Tüm alıştırma soruları

A triage nurse in the emergency department is evaluating four clients, each with a history of substance use. Based on the presenting clinical findings, which client should the nurse identify as the highest priority for immediate medical intervention?

A critical care nurse is managing a client diagnosed with severe diabetic ketoacidosis. The client is currently receiving intravenous $0.9\%$ sodium chloride and a continuous regular insulin infusion. Clinical assessment reveals lethargy and a regular, deep respiratory rate of $32$ breaths per minute. The most recent laboratory results indicate:

• Arterial blood gas: pH $7.26$, PaCO $_2$ $29$ mmHg, HCO $_3^-$ $12$ mEq/L, PaO $_2$ $94$ mmHg
• Serum glucose: $242$ mg/dL ($13.4$ mmol/L)
• Serum potassium: $3.1$ mEq/L ($3.1$ mmol/L)

Which intervention should the nurse perform first to mitigate the risk of a fatal physiological complication?

A client admitted with community-acquired pneumonia is receiving a continuous intravenous infusion of 5% dextrose in water. The healthcare provider orders a scheduled dose of intravenous levofloxacin. What is the priority nursing action before attaching the secondary medication to the existing intravenous line?

A client arrives at the emergency department after sustaining a large laceration with significant blood loss. The bleeding is now controlled. Which vital sign change represents the body's earliest physiological adaptation to maintain adequate tissue perfusion?

A client is brought to the emergency department by law enforcement due to severe agitation, paranoia, and physical aggression after ingesting synthetic cathinones ('bath salts'). Arrange the following nursing actions in the prioritized order of execution.

A nurse is analyzing the physiological data of a client who is $36$ hours post-operative following an exploratory laparotomy for an ischemic bowel. The client is intubated, mechanically ventilated, and has an arterial line and a central venous catheter in place. The latest assessment data reveals the following:

Based on these findings, which of the following conclusions and corresponding nursing actions are correct? (Select all that apply)

A nurse is assessing a client who is 4 hours post-operative following a total thyroidectomy. Which assessment findings should indicate to the nurse that the client is developing a severe physiological complication requiring immediate intervention? Select all that apply.

A physician orders an intramuscular analgesic for a client in acute pain. The medication is dispensed by the pharmacy in a small glass ampule. Which sequence of actions should the nurse follow to safely extract the medication and prepare the syringe for injection?

An ambulatory care nurse is monitoring a 61-year-old client who underwent a percutaneous needle biopsy of the liver one hour ago. The client is currently lying supine with the head of the bed elevated and reports a new onset of dull right shoulder ache. The current heart rate is 112 beats per minute with a blood pressure of 98/62 mm Hg. Pre-procedure baseline vital signs were a heart rate of 78 beats per minute and a blood pressure of 128/76 mm Hg. Which action is the priority for the nurse to take?

A nurse is developing a discharge plan for a client with advanced heart failure. The client requires home oxygen therapy equipment, needs to learn energy conservation techniques for bathing, and requires initial education on a strict low-sodium diet. The client expresses anxiety about managing these changes at home. Which collaborative actions should the nurse include in the plan of care? (Select all that apply.)

A client is admitted to the intensive care unit with severe diabetic ketoacidosis (DKA). The client is lethargic with a blood glucose of 680 mg/dL (37.7 mmol/L), a serum pH of 7.12, and a blood pressure of 82/48 mm Hg. Arrange the following collaborative nursing actions in the priority order they should be implemented.

While completing morning rounds, a nurse assesses a client who underwent a partial colectomy the previous day. The client is receiving continuous intravenous fluids and utilizing a morphine patient-controlled analgesia (PCA) device. The nurse observes that the client is profoundly somnolent, minimally responsive to tactile stimuli, and exhibits shallow respirations at a rate of 7 breaths per minute with an oxygen saturation of 85% on room air. Which immediate interventions are appropriate to mitigate further physiological risk? Select all that apply.

A registered nurse is providing discharge instructions to a client with a right tibial fracture who must maintain strict non-weight-bearing status on the affected extremity. Arrange the following steps in the correct chronological sequence for safely ascending a flight of stairs using bilateral axillary crutches without the use of a handrail.

A nurse is caring for a client who is receiving treatment for severe sepsis secondary to a perforated bowel. Upon assessment, the client is restless with cold, clammy skin. Vital signs include a heart rate of 134 beats/min, a blood pressure of 82/46 mm Hg, and a respiratory rate of 36 breaths/min with deep, rapid inspirations. The latest arterial blood gas (ABG) results are: pH 7.23, PaCO2 27 mm Hg, PaO2 84 mm Hg, and HCO3- 12 mEq/L. Based on these findings, which conclusion correctly directs the nurse's immediate priorities?

During the initial recovery period following a percutaneous coronary intervention via the right femoral approach, a client reports a new, deep ache in the right lower back. Vital sign trending over the past 30 minutes shows the heart rate increasing from 82 to 114 bpm and the blood pressure decreasing from 128/74 to 104/58 mm Hg. Which action is the priority?

A nurse is preparing to administer an intermittent bolus enteral feeding to a client via a nasogastric (NG) tube. To reduce the risk of aspiration and maintain tube patency, arrange the following steps in the correct order. All options must be used.

A registered nurse coordinating an occupational health and wellness program at a corporate facility is planning activities for the upcoming fiscal year. Which of the proposed activities should the nurse classify as primary prevention strategies? Select all that apply.

A 65-year-old client is admitted to the progressive care unit 2 hours after a cardiac catheterization utilizing the right femoral artery approach. The provider prescribes strict supine bed rest with the affected extremity kept straight for 6 hours. The client reports a severe backache, feels hungry, and states an urgent need to void. Which nursing actions are appropriate to address the client's basic care and comfort needs? Select all that apply.

A registered nurse is evaluating a client being treated for severe bacterial pneumonia. Over the past hour, the client has become visibly agitated and restless. Current assessment parameters include a heart rate of 118 beats per minute, a respiratory rate of 32 breaths per minute, and cool, diaphoretic extremities. Arterial blood gas (ABG) analysis on room air yields the following: pH 7.50, PaCO2 26 mm Hg, PaO2 54 mm Hg, and HCO3 22 mEq/L. Which of the following is the priority nursing intervention?

A nurse is assuming care for a client who underwent a lumbar puncture 30 minutes ago. Which of the following positions should the nurse maintain to minimize the client's risk of developing a post-procedure complication?