Tüm alıştırma soruları

An older adult client is hospitalized for observation following a mechanical fall that caused blunt abdominal trauma. During the night shift, the nurse notes that the client has become restless and mildly confused about their current location. Vital signs demonstrate a heart rate of 114 beats per minute, a blood pressure of 102/74 mm Hg, and a respiratory rate of 22 breaths per minute. The client's peripheral pulses are weak and extremities are cool. Which action should the nurse take first?

Upon entering a client's room in a rehabilitation center, a practical nurse observes smoke and small flames coming from a wastebasket near the privacy curtain. The client is currently resting in bed. Arrange the following actions in the priority order the nurse should perform them.

During a routine morning assessment, a client receiving pharmacological therapy for heart failure states, "I feel sick to my stomach, and all the lights have a strange yellow glow around them." The client's medication profile includes daily oral digoxin and furosemide. A review of today's laboratory results reveals a serum digoxin level of $2.8\text{ ng/mL}$. Which action should the practical nurse implement?

A community health clinic is triaging a high volume of walk-in clients. The supervising registered nurse (RN) delegates several pending tasks to the practical nurse (PN). Which assigned task should the PN accept and perform?

Following an abdominal hysterectomy, a client is transferred to the surgical unit. During the initial data collection, the practical nurse notes a heart rate of 114 beats/min and a blood pressure of 94/58 mm Hg. The client states, 'I feel a little nauseous and my incision hurts.' Which action should the nurse take first?

A practical nurse (PN) is collecting data on a client admitted with a severe exacerbation of ulcerative colitis. The client has had several large, bloody bowel movements over the past four hours. The client's current vital signs are: heart rate 112 beats/min, blood pressure 106/68 mm Hg, and respiratory rate 22 breaths/min. The client's admission vital signs were: heart rate 78 beats/min, blood pressure 134/82 mm Hg, and respiratory rate 16 breaths/min. The client appears restless and reports abdominal cramping. Which action should the PN take first?

A practical nurse (PN) provides care for a 75-year-old resident in a skilled nursing facility who is receiving oral antibiotics for a lower urinary tract infection. During the afternoon shift, the PN discovers the resident is unusually restless, picking at their clothing, and breathing at a rate of 26 breaths/min. Which actions should the PN prioritize? Select all that apply.

During a busy morning shift on a pediatric unit, a practical nurse (PN) encounters several situations involving the handling of protected health information (PHI). Which actions by the PN correctly maintain client confidentiality? Select all that apply.

An older adult client is resting in the surgical unit following a left cataract extraction. The client reports mild postoperative discomfort and asks to be repositioned in bed. Which positioning strategy should the licensed practical nurse implement?

Four hours after a percutaneous liver biopsy, an assigned client reports the new onset of right shoulder pain. The client's baseline vital signs were a blood pressure of $134/82 \text{ mm Hg}$ and a heart rate of $76 \text{ beats/min}$. The licensed practical nurse (LPN/LVN) assesses current vital signs, noting a blood pressure of $108/72 \text{ mm Hg}$ and a heart rate of $114 \text{ beats/min}$. Which action must the nurse take first?

While monitoring an older adult client who is being treated with a continuous intravenous heparin infusion for a pulmonary embolism, a practical nurse (PN) reviews the trend of the client's vital signs. Over the past four hours, the client's heart rate has climbed from $78\text{ bpm}$ to $112\text{ bpm}$, and the blood pressure has trended downward from $134/82\text{ mmHg}$ to $104/68\text{ mmHg}$. The client currently reports feeling faint. What is the priority action for the PN?

A practical nurse is preparing to provide oral hygiene for a client who is unresponsive following a severe traumatic brain injury. In what order should the nurse perform the following actions? (Arrange the steps from first to last.)

A practical nurse enters the room of a client receiving intravenous fluids via a central venous catheter. The nurse observes that the intravenous tubing has become disconnected from the catheter hub. The client is suddenly grasping their chest, gasping for air, and appears cyanotic. In which order should the nurse perform the following emergency actions to mitigate the risk of a fatal complication? Arrange the steps from first (highest priority) to last.

A practical nurse is evaluating a septuagenarian client residing in an assisted living apartment. The client's caregiver reports that over the past 48 hours, the client has developed new-onset urinary incontinence, poor appetite, and increased lethargy. The client is currently oriented to person only, which represents a change from their baseline of being fully oriented to person, place, and time. Which actions should the practical nurse take? Select all that apply.

A practical nurse is caring for a client who is 4 hours postoperative following an open cholecystectomy. The registered nurse (RN) is managing the client's continuous intravenous (IV) fluids and delegates the administration of scheduled oral metoprolol, oral oxycodone, and a PRN dose of IV push ondansetron to the practical nurse. The client's current vital signs are blood pressure 86/52 mmHg, heart rate 118 bpm, and respiratory rate 16 breaths/min. The client reports a pain level of 7 on a 0 to 10 scale. Which action should the practical nurse take first?

A practical nurse is providing postoperative care for a client who recently returned to the unit following a right-sided cataract extraction. Which basic care and positioning interventions should the nurse implement to prevent complications? Select all that apply.

The nursing care team is managing the daily needs of a client who is non-ambulatory and receiving continuous enteral feedings via a gastrostomy tube following a recent abdominal surgery. When implementing basic hygiene and comfort measures, which actions are appropriate for the practical nurse (PN) to perform? Select all that apply.

A practical nurse (PN) is reviewing the morning clinical data for a client who is $2$ days postoperative following a total hip arthroplasty. The client is scheduled to receive subcutaneous enoxaparin, oral celecoxib, and oral pantoprazole.

Morning clinical data:
- Blood pressure: $96/58\text{ mmHg}$
- Heart rate: $112\text{ beats/min}$
- Hemoglobin: $10.4\text{ g/dL}$
- Platelet count: $85,000/\text{mm}^3$

Which action should the PN take FIRST?

A practical nurse (PN) is assigned to a client in a neurological rehabilitation unit. The client has a new prescription for phenytoin $5\text{ mg/kg/day}$ by mouth, to be given in two equally divided doses. The client's current weight is $176\text{ lb}$. The facility pharmacy provides phenytoin oral suspension at a concentration of $125\text{ mg}/5\text{ mL}$. Which of the following actions represents safe nursing practice by the PN?

A practical nurse (PN) is preparing an older adult client for an elective surgical procedure. The charge nurse delegates the task of witnessing the client's signature on the informed consent form. When the PN presents the form, the client states, "I will sign it so we do not lose my spot, but the surgeon was in a hurry and I still do not understand what the major risks are." The client's spouse, standing near the open doorway, says, "It is fine, I read the surgical brochure and I can explain the risks to you right now." Which action should the PN take?