Tüm alıştırma soruları

During hourly rounds on an adult surgical acute care unit, the nurse evaluates the status of several assigned clients. Which of the following client findings require immediate intervention? Select all that apply.

A client in the intensive care unit is intubated and continuously attempting to pull out their endotracheal tube. After exhausting all alternative safety measures, the healthcare provider prescribes bilateral soft wrist restraints. Which nursing interventions are appropriate while the restraints are in place? Select all that apply.

A school nurse is evaluating a 16-year-old student who presents to the health office. During the assessment, the student tearfully discloses that a stepparent has secretly installed hidden recording cameras in the student's bedroom and bathroom. The student states, "I am only telling you this in strict medical confidence. Because of HIPAA laws, you cannot tell the police or my other parent, or things will get much worse for me." Which of the following is the most appropriate action by the nurse regarding the student's request for confidentiality?

A client hospitalized for a severe exacerbation of rheumatoid arthritis is medically stable and preparing to return home. During the morning assessment, the client states, "I am terrified of going home. My hands are so stiff and painful that I can barely hold my toothbrush or button my own clothes." Which action by the nurse represents the most appropriate interdisciplinary collaboration?

A nurse is using the SBAR (Situation, Background, Assessment, Recommendation) communication tool to report a client's sudden clinical deterioration to the on-call physician. Arrange the nurse's planned statements in the correct chronological sequence according to the SBAR interprofessional handoff framework.

An interdisciplinary care team is managing an older adult client admitted for severe aspiration pneumonia. The client, who has a documented history of major neurocognitive disorder, is colonized with methicillin-resistant Staphylococcus aureus (MRSA) in the nares. Over the past hour, the client has developed acute hyperactive delirium, continuously attempts to climb out of bed, and is aggressively picking at their peripheral intravenous (PIV) site. Which comprehensive action plan should the nurse implement first to prevent client injury?

A nurse is developing a plan of care for a client admitted with active pulmonary tuberculosis and a large, uncontained abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which of the following infection control interventions should the nurse include in the plan of care? Select all that apply.

A registered nurse is planning care for a client who requires airborne precautions for confirmed active pulmonary tuberculosis. Which of the following infection control interventions should the nurse implement? Select all that apply.

An adult client who only speaks Mandarin is scheduled for an elective cardiac catheterization. The healthcare provider arrives at the bedside to explain the procedure and obtain informed consent. The client's bilingual 15-year-old grandson is present in the room and offers to translate the provider's explanation. Which action should the registered nurse take?

During hourly rounds, a registered nurse discovers that a client's central venous catheter (CVC) has disconnected at the hub. The client suddenly gasps, becomes visibly dyspneic, and reports acute chest pain. Arrange the following nursing actions in the priority order they should be performed to prevent further catastrophic injury.

Match each complex clinical scenario on the left with the specific ethical concept or phenomenon it best illustrates on the right.

An emergency department (ED) registered nurse (RN) is working with an unlicensed assistive personnel (UAP) during a high-volume shift. Which of the following client care activities is most appropriate for the RN to delegate to the UAP?

An older adult client is scheduled for a total hip arthroplasty. The orthopedic surgeon previously discussed the procedure, risks, benefits, and alternatives with the client. When the registered nurse (RN) presents the informed consent document for signature, the client expresses anxiety and states, "The doctor explained everything this morning, but I completely forgot what was said about the risk of blood clots. Should I be worried?" Which of the following actions by the RN are appropriate? (Select all that apply)

A registered nurse is caring for a client who recently underwent an open reduction internal fixation (ORIF) of a left femoral shaft fracture. The nurse observes the client developing acute dyspnea, tachypnea, and a petechial rash on the anterior chest. The nurse initiates an emergency call to the rapid response physician. Arrange the following statements in the correct sequence according to the SBAR (Situation, Background, Assessment, Recommendation) interprofessional communication tool.

A registered nurse in a community health clinic is assessing a 78-year-old client who presents with vague abdominal pain. During the physical examination, the nurse observes distinct, patterned bruising on the client's back and upper arms. The client tearfully confides that their primary caregiver intentionally causes these injuries but explicitly states, 'I forbid you from telling anyone about this. I will lose my only home if you report it.' Which of the following is the most appropriate action by the nurse regarding the client's demand for confidentiality?

A registered nurse on a medical-surgical unit is contacting the neurointensivist regarding a client whose neurologic status has suddenly deteriorated. Arrange the nurse's statements in the correct chronological sequence to follow the SBAR (Situation, Background, Assessment, Recommendation) interprofessional communication protocol.

A registered nurse is developing a safety care plan for an older adult client who has severe dysphagia following an ischemic stroke. Which intervention is the priority to include in the plan to prevent a life-threatening injury?

A competent adult client is admitted to the medical-surgical unit for diagnostic testing. The healthcare provider informs the client's adult children that the client has advanced, inoperable cancer. The children urgently request that the healthcare team withhold this diagnosis from the client, explaining that in their culture, delivering terminal news removes a person's hope and accelerates death. Shortly after, the client asks the primary nurse, "What did the scan show? Am I going to be okay?" Which of the following is the most appropriate ethical action by the nurse?

A nurse on a surgical unit is coordinating the interdisciplinary discharge process for a client recovering from bilateral below-the-knee amputations who will be transferred to an acute inpatient rehabilitation facility. Arrange the following nursing actions in the correct chronological order to facilitate a collaborative and safe transition of care.

At the beginning of the shift on a respiratory medical unit, the nurse receives a handoff report. In what order should the nurse assess the following clients? Arrange the clients from highest priority (first to assess) to lowest priority (last to assess).