Tüm alıştırma soruları

While performing morning rounds, a practical nurse discovers that a client's intravenous tubing has disconnected from their central venous catheter hub. The client is suddenly gasping for air, extremely anxious, and cyanotic. To reduce the risk of a life-threatening complication, place the following nursing actions in the correct priority sequence.

An older adult client with a history of chronic obstructive pulmonary disease (COPD) is assigned to a bed located directly across from the busy central nursing station. After three days of constant exposure to telemetry alarms, overhead pages, and staff conversations, the client becomes increasingly restless, disoriented to time, and states they see insects crawling on the walls. Which actions should the practical nurse (PN) take to address this client's sensory alteration? Select all that apply.

A practical nurse is caring for a client who is 48 hours post-operative following a right above-the-knee amputation. To promote comfort and prevent hip flexion contractures, which position should the nurse encourage the client to assume for 20 to 30 minutes several times a day?

During morning rounds, a practical nurse reviews the electronic health record of a client diagnosed with bipolar disorder and hypertension. The client was admitted overnight for severe viral gastroenteritis with persistent vomiting and diarrhea. The morning laboratory results reveal a serum sodium level of $128\text{ mEq/L}$ ($128\text{ mmol/L}$). The client is scheduled to receive their routine oral lithium carbonate and oral hydrochlorothiazide in 30 minutes. Current vital signs indicate a heart rate of $115\text{ beats/min}$ and a blood pressure of $94/58\text{ mm Hg}$. Based on the client's clinical presentation, which action is the priority for the practical nurse?

During a shift on a medical-surgical unit, a practical nurse (PN) is caring for an adult client who begins to deteriorate rapidly, exhibiting severe respiratory distress. As the PN prepares to intervene, the client's sibling presents a handwritten document they claim is a valid living will refusing all mechanical ventilation. Simultaneously, the client's legally separated spouse arrives, demands that all life-saving measures be initiated immediately, and claims to be the client's designated healthcare proxy. In what order should the PN take the following actions? (Arrange the actions from first to last.)

A client is admitted to the medical unit with active gastrointestinal bleeding. Upon admission, the client's blood pressure was 122/80 mm Hg and heart rate was 78 beats per minute. One hour later, the practical nurse observes that the client's blood pressure has decreased to 98/62 mm Hg and the heart rate has increased to 112 beats per minute. Which action should the practical nurse take first?

A practical nurse (PN) is assisting a female client with collecting a midstream clean-catch urine specimen for a culture and sensitivity test. In which order should the PN perform or instruct the client to perform the following steps? (Arrange from first to last)

A practical nurse is caring for a client who is 36 hours postoperative following a right above-the-knee amputation. The client has a history of dysphagia and is receiving continuous enteral nutrition via a nasogastric tube. The nursing care plan includes interventions to prevent hip flexion contractures. Which action is most appropriate for the practical nurse to implement?

A practical nurse is providing basic care for a client who returned to the medical unit 2 hours ago following an esophagogastroduodenoscopy (EGD) performed with a topical anesthetic throat spray. The client reports feeling hungry, and their family has brought a culturally specific, home-cooked meal. Which of the following actions should the nurse take first?

During morning medication rounds, a client examines a newly provided pill and tells the practical nurse, "This does not look like my usual blood pressure medicine. Mine is always white, not blue." What is the safest response by the nurse?

While reviewing morning laboratory reports, a practical nurse (PN) notes that a client receiving a daily subcutaneous dose of enoxaparin has a platelet count of $65,000/\text{mm}^3$ ($65 \times 10^9/\text{L}$). Which action should the PN take first?

An older adult client recovering from a stroke has residual left-sided weakness. The licensed practical nurse is preparing to help the client move from the bed into a wheelchair. Arrange the following actions in the correct chronological sequence to ensure a safe transfer.

An adult client who underwent an open partial gastrectomy earlier in the day activates the call bell. The client states, "I feel incredibly thirsty and my heart is racing," while repeatedly pulling at the bed linens. Data collection reveals a temperature of 98.9°F (37.2°C), heart rate of 118 beats/minute, respiratory rate of 24 breaths/minute, and blood pressure of 102/82 mm Hg. Which of the following interventions should the practical nurse implement? Select all that apply.

A practical nurse is caring for a conscious client with diabetes mellitus who suddenly reports feeling shaky and weak. The client's skin is cool and clammy, and their capillary blood glucose is 58 mg/dL. In what order should the practical nurse implement the following actions?

A practical nurse (PN) is reviewing assessment data for a group of assigned clients. Which of the following findings indicate a developing complication and require the PN to immediately escalate care to the registered nurse (RN)? Select all that apply.

A licensed practical nurse is collecting data from a client who is 12 hours postpartum following an uncomplicated vaginal delivery. The nurse observes that the client has completely saturated a perineal pad with lochia rubra over the past 45 minutes. Upon palpation, the uterine fundus is boggy and located 2 centimeters above the umbilicus. Which action should the nurse take first?

An older adult client is admitted to a long-term care facility after undergoing a total right hip replacement (posterior approach). When turning and repositioning the client in bed, which action should the practical nurse take?

A practical nurse is changing a dressing for a client who is 3 days postoperative following abdominal surgery. The client coughs forcefully, and the nurse observes loops of intestine protruding through the surgical incision. In what order should the nurse perform the following actions? (Arrange the actions from first priority to last priority.)

A practical nurse (PN) is assisting an older adult client with morning hygiene and elimination. The client is 2 days postoperative following a right total hip arthroplasty (posterior approach) and requires strict adherence to hip precautions. Which of the following actions by the PN are appropriate? (Select all that apply.)

A licensed practical nurse is preparing to administer a prescribed large-volume cleansing enema to an adult client who is experiencing constipation. In what order should the nurse perform the following actions? Arrange the steps from first to last.