Tüm alıştırma soruları

A practical nurse is caring for a client admitted with severe gastroenteritis and prolonged diarrhea. The client's admission blood pressure was $118/76$ mm Hg with a heart rate of $84$ beats per minute. Four hours later, the nurse notes the blood pressure is $100/62$ mm Hg and the heart rate is $112$ beats per minute. The client's oral mucosa is dry. Which of the following actions should the practical nurse take first?

A practical nurse (PN) is preparing to administer a scheduled dose of oral metoprolol to an adult client. Prior to administration, the PN assesses the following vital signs: blood pressure $92/58\text{ mm Hg}$, heart rate $54\text{ beats/minute}$, and respiratory rate $16\text{ breaths/minute}$. Which action should the PN take?

While performing a routine assessment for a client who is 3 days postoperative from an exploratory laparotomy, a practical nurse observes a loop of bowel protruding through the abdominal incision after the client forcefully sneezes. The client reports a sudden 'popping' feeling. Arrange the following emergency interventions in the correct priority sequence.

An unlicensed assistive personnel (UAP) informs the practical nurse (PN) that a 77-year-old client is suddenly agitated and disoriented. The client had a surgical repair of a fractured femur 24 hours ago. Upon assessment, the PN notes the client has a respiratory rate of 26 breaths/minute, a heart rate of 109 beats/minute, and a blood pressure of 102/64 mm Hg. Which of the following actions should the PN take? Select all that apply.

After receiving the shift handoff report for four assigned clients on a step-down medical unit, which client should the practical nurse (PN) evaluate first?

An adult client is prescribed iron dextran via intramuscular injection. To prevent tissue irritation and skin staining, the practical nurse utilizes the Z-track technique. Place the steps of this administration technique in the appropriate chronological order, assuming standard pre-administration safety checks and hand hygiene have already been completed.

A practical nurse (PN) is providing care for a client who is $4$ hours postoperative following a percutaneous coronary intervention (PCI) via the right femoral artery. Which nursing action demonstrates the correct application of risk reduction principles?

A nursing supervisor is evaluating task delegation on a medical-surgical unit. What specific medication administration task is appropriate for the charge nurse to delegate to the practical nurse?

A practical nurse is assigned to care for an adult client who is receiving intravenous fluid therapy for fluid volume deficit following an episode of gastroenteritis. The client has a heart rate of $108$ bpm and a blood pressure of $98/60$ mmHg. The healthcare provider has prescribed $500$ mL of $0.9\%$ sodium chloride to infuse over $6$ hours. The primary intravenous tubing has a drop factor of $20$ gtt/mL. At how many drops per minute (gtt/min) should the infusion be regulated? Record the answer to the nearest whole number. Do not include units in the answer.

A practical nurse (PN) is evaluating a client who is 6 hours post-operative following an abdominal hysterectomy. The client reports feeling slightly dizzy, exhausted, and having mild abdominal cramping. During the data collection, the PN notes a heart rate of 112 beats/min, a blood pressure of 98/60 mm Hg, and a fully saturated perineal pad with bright red blood. The surgical abdominal dressing remains clean and dry. Which action should the PN take first?

A client who is 2 days post-operative following a right hip replacement suddenly complains of stabbing chest discomfort and difficulty breathing. In what chronological order should the practical nurse (PN) perform the following actions?

During morning rounds, a practical nurse evaluates a $71$-year-old client who takes oral warfarin for atrial fibrillation. The client's most recent laboratory report reveals an International Normalized Ratio (INR) of $5.8$. The current vital signs show a heart rate of $112$ beats per minute and a blood pressure of $92/56\text{ mm Hg}$. The client reports feeling unusually fatigued and dizzy when sitting up. What is the priority action for the nurse?

A practical nurse (PN) enters the room of a client with type 1 diabetes mellitus. The client is pale, diaphoretic, and states, 'I feel very shaky.' The PN checks the capillary blood glucose, which is 42 mg/dL (2.3 mmol/L). The client is conscious and able to swallow. In what order should the PN perform the following actions? (Arrange the items in the correct sequence from first to last.)

A practical nurse (PN) is monitoring a client who underwent a percutaneous liver biopsy $2$ hours ago. The client is currently positioned on their right side. The client reports mild lightheadedness. The PN notes that the client's heart rate has increased from $80$ to $108$ beats/minute, and their blood pressure has decreased from $126/78$ to $108/68$ mmHg over the past hour. The client's skin feels slightly cool and clammy.

Which of the following is the most appropriate initial action for the PN to take?

A client is being monitored on the surgical unit 24 hours after a thoracotomy with a closed chest drainage system in place. Which assessment findings should the practical nurse immediately report to the registered nurse as indicators of a developing tension pneumothorax? Select all that apply.

A practical nurse is preparing to administer a combined dose of NPH insulin and regular insulin in a single syringe for a client with diabetes mellitus. In what order should the nurse perform the following steps to safely mix these medications?

A practical nurse (PN) is assigned to care for a 78-year-old client with a history of chronic kidney disease who is receiving a continuous intravenous (IV) infusion of normal saline at 125 mL/hr. During hourly rounds, the client suddenly becomes restless, repeatedly asks where they are, and exhibits a respiratory rate of 26 breaths/min with a heart rate of 104 beats/min. Which action should the PN take FIRST?

While conducting a morning assessment on a surgical unit, a licensed practical nurse evaluates a client who is $24\text{ hours}$ post-subtotal thyroidectomy. The electronic health record displays a newly resulted serum calcium level of $7.1\text{ mg/dL}$. At the bedside, the client describes a "pins and needles" sensation around their lips and fingers. Assessment reveals a heart rate of $104\text{ beats/min}$, a blood pressure of $96/60\text{ mmHg}$, and mild facial muscle twitching. What is the priority action for the nurse to take?

A practical nurse (PN) is caring for a client who is 4 days post-operative following a colon resection. The client experiences a severe coughing fit and reports, 'I felt something pop in my stomach.' Upon inspection, the PN notes that the surgical incision has separated and loops of bowel are protruding. In what order should the PN perform the following actions? Arrange the actions from first to last.

While reviewing the electronic health record of a client diagnosed with a severe infection, a practical nurse observes a significant change in the client's laboratory results. The morning serum creatinine has increased to 2.9 mg/dL (reference range: 0.6–1.2 mg/dL) from a baseline of 1.0 mg/dL upon admission. The client is prescribed intravenous gentamicin, and the next dose is scheduled to be administered in 15 minutes. Which action should the nurse take?