Physiological Integrity

1313 soru

Tüm türler1,313 Çoktan seçmeli672 Çoklu seçim289 Sayısal68 Sıralama284

A practical nurse is caring for a client who is scheduled to receive a prescribed dose of oral azithromycin. The morning diagnostic reports indicate a serum potassium level of 3.1 mEq/L (3.1 mmol/L) and a newly prolonged QT interval on the electrocardiogram. Which action should the practical nurse take?

Withhold the azithromycin and immediately report the clinical findings to the registered nurse.

Administer the medication as prescribed and note the potassium level in the end-of-shift report.

Administer an intravenous potassium bolus to correct the deficit before giving the azithromycin.

Bypass the electronic barcode scanning process to expedite the administration of the prescribed antibiotic.

Cevabı ve açıklamayı göster

Cevap: Withhold the azithromycin and immediately report the clinical findings to the registered nurse.

Cevap

The practical nurse should withhold the azithromycin and immediately report the clinical findings to the registered nurse.

Azithromycin is a macrolide antibiotic that carries a known risk of prolonging the QT interval. This client already has a newly prolonged QT interval and concurrent hypokalemia (potassium level of 3.1 mEq/L). The combination of hypokalemia and a QT-prolonging medication drastically increases the risk of developing a lethal ventricular arrhythmia, such as torsades de pointes. The most appropriate action within the practical nursing scope of practice is to prioritize client safety by withholding the medication and immediately communicating these critical findings to the supervising registered nurse or healthcare provider.

Adım Adım Çözüm

Analyze the provided clinical data, including the serum potassium level of 3.1 mEq/L and the prolonged QT interval.

The potassium level indicates hypokalemia (normal is typically 3.5 to 5.0 mEq/L), and the electrocardiogram shows a cardiac rhythm abnormality.

Identifying abnormal baseline data is required before safely administering medications.

Determine the pharmacological risks of azithromycin in this specific client.

Azithromycin is known to cause QT interval prolongation, and concurrent hypokalemia significantly increases the risk of life-threatening cardiac arrhythmias such as torsades de pointes.

Connecting the drug's adverse effects with the client's current status prevents severe patient harm.

Select the most appropriate nursing intervention based on the practical nurse scope of practice.

The medication must be withheld, and the registered nurse must be notified immediately.

The practical nurse must escalate critical safety concerns and abnormal findings to the supervising registered nurse.

Anahtar Kavram

Safe medication administration requires the practical nurse to evaluate pertinent laboratory values and diagnostic results prior to giving a drug, withholding medications that pose an immediate risk of adverse effects, and promptly escalating these findings to the registered nurse.

Soru 1302Soru →

Following an open partial gastrectomy, a client is transferred to the medical-surgical unit. $6$ hours later, the client exhibits new-onset restlessness. The client's initial vital signs were blood pressure $126/78$ mmHg and heart rate $78$ bpm. Current vital signs show a blood pressure of $104/64$ mmHg, heart rate of $114$ bpm, and respiratory rate of $22$ breaths/min. A recent laboratory report indicates a hemoglobin level of $8.2$ g/dL ( $82$ g/L), which has dropped from a preoperative baseline of $12.4$ g/dL ( $124$ g/L). Which actions are appropriate for the practical nurse to take in this situation? Select all that apply.

Geçerli olan tümünü seçin

Immediately notify the registered nurse about the clinical changes.

Inspect the abdominal surgical dressing and drains for excessive sanguineous drainage.

Confirm the patency of the client's peripheral intravenous catheter.

Administer the prescribed intravenous push (IVP) analgesic to alleviate the client's restlessness.

Document the findings as expected postoperative variations and reassess vital signs during the next scheduled round.

Defer reporting the hemoglobin result until the healthcare provider's rounds, as the value remains above the typical transfusion threshold.

Cevabı ve açıklamayı göster

Cevap: Immediately notify the registered nurse about the clinical changes.; Inspect the abdominal surgical dressing and drains for excessive sanguineous drainage.; Confirm the patency of the client's peripheral intravenous catheter.

Cevap

The practical nurse should immediately notify the registered nurse about the clinical changes, inspect the abdominal surgical dressing and drains for excessive sanguineous drainage, and confirm the patency of the client's peripheral intravenous catheter.

The client is demonstrating classic early signs of hypovolemic shock (tachycardia, mild hypotension, tachypnea, and restlessness) likely due to postoperative hemorrhage, supported by a significant drop in hemoglobin. The practical nurse must immediately notify the registered nurse, visually inspect the surgical site for external bleeding, and ensure intravenous access is patent for potential fluid resuscitation or blood product administration.

Adım Adım Çözüm

Analyze the assessment data to identify abnormal trends.

The client shows a narrowing pulse pressure with hypotension, tachycardia, tachypnea, and new-onset restlessness, accompanied by a significant drop in hemoglobin.

Identifying trends is essential to distinguish expected postoperative recovery from life-threatening complications.

Determine the underlying complication indicated by the findings.

These systemic findings strongly indicate developing hypovolemic shock secondary to acute postoperative hemorrhage.

Early recognition of the compensatory mechanisms of shock allows for prompt, life-saving intervention before irreversible damage occurs.

Select appropriate actions that fall within the practical nursing scope of practice.

The practical nurse must escalate the critical findings to the registered nurse immediately, visually assess for the source of external bleeding, and secure intravenous access.

The practical nursing role involves collecting focused data, recognizing critical abnormalities, escalating care, and preparing the client for emergency interventions.

Anahtar Kavram

Early Recognition and Escalation of Postoperative Hypovolemic Shock

Soru 1303Soru →

A practical nurse enters the room of a client receiving a continuous enteral tube feeding and observes the client coughing vigorously and exhibiting sudden tachypnea. In which order should the practical nurse perform the following actions? Arrange the steps from first to last.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first stop the continuous enteral tube feeding, elevate the head of the bed to a high-Fowler's position, measure the client's oxygen saturation and respiratory rate, report the findings to the supervising registered nurse, and finally document the respiratory event and the client's response.

In any emergency situation involving a continuous infusion or feeding where a severe complication is suspected, the first priority is to stop the source of potential harm. Next, the airway and breathing must be supported through proper positioning. Only after these immediate, risk-reducing interventions are completed should the nurse gather objective assessment data (vital signs) to report to the supervising registered nurse. Documentation is performed last once the client is stabilized and the healthcare team has been notified.

Adım Adım Çözüm

Stop the enteral tube feeding immediately.

The source of potential aspiration is halted.

Halting the infusion is the most critical first step to prevent further fluid from entering the airway.

Elevate the head of the bed.

The client is placed in a high-Fowler's position.

An upright position maximizes lung expansion, aids in clearing the airway, and uses gravity to prevent further aspiration.

Assess oxygen saturation and respiratory rate.

Objective respiratory data is collected.

Once the immediate risk is mitigated and the airway is protected, the nurse must quantify the extent of respiratory compromise.

Notify the registered nurse.

The healthcare team is alerted to the client's changing condition.

The practical nurse must report the adverse event along with the current vital signs so the registered nurse can assess and escalate to the provider if necessary.

Document the event.

The incident is recorded in the electronic health record.

Documentation is always the final step after prioritizing client safety, interventions, and communication.

Anahtar Kavram

Prioritization and Risk Reduction in Suspected Aspiration

Soru 1304Soru →

A practical nurse is monitoring a client who is $6\text{ hours}$ postoperative following a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation (CBI). Which of the following assessment findings indicate a developing complication that requires immediate escalation to the registered nurse? Select all that apply.

Geçerli olan tümünü seçin

Urinary drainage in the collection bag that rapidly transitions from light pink to bright red with large clots

A morning serum hemoglobin level of

14.2\text{ g/dL}

and hematocrit of

42\%

A heart rate of

118\text{ beats/minute}

and a blood pressure of

92/54\text{ mm Hg}

An oral temperature of

99.1^\circ\text{F}

(

37.3^\circ\text{C}

) during the most recent vital signs check

The client reports sudden, severe lower abdominal cramping and an intense urge to void

The client resting comfortably in a supine position with the head of the bed elevated

30

degrees

Cevabı ve açıklamayı göster

Cevap: Urinary drainage in the collection bag that rapidly transitions from light pink to bright red with large clots; A heart rate of $118\text{ beats/minute}$ and a blood pressure of $92/54\text{ mm Hg}$ ; The client reports sudden, severe lower abdominal cramping and an intense urge to void

Cevap

The correct findings requiring immediate escalation are the transition to bright red drainage with clots, tachycardia with hypotension, and severe lower abdominal cramping.

The correct findings directly point to life-threatening complications of a transurethral resection of the prostate (TURP). Bright red drainage with large clots indicates active arterial bleeding rather than expected venous oozing. A heart rate of

118\text{ beats/minute}

with a blood pressure of

92/54\text{ mm Hg}

are decompensatory signs of hypovolemic shock resulting from blood loss. Sudden, severe lower abdominal cramping with an urge to void indicates severe bladder spasms or a blocked catheter, which can cause bladder trauma and worsen bleeding. All three require immediate escalation for registered nurse or provider intervention.

Adım Adım Çözüm

Analyze the client's postoperative status.

The client is

6\text{ hours}

post-TURP with continuous bladder irrigation, making them highly vulnerable to hemorrhage and catheter obstruction.

Identifying the specific surgical procedure and time frame highlights the expected risks versus normal recovery signs.

Evaluate each finding to differentiate expected post-procedure outcomes from acute complications.

Bright red drainage with clots, tachycardia with hypotension, and severe cramping represent active bleeding, shock, and obstruction.

The practical nurse must recognize signs that deviate from normal recovery and fall outside their independent scope of practice to resolve.

Identify findings that are benign or expected.

Normal hemoglobin and hematocrit, mild temperature elevation, and a

30

-degree bed elevation are all safe, expected findings.

Escalating normal findings demonstrates a lack of clinical judgment regarding physiological adaptation to surgery.

Anahtar Kavram

Recognizing postoperative complications following TURP, specifically hemorrhage, shock, and catheter obstruction.

Soru 1305Soru →

Following breakfast, a client receiving treatment for heart failure experiences multiple episodes of emesis and states, 'The lights in the room have strange yellow rings around them.' The client is scheduled to receive a daily dose of oral digoxin in 30 minutes. A review of today's laboratory panel reveals a serum digoxin level of 2.7 ng/mL. What is the most appropriate action for the practical nurse to take?

Note the abnormal laboratory value in the flow sheet and administer the medication as prescribed.

Hold the scheduled medication and promptly communicate the clinical findings and laboratory value to the registered nurse.

Prepare and administer a prescribed intravenous push medication for nausea prior to giving the cardiac medication.

Skip the barcode verification step to rapidly provide the cardiac medication before further gastrointestinal distress occurs.

Cevabı ve açıklamayı göster

Cevap: Hold the scheduled medication and promptly communicate the clinical findings and laboratory value to the registered nurse.

Cevap

The practical nurse should hold the scheduled medication and immediately report the findings to the registered nurse.

The client is exhibiting classic signs of digoxin toxicity, including gastrointestinal distress and visual changes (yellow halos). This is confirmed by the critical laboratory value of 2.7 ng/mL, which exceeds the normal therapeutic range of 0.8 to 2.0 ng/mL. The safest and most appropriate action within the practical nurse's scope of practice is to withhold the next scheduled dose and immediately report these assessment findings to the registered nurse to prevent further harm.

Adım Adım Çözüm

Assess the client's clinical presentation.

The client has nausea, vomiting, and visual disturbances.

These symptoms are classic indicators of digoxin toxicity.

Evaluate the relevant laboratory data.

The serum digoxin level is 2.7 ng/mL.

A digoxin level greater than 2.0 ng/mL confirms the suspicion of medication toxicity.

Determine the appropriate intervention within the practical nursing scope of practice.

The medication must be withheld and the registered nurse must be notified.

Administering the drug would worsen toxicity, and practical nurses are required to report critical findings to the supervising registered nurse.

Anahtar Kavram

Recognizing medication toxicity and safely applying the practical nurse scope of practice.

Soru 1306Soru →

Family members call the nurse to the room of an older adult client who is receiving intravenous antibiotics for severe pneumonia. The client has suddenly become agitated, confused about their surroundings, and is pulling at the intravenous tubing. Baseline mental status is alert and oriented. Which action should the nurse prioritize?

Check the client's oxygen saturation and respiratory rate.

Review the admission assessment for a history of dementia.

Apply soft wrist restraints to prevent removal of the tubing.

Contact the primary healthcare provider to request an order for a sedative.

Cevabı ve açıklamayı göster

Cevap: Check the client's oxygen saturation and respiratory rate.

Cevap

Check the client's oxygen saturation and respiratory rate.

Sudden onset of restlessness, agitation, and confusion in a client with a respiratory infection is a classic early sign of hypoxia. The nurse must prioritize airway, breathing, and circulation (ABC) by assessing the client's oxygen saturation and respiratory status before assuming the behavior is due to age, psychiatric issues, or requiring physical restraints.

Adım Adım Çözüm

Analyze the client's symptoms and baseline status.

The client has a sudden onset of agitation and confusion, which is a significant change from their alert and oriented baseline.

Identifying an acute change in condition is the first step in clinical judgment.

Determine the most life-threatening potential cause for the symptoms based on the client's diagnosis.

The client has severe pneumonia, making hypoxia the most critical potential cause of sudden restlessness and confusion.

Airway, Breathing, and Circulation (ABCs) must be prioritized in emergent situations.

Select the intervention that addresses the highest priority concern.

Checking oxygen saturation and respiratory rate directly assesses for hypoxia.

Data collection related to ABCs precedes other interventions like restraints, medications, or provider notification.

Anahtar Kavram

Prioritization of Airway, Breathing, and Circulation (ABCs) and recognition of hypoxia in acute respiratory illness.

Soru 1307Soru →

A practical nurse (PN) is caring for a client who is receiving continuous enteral tube feedings. The client suddenly begins to cough severely, becomes dyspneic, and exhibits circumoral cyanosis. Arrange the following nursing actions in the correct order of priority.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct priority sequence is to first stop the feeding pump, then elevate the head of the bed, auscultate lung sounds, notify the RN, and finally document the event.

In any acute physiological crisis, the nursing process dictates prioritizing actions that eliminate the immediate threat to life (Airway, Breathing, Circulation). For suspected aspiration, stopping the feeding pump directly halts the threat. Positioning the client upright is the next immediate physical intervention to support the airway and breathing. Once these rapid physical interventions are complete, the nurse collects focused assessment data (lung sounds, oxygen saturation) to understand the severity of the event. This data is then reported to the RN to coordinate further care. Documentation is always the final administrative step in the nursing process.

Adım Adım Çözüm

Stop the continuous enteral feeding pump.

The flow of enteral formula is halted.

Prevents any additional formula from being aspirated into the lungs, addressing the root cause of the immediate threat.

Elevate the head of the bed to a high-Fowler's position.

The client is positioned upright at 90 degrees.

Utilizes gravity to keep remaining gastric contents down, promotes optimal diaphragmatic excursion, and improves oxygenation.

Auscultate the client's lung sounds and obtain oxygen saturation.

Objective respiratory data is collected.

Provides essential clinical information regarding airway clearance and oxygenation status to guide further treatment.

Notify the registered nurse (RN) of the acute change in condition.

The clinical team is alerted to the emergency.

Ensures the client receives advanced interventions beyond the PN scope if needed, communicating the objective data just gathered.

Document the respiratory event and the interventions performed.

The legal medical record is updated.

Maintains continuity of care and fulfills legal requirements for nursing practice.

Anahtar Kavram

Prioritization of Care During Acute Enteral Feeding Aspiration

Soru 1308Soru →

A licensed practical nurse reviews the electronic health records and physical assessment findings for multiple clients on a progressive care unit. To minimize the risk of adverse outcomes, which of the following clinical observations dictate an urgent report to the supervising registered nurse? Select all that apply.

Geçerli olan tümünü seçin

A client receiving a continuous intravenous heparin infusion who has an activated partial thromboplastin time (aPTT) of

140\text{ seconds}

A client who is

12\text{ hours}

postoperative with a blood pressure of

88/52\text{ mm Hg}

, a resting heart rate of

118\text{ beats/minute}

, and new-onset restlessness

A client recovering from a cardiac catheterization who reports sudden, severe lower back pain and has a firm, tender flank

A client taking daily oral furosemide whose morning serum potassium level is

4.2\text{ mEq/L}

A client receiving warfarin therapy for atrial fibrillation who has an International Normalized Ratio (INR) of

2.6

A client who is

24\text{ hours}

post-appendectomy with a blood pressure of

116/74\text{ mm Hg}

and a heart rate of

78\text{ beats/minute}

Cevabı ve açıklamayı göster

Cevap: A client receiving a continuous intravenous heparin infusion who has an activated partial thromboplastin time (aPTT) of $140\text{ seconds}$ ; A client who is $12\text{ hours}$ postoperative with a blood pressure of $88/52\text{ mm Hg}$ , a resting heart rate of $118\text{ beats/minute}$ , and new-onset restlessness; A client recovering from a cardiac catheterization who reports sudden, severe lower back pain and has a firm, tender flank

Cevap

The observations that require urgent reporting include the critically elevated aPTT of 140 seconds, the signs of hypovolemic shock (hypotension, tachycardia, restlessness), and the indicators of a retroperitoneal hemorrhage (severe back pain, firm flank).

The correct selections represent life-threatening complications that require immediate intervention. An aPTT of 140 seconds is a critical panic value that necessitates stopping the heparin infusion to prevent severe hemorrhage. Hypotension combined with tachycardia and restlessness in a postoperative client are classic compensatory signs of hypovolemic shock. Sudden severe back pain and a firm, tender flank following a femoral catheterization strongly indicate retroperitoneal bleeding, a medical emergency.

Adım Adım Çözüm

Evaluate the laboratory results for the clients receiving anticoagulants.

The aPTT of 140 seconds is critically high and poses a severe bleeding risk. The INR of 2.6 is within the safe, expected therapeutic range.

Identifying panic values allows for rapid intervention to prevent spontaneous hemorrhage.

Analyze the vital signs and physical assessments for the postoperative clients.

The client with a blood pressure of 88/52 mm Hg, a heart rate of 118 beats/minute, and restlessness is exhibiting early signs of shock. The client with a blood pressure of 116/74 mm Hg and a heart rate of 78 beats/minute is stable.

Borderline or deteriorating vital signs can indicate internal bleeding, which must be immediately escalated.

Assess the post-procedure client for localized complications.

New-onset severe back pain and a firm flank after a cardiac catheterization strongly suggest retroperitoneal bleeding.

Prompt recognition of arterial bleeding complications prevents hypovolemic shock and cardiovascular collapse.

Anahtar Kavram

Recognizing early signs of life-threatening complications, such as internal bleeding and critical laboratory values, is essential for the practical nurse to reduce client risk through immediate escalation.

Soru 1309Soru →

A practical nurse (PN) is preparing to collect a urine specimen for culture and sensitivity from a client with an indwelling urinary catheter. Arrange the steps of this procedure in the correct chronological order to minimize the risk of contamination and client injury. All options must be used.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

First clamp the drainage tubing, then cleanse the specimen port, attach a sterile syringe to withdraw the urine, transfer the urine into a sterile cup, and finally unclamp the drainage tubing.

Collecting a urine specimen from an indwelling catheter requires maintaining a closed, sterile system to reduce the risk of infection and ensure an accurate laboratory result. First, the tubing must be clamped to allow fresh urine to collect. Once sufficient urine is present, the port is cleansed immediately before access to ensure sterility. The urine is then aspirated with a sterile syringe and safely transferred to a sterile cup. The most critical safety step concludes the procedure: unclamping the tubing to restore urinary flow and prevent dangerous bladder distention.

Adım Adım Çözüm

Clamp the drainage tubing below the specimen port for 15 to 30 minutes.

Fresh urine accumulates in the tubing above the clamp.

Urine in the drainage bag is stagnant and not suitable for a culture; fresh urine must be collected directly from the closed system.

Cleanse the specimen port with an antiseptic wipe and allow it to dry.

Surface pathogens are eliminated from the access port.

Prevents the introduction of bacteria into the catheter system and the specimen during syringe attachment.

Attach a sterile syringe to the port and withdraw the urine sample.

A sterile urine sample is safely extracted.

Maintains the sterility of the closed urinary drainage system.

Transfer the urine into a sterile specimen cup without touching the inside.

The sample is secured for transport to the laboratory.

Prevents environmental contamination of the culture specimen.

Unclamp the drainage tubing to restore urine flow to the collection bag.

Normal urinary drainage resumes.

Failing to unclamp the tubing can cause severe bladder distention, pain, autonomic dysreflexia, and kidney damage.

Anahtar Kavram

Maintaining a closed urinary drainage system and preventing complications during specimen collection.

Soru 1310Soru →

During morning data collection, the practical nurse evaluates four assigned clients. Which client's clinical presentation indicates a potential acute physiological complication that must be reported to the registered nurse immediately?

A client with a closed fractured radius who is crying and rates their throbbing arm pain as a 9 on a 10-point scale.

A client who is 2 days postoperative following an open cholecystectomy with a heart rate of 88 beats per minute and a blood pressure of 118/76 mm Hg.

A client who had a percutaneous kidney biopsy 4 hours ago and has a resting heart rate of 114 beats per minute with a blood pressure of 100/64 mm Hg.

A client who delivered a newborn 12 hours ago and has saturated one perineal pad with rubra drainage over the last three hours.

Cevabı ve açıklamayı göster

Cevap: A client who had a percutaneous kidney biopsy 4 hours ago and has a resting heart rate of 114 beats per minute with a blood pressure of 100/64 mm Hg.

Cevap

The client who had a percutaneous kidney biopsy and is now exhibiting a heart rate of 114 beats per minute and a blood pressure of 100/64 mm Hg requires immediate reporting.

The client recovering from a percutaneous kidney biopsy is at high risk for internal retroperitoneal bleeding. The presentation of a new tachycardia (114 beats per minute) coupled with borderline low blood pressure (100/64 mm Hg) represents early, subtle signs of hypovolemic shock. According to the ABC (Airway, Breathing, Circulation) framework, this circulatory compromise is a life-threatening emergency that must be reported to the registered nurse immediately so rapid volume replacement and intervention can begin.

Adım Adım Çözüm

Analyze the clinical presentation of the postoperative kidney biopsy client.

Tachycardia (heart rate 114 bpm) and borderline hypotension (blood pressure 100/64 mm Hg) are identified.

Kidney biopsies have a high risk of vascular injury. These vital signs indicate early hypovolemic shock.

Evaluate the client with the fractured radius.

The client is experiencing severe pain (9/10).

Pain is expected after a fracture and is not immediately life-threatening compared to circulatory shock.

Assess the postoperative cholecystectomy client.

Vital signs are stable and within normal limits.

Expected recovery findings do not require urgent escalation.

Evaluate the postpartum client's bleeding.

Saturating one pad in three hours is a moderate, expected amount of lochia rubra.

Postpartum hemorrhage would be indicated by saturating a pad in 15 minutes or less.

Apply the ABC (Airway, Breathing, Circulation) prioritization framework.

The biopsy client has an active Circulation compromise, taking highest priority.

Life-threatening physiological changes must always be addressed before pain management or normal expected findings.

Anahtar Kavram

Prioritization of early physiological signs of hypovolemic shock using the ABC framework.

Tahmini Süre:1m 30s

Soru 1311Soru →

Following a tonsillectomy, a young adult client is resting on the surgical unit. The practical nurse observes the sleeping client making repeated swallowing motions. The client's heart rate has climbed to 114 beats per minute from a baseline of 72 beats per minute. Which action should the practical nurse prioritize?

Provide the scheduled dose of intravenous analgesic to ensure comfort.

Awaken the client and carefully inspect the throat using a penlight.

Note the current vital signs in the chart and continue to observe quietly.

Instruct the client to cough forcefully to clear any accumulated secretions.

Cevabı ve açıklamayı göster

Cevap: Awaken the client and carefully inspect the throat using a penlight.

Cevap

The correct approach is to awaken the client and carefully inspect the throat using a penlight.

Frequent swallowing combined with unexplained tachycardia after throat surgery strongly suggests active hemorrhage. Inspecting the surgical site directly with a penlight is the critical first step in data collection to confirm bleeding and escalate care.

Adım Adım Çözüm

Identify the clinical significance of frequent swallowing after throat surgery.

Frequent swallowing is a primary indicator of active bleeding as blood drips down the posterior pharynx.

Recognizing early postoperative complications is essential for client safety.

Analyze the vital sign changes.

The transition from a baseline heart rate of 72 to 114 beats per minute is an early compensatory sign of potential hypovolemia.

Tachycardia often precedes hypotension in the early stages of hemorrhagic shock.

Prioritize the nursing response.

Direct visualization of the surgical site is necessary to confirm active hemorrhage before rapidly escalating the situation to the registered nurse or provider.

The practical nurse must collect focused data to inform immediate emergency interventions.

Anahtar Kavram

Postoperative Hemorrhage Recognition

Tahmini Süre:1m 0s

Soru 1312Soru →

A client with a confirmed gastric ulcer is being monitored on the medical-surgical unit. Over the last three hours, the practical nurse observes that the client's resting heart rate has steadily increased from 76 to 118 beats per minute, and the blood pressure has narrowed from 128/78 mm Hg to 112/88 mm Hg. The client is moving restlessly in bed and repeatedly asking for water. Which action should the practical nurse take first?

Record the observations in the electronic health record and reassess in one hour.

Promptly alert the charge nurse about the changing vital sign trends.

Provide a small cup of ice chips to relieve the client's reported thirst.

Dim the room lights and instruct the client to practice deep breathing for relaxation.

Cevabı ve açıklamayı göster

Cevap: Promptly alert the charge nurse about the changing vital sign trends.

Cevap

Promptly alert the charge nurse about the changing vital sign trends.

The client is demonstrating classic early signs of hypovolemic shock (the compensatory stage), including unexplained tachycardia, a narrowing pulse pressure, restlessness, and severe thirst, likely due to active gastrointestinal bleeding. The immediate priority is to escalate these findings to the charge nurse or provider so that rapid life-saving interventions, such as intravenous fluid resuscitation or blood products, can be initiated.

Adım Adım Çözüm

Analyze the client's vital sign trends and physical presentation.

The increasing heart rate, narrowing pulse pressure, restlessness, and thirst indicate early compensatory hypovolemic shock due to potential active bleeding.

Identifying early signs of physiological deterioration is essential to prevent progression to irreversible shock.

Determine the appropriate priority action within the practical nurse's scope of practice.

The practical nurse must immediately escalate these critical findings to the supervising registered nurse or provider.

Acute hemodynamic instability requires advanced assessment and collaborative medical interventions beyond the independent scope of a practical nurse.

Anahtar Kavram

Recognition of Early Hypovolemic Shock

Soru 1313Soru →

A licensed practical nurse is caring for a client who has a closed-wound drainage system (Jackson-Pratt) in place following a mastectomy. The nurse needs to empty the device to maintain continuous negative pressure. In what order should the nurse perform the following actions? (Arrange the steps in the correct sequence.)

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is to don gloves and open the port, empty the drainage, compress the bulb, replace the plug while the bulb is compressed, and finally measure and document the drainage.

To effectively reduce the risk of surgical site complications, a closed-wound drain must maintain constant negative pressure. The nurse first applies gloves and opens the system to empty the collected fluid. Next, the nurse must compress the bulb to expel ambient air and immediately cap it while it remains compressed. This action creates the vacuum necessary to pull exudate from the wound. Finally, the collected fluid is measured and documented to track output and monitor for abnormal bleeding or infection.

Adım Adım Çözüm

Put on clean gloves and open the port on the drainage bulb.

The system is opened safely.

Standard precautions prevent exposure to bloodborne pathogens, and opening the port breaks the vacuum to allow fluid removal.

Empty the bulb's contents into a graduated measuring container.

The drainage is cleared from the bulb.

Fluid must be removed to clear the reservoir and to measure the output accurately.

Squeeze the bulb completely flat to expel all air.

Air is pushed out of the bulb.

Expelling air is necessary to prepare the device for negative pressure suction.

Replace the plug securely into the port while maintaining pressure on the bulb.

The system is sealed under vacuum.

Sealing the device while flat locks in the negative pressure, which actively draws fluid from the surgical site to reduce hematoma risk.

Measure the drainage amount at eye level and document the findings.

Output is recorded accurately.

Accurate documentation is necessary for evaluating the client's fluid status and risk for hemorrhage or infection.

Anahtar Kavram

Proper maintenance of a closed-wound drainage system requires establishing a vacuum to actively pull fluid from the surgical site, reducing the risk of fluid accumulation and infection.

Tahmini Süre:1m 0s

ÖncekiSayfa 66 / 66

Physiological Integrity

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar