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Soru 2121Soru →

A nurse is conducting initial rounds and reviewing assessment findings for several clients on a medical-surgical unit. Which of the following client presentations require immediate intervention by the nurse? (Select all that apply.)

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Cevap: A client with a head injury whose Glasgow Coma Scale (GCS) score has decreased from 14 to 11; A client with a recent femur fracture who develops sudden confusion and a petechial rash on the chest; A client with pneumonia who has a new oxygen saturation reading of 87% on room air and circumoral cyanosis

Cevap

The clients requiring immediate intervention are the one with a head injury and a dropping GCS score, the one with a femur fracture showing signs of fat embolism, and the one with pneumonia presenting with acute hypoxia and cyanosis.
The correct selections represent clients experiencing acute, unexpected, and potentially life-threatening physiological changes. A dropping GCS indicates rising intracranial pressure. Sudden confusion and petechiae after a bone fracture indicate a fat embolism. An oxygen saturation of 87% with cyanosis indicates acute respiratory failure. All of these require immediate emergency response.

Adım Adım Çözüm

1
Evaluate each client's presentation to determine if the findings are expected (chronic/stable) or unexpected (acute/unstable).
Three clients have acute, unexpected, or life-threatening changes, while two have expected, chronic disease manifestations.
Prioritization requires identifying which conditions pose an immediate threat to life, typically utilizing the Airway-Breathing-Circulation (ABC) framework and acute versus chronic principles.
2
Apply prioritization frameworks to select all clients requiring immediate attention.
The GCS drop (neurological deterioration), fat embolism signs (circulation/oxygenation threat), and low oxygen saturation with cyanosis (airway/breathing threat) are identified as immediate priorities.
Clients with acute, unstable changes or ABC compromises always take precedence over clients with expected, stable, or chronic findings.

Anahtar Kavram

Prioritization: Acute vs. Chronic and Unexpected vs. Expected Findings
Soru 2122Soru →

Amidst a staffing shortage on a high-acuity medical-surgical ward, a registered nurse (RN) is coordinating care with one licensed practical nurse (LPN/VN) and one unlicensed assistive personnel (UAP). The RN must safely delegate interventions while managing a highly complex client census. Which delegation decision by the RN is the most legally and clinically appropriate?

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Cevap: Assigning the LPN/VN to perform a sterile dressing change and administer a scheduled dose of oral sevelamer to a client with end-stage renal disease.

Cevap

The most appropriate delegation is assigning the LPN/VN to perform the sterile dressing change and administer the oral medication to the client with end-stage renal disease.
Assigning the LPN/VN to perform a sterile dressing change and administer oral sevelamer to a client with end-stage renal disease is correct because both tasks fall safely within the LPN/VN scope of practice. The client is described with a chronic, expected condition without signs of acute instability, making this a legally sound and clinically safe delegation choice.

Adım Adım Çözüm

1
Analyze each delegation option against the rights of delegation and core nursing scope of practice principles.
Identify which tasks require RN clinical judgment (Evaluate, Assess, Teach) and which can be safely delegated.
To ensure legal compliance and maintain client safety during care delivery.
2
Evaluate the clinical acuity and stability of the clients described in each scenario.
Identify unstable clients or those experiencing acute physiological changes (e.g., new wet cough, sudden chest pain).
Unstable clients or those with sudden changes require the advanced assessment skills of a Registered Nurse.
3
Determine the appropriate scope for the LPN/VN and UAP based on the identified client needs.
Confirm that sterile procedures and routine oral medications on stable clients fall within the LPN/VN scope, while evaluation, initial assessment, and care of unstable clients do not.
To select the single legally and clinically appropriate delegation option.

Anahtar Kavram

Delegation and Scope of Practice in Complex Clinical Scenarios
Soru 2123Soru →

A nurse realizes that a double dose of a prescribed oral antihypertensive medication was inadvertently administered to a client 15 minutes ago. In which order should the nurse perform the following actions to manage this error and prevent client injury? Arrange the actions from first to last.

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Cevap

The correct sequence is: Assess the client, notify the healthcare provider, implement interventions, inform the client/family, and complete the variance report.
When managing a medication error, the nurse must prioritize immediate physiological safety. Following the nursing process, assessment is always the first step to identify any acute adverse effects. Once the client's status is known, the nurse notifies the healthcare provider to obtain necessary orders. The nurse then implements these interventions to stabilize the client. After clinical safety is secured, ethical obligations require disclosing the error to the client or family. Finally, an institutional safety variance report is completed for risk management, as administrative duties must never take precedence over direct patient care.

Adım Adım Çözüm

1
Assess the client's physiological status.
Determines if the client is experiencing acute adverse effects from the double dose.
The nursing process mandates assessment as the primary action before any intervention or notification.
2
Notify the primary healthcare provider.
Provides the provider with critical clinical data to guide further medical management.
The provider must be informed to prescribe necessary antidotes, fluid resuscitation, or monitoring parameters.
3
Implement prescribed interventions.
Stabilizes the client and mitigates the physiological impact of the medication error.
Executing new medical orders is necessary to prevent severe injury or adverse outcomes.
4
Inform the client and their family.
Fulfills the ethical and legal obligation of transparency.
Disclosure should occur promptly, but only after immediate clinical stabilization is ensured.
5
Complete a safety variance report.
Documents the event for internal risk management and quality improvement.
Administrative tasks are the lowest priority and must never delay direct client care.

Anahtar Kavram

Prioritization in Error Management and Nursing Process
Tahmini Süre:1m 30s
Soru 2124Soru →

During discharge preparations, a client who had a unilateral below-the-knee amputation three days ago expresses acute anxiety about returning home. The client states to the registered nurse, "I cannot imagine how I will be able to safely take a shower or get dressed without help." Which intervention demonstrates the most appropriate interprofessional coordination of care?

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Cevap: Request a consultation with occupational therapy to assess the client's need for adaptive equipment and provide self-care training.

Cevap

Request a consultation with occupational therapy to assess the client's need for adaptive equipment and provide self-care training.
The client's primary concern relates to safely performing activities of daily living (ADLs), specifically bathing and dressing. Occupational therapists specialize in promoting client independence by evaluating the ability to perform ADLs, recommending specific adaptive equipment, and providing targeted self-care training. Requesting an occupational therapy consultation directly addresses the client's functional deficit through appropriate interprofessional collaboration.

Adım Adım Çözüm

1
Analyze the specific nature of the client's verbalized concern.
The client is expressing anxiety specifically related to performing activities of daily living (ADLs), such as bathing and dressing, following an amputation.
Identifying the precise functional deficit is necessary to determine which interdisciplinary team member has the correct scope of practice.
2
Determine the appropriate allied health discipline for the identified need.
Occupational therapy (OT) is identified as the correct discipline.
Occupational therapists specialize in evaluating clients, recommending adaptive equipment, and providing training to restore independence in ADLs and fine motor skills.
3
Evaluate the remaining distractors for clinical safety and scope of practice errors.
Delegation of teaching to a UAP, using false reassurance, and improper post-operative positioning are identified as incorrect nursing actions.
The nurse must synthesize knowledge of delegation rules, therapeutic communication, and physiological safety (preventing contractures) to eliminate inappropriate interventions.

Anahtar Kavram

Interprofessional Scope of Practice and Care Coordination
Soru 2125Soru →

An acute care unit RN is managing client assignments alongside a licensed practical nurse (LPN/VN) and an unlicensed assistive personnel (UAP). After concluding a multidisciplinary huddle, the RN receives several simultaneous updates. Arrange the following required actions in order from highest to lowest priority.

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Cevap

The correct sequence is: assess the client with chest pain, halt the LPN/VN from teaching, evaluate the skin integrity after the bed bath, and establish vital sign parameters with the UAP.
The correct sequence prioritizes immediate physiological threats, followed by imminent scope of practice violations, routine evaluation of delegated tasks, and finally, communication for stable clients. The client with chest pain has a potentially fatal condition requiring immediate assessment. Next, the RN must stop the LPN/VN from performing initial teaching, as this is solely an RN responsibility. The RN then evaluates the outcome of a delegated task (bed bath) to fulfill the Right Supervision. Finally, the RN provides parameters for a stable discharge client, which fulfills the Right Direction but is not immediately time-sensitive.

Adım Adım Çözüm

1
Analyze the scenarios to identify any immediate, life-threatening physiological crises.
The client with substernal chest pain and diaphoresis is identified as having an unstable, highly acute condition.
The ABCs (Airway, Breathing, Circulation) always dictate the highest priority of nursing care.
2
Evaluate the remaining scenarios for legal, safety, or scope of practice violations.
The LPN/VN attempting to formulate an initial teaching plan is identified as a scope of practice violation.
Initial assessment, care planning, and teaching are exclusive RN responsibilities. The RN must intervene to prevent unsafe or illegal practice.
3
Differentiate between the remaining routine delegation tasks based on clinical need.
Evaluating the skin integrity of an immobile client after a bath is prioritized over setting reporting parameters for a discharging client.
Clinical evaluation (Right Supervision) of a vulnerable client takes precedence over routine communication (Right Direction) for a stable client.

Anahtar Kavram

Prioritization of care must integrate the ABCs of physiological stability with the Five Rights of Delegation and strict adherence to the nursing scope of practice.
Soru 2126Soru →

A nurse working on a medical-surgical unit receives a phone call from an individual claiming to be the spouse of a newly admitted competent adult client. The caller sounds highly anxious and demands a clinical update. The client's chart indicates that no privacy code has been established and no consent for information sharing has been signed. Which of the following actions should the nurse take?

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Cevap: Explain that no information about the client can be confirmed or shared without explicit authorization.

Cevap

The nurse must explain that no information about the client can be confirmed or shared without explicit authorization.
The correct action strictly adheres to HIPAA guidelines. A nurse cannot confirm a client's admission or share any health information with a caller unless the competent adult client has explicitly authorized it, typically through a designated privacy code or signed release.

Adım Adım Çözüm

1
Assess the legal and ethical requirements for sharing Protected Health Information (PHI) over the phone.
Identify that the client has not provided a privacy code or signed consent for information disclosure.
HIPAA strictly prohibits the sharing of PHI, including confirming a client's presence in a facility, without explicit permission from a competent adult.
2
Determine the appropriate response to the unauthorized caller.
Refuse to disclose any information, including confirming the client's presence on the unit.
Maintaining strict confidentiality is legally mandated, regardless of the caller's stated relationship or emotional state.

Anahtar Kavram

Confidentiality and Protected Health Information (PHI)
Tahmini Süre:45s
Soru 2127Soru →

During a multidisciplinary safety huddle, the rapid response team (RRT) reviews electronic health record alerts triggered for clients across the hospital. Which of the following client alerts indicate an acute, unstable deterioration requiring the RRT's immediate intervention? (Select all that apply.)

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Cevap: A client 1212 hours post-splenectomy whose vital signs show a blood pressure of 106/86106/86 mm Hg and a heart rate of 118118 bpm.; A client receiving a continuous intravenous heparin infusion who reports a sudden, 'thunderclap' headache and new-onset diplopia.; A client with severe acute pancreatitis who demonstrates carpopedal spasms during noninvasive blood pressure monitoring and reports circumoral tingling.

Cevap

The clients requiring immediate intervention are the post-splenectomy client with a narrow pulse pressure, the client on heparin with a sudden headache, and the pancreatitis client with carpopedal spasms.
The correct clients require immediate, life-saving intervention. A narrow pulse pressure (2020 mm Hg) with tachycardia in a post-surgical client indicates early hemorrhagic shock. A sudden 'thunderclap' headache and diplopia in a client on heparin signals a life-threatening intracranial hemorrhage. Finally, carpopedal spasms (Trousseau's sign) and circumoral tingling in a pancreatitis client indicate severe hypocalcemia, which can rapidly cause fatal cardiac arrhythmias or airway-blocking laryngospasm.

Adım Adım Çözüm

1
Analyze each client presentation to differentiate between expected chronic disease manifestations and acute, life-threatening deteriorations.
Clients with unexpected, critical physiological cues require priority intervention based on the Airway-Breathing-Circulation (ABC) framework.
Establishing priorities ensures critical resources are allocated to clients with the highest risk of immediate morbidity or mortality.
2
Evaluate the hemodynamic status of the post-splenectomy client.
The client exhibits a narrow pulse pressure (106−86=20106 - 86 = 20 mm Hg) and tachycardia (118118 bpm), indicating early hemorrhagic shock.
A narrowing pulse pressure is a subtle but highly critical early sign of compensatory shock, requiring immediate evaluation for internal bleeding.
3
Evaluate the neurological status of the client receiving continuous heparin.
The sudden 'thunderclap' headache and diplopia strongly indicate a potential intracranial hemorrhage.
Systemic anticoagulation carries a severe risk of bleeding; abrupt neurological deficits represent a life-threatening emergency requiring immediate cessation of the infusion.
4
Evaluate the neuromuscular symptoms of the client with acute pancreatitis.
Carpopedal spasms (Trousseau's sign) and circumoral tingling indicate profound, symptomatic hypocalcemia.
Severe hypocalcemia can rapidly progress to life-threatening laryngospasm, tetany, or cardiac arrhythmias, necessitating immediate intravenous calcium replacement.
5
Identify the expected/chronic findings in the remaining clients.
The COPD client has compensated respiratory acidosis, and the heart failure client displays signs of chronic fluid overload.
While abnormal, these are expected baseline manifestations for their respective chronic disease processes and do not require rapid response intervention compared to the highly unstable clients.

Anahtar Kavram

Prioritizing Unstable Clients with Acute, Unexpected Findings
Soru 2128Soru →

A nurse is admitting an older adult client who has a history of falls and occasionally experiences acute confusion. Which of the following is the most appropriate initial nursing action to promote safety and prevent injury?

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Cevap: Keep the client's bed in the lowest position and place the call light within easy reach.

Cevap

Keep the client's bed in the lowest position and place the call light within easy reach.
Keeping the bed in the lowest position and ensuring the call light is immediately accessible are standard, universal fall precautions. These non-restrictive interventions empower the client to call for help while minimizing the physical distance to the floor should a fall occur, thereby directly reducing the risk of severe injury.

Adım Adım Çözüm

1
Identify the client's specific safety risk factors based on the clinical presentation.
The client has a history of falls and experiences acute confusion, placing them at high risk for subsequent falls and injuries.
Recognizing risk factors dictates the prioritization of preventative safety interventions.
2
Determine the most appropriate, least restrictive initial safety measure.
Implementing universal fall precautions, such as keeping the bed low and the call bell accessible, is chosen.
Nursing standards mandate using the least restrictive interventions first to promote safety while maintaining the client's autonomy and dignity.

Anahtar Kavram

Universal Fall Precautions and Least Restrictive Interventions
Tahmini Süre:1m 0s
Soru 2129Soru →

A multidisciplinary team including a registered nurse, a licensed practical/vocational nurse, and an assistive personnel is assuming care for clients on a trauma step-down unit. The registered nurse must rapidly distribute tasks following the morning handoff. Which of the following assignments are within the appropriate scope of practice for the designated team member? Select all that apply.

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Cevap: Assigning the licensed practical/vocational nurse to perform a sterile dressing change on a 4-day-old external fixation pin site with minimal serous drainage.; Directing the assistive personnel to empty and record the output from a closed-suction surgical drain for a client recovering from an exploratory laparotomy.; Instructing the licensed practical/vocational nurse to administer scheduled oral analgesics to a client with a stable pelvic fracture reporting moderate pain.

Cevap

The appropriate assignments include having the licensed practical/vocational nurse perform a sterile dressing change on a healing pin site, having the assistive personnel record output from a surgical drain, and having the licensed practical/vocational nurse administer scheduled oral pain medication.
The correct delegation decisions strictly adhere to the scope of practice guidelines. The licensed practical/vocational nurse is safely assigned to perform a sterile dressing change on a healing, 4-day-old pin site and to administer scheduled oral analgesics to a stable client, as both are predictable tasks with established protocols. The assistive personnel is appropriately assigned to empty and record the output of a surgical drain, which is a routine data collection task that does not require clinical interpretation.

Adım Adım Çözüm

1
Analyze the acuity and stability of each client described in the task.
Identify clients who are unstable (e.g., sudden respiratory distress, new admission) versus stable (e.g., 4-day-old wound, routine drain care).
The registered nurse must retain care for unstable clients, as they require continuous assessment and immediate clinical judgment.
2
Determine if the task involves the core nursing process components of Evaluation, Assessment, or initial Teaching.
Identify tasks like evaluating sudden tachypnea or developing a discharge plan as core RN responsibilities.
Tasks requiring independent clinical judgment, complex assessment, or formulation of care/education plans cannot be delegated to LPNs/VNs or assistive personnel.
3
Evaluate the scope of practice for the licensed practical/vocational nurse for the remaining tasks.
Determine that administering oral medications to a stable client and performing sterile dressing changes on established wounds are appropriate.
LPNs/VNs are trained to perform specific procedures and administer medications to clients with predictable outcomes.
4
Evaluate the scope of practice for the assistive personnel for the remaining tasks.
Determine that emptying and recording drain output is appropriate, but taking initial vital signs on a new trauma admission is not.
Assistive personnel can perform routine, standard tasks that do not require clinical interpretation.

Anahtar Kavram

Delegation decisions must be based on client stability, the complexity of the task, and the strict legal scopes of practice for the RN, LPN/VN, and UAP, specifically retaining assessment, clinical judgment, and initial teaching for the RN.
Soru 2130Soru →

After receiving the morning handoff report on a neurology step-down unit, the nurse must plan the initial client assessments. Arrange the following clients in the order they should be assessed, from first (highest priority) to last (lowest priority).

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Cevap

The correct priority order is: 1) The client with a subarachnoid hemorrhage and worsening headache, 2) The client needing time-critical pyridostigmine, 3) The client waiting for a scheduled MRI, and 4) The client awaiting discharge teaching.
Prioritization follows the framework of addressing acute, unstable, and life-threatening issues first, followed by time-sensitive interventions, scheduled activities, and finally routine or non-urgent tasks. The subarachnoid hemorrhage client is exhibiting acute instability. The myasthenia gravis client has a strict time-critical need. The TIA client is stable but has a scheduled commitment. The Parkinson's client requires a routine discharge intervention.

Adım Adım Çözüm

1
Identify life-threatening or unstable conditions (ABCs and neurological emergencies).
The client with a subarachnoid hemorrhage exhibiting new restlessness and a worsening headache is experiencing an acute neurological decline.
Changes in level of consciousness and worsening pain after a hemorrhagic event indicate potential increased intracranial pressure or rebleeding, which requires immediate life-saving intervention.
2
Identify time-sensitive interventions that prevent deterioration.
The client with myasthenia gravis requires pyridostigmine prior to breakfast.
Without this medication, the client risks severe muscle weakness, which can rapidly compromise their airway and swallowing ability.
3
Evaluate remaining clients based on scheduled needs versus routine tasks.
The client scheduled for an MRI needs to be prepared before the client who is simply waiting for discharge.
Scheduled diagnostic procedures take precedence over routine discharge teaching, which can be completed at any point during the shift.

Anahtar Kavram

Prioritization of client care based on physiological instability, acuity, and time-sensitivity.
Tahmini Süre:1m 30s
Soru 2131Soru →

While administering morning medications, a nurse is interrupted by several simultaneous client situations. Which situation requires the nurse's immediate attention?

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Cevap: A client receiving a packed red blood cell transfusion who reports sudden chills and lower back pain.

Cevap

The client receiving a packed red blood cell transfusion who reports sudden chills and lower back pain.
The correct answer identifies a client experiencing an acute hemolytic transfusion reaction, indicated by sudden chills and back pain. This is a life-threatening emergency that requires the nurse to stop the transfusion immediately to prevent renal failure or shock.

Adım Adım Çözüm

1
Evaluate the clinical significance of sudden chills and back pain during a blood transfusion.
Identified as classic signs of an acute hemolytic transfusion reaction.
Recognizing life-threatening complications is the first step in clinical triage.
2
Compare the severity of the transfusion reaction to the other client scenarios.
The transfusion reaction is an acute, unstable emergency, whereas the other situations represent chronic expected findings, equipment issues, or routine care needs.
Prioritization requires identifying the client with the most unstable and immediately life-threatening condition.

Anahtar Kavram

Prioritizing Acute vs. Chronic and Unstable vs. Stable Clients
Soru 2132Soru →

The charge nurse on a nephrology unit is evaluating the current status of four assigned clients. Which client requires the most immediate assessment by the nurse?

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Cevap: A client with the oliguric phase of acute kidney injury who exhibits new-onset peaked T-waves on telemetry and reports generalized muscle weakness.

Cevap

The client with the oliguric phase of acute kidney injury who exhibits new-onset peaked T-waves on telemetry and reports generalized muscle weakness.
The correct answer identifies a client experiencing hyperkalemia, indicated by peaked T-waves and generalized muscle weakness, which is a direct consequence of the oliguric phase of acute kidney injury (inability to excrete potassium). Hyperkalemia represents an immediate Circulation (ABC) threat because it can quickly trigger fatal cardiac dysrhythmias, such as ventricular fibrillation or asystole. This client is the most unstable and requires immediate medical intervention.

Adım Adım Çözüm

1
Analyze each client's presentation to identify the underlying physiological issue.
Client 1 has expected post-operative symptoms; Client 2 has signs of severe hyperkalemia; Client 3 has expected pain from a kidney stone; Client 4 has expected chronic signs of uremia.
Accurate identification of the underlying pathology is necessary before prioritizing.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework.
The client with peaked T-waves and muscle weakness has an acute electrolyte imbalance (hyperkalemia) threatening cardiac function (Circulation).
The ABC framework dictates that immediate threats to life must be addressed before pain, expected post-operative findings, or chronic conditions.
3
Distinguish between acute/unexpected complications and chronic/expected disease manifestations.
The hyperkalemia is an acute, life-threatening complication. The manifestations in the other three clients are expected consequences of their respective conditions or procedures.
Clients with unexpected, unstable conditions always take precedence over those with predictable, stable, or chronic symptoms.

Anahtar Kavram

Prioritization: ABC Framework and Acute vs. Chronic Conditions
Soru 2133Soru →

An older adult client with Parkinson's disease is medically stable and ready for discharge following treatment for aspiration pneumonia. The client demonstrates persistent dysphagia, exhibits a recent 10% unintentional weight loss, and is experiencing sudden episodes of acute confusion. The client's spouse will provide all care at home. Which actions should be included in the collaborative discharge plan? Select all that apply.

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Cevap: Involve a speech-language pathologist to assess swallowing safety and determine appropriate dietary textures.; Engage a registered dietitian to design a high-calorie nutritional regimen that accommodates the swallowing limitations.; Coordinate with a medical social worker to identify available community resources and caregiver support services.

Cevap

The appropriate actions are involving a speech-language pathologist for swallowing assessment, engaging a registered dietitian for nutritional planning, and coordinating with a medical social worker for caregiver support.
A speech-language pathologist is essential to evaluate the client's dysphagia and prevent further aspiration. A registered dietitian is necessary to address the 10% weight loss by formulating a high-calorie diet tailored to the client's swallowing abilities. A medical social worker is vital to support the spouse by arranging community resources, home health, and respite care.

Adım Adım Çözüm

1
Analyze the client's specific clinical presentation and care needs.
The client has dysphagia, significant weight loss, acute confusion, and a spouse requiring support.
Identifying specific deficits dictates which interdisciplinary team members are required for a safe discharge.
2
Match the identified needs with the correct interdisciplinary team members' scope of practice.
Dysphagia requires a speech-language pathologist; weight loss requires a registered dietitian; caregiver burden requires a medical social worker.
Effective collaboration relies on utilizing specialized team members for specific client issues.
3
Evaluate the remaining options against core nursing principles.
Delegating assessments to UAP, dismissing sudden confusion as normal aging, and providing false reassurance are all incorrect nursing actions.
Ensuring safe delegation, recognizing pathology, and maintaining therapeutic communication are fundamental RN responsibilities.

Anahtar Kavram

Interdisciplinary collaboration involves utilizing specialized team members to address specific client deficits while maintaining appropriate RN responsibilities for assessment, safety, and therapeutic communication.
Tahmini Süre:1m 30s
Soru 2134Soru →

A nurse and an unlicensed assistive personnel (UAP) are in the room of a client experiencing severe alcohol withdrawal syndrome. The client suddenly becomes highly agitated, reports seeing insects on the walls, and actively attempts to climb over the bed rails. Which instruction should the nurse give the UAP to best ensure immediate client safety?

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Cevap: Remain at the bedside to provide continuous observation and speak calmly to the client while the nurse obtains the prescribed medication

Cevap

The instruction to remain at the bedside to provide continuous observation and speak calmly to the client while the nurse obtains the prescribed medication is the safest intervention.
The immediate priority for a highly agitated, hallucinating client attempting to climb out of bed is direct observation to prevent a fall. Having the UAP act as a sitter is a safe, least-restrictive alternative that protects the client from injury while the RN obtains necessary pharmacological interventions.

Adım Adım Çözüm

1
Analyze the immediate threat to the client.
The client is actively attempting to climb out of bed while hallucinating, presenting an imminent fall and injury risk.
Identifying the highest priority risk dictates the urgency and type of the required intervention.
2
Evaluate the available resources and scope of practice.
A UAP is present. The UAP cannot assess the client or initiate physical restraints, but they can provide basic safety observation.
Delegating appropriately ensures interventions are legal, safe, and effective without violating the nurse practice act.
3
Select the least restrictive, most effective safety measure.
Assigning the UAP to stay at the bedside provides a 1:1 observation alternative to restraints, protecting the client from falling while the RN retrieves necessary medication to treat the underlying withdrawal.
Restraint alternatives must be exhausted first, and a client at high risk of falling must never be left completely unattended.

Anahtar Kavram

Accident, Error, and Injury Prevention: Restraint Alternatives and Delegation
Soru 2135Soru →

A nurse is removing a central venous catheter (CVC) from a client's subclavian vein. Immediately after the catheter is removed, the client reports acute, severe shortness of breath, grasps their chest, and exhibits cyanosis. The vital signs indicate sudden tachycardia and hypotension. Suspecting an air embolism, arrange the following nursing actions in the priority order they should be performed.

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Cevap

The correct sequence is to first occlude the source of air entry, then position the client to trap the air, followed by administering oxygen, and finally notifying the provider.
In any acute emergency, the nurse must follow the airway-breathing-circulation (ABC) framework and the principle of source control. When a central line is removed and an air embolism is suspected, the immediate priority is to stop more air from entering by sealing the site. The very next step is to prevent the air already in the system from causing fatal obstruction by placing the client in the left lateral Trendelenburg position. Once the mechanical threat is stabilized, oxygen is applied to treat the resulting hypoxia. Finally, the provider is notified to escalate medical care.

Adım Adım Çözüm

1
Apply an impermeable, occlusive dressing over the catheter insertion site.
Prevents additional air from being drawn into the venous circulation.
Source control is always the immediate first step to prevent a critical situation from worsening.
2
Place the client in a left lateral Trendelenburg position.
Traps the existing air in the right atrium.
This physical maneuver relies on gravity and buoyancy to prevent the air embolism from entering the right ventricular outflow tract, which would cause sudden cardiovascular collapse.
3
Administer high-flow oxygen via a non-rebreather mask.
Improves oxygenation and promotes gas resorption.
The embolism creates a severe ventilation-perfusion mismatch; 100% oxygen combats hypoxemia and creates a nitrogen gradient that shrinks the air bubble.
4
Notify the rapid response team and the primary healthcare provider.
Brings advanced life support to the bedside.
After immediate stabilizing interventions are complete, the nurse must summon the medical team for further evaluation and management, such as potential aspiration of the air or intensive care transfer.

Anahtar Kavram

Prioritization of life-saving interventions for a suspected central line air embolism.
Tahmini Süre:1m 30s
Soru 2136Soru →

While coordinating care on a specialized neurological telemetry unit, the registered nurse receives simultaneous updates regarding four assigned clients. Which client presentation mandates the nurse's immediate assessment?

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Cevap: A client with Guillain-Barré syndrome who exhibits new-onset drooling and a decrease in forced vital capacity from 35 mL/kg to 12 mL/kg.

Cevap

The client with Guillain-Barré syndrome who exhibits new-onset drooling and a severely decreased forced vital capacity.
The correct answer identifies a client with Guillain-Barré syndrome experiencing rapid ascending paralysis that has reached the bulbar and respiratory muscles. Drooling indicates an inability to swallow and protect the airway. A forced vital capacity (FVC) that drops below 15 mL/kg is a critical threshold indicating the respiratory muscles can no longer maintain adequate ventilation, signaling impending respiratory arrest. This is a severe, immediate threat to airway and breathing.

Adım Adım Çözüm

1
Analyze each client's presentation for threats to Airway, Breathing, and Circulation (ABCs).
The client with Guillain-Barré syndrome has clinical indicators of airway compromise and respiratory failure.
Airway and breathing issues take highest priority in critical care triage.
2
Evaluate the remaining clients for expected versus unexpected findings.
The clients with the aneurysm, meningitis, and trigeminal neuralgia are exhibiting expected disease trajectories, complications, or stable baseline assessments.
Clients with expected findings or stable chronicity are a lower priority than those with acute, unexpected physiological decline.
3
Select the client requiring immediate life-saving intervention.
The client with Guillain-Barré syndrome is selected.
A forced vital capacity below 15 mL/kg combined with loss of airway protection (drooling) mandates immediate rapid response activation and intubation.

Anahtar Kavram

Prioritization: Recognizing Acute Airway and Breathing Compromise
Soru 2137Soru →

A nurse has received the morning handoff report for four clients. Using the principles of prioritization, in what order should the nurse assess these clients? Arrange the clients from first to be seen (highest priority) to last to be seen (lowest priority).

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Cevap

The correct order is to first see the client with lip swelling and wheezes, followed by the client with gastrointestinal bleeding and hypotension, then the client requiring a pre-medication assessment, and finally the client needing assistance with packing.
Prioritization in nursing strictly follows the Airway, Breathing, and Circulation (ABC) framework. Unstable, acute, and life-threatening conditions must be prioritized over stable, chronic, or routine situations. Anaphylaxis (airway) comes first, followed by hypovolemic shock (circulation), then urgent clinical assessments, and finally routine daily tasks.

Adım Adım Çözüm

1
Identify the most critically unstable client using the Airway, Breathing, Circulation (ABC) framework.
The client with lip swelling and wheezing has an airway emergency.
Airway compromise is the most rapid cause of death and always takes the highest priority.
2
Evaluate the remaining clients for other acute, life-threatening conditions.
The client with gastrointestinal bleeding, diaphoresis, and hypotension has a critical circulation issue.
Hypovolemic shock requires urgent intervention to restore tissue perfusion, making it the second highest priority after airway stability.
3
Differentiate between urgent clinical needs and routine care for the remaining stable clients.
The client with a deep vein thrombosis requires a clinical assessment before a scheduled medication.
Time-sensitive medication administration and assessment are important clinical duties that take precedence over non-clinical tasks, making this the third priority.
4
Identify routine, non-urgent, or delegable tasks.
The stable client needing help packing belongings is placed last.
Assisting with packing is a routine task that does not affect patient safety and can be delayed until all acute clinical needs are met.

Anahtar Kavram

Prioritization using the Airway-Breathing-Circulation (ABC) framework and the unstable versus stable client approach.
Soru 2138Soru →

A 28-year-old client is preparing for discharge to an inpatient rehabilitation facility following a prolonged acute care stay for full-thickness burns to the bilateral upper extremities, anterior chest, and neck. The client has healing skin grafts, requires continuous pressure garments, and frequently expresses intense fear of permanent physical disfigurement. The client receives supplemental nutrition via a percutaneous endoscopic gastrostomy (PEG) tube but has recently begun oral diet trials. Which interprofessional collaborative actions should the nurse include in the client's plan of care? Select all that apply.

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Cevap: Coordinate with the occupational therapist to evaluate the fit of custom pressure garments and modify the upper extremity splinting schedule.; Consult the registered dietitian to analyze daily oral caloric intake versus hypermetabolic demands to guide the PEG tube weaning process.; Facilitate a referral to a clinical psychologist to evaluate for acute stress disorder and address severe body image disturbances.

Cevap

The correct actions include coordinating with the occupational therapist for pressure garment and splint evaluation, consulting the registered dietitian for metabolic and PEG weaning management, and referring to a clinical psychologist for trauma and body image support.
The correct collaborative actions align perfectly with the specialized scopes of practice required for complex burn rehabilitation. Occupational therapists are uniquely trained to manage upper extremity contractures using custom splints and pressure garments. Registered dietitians are necessary to manage the high metabolic demands of burn healing and safely calculate the transition from enteral feeding to an oral diet. Clinical psychologists or psychiatric specialists are essential to address the profound psychological trauma and body image disturbances associated with severe burns.

Adım Adım Çözüm

1
Analyze the client's complex physiological and psychological needs.
The client has upper extremity contracture risks, hypermetabolic nutritional needs (PEG to oral weaning), and severe psychosocial distress regarding disfigurement.
Identifying the specific deficits determines which specialized interdisciplinary team members are required for safe and effective discharge planning.
2
Evaluate each proposed collaboration against the legal and ethical scope of practice for each discipline.
Occupational therapy (splinting/garments), dietetics (nutrition weaning), and psychology (trauma therapy) are matched correctly. Delegating assessment to UAP, using false reassurance, and ignoring ABCs for paperwork are incorrect.
The RN is responsible for ensuring that referrals are appropriate and that delegated tasks do not violate the Nurse Practice Act or standard safety protocols.
3
Select the appropriate multidisciplinary interventions.
The valid interventions are selected, avoiding prioritization, delegation, and therapeutic communication traps.
This confirms a holistic, safe, and collaborative approach to complex client care.

Anahtar Kavram

Collaboration with Interdisciplinary Team
Soru 2139Soru →

A competent adult client informs the nurse of their decision to refuse a recommended medical procedure. Which of the following nursing actions appropriately uphold the ethical principle of autonomy? Select all that apply.

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Cevap: Asking open-ended questions to understand the client's rationale for the refusal; Verifying that the client comprehends the potential health risks of declining the procedure; Communicating the client's decision promptly to the prescribing healthcare provider

Cevap

The correct actions include asking open-ended questions to understand the client's reasoning, verifying their comprehension of the risks, and communicating their decision to the provider.
Autonomy is the ethical principle that recognizes a client's right to self-determination and independent decision-making. Actions that uphold this principle involve providing the client with necessary information to make informed choices, assessing their understanding without judgment, and advocating for their decisions with the healthcare team. Asking open-ended questions, verifying comprehension of risks, and notifying the provider all directly support the client's autonomous choice.

Adım Adım Çözüm

1
Identify the core ethical principle being tested in the scenario.
The principle is autonomy, which is the client's right to make their own healthcare decisions.
Understanding the principle is necessary to evaluate which nursing actions support it.
2
Evaluate each option to determine if it supports or hinders the client's right to self-determination.
Exploring reasons, verifying understanding, and notifying the provider support autonomy. Giving personal advice and making assumptions hinder it.
Nursing actions must align with ethical guidelines and promote client rights.

Anahtar Kavram

Autonomy in nursing practice
Soru 2140Soru →

A nursing care team comprising a registered nurse (RN), a licensed practical/vocational nurse (LPN/VN), and an unlicensed assistive personnel (UAP) is initiating the day shift on a busy orthopedic and trauma ward. Which specific client care directive represents the most appropriate delegation by the RN?

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Cevap: Authorizing the LPN/VN to execute a routine sterile dressing change and administer scheduled oral analgesics for a client who is three days post-total knee arthroplasty.

Cevap

The most appropriate delegation is authorizing the LPN/VN to perform a sterile dressing change and administer oral analgesics for a stable, three-day post-operative client.
The correct delegation involves assigning an LPN/VN to provide care for a stable, three-day post-operative client. Performing a routine sterile dressing change and administering scheduled oral medications are entirely within the legal scope of practice for an LPN/VN, provided the client's condition is predictable and not rapidly changing.

Adım Adım Çözüm

1
Analyze the delegation to the LPN/VN for the total knee arthroplasty client.
The client is three days post-operative and stable. The required tasks are a sterile dressing change and oral medication administration.
To verify that the tasks fall within the LPN/VN scope of practice, which safely includes standard procedures and medication administration for clients with predictable outcomes.
2
Evaluate the task assigned to the UAP regarding the external fixator.
The task involves demonstrating a technique to a client, which is considered initial teaching.
To apply the National Council of State Boards of Nursing (NCSBN) principle that teaching and evaluation cannot be delegated to unlicensed personnel.
3
Assess the clinical stability of the client who had an anterior cervical discectomy.
The client is exhibiting hoarseness and throat clearing, which are signs of potential airway edema or new-onset dysphagia.
To recognize that feeding a client with a potential airway or swallowing compromise carries a high risk of aspiration and must be assessed by the RN first.
4
Review the LPN/VN assignment for the newly admitted client with a pelvic binder.
The client requires a comprehensive admission assessment and possesses a high-acuity trauma injury (pelvic fracture).
To enforce the rule that RNs must perform all initial admission assessments and must retain care for highly unstable clients.

Anahtar Kavram

RNs must delegate tasks based on client stability, potential for harm, task complexity, and the legal scope of practice for LPNs/VNs and UAPs.
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