Tüm alıştırma soruları

A practical nurse is collecting data from a client who was admitted with a pulmonary embolism and is currently receiving a continuous intravenous heparin infusion. Which of the following findings indicate a high risk for potential complications and require immediate notification of the supervising registered nurse? Select all that apply.

A practical nurse (PN) is preparing to administer scheduled oral digoxin to a 4-month-old infant diagnosed with a ventricular septal defect. Prior to administration, the PN assesses the sleeping infant's vital signs and notes an apical pulse of 84 beats/minute and a respiratory rate of 32 breaths/minute. Which action should the PN take first?

A client returns to the medical-surgical unit following a percutaneous liver biopsy. Which interventions should the practical nurse implement to reduce the risk of post-procedure complications? Select all that apply.

A pediatric client diagnosed with acute otitis media is receiving care in a clinic. The practical nurse (PN) reviews the electronic health record:

Vital Signs & Measurements:
Temperature: $101.4^\circ\text{F}$ ($38.6^\circ\text{C}$)
Weight: $35.2\text{ lb}$
Allergies: Penicillin (mild rash)

Provider Prescriptions:
Ceftriaxone $50\text{ mg/kg/day}$ intramuscularly, divided into two equal doses.

Pharmacy Dispenses:
Ceftriaxone $1\text{ g}$ vial of sterile powder.
Reconstitution instructions: Add $2.1\text{ mL}$ of sterile water for injection to yield a final concentration of $350\text{ mg/mL}$.

How many $\text{mL}$ should the PN administer per dose? (Record the answer to the nearest tenth. Do not include units in the answer.)

A practical nurse is caring for a client who is 24 hours postoperative following an abdominal surgery. The client is prescribed oral hydromorphone every 4 hours as needed for pain. Upon entering the room to administer a requested dose, the nurse observes that the client is difficult to arouse, with a respiratory rate of 8 breaths per minute and an oxygen saturation of 88% on room air. Which action should the nurse take first?

A practical nurse is assessing an $82$-year-old client diagnosed with acute pyelonephritis who is receiving intravenous antibiotics. The client, who was previously oriented, suddenly exhibits marked restlessness and confusion. Vital signs reveal a blood pressure of $92/60$ mm Hg (baseline was $136/82$ mm Hg), a heart rate of $118$ beats/minute, and a respiratory rate of $24$ breaths/minute. Which action should the practical nurse implement first?

A practical nurse is evaluating an older adult resident in a long-term care setting who has been receiving oral antibiotics for the past three days to treat a lower extremity soft tissue infection. During an evening check, the resident appears unusually drowsy, is unable to identify a visiting family member, and has a blood pressure of 104/60 mm Hg with a resting pulse of 102 beats per minute. The resident's documented baseline blood pressure is 138/78 mm Hg. Which conclusion should guide the nurse's immediate response?

A practical nurse enters the room of a client who has a central venous catheter. The nurse discovers that the intravenous tubing has disconnected from the catheter hub. The client suddenly reports sharp chest pain, is gasping for air, and appears cyanotic. In what order should the nurse perform the following actions to reduce the client's risk of further harm? Arrange the steps in the correct sequence from first to last.

A 55-year-old individual is recovering on the surgical unit 24 hours after a right-sided modified radical mastectomy with axillary lymph node dissection. As the practical nurse organizes basic care and comfort measures for the shift, which of the following actions should be included in the plan of care? Select all that apply.

A practical nurse is preparing to collect a sterile urine specimen for culture and sensitivity from a client's indwelling urinary catheter. To reduce the risk of sample contamination and client infection, in what order should the nurse perform the following actions? (Arrange the steps in the correct sequence from first to last.)

A practical nurse (PN) is preparing to administer prescribed timolol eye drops to a client diagnosed with glaucoma. Assuming hand hygiene has been performed and clean gloves are applied, in what order should the PN perform the following steps?

A practical nurse is assessing a client who underwent an open bowel resection $12$ hours ago. Which clinical finding should the nurse identify as the highest priority to report to the registered nurse?

A practical nurse (PN) is assigned to care for a client with bipolar disorder who is receiving scheduled oral lithium carbonate. The PN reviews the client's morning electronic health record and notes a serum lithium level of $2.2 \text{ mEq/L}$. The next dose of lithium is due in 30 minutes. Which of the following actions should the PN take?

The practical nurse (PN) is providing care for a client who recently returned to the surgical unit following a subtotal thyroidectomy. Which positioning technique should the PN implement to maintain client comfort and safety?

Following the change-of-shift report, a practical nurse reviews the electronic health record of an older adult client hospitalized for a heart failure exacerbation. The client's morning serum potassium result is $2.8\text{ mEq/L}$ ($2.8\text{ mmol/L}$). The active medication administration record includes scheduled oral furosemide, oral potassium chloride, and a new one-time order for intravenous (IV) push bumetanide. Which of the following actions should the practical nurse take? Select all that apply.

A practical nurse (PN) is preparing to apply knee-high anti-embolism stockings to a client who is prescribed prolonged bed rest. In what order should the PN perform the following actions? Arrange the steps in the correct sequence.

During a postoperative check, a practical nurse observes a 28-year-old client recovering from an open reduction and internal fixation of a femur fracture. Six hours after surgery, the client has developed new-onset restlessness and pale, cool skin. Vital signs show a heart rate of 118 bpm, a blood pressure of 102/68 mmHg, and a respiratory rate of 22 breaths/min. The client complains of moderate leg discomfort. Which priority action should the nurse implement?

An older adult client with a methicillin-resistant Staphylococcus aureus (MRSA) infection in a venous stasis ulcer is scheduled to visit the rehabilitation department for ambulation training. Which action by the practical nurse best demonstrates adherence to both infection control and professional safety standards?

A practical nurse is providing care for a client who is on strict bed rest for a deep vein thrombosis. The client abruptly becomes restless and confused, exhibiting a respiratory rate of 24 breaths per minute and a heart rate of 98 beats per minute (baseline 72 beats per minute). The client also reports a vague sense of impending doom. Which action should the practical nurse take first?

A client diagnosed with active tuberculosis is receiving a daily pharmacological regimen that includes oral isoniazid, rifampin, pyrazinamide, and ethambutol. Prior to administering the scheduled morning doses, the practical nurse (PN) reviews the client's current data. The client states, "My urine has been a bright orange-red color for the last two days." The morning laboratory results show an aspartate aminotransferase (AST) of 152 U/L and an alanine aminotransferase (ALT) of 168 U/L. Based on these clinical findings, which action is most appropriate for the practical nurse to take?