Tüm alıştırma soruları

2933 soru

Soru 2261Soru →

A practical nurse is caring for a client who has just returned to the surgical unit following a total thyroidectomy. To promote comfort and prevent complications, which of the following positions should the nurse assist the client into?

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Cevap: Semi-Fowler's position with pillows supporting the head and neck

Cevap

The correct answer is the semi-Fowler's position with pillows supporting the head and neck.
Placing the client in a semi-Fowler's position uses gravity to help reduce swelling and edema in the neck area, which is critical for protecting the airway after a thyroidectomy. Supporting the head and neck with pillows prevents hyperextension, reducing tension on the surgical incision and promoting comfort.

Adım Adım Çözüm

1
Analyze the surgical procedure and potential physiological complications.
A thyroidectomy involves an incision in the neck. Post-operative tissue edema or bleeding in this area can quickly compromise the client's airway.
Airway patency is the highest priority following head and neck surgery.
2
Identify the effects of different bed positions on the neck.
Elevating the head of the bed decreases fluid accumulation (edema) in the neck. Supporting the head reduces tension on the surgical sutures.
Proper positioning uses gravity to minimize swelling and maintains anatomical alignment to promote wound healing.
3
Select the safest and most comfortable position for the client.
The semi-Fowler's position with dedicated head and neck support is the most appropriate choice.
This directly prevents airway compromise and incision rupture.

Anahtar Kavram

Post-operative positioning for airway protection and comfort
Soru 2262Soru →

A practical nurse (PN) is monitoring a client who is receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes into the infusion, the client suddenly reports severe lower back pain, chills, and difficulty breathing. In which order should the PN perform the following actions? (Arrange the actions from first to last.)

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Cevap

The correct sequence is to first stop the blood transfusion immediately, followed by initiating a normal saline infusion using new IV tubing. Next, the PN must notify the RN and healthcare provider, and finally, obtain a complete set of vital signs.
In any acute transfusion reaction, the primary goal is to limit the client's exposure to the offending antigen. Therefore, stopping the transfusion is the immediate first step. Venous access must be maintained to administer emergency drugs, but it must be done with entirely new tubing to prevent infusing residual blood. Once the immediate danger is halted and the line is secured, the PN must escalate the situation by notifying the RN and provider. Finally, obtaining vital signs provides essential data for the provider to direct further care.

Adım Adım Çözüm

1
Stop the blood transfusion.
Prevents additional incompatible blood cells from entering the systemic circulation.
Lower back pain, chills, and dyspnea are classic signs of an acute hemolytic transfusion reaction, which is a life-threatening emergency requiring immediate cessation of the causative agent.
2
Disconnect the blood tubing and start normal saline with new tubing.
Maintains patent venous access for emergency medications while preventing further exposure.
Flushing the existing tubing would push the remaining incompatible blood into the client. New tubing must be attached directly to the IV catheter hub.
3
Notify the RN and healthcare provider.
Escalates the clinical emergency to the appropriate personnel.
The client will require immediate medical intervention, emergency medications, and activation of the facility's blood bank reaction protocol.
4
Obtain vital signs and monitor.
Provides objective baseline data regarding the client's hemodynamic and respiratory stability.
Continuous monitoring is required to assess the severity of the reaction and guide ongoing emergency treatment.

Anahtar Kavram

Management of Acute Hemolytic Transfusion Reactions
Soru 2263Soru →

A client in the preoperative staging area is scheduled for an elective surgical procedure and has previously signed the informed consent document. When the practical nurse (PN) approaches to administer a prescribed preoperative sedative, the client abruptly declares, 'I have changed my mind. I am refusing this surgery.' Arrange the following nursing actions in the correct priority order from first to last.

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Cevap

The correct sequence prioritizes client safety and legal capacity by first withholding the sedative, followed by exploring the client's concerns, notifying the provider and RN, and finally documenting the event.
The sequence follows the nursing process and clinical prioritization principles: safety first (holding the medication to preserve cognitive capacity), followed by data collection (assessing reasons), implementation and communication (notifying the provider), and finally, documentation.

Adım Adım Çözüm

1
Withhold the administration of the prescribed preoperative sedative medication.
The client's cognitive capacity remains intact.
Administering a sedative would impair the client's mental state, preventing them from legally and clearly discussing their revocation of consent with the surgeon.
2
Ask open-ended questions to explore the client's reasons for withdrawing their consent.
The PN gathers relevant clinical data regarding the client's fears or misunderstandings.
Data collection is essential to determine if the refusal is due to anxiety, a need for more information, or a definitive decision, which must be reported to the team.
3
Notify the attending surgeon and the supervising registered nurse (RN) of the client's decision.
The healthcare provider is alerted to the situation and can intervene.
It is the provider's strict legal obligation to discuss the consequences of refusing the procedure and to formally accept the revocation of informed consent.
4
Document the client's exact verbal statement and the subsequent notifications in the medical record.
A permanent legal record of the event is established.
Accurate, objective documentation is required, but only after all immediate safety and communication interventions have been completed.

Anahtar Kavram

When a client revokes informed consent, the nurse must prioritize maintaining the client's cognitive capacity by withholding mind-altering medications, followed by data collection and immediate communication to the provider responsible for the procedure.
Tahmini Süre:1m 30s
Soru 2264Soru →

A practical nurse is preparing to administer a scheduled dose of oral warfarin to a client diagnosed with atrial fibrillation. Which of the following actions must the nurse take before administering this medication?

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Cevap: Review the client's most recent international normalized ratio (INR).

Cevap

Review the client's most recent international normalized ratio (INR).
Warfarin is an oral anticoagulant, and its therapeutic effect is directly measured by the prothrombin time (PT) and international normalized ratio (INR). Before administering warfarin, the nurse must review the most recent INR to ensure it is within the prescribed therapeutic range. Administering the medication without verifying this lab value places the client at a high risk for severe bleeding if the level is too high, or at risk for clotting if the level is subtherapeutic.

Adım Adım Çözüm

1
Identify the medication class and its primary function.
Warfarin is recognized as an oral anticoagulant used to prevent blood clots.
Understanding the drug class is the first step in identifying its specific monitoring parameters.
2
Determine the specific laboratory value used to monitor this medication.
The therapeutic effect of warfarin is monitored using the international normalized ratio (INR).
Anticoagulants have a narrow therapeutic index and require strict lab monitoring to prevent hemorrhage or clotting.
3
Select the appropriate pre-administration safety check.
The nurse must check the most recent INR results before giving the dose.
If the INR is supra-therapeutic (too high), the dose must be withheld and reported to the RN or provider to prevent severe bleeding.

Anahtar Kavram

Pre-administration safety checks for oral anticoagulants
Soru 2265Soru →

During evening rounds, an older adult client receiving intravenous antibiotics for community-acquired pneumonia suddenly appears restless, mutters incoherently, and repeatedly attempts to pull out their peripheral catheter. The client's skin is pale and slightly clammy. Vital signs display a heart rate of 116 bpm, a respiratory rate of 24/min, and a blood pressure of 100/74 mm Hg, whereas the baseline blood pressure from the previous shift was 136/82 mm Hg. The urinary drainage bag contains 65 mL of concentrated urine representing the past 4 hours of output. Which action should the practical nurse implement first?

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Cevap: Immediately escalate the clinical findings to the supervising registered nurse for rapid intervention.

Cevap

The correct action is to immediately escalate the clinical findings to the supervising registered nurse for rapid intervention.
The correct answer identifies that the client is exhibiting a dangerous triad of symptoms: a significantly narrowed pulse pressure with tachycardia (indicative of decreased cardiac output and sympathetic nervous system activation), severe oliguria (decreased renal perfusion), and acute restlessness (cerebral hypoxia). Recognizing these subtle, borderline systemic signs of physiological failure requires immediate escalation to the registered nurse or rapid response team, as it exceeds the practical nursing scope to independently manage hemodynamically unstable clients.

Adım Adım Çözüm

1
Analyze the client's vital signs and physical assessment findings in combination.
The client has a narrowed pulse pressure (100/74 = 26 mm Hg difference), tachycardia (116 bpm), tachypnea (24/min), pale/clammy skin, and severe oliguria (65 mL over 4 hours = 16.25 mL/hr).
Identifying subtle deviations from baseline is critical for recognizing early physiological failure before cardiovascular collapse occurs.
2
Evaluate the new-onset restlessness and incoherent muttering.
Combined with the hemodynamic changes, this altered mental status indicates cerebral hypoxia and hypoperfusion, not simple confusion or dementia.
Restlessness is often the earliest behavioral sign of impaired oxygenation and compromised cardiac output.
3
Determine the priority intervention within the practical nursing scope of practice.
The client is in early compensatory shock (likely septic shock) and requires immediate advanced critical care interventions.
Managing hemodynamically unstable clients exceeds the practical nurse scope; recognizing the emergency and immediately escalating to the registered nurse or rapid response team is the most critical priority.

Anahtar Kavram

Recognition and Prioritization of Compensatory Shock
Soru 2266Soru →

A practical nurse is preparing to transfer a client who has right-sided hemiparesis from the bed to a wheelchair. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence from first to last.

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Cevap

The correct sequence is to first position the wheelchair on the client's strong (left) side, then lock all wheels, assist the client to sit on the edge of the bed, apply the transfer belt, instruct the client to reach for the armrest with their strong hand, and finally pivot the client into the chair.
Safe client handling for a client with unilateral weakness (hemiparesis) requires leveraging their functional abilities while minimizing fall risks. Positioning the chair on the unaffected side (left) is the critical first step because it ensures the client will pivot on their strong leg. Locking the wheels is a mandatory safety prerequisite before initiating any movement. Bringing the client to a seated position allows for cardiovascular accommodation and provides access to properly apply the gait belt around the waist. Finally, directing the client to reach with their strong arm stabilizes their descent into the chair as the nurse physically assists the pivot.

Adım Adım Çözüm

1
Place the equipment on the client's strong side.
The wheelchair is positioned on the left side at a 45-degree angle.
Maximizes the use of the client's unaffected side for weight-bearing during the pivot.
2
Lock the wheels on all equipment.
The bed and wheelchair are immobilized.
Prevents the equipment from rolling away, which is a primary cause of transfer-related falls.
3
Bring the client to a sitting position.
The client is sitting at the edge of the bed with feet flat on the floor.
Allows the cardiovascular system to adjust, preventing dizziness, and establishes a stable base of support.
4
Apply the transfer belt.
The belt is secured securely around the client's waist.
Provides the nurse with a safe, ergonomic hold on the client's center of gravity without pulling on their arms.
5
Guide the client's movement.
The client reaches for the wheelchair armrest with their left (unaffected) hand.
Uses the strong arm to stabilize the body and guide the hips into the center of the seat.
6
Execute the pivot transfer.
The client is successfully seated in the wheelchair.
Completes the transfer by utilizing the strength of the unaffected leg to bear the body's weight.

Anahtar Kavram

Safe client handling and mobility transfer principles for a client with hemiparesis.
Soru 2267Soru →

A practical nurse (PN) is working in a behavioral health facility. A client with acute methamphetamine intoxication is pacing the hallway, shouting aggressively at unseen individuals, and clenching their fists. Arrange the following nursing actions in the correct sequence from highest to lowest priority.

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Cevap

The correct sequence is to first ensure personal safety, then call for backup, protect bystanders, attempt verbal de-escalation, and finally assist with chemical interventions.
In any situation involving acute aggression and substance-induced psychosis, the hierarchy of response focuses on safety and the principle of least restrictive intervention. The nurse must first ensure personal safety by maintaining distance, as an injured nurse cannot provide care. Next, calling for backup ensures sufficient personnel are present to manage potential violence safely. The third step is protecting bystanders by clearing the area. Once the environment is secure, the nurse attempts verbal de-escalation as the least restrictive direct intervention. Finally, if verbal methods fail to reduce the danger, assisting the registered nurse with prescribed medications serves as the appropriate next step for chemical restraint.

Adım Adım Çözüm

1
Ensure personal safety.
The nurse maintains a safe physical distance.
Personal safety is the absolute first priority in any psychiatric emergency to prevent injury to the healthcare provider.
2
Call for staff assistance.
Additional staff members are alerted to the situation.
Engaging a potentially violent, intoxicated client alone is dangerous; backup is required before initiating direct intervention.
3
Clear the area of bystanders.
Other clients are directed to a safe location.
Removing other clients prevents them from being harmed by the aggressive client or triggering further paranoia.
4
Attempt verbal de-escalation.
The nurse addresses the client calmly.
Least restrictive interventions must be attempted first once the environment is secure.
5
Prepare pharmacological interventions.
The PN assists the RN with PRN medication.
If verbal de-escalation is ineffective, pharmacological support is necessary to manage methamphetamine-induced psychosis and aggression.

Anahtar Kavram

Prioritization of safety and least restrictive interventions in acute substance-induced psychosis
Soru 2268Soru →

An older adult client with generalized weakness is preparing to get out of bed for the first time today. In what order should the following actions be performed to safely transfer the client to a wheelchair? (Arrange the steps in the correct sequence, from first to last.)

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Cevap

First, lock the wheels on the bed and wheelchair. Second, assist the client to sit on the edge of the bed. Third, place the transfer belt. Fourth, assist the client to stand and pivot. Finally, have the client grasp the armrests while sitting down.
Safe transfer protocols require establishing a stable environment first by locking all wheels. Next, physiological safety is ensured by allowing the client to adjust to sitting. Then, physical safety devices like a transfer belt are applied. Only after these preparations should the physical movement (standing and pivoting) occur, ending with a controlled descent using the armrests.

Adım Adım Çözüm

1
Secure all equipment by locking the wheels.
The bed and wheelchair are completely stationary.
Prevents accidental movement that could lead to a fall during the transfer.
2
Help the client sit up on the side of the bed.
The client is dangling their legs over the edge of the mattress.
Allows the cardiovascular system to adjust to the upright position, reducing the risk of dizziness.
3
Apply the transfer belt around the client's waist.
The care provider has a safe, secure handhold on the client.
Provides mechanical advantage and prevents injury to both the client and the provider during the physical lift.
4
Assist the client to stand up and pivot.
The client is standing and aligned with the wheelchair.
Moves the client's center of gravity from the bed to the chair in a controlled motion.
5
Guide the client to reach for the armrests and sit.
The client is safely seated in the wheelchair.
Reaching for the armrests provides stability and allows for a controlled descent into the chair.

Anahtar Kavram

Safe client transfer techniques and basic mobility assistance
Soru 2269Soru →

A practical nurse is preparing to administer a large-volume cleansing enema to an adult client experiencing severe constipation. Arrange the following procedural steps in the correct sequential order to ensure client safety, procedure effectiveness, and comfort.

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Cevap

The correct sequence is to first position the client in the left lateral Sims position, lubricate the tubing tip, insert the tubing 3 to 4 inches toward the umbilicus, elevate the container 12 to 18 inches while opening the clamp, and finally, lower the container if severe cramping occurs.
Administering an enema safely requires a highly specific sequence encompassing anatomical positioning, preparation, careful insertion, controlled instillation, and complication management. The client must first be in the left lateral Sims position to allow gravity to assist fluid flow into the descending and sigmoid colon. The tubing tip must then be lubricated to ensure atraumatic insertion. Next, the tube is safely inserted 3 to 4 inches, following the anatomical direction of the umbilicus. Once the tube is secured in the rectum, the fluid is instilled by elevating the bag 12 to 18 inches to provide safe hydrostatic pressure. Finally, the nurse continuously evaluates the client's tolerance, lowering the bag immediately if rapid distention causes severe cramping.

Adım Adım Çözüm

1
Position the client.
Client is in the left lateral Sims position.
Follows the natural curvature of the descending and sigmoid colon, using gravity to assist fluid flow.
2
Lubricate the tubing.
The distal tip is fully coated with a water-soluble lubricant.
Prevents tissue trauma and sphincter spasm during the invasive insertion.
3
Insert the tubing.
The tube is placed safely 3 to 4 inches into the rectum.
Bypasses the internal sphincter securely when aimed forward toward the umbilicus.
4
Administer the solution.
Fluid flows into the bowel at a safe hydrostatic pressure.
Holding the bag strictly 12 to 18 inches high prevents excessively rapid bowel distention.
5
Monitor for complications.
The flow rate is immediately decreased by lowering the bag if cramping occurs.
Allows the bowel musculature to relax without having to completely abandon and restart the procedure prematurely.

Anahtar Kavram

Procedural Sequence for Safe Cleansing Enema Administration
Soru 2270Soru →

A resident in a rehabilitation facility is recovering from a left above-knee amputation performed 48 hours ago. The individual expresses feelings of stiffness and aching in the remaining hip. What is the most appropriate positioning strategy the practical nurse should utilize to optimize comfort and preserve joint mobility?

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Cevap: Assist the client into a prone position for 20 to 30 minutes several times a day.

Cevap

The most appropriate strategy is to assist the client into a prone position for 20 to 30 minutes several times a day.
Prone positioning for 20 to 30 minutes, three to four times a day, is a critical nursing intervention for clients recovering from an above-knee amputation. This position actively extends the hip joint, stretching the flexor muscles and preventing the development of hip flexion contractures. Preventing these contractures is essential for the client's future ability to walk and properly fit a prosthesis.

Adım Adım Çözüm

1
Analyze the client's postoperative timeframe (48 hours post-amputation) and identify the specific physiological risks associated with this recovery phase.
The initial 24-hour period for edema management has passed, making the prevention of hip flexion contractures the primary mobility priority.
Contractures can severely impair future mobility and prevent successful prosthetic fitting.
2
Evaluate the physiological effects of each positioning option on the hip joint.
Elevation on pillows, high-Fowler's positioning, and prolonged sitting all place the hip joint into a flexed position.
Maintaining the hip in prolonged flexion causes the muscles and ligaments to shorten, leading to contractures.
3
Select the intervention that actively counteracts hip flexion while promoting comfort.
Prone positioning is identified as the correct intervention.
Lying prone forces the hip into extension, stretching the flexor muscles and preserving joint mobility.

Anahtar Kavram

Positioning and contracture prevention following lower extremity amputation
Soru 2271Soru →

A client admitted with an exacerbation of heart failure is scheduled to receive oral furosemide and oral metoprolol. Prior to administration, the practical nurse obtains the following data: blood pressure 88/54 mm Hg, heart rate 116 beats/min, respiratory rate 22 breaths/min, and a morning serum potassium level of 3.1 mEq/L (3.1 mmol/L). Which action is the most appropriate for the practical nurse to take?

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Cevap: Withhold both medications and promptly report the vital signs and laboratory findings to the registered nurse.

Cevap

The most appropriate action is to withhold both the furosemide and the metoprolol, and immediately report the client's vital signs and potassium level to the registered nurse.
The client's hypotension (88/54 mm Hg) and compensatory tachycardia (116 beats/min) strongly suggest hypovolemia or decreased cardiac output. Metoprolol (a beta-blocker) will further decrease blood pressure, and furosemide (a loop diuretic) will exacerbate both the volume depletion and the existing hypokalemia (3.1 mEq/L). The safe and correct action is to withhold these medications and immediately escalate these critical findings to the registered nurse.

Adım Adım Çözüm

1
Analyze the client's vital signs.
The blood pressure of 88/54 mm Hg is hypotensive, and the heart rate of 116 beats/min is tachycardic, suggesting potential hypovolemia or inadequate cardiac output.
Vital signs must be evaluated against standard parameters prior to administering cardiac or antihypertensive medications.
2
Analyze the laboratory data.
The serum potassium level is 3.1 mEq/L, which indicates significant hypokalemia (normal is typically 3.5 to 5.0 mEq/L).
Diuretics actively alter electrolyte balances, making baseline lab checks mandatory.
3
Evaluate the mechanism and adverse effects of the scheduled medications.
Furosemide is a potassium-wasting loop diuretic that will worsen the hypokalemia and hypovolemia/hypotension. Metoprolol is a beta-blocker that will further lower the blood pressure.
Understanding pharmacodynamics prevents administering medications that could cause patient harm.
4
Determine the correct nursing intervention within the practical nurse scope of practice.
The practical nurse must withhold the contraindicated medications and escalate the critical findings to the registered nurse for immediate medical intervention.
Advocating for patient safety requires recognizing adverse trends and communicating effectively with the supervising nurse.

Anahtar Kavram

Pre-administration Medication Safety, Hemodynamic Instability, and Practical Nurse Scope of Practice
Soru 2272Soru →

A practical nurse (PN) is assisting with a 2-week-old neonate's well-child visit at a pediatric clinic. Which of the following actions by the PN are within the scope of practice and demonstrate safe care? (Select all that apply.)

Geçerli olan tümünü seçin

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Cevap: Verifying the neonate's identity using two unique identifiers before administering any prescribed medications.; Documenting the presence of a symmetrical startle response to a loud noise as an expected Moro reflex.; Immediately reporting a capillary refill time of 5 seconds and a mottled skin appearance to the registered nurse.

Cevap

The correct actions are verifying the neonate's identity with two identifiers, documenting the Moro reflex as an expected finding, and reporting a delayed capillary refill time to the registered nurse.
Verifying patient identity with two identifiers ensures fundamental medication safety. The Moro (startle) reflex is a normal, expected neurologic response in a 2-week-old neonate that should simply be documented. A capillary refill time of 5 seconds paired with mottled skin indicates poor perfusion and potential shock, requiring immediate escalation to the registered nurse.

Adım Adım Çözüm

1
Evaluate each action for adherence to safety standards and the practical nurse scope of practice.
Identified actions requiring basic data collection, safety verification, and immediate reporting of physiological abnormalities.
The practical nurse must differentiate between normal neonatal findings and critical abnormalities requiring registered nurse intervention.
2
Analyze the developmental and physiological expectations for a 2-week-old neonate.
The Moro reflex is recognized as normal, whereas the inability to roll over is also normal at this age. A prolonged capillary refill is abnormal.
Accurate developmental and physical data collection prevents false reporting of delays and ensures timely escalation of true emergencies.
3
Assess communication techniques and procedural safety protocols.
Using two patient identifiers is a mandatory safety standard. Conversely, asking 'why' questions is non-therapeutic and inappropriate.
Ensuring correct patient identification and utilizing therapeutic communication are core competencies required for safe practice.

Anahtar Kavram

Practical Nursing Scope of Practice in Newborn Care and Safety
Soru 2273Soru →

A client recovering from severe pneumonia is receiving intravenous antibiotics and continuous supplemental oxygen. The practical nurse enters the room to find the previously oriented client highly agitated, struggling to sit up, and picking aimlessly at the bed linens. Which action should the practical nurse take initially?

Cevabı ve açıklamayı göster

Cevap: Obtain the client's oxygen saturation level and count the respiratory rate.

Cevap

The nurse should prioritize obtaining the client's oxygen saturation level and counting the respiratory rate.
In a client with a respiratory infection, sudden restlessness, agitation, and acute confusion are classic early signs of hypoxia. Using the nursing process and prioritizing Airway, Breathing, and Circulation (ABCs), the practical nurse must first collect objective data regarding the client's respiratory status before implementing any other interventions. Treating the symptoms without investigating the cause could lead to severe physiological deterioration.

Adım Adım Çözüm

1
Identify the client's sudden change in condition.
The client is exhibiting acute agitation, restlessness, and confusion.
Recognizing a change from baseline is the first step in the clinical judgment process.
2
Correlate the behavioral changes with the client's underlying diagnosis.
The client has severe pneumonia, making them highly susceptible to impaired gas exchange and hypoxia.
Restlessness and acute confusion are classic early neurological signs of inadequate oxygenation to the brain.
3
Determine the priority nursing action using the ABCs (Airway, Breathing, Circulation) framework.
The nurse must obtain objective data regarding the client's respiratory status (oxygen saturation and respiratory rate).
Before implementing any interventions such as medications or restraints, the nurse must assess the most life-threatening potential cause of the behavioral change.

Anahtar Kavram

Recognizing early signs of hypoxia (restlessness and confusion) and prioritizing objective respiratory data collection.
Soru 2274Soru →

An assistive personnel (AP) calls the practical nurse to the room of an 84-year-old client who had a bowel resection two days ago. The client, who was previously alert, is now highly restless and disoriented. The client's pulse is 110 beats/min and blood pressure is 96/58 mmHg. Which action should the practical nurse take first?

Cevabı ve açıklamayı göster

Cevap: Assess the client's airway, breathing, and oxygen saturation.

Cevap

Assess the client's airway, breathing, and oxygen saturation.
Sudden restlessness and disorientation, combined with tachycardia and a borderline low blood pressure, are classic early signs of hypoxia or hypovolemic shock. According to the Airway, Breathing, and Circulation (ABC) priority framework, the nurse must first assess the client's respiratory and oxygenation status to rule out or treat life-threatening complications before pursuing other interventions.

Adım Adım Çözüm

1
Analyze the client's sudden change in mental status and vital signs.
The client is demonstrating signs of acute delirium, tachycardia, and borderline hypotension.
Sudden confusion and restlessness in a postoperative client are often early indicators of hypoxia or shock.
2
Determine the priority framework to apply to the situation.
The Airway, Breathing, Circulation (ABC) framework must be utilized.
Life-threatening physiological changes take priority over pain management, routine documentation, or family reassurance.
3
Select the action that addresses the highest priority physiological need.
Assessing airway, breathing, and oxygen saturation directly addresses the most critical potential cause of the client's symptoms.
Identifying and treating hypoxia or circulatory collapse is essential before taking any secondary nursing actions.

Anahtar Kavram

Prioritizing ABCs and recognizing early signs of physiological deterioration in postoperative clients.
Soru 2275Soru →

An older adult client arrives at the recovery unit after undergoing surgical removal of a cataract in the left eye. When setting up the bed and assisting the client to rest, which positioning action should the practical nurse implement?

Cevabı ve açıklamayı göster

Cevap: Position the client flat on the back or onto the non-operative right side

Cevap

Position the client flat on the back or onto the non-operative right side.
Placing the client on their back (supine) or on the unoperated side (the right side) is the standard postoperative intervention for cataract surgery. This position prevents the mattress or pillows from applying direct pressure to the operative eye, effectively minimizing intraocular pressure and preventing surgical site disruption.

Adım Adım Çözüm

1
Identify the surgical procedure and the affected side.
The client had a left-eye cataract extraction.
Knowing the affected side determines which positioning strategies are safe to use.
2
Determine the primary physiological risk following this surgery.
The major risk is increased intraocular pressure (IOP) or direct trauma to the operative site.
Any increase in IOP can lead to bleeding, suture rupture, or impaired healing.
3
Select the position that minimizes pressure on the left eye.
Supine or right-sided lying positions are chosen.
These positions use gravity to keep pressure off the left eye and prevent accidental physical pressure against the mattress.

Anahtar Kavram

Following eye surgery, the client must be positioned to prevent any increase in intraocular pressure, which means avoiding lying on the operative side, bending the neck, or assuming a prone position.
Soru 2276Soru →

During a morning shift, a practical nurse (PN) brings routine oral medications to a 65-year-old client. The client's vital signs include a blood pressure of 128/78 mmHg128/78\text{ mmHg} and a heart rate of 76 beats/minute76\text{ beats/minute}. The client reports no medication allergies. Which of the following actions should the PN take to ensure safe administration? Select all that apply.

Geçerli olan tümünü seçin

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Cevap: Compare the medication label to the medication administration record three times.; Assess the client's ability to swallow before providing the oral pills.; Document the medication administration immediately after the client takes the medication.

Cevap

The nurse should compare the medication label to the MAR three times, assess the client's ability to swallow, and document the administration immediately after the medication is taken.
Safe medication administration requires strict adherence to safety protocols. Comparing the label to the medication administration record three times ensures the correct drug is selected. Assessing swallowing ability confirms the oral route is safe and prevents aspiration. Finally, documenting immediately after the client takes the drug ensures accurate records and prevents accidental double dosing.

Adım Adım Çözüm

1
Identify the standard rights of medication administration.
Safe practice requires right client, medication, dose, route, time, and documentation.
Adhering to these rights systematically prevents medication errors.
2
Evaluate each action against safety guidelines and the practical nurse's scope of practice.
Checking the MAR three times, assessing swallowing, and immediate documentation directly align with safe practice.
These actions support the rights of medication administration and prioritize client safety.
3
Identify unsafe or out-of-scope practices among the choices.
Using a room number for identification and delegating medication administration to an unlicensed assistive personnel are incorrect.
Room numbers are not valid patient identifiers, and medication administration cannot be delegated to unlicensed staff.

Anahtar Kavram

Rights of Medication Administration and PN Scope of Practice
Soru 2277Soru →

A practical nurse is preparing an adult client with severe hepatic cirrhosis and ascites for a bedside abdominal paracentesis. Arrange the following pre-procedure actions in the correct chronological sequence to minimize the risk of procedural complications.

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Cevap

The correct sequence is: Verify informed consent, instruct the client to empty their bladder, obtain baseline measurements, position the client upright, and finally set up the sterile tray.
The correct sequence prioritizes legal readiness, then proceeds to crucial physiological risk reduction. The client must void first to prevent accidental bladder perforation by the trocar. Once the bladder is empty, an accurate baseline weight, abdominal girth, and vital signs can be obtained. The client is then positioned upright to pool the fluid, and the sterile tray is opened last to maintain strict asepsis immediately prior to insertion.

Adım Adım Çözüm

1
Verify informed consent.
Legal authorization is confirmed.
Must be completed before any physical preparation begins.
2
Instruct client to empty bladder.
Bladder size is reduced.
Prevents accidental puncture of the bladder during trocar insertion.
3
Obtain baseline measurements.
Accurate dry weight and baseline vital signs are recorded.
Crucial for detecting post-procedure hypovolemic shock caused by rapid fluid shifts.
4
Position the client upright.
Ascitic fluid pools in the lower abdomen.
Uses gravity to facilitate safe and effective fluid aspiration.
5
Prepare the sterile tray.
Sterile field is established.
Must be done immediately prior to the procedure to minimize contamination risk.

Anahtar Kavram

Risk reduction during paracentesis preparation involves preventing bladder perforation, establishing baselines for shock detection, and ensuring proper gravity pooling of fluid.
Soru 2278Soru →

A practical nurse is caring for an older adult client receiving continuous enteral nutrition via a nasogastric tube. The client suddenly experiences forceful coughing, tachypnea, and expels enteral formula from their mouth. In which order should the practical nurse perform the following actions to minimize the client's risk for severe complications?

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Cevap

The correct sequence is to first pause the feeding pump, then turn the client to a side-lying position, suction the oral cavity, auscultate lung sounds with oxygen saturation, and finally report the findings to the registered nurse.
In any acute respiratory emergency where a clear causative agent is actively being introduced, the absolute priority is to stop the agent (pause the pump). Following the ABCs (Airway, Breathing, Circulation), the next immediate steps are to physically protect the airway (lateral position) and clear it (suction). Only after the airway is secured and the immediate physical threat is neutralized should the practical nurse proceed to data collection (auscultation and oxygen saturation) and escalation of care (notifying the RN).

Adım Adım Çözüm

1
Pause the continuous enteral feeding pump.
The flow of enteral formula into the client is halted.
This immediately removes the source of the aspiration, which is the absolute highest priority to prevent further volume from entering the lungs.
2
Turn the client into a lateral side-lying position.
The client's airway is protected by gravity.
This position facilitates the immediate drainage of the expelled formula out of the mouth rather than allowing it to pool and travel down into the trachea.
3
Use a Yankauer catheter to suction the oral cavity.
Visible formula is removed from the oropharynx.
Suctioning physically clears the upper airway, establishing patency and minimizing the risk of secondary aspiration of residual formula in the mouth.
4
Auscultate bilateral lung sounds and obtain an oxygen saturation reading.
Baseline respiratory compromise is quantified.
Once the airway is completely secured and the immediate threat is neutralized, the nurse must assess the extent of the client's physiological reaction to guide further medical interventions.
5
Report the clinical findings and interventions to the registered nurse.
The healthcare team is alerted to the critical event.
Escalation to the supervising RN is required so that higher-level interventions, such as a chest radiograph or provider notification, can be initiated based on the assessment data.

Anahtar Kavram

Prioritization of immediate life-saving interventions (stopping the source and protecting the airway) over data collection during an acute aspiration event.
Soru 2279Soru →

While preparing a client's morning medications, a practical nurse needs to combine prescribed doses of regular insulin and NPH insulin into one syringe. Place the actions required to safely prepare this mixed insulin injection into the correct chronological sequence.

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Cevap

The correct sequence is to roll the NPH vial, inject air into the NPH vial, inject air into the regular insulin vial, withdraw the regular insulin, and finally withdraw the NPH insulin.
The standard procedure for mixing insulins dictates that the intermediate-acting NPH insulin (cloudy) must be gently rolled first to mix the suspension. To avoid negative pressure without contaminating the needle, air is injected into the NPH vial first, followed by injecting air into the regular insulin (clear) vial. The regular insulin is then withdrawn first ('clear before cloudy') to ensure that no intermediate-acting insulin accidentally contaminates the rapid or short-acting regular insulin vial. Finally, the NPH insulin is withdrawn.

Adım Adım Çözüm

1
Roll the vial of NPH insulin gently between the palms of the hands.
The cloudy insulin suspension is mixed uniformly.
NPH insulin is a suspension that settles. Rolling mixes it gently without creating bubbles that could lead to an inaccurate dose.
2
Inject a volume of air equal to the prescribed dose into the NPH insulin vial.
The NPH vial is pressurized.
Injecting air first prevents the creation of a vacuum later. The needle touches only air, remaining uncontaminated for the next vial.
3
Inject a volume of air equal to the prescribed dose into the regular insulin vial.
The regular insulin vial is pressurized.
The regular insulin vial must be pressurized immediately before drawing up the medication.
4
Withdraw the prescribed dose of regular insulin into the syringe.
The clear insulin is drawn into the syringe.
The clear (regular) insulin is always drawn first to prevent the cloudy (NPH) insulin from entering and contaminating the regular insulin vial.
5
Withdraw the prescribed dose of NPH insulin into the syringe.
The exact dose of cloudy insulin is added to the syringe.
The cloudy insulin is drawn last to complete the mixture. If too much NPH is drawn inadvertently, the entire syringe must be discarded as the insulins are already mixed.

Anahtar Kavram

Safe Preparation of Mixed Insulins (Clear before Cloudy)
Soru 2280Soru →

A practical nurse (PN) is performing a routine dressing change for a client who is 4 days postoperative following an abdominal surgery. The client suddenly coughs forcefully, and the PN observes a loop of bowel protruding through the incision line. Arrange the following actions in the order the PN should perform them, from first to last.

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Cevap

The PN must first call for immediate assistance while remaining with the client, then position the client to decrease abdominal tension, cover the evisceration with sterile moist dressings, and finally monitor vital signs for shock.
Wound evisceration is a critical surgical emergency. The nurse's first priority is to call for help while staying with the client to ensure safety and rapidly mobilize the team. Next, positioning the client in low Fowler's with flexed knees reduces intra-abdominal pressure. Third, covering the wound with sterile, saline-soaked dressings protects the tissue viability. Finally, obtaining vital signs establishes a baseline to monitor for impending shock.

Adım Adım Çözüm

1
Stay with the client and call for immediate assistance.
Additional nursing staff is alerted to bring supplies and notify the provider.
An evisceration is a medical emergency requiring teamwork; the nurse cannot leave the client unattended to gather sterile supplies.
2
Place the client in a low Fowler's position with the knees flexed.
Intra-abdominal pressure is minimized.
Flexing the hips and knees relaxes the abdominal wall, preventing further visceral protrusion from the wound.
3
Cover the protruding organs with sterile, saline-soaked dressings.
The exposed bowel is kept moist and protected from contaminants.
Drying of the viscera can cause irreversible tissue damage. Using sterile technique prevents severe intra-abdominal infection.
4
Assess the client's vital signs to monitor for symptoms of shock.
The client's hemodynamic status is documented.
Evisceration can trigger a massive fluid shift or hemorrhage leading to hypovolemic shock, requiring close monitoring.

Anahtar Kavram

Management of Wound Evisceration
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