.

Cevap

The findings requiring immediate escalation are the sudden inability to state location/year, the rising heart rate with falling blood pressure, and the critically low serum sodium of 120 mEq/L.
The correct choices identify emergent, life-threatening complications of a TURP procedure. A sudden change in mental status and a critically low serum sodium level (120120 mEq/L) are classic indicators of TURP syndrome, caused by the systemic absorption of irrigation fluid leading to dilutional hyponatremia and potential cerebral edema. Additionally, the development of borderline tachycardia (108108 bpm) and mild hypotension (94/5694/56 mmHg) are early, subtle signs of hypovolemic shock secondary to postoperative hemorrhage. These findings necessitate immediate escalation to the RN for rapid medical intervention.

Adım Adım Çözüm

1
Evaluate neurological and laboratory findings for signs of TURP syndrome.
The acute confusion and sodium of 120 mEq/L indicate severe dilutional hyponatremia.
Irrigation fluid can be absorbed into the systemic circulation, causing life-threatening water intoxication.
2
Analyze the vital sign trends.
A rising heart rate (108 bpm) and decreasing blood pressure (94/56 mmHg) are identified.
These are classic early indicators of hypovolemic shock, likely from postoperative hemorrhage.
3
Assess the urinary output and client comfort reports.
The net urine output is 400 mL, and the urge to void is related to expected bladder spasms.
Expected postoperative findings must be differentiated from true medical emergencies to prioritize care appropriately.

Anahtar Kavram

Early recognition of TURP syndrome (dilutional hyponatremia) and hypovolemic shock during continuous bladder irrigation.
Tahmini Süre:2m 0s
Soru 2134Soru →

A practical nurse is monitoring a client who underwent a percutaneous liver biopsy 3 hours ago. The client's current vital signs are blood pressure 102/64 mm Hg, pulse 98 beats/minute, and respirations 20 breaths/minute. Two hours ago, the blood pressure was 126/78 mm Hg and the pulse was 72 beats/minute. The client now reports a new onset of dull right shoulder pain. Which action should the nurse take first?

Cevabı ve açıklamayı göster

Cevap: Report the findings to the supervising registered nurse immediately.

Cevap

The correct action is to report the findings to the supervising registered nurse immediately.
The client is exhibiting a classic presentation of internal bleeding following a liver biopsy. The trend of an increasing heart rate and decreasing blood pressure indicates early hypovolemic shock, even if the current numbers do not yet meet the strict criteria for severe hypotension. Additionally, blood pooling under the diaphragm irritates the phrenic nerve, causing referred pain to the right shoulder. Because this represents an acute, life-threatening physiological alteration, the practical nurse's immediate priority is to notify the registered nurse so that rapid medical intervention can be initiated.

Adım Adım Çözüm

1
Analyze the vital sign trends.
The blood pressure has dropped significantly (from 126/78 to 102/64 mm Hg) and the heart rate has increased (from 72 to 98 beats/minute) over a short period.
Identifying trends in vital signs helps detect early hemodynamic instability before the client enters uncompensated shock.
2
Evaluate the new onset of right shoulder pain.
The pain is identified as referred pain caused by blood accumulating under the diaphragm, irritating the phrenic nerve.
Understanding complication-specific symptoms is critical for safe post-procedure monitoring.
3
Determine the priority practical nursing intervention.
The findings indicate active internal hemorrhage, which requires immediate escalation to the registered nurse.
Internal bleeding is an emergency that requires interventions beyond the practical nurse's scope of practice, making rapid reporting the highest priority.

Anahtar Kavram

Early recognition of internal hemorrhage and hypovolemic shock following invasive procedures
Soru 2135Soru →

A practical nurse (PN) receives a clear liquid diet tray for a client who observes traditional Hindu dietary practices. The tray contains beef broth, apple juice, lemon gelatin, and hot tea. Which action should the PN take first?

Cevabı ve açıklamayı göster

Cevap: Return the tray to the dietary department and request vegetable broth and fruit ice.

Cevap

Return the tray to the dietary department and request vegetable broth and fruit ice.
Traditional Hindu dietary practices strictly prohibit the consumption of beef, as the cow is considered sacred. Additionally, many Hindus practice vegetarianism and avoid animal-derived products like gelatin. Returning the tray to request culturally appropriate clear liquids, such as vegetable broth and fruit ice, demonstrates cultural competence and ensures the client receives adequate nutrition and hydration.

Adım Adım Çözüm

1
Identify the client's cultural and religious dietary restrictions.
The client follows traditional Hindu practices, which strictly prohibit the consumption of beef because the cow is considered sacred.
Cultural competence requires knowing major dietary restrictions associated with religious beliefs.
2
Analyze the items provided on the dietary tray for compliance.
The tray contains beef broth (strictly prohibited) and lemon gelatin (often derived from animal byproducts, including beef or pork, and generally avoided by vegetarians and practicing Hindus).
Nurses must verify that meals served align with the client's prescribed diet and spiritual beliefs before serving them.
3
Determine the most appropriate nursing intervention to correct the discrepancy.
The PN must return the tray to dietary services to request culturally acceptable substitutes, such as vegetable broth and fruit ice.
Simply removing the prohibited items leaves the client with inadequate nutrition, and serving the tray violates the client's religious beliefs.

Anahtar Kavram

Accommodating traditional Hindu dietary practices involves recognizing prohibited items (such as beef and animal-derived gelatin) and proactively coordinating with dietary services for appropriate substitutes.
Tahmini Süre:1m 0s
Soru 2136Soru →

During bedside handoff in a surgical step-down unit, a practical nurse reviews the clinical data of a young adult client who underwent a laparoscopic splenectomy earlier in the day. The client is drowsy but rouses to verbal stimuli. The flow sheet indicates that over the past three hours, the client's heart rate has climbed from 82 to 118 beats per minute, and blood pressure has narrowed from 120/78 to 106/82 mmHg. The client reports new, mild left shoulder pain and slight abdominal fullness. Based on these clinical findings, which action is the priority for the practical nurse to implement?

Cevabı ve açıklamayı göster

Cevap: Notify the supervising registered nurse immediately regarding the vital sign trends and shoulder pain.

Cevap

Notify the supervising registered nurse immediately regarding the vital sign trends and shoulder pain.
The correct action is to immediately notify the registered nurse because the combination of a narrowing pulse pressure, progressive tachycardia, and left shoulder pain (Kehr's sign) strongly suggests acute internal hemorrhage following a highly vascular surgery like a splenectomy. This is a medical emergency requiring rapid intervention beyond independent practical nursing actions.

Adım Adım Çözüm

1
Analyze the trend in the client's vital signs over the past three hours.
The heart rate increased significantly to 118 bpm, and the pulse pressure narrowed from 42 mmHg to 24 mmHg.
Recognizing a narrowing pulse pressure combined with tachycardia is critical, as these are early, subtle indicators of compensatory hypovolemic shock.
2
Correlate the physical symptoms with the surgical history and physiological changes.
The client is experiencing new left shoulder pain and abdominal fullness following a splenectomy.
The spleen is a highly vascular organ. Left shoulder pain (Kehr's sign) indicates diaphragmatic irritation from internal abdominal bleeding, rather than routine post-laparoscopic gas pain.
3
Determine the priority nursing intervention based on the practical nursing scope of practice.
The priority action is to escalate these findings to the supervising registered nurse or provider without delay.
The client is exhibiting signs of active internal hemorrhage, a life-threatening medical emergency requiring rapid collaborative intervention and potential surgical revision.

Anahtar Kavram

Recognition of early hemorrhagic shock and appropriate clinical escalation
Soru 2137Soru →

A practical nurse is assigned to care for a client who receives continuous medical nutrition via a percutaneous endoscopic gastrostomy (PEG) tube. The client recently underwent a complex lumbar laminectomy that was complicated by a dural tear. The surgeon has prescribed strict bed rest in a completely flat (0-degree) supine position to prevent a cerebrospinal fluid leak. Which action should the practical nurse implement to safely manage this client's basic care needs?

Cevabı ve açıklamayı göster

Cevap: Pause the continuous PEG feeding immediately and report the conflicting positional requirements to the registered nurse.

Cevap

The correct action is to pause the continuous PEG feeding immediately and report the conflicting positional requirements to the registered nurse.
The correct answer identifies a direct and dangerous conflict between standard nutritional care and post-operative safety. Standard practice dictates that continuous enteral feedings require the head of the bed to be elevated at least 30 degrees to prevent aspiration. However, a dural tear strictly requires a flat, 0-degree supine position to prevent a cerebrospinal fluid leak. Because it is physically impossible to safely accommodate both fundamental requirements, the practical nurse must prioritize immediate physiological safety by pausing the feeding and escalating the conflict to the registered nurse or provider for an alternative nutritional or hydration plan.

Adım Adım Çözüm

1
Analyze the surgical prescription.
The client must remain completely flat (0-degree elevation) to prevent a cerebrospinal fluid (CSF) leak from the dural tear.
Post-operative positioning requirements for a dural tear are absolute to ensure proper healing and prevent neurological complications.
2
Evaluate the basic care intervention (enteral feeding).
Continuous PEG feedings require the head of the bed to be elevated to at least 30 to 45 degrees.
Elevation utilizes gravity to prevent gastric reflux and life-threatening aspiration of the formula into the lungs.
3
Synthesize the findings to identify the conflict.
A direct physiological contraindication exists between the required flat position for the dural tear and the required elevated position for the enteral feeding.
The nurse cannot safely implement both interventions simultaneously.
4
Determine the priority nursing action.
The nurse must pause the feeding and notify the registered nurse or healthcare provider.
Operating within the practical nurse scope of practice requires halting unsafe interventions and escalating conflicting orders for resolution (e.g., initiating temporary IV fluids or total parenteral nutrition).

Anahtar Kavram

Synthesis of enteral nutrition safety, post-operative positioning constraints, and scope of practice prioritization.
Soru 2138Soru →

An older adult client with a history of heart failure suddenly becomes highly restless, confused, and demonstrates a respiratory rate of 30 breaths per minute. Which intervention should be prioritized immediately?

Cevabı ve açıklamayı göster

Cevap: Elevate the head of the bed to an upright sitting position

Cevap

Elevate the head of the bed to an upright sitting position
Elevating the head of the bed expands lung capacity and improves oxygenation, addressing the immediate physiological need. Sudden restlessness and confusion combined with tachypnea are early signs of hypoxia, so stabilizing the airway and breathing takes priority over all other interventions.

Adım Adım Çözüm

1
Analyze the client's presenting symptoms.
The combination of sudden restlessness, confusion, and tachypnea (30 breaths/min) indicates acute hypoxia and respiratory distress.
Identifying the physiological meaning of the symptoms determines the level of urgency.
2
Apply the ABC (Airway, Breathing, Circulation) priority framework.
Breathing is significantly compromised, meaning respiratory support is the most critical need.
Life-threatening issues must be addressed before secondary symptoms like confusion or potential pain.
3
Select the most immediate and effective nursing intervention.
Placing the client in an upright sitting position facilitates immediate lung expansion.
Gravity pulls the diaphragm downward, increasing chest cavity volume and improving oxygenation.

Anahtar Kavram

Hypoxia Recognition and Airway Prioritization
Soru 2139Soru →

A practical nurse is assisting an 84-year-old client who experiences age-related dysphagia and a diminished gag reflex with their meal. To prevent aspiration and promote safe swallowing, arrange the nursing actions in the correct chronological order.

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Cevap

The correct sequence is to first elevate the head of the bed, then provide a small bite of food, instruct the client to use the chin-tuck maneuver, inspect the mouth for pocketed food, and finally maintain an upright position after the meal.
The sequence of interventions prioritizes safety from the preparation phase through the post-meal phase. Proper upright positioning is the foundation of safe swallowing. Introducing a small amount of food followed by the chin-tuck maneuver protects the airway during the active phase of swallowing. Post-swallow assessment ensures no food remains that could be aspirated later. Finally, maintaining an upright posture prevents delayed aspiration from reflux, directly addressing age-related gastrointestinal changes.

Adım Adım Çözüm

1
Ensure optimal positioning.
The client is placed in a high-Fowler's position.
Gravity assists the passage of food and reduces the immediate risk of aspiration before any intake occurs.
2
Administer food safely.
A small bite is placed in the mouth.
Smaller boluses are easier to manage for older adults with delayed swallowing reflexes.
3
Implement swallowing strategies.
The client performs the chin-tuck maneuver.
This physical action mechanically narrows the airway and widens the esophagus to protect the trachea during the swallow.
4
Evaluate the swallow.
The oral cavity is checked for pocketing.
Age-related sensory decline can cause clients to be unaware of retained food inside their cheeks.
5
Provide post-meal safety.
The client remains upright for at least 30 minutes.
This prevents reflux caused by an age-related decrease in lower esophageal sphincter tone.

Anahtar Kavram

Nursing interventions for age-related dysphagia and aspiration prevention.
Soru 2140Soru →

A practical nurse is providing care for a client who has just returned to the unit following a percutaneous liver biopsy. The nurse is preparing to assist the client into a resting position. Which position is most appropriate to promote client safety and prevent bleeding complications?

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Cevap: Right side-lying position with a small towel roll placed under the puncture site

Cevap

The client should be placed in a right side-lying position with a small towel roll beneath the puncture site.
After a percutaneous liver biopsy, the most critical intervention is preventing hemorrhage because the liver is highly vascular. The liver is located on the right side of the body. Placing the client in a right side-lying (lateral) position uses their own body weight to apply direct, continuous pressure to the puncture site. A small towel or pillow placed directly under the site provides additional localized compression to promote hemostasis.

Adım Adım Çözüm

1
Identify the procedure performed and its anatomical location.
The client had a liver biopsy. The liver is located on the right side of the upper abdomen.
Understanding the anatomy is essential to determine where direct pressure must be applied.
2
Determine the primary post-procedure risk.
The greatest risk following a percutaneous liver biopsy is internal bleeding (hemorrhage) from the puncture site.
The liver is a highly vascular organ and bleeds easily when punctured.
3
Select the position that best mitigates this risk.
The right side-lying position applies the client's own body weight against the bed to create direct pressure on the liver.
Continuous direct pressure promotes hemostasis and prevents bleeding complications.

Anahtar Kavram

Post-procedure positioning to prevent hemorrhage following a liver biopsy.
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