Tüm alıştırma soruları

A client with a urinary tract infection and acute delirium is admitted to a medical-surgical unit. The client is highly agitated and repeatedly attempts to remove their peripheral intravenous (IV) catheter. Which action should the nurse take FIRST to manage the client's risk for injury?

A first-generation immigrant client is scheduled for an elective cardiac catheterization. While preparing to sign the consent paperwork, the client tells the registered nurse, "I truly do not want this test, but the doctor said I must sign this or my insurance will cancel my coverage for this hospital admission." Which action is most appropriate for the nurse to take?

A nurse is removing a central venous catheter (CVC) from a client's right subclavian vein. Immediately after the catheter is withdrawn, the client gasps, reports sudden severe chest pain, and becomes acutely tachycardic and dyspneic with a rapidly dropping oxygen saturation. The nurse suspects a venous air embolism. Arrange the following nursing interventions in the correct order of clinical priority from first to last.

On a progressive neurology unit, a registered nurse (RN) coordinates care with a licensed practical/vocational nurse (LPN/VN) and an unlicensed assistive personnel (UAP). Upon reviewing the ongoing unit activities, which observed actions indicate that delegation has been implemented safely and correctly? Select all that apply.

A client is in the preoperative holding area awaiting an elective lumbar laminectomy. When the registered nurse presents the informed consent document for a witness signature, the client states, "I am really scared. I don't think I want to have this surgery anymore." Arrange the following nursing actions in the correct priority order.

During interdisciplinary rounds, a nurse utilizes the SBAR framework to report on a client preparing for discharge following a complex surgical resection of an acoustic neuroma. The assessment reveals that the client chokes on thin liquids, exhibits ataxia that prevents them from holding utensils, and is tearful, stating, "I am completely hopeless." Which collaborative action by the nurse is the most appropriate?

A nurse working on an oncology unit discovers that a 500 mL bag of intravenous antineoplastic (chemotherapy) medication has accidentally ruptured and spilled onto the floor. Arrange the following actions in the correct sequence to safely manage this hazardous spill. All options must be used.

A registered nurse (RN) and an unlicensed assistive personnel (UAP) are caring for a 78-year-old client who is hospitalized for a severe urinary tract infection. The client becomes increasingly restless and repeatedly attempts to climb over the bed rails. Which action is the most appropriate initial intervention to ensure the client's safety?

An 81-year-old client is evaluated in the emergency department after a neighbor found them wandering outside in freezing temperatures. The client is severely undernourished, has multiple faded bruises on the torso in various stages of healing, and exhibits extreme apprehension. While the healthcare provider is examining the client, the client's legally appointed healthcare proxy arrives, angrily interrupts the assessment, and insists on taking the client home immediately. When the proxy speaks, the client visibly trembles and withdraws. Which action reflects the nurse's primary legal responsibility in this situation?

A registered nurse is preparing a client who has limited English proficiency for an elective lumbar laminectomy. The healthcare provider recently completed the preoperative briefing and left the unit. When the nurse presents the informed consent document for the client's signature, the client hesitates and says, "This operation... I will walk perfectly without pain tomorrow, yes?" Which of the following actions should the nurse take? (Select all that apply)

Upon returning from a break, a registered nurse receives status updates regarding four assigned clients. Which client must the nurse assess first?

A nurse is initiating an urgent call to the on-call orthopedic provider regarding a change in a client's condition. Arrange the nurse's statements in the correct sequence using the ISBAR (Identify, Situation, Background, Assessment, Recommendation) interprofessional communication framework.

A client with terminal pulmonary fibrosis experiences an acute respiratory crisis. A relative at the bedside urgently demands that the clinical team intubate the client. The client's medical record contains an advance directive. Arrange the following nursing actions in the legally correct and prioritized sequence.

A nurse is preparing an SBAR (Situation, Background, Assessment, Recommendation) report for interdisciplinary rounds regarding a client who recently suffered an acute cerebellar infarction. The client exhibits severe appendicular ataxia, dysmetria, and bilateral intention tremors. The nurse reports that the client is consuming less than 25% of their meals because they become exhausted trying to manipulate standard utensils, frequently spilling hot food. The attending provider suggests delegating total feeding assistance to the unit's Unlicensed Assistive Personnel (UAP) for all meals to ensure adequate nutritional intake. Which statement by the nurse in the "Recommendation" phase demonstrates the most appropriate clinical judgment and interdisciplinary collaboration?

A $7$-year-old client weighing $25$ kg ($55$ lb) is hospitalized for induction chemotherapy to treat acute lymphoblastic leukemia. The first infusion was completed $48$ hours ago. The nurse reviews the morning assessment data and laboratory results. Which of the following findings demand immediate clinical intervention? Select all that apply.

During the morning shift on a cardiac step-down unit, a registered nurse (RN) is organizing the daily workload. Which of the following tasks are safe and appropriate for the RN to delegate to an unlicensed assistive personnel (UAP)? Select all that apply.

A client is admitted to the neurology unit following a traumatic brain injury. The client is experiencing acute delirium, is highly disoriented, and repeatedly attempts to climb over the bed rails, creating a significant fall hazard. To ensure the client's safety and prevent injury, which intervention should the nurse implement first?

The unit educator is conducting an infection control review for newly hired nurses. Match each infectious disease or clinical condition with its primary required category of precautions.

At 1400 hours on an infectious disease unit, a registered nurse (RN) must distribute care tasks to a licensed practical/vocational nurse (LPN/VN) and an unlicensed assistive personnel (UAP). Which delegation decision demonstrates safe and effective care management?

A competent adult client admitted for an acute exacerbation of heart failure abruptly packs their belongings and states, 'I am going home right now. I do not want to stay in this hospital anymore.' Arrange the following nursing actions in the correct sequence to legally and ethically manage this situation. (Place the first action at the top and the final action at the bottom.)