Tüm alıştırma soruları

A nurse is planning care for an older adult client with moderate dementia who frequently wanders the unit during the night and repeatedly attempts to open the stairwell doors. Which action is the most appropriate initial intervention to prevent injury?

A client is in the preoperative holding area preparing for an elective laparoscopic cholecystectomy. The client has not yet received any preoperative sedatives. When the registered nurse approaches to witness the signature on the informed consent form, the client withdraws their hand and states, "I am too frightened. I do not think I want to go through with this operation today." Arrange the following nursing actions in the correct order of priority from first to last.

The bed alarm sounds for a client who has severe diabetic peripheral neuropathy and is receiving continuous intravenous (IV) fluids. The nurse enters the room and observes the client standing barefoot next to the bed, attempting to walk to the bathroom unassisted. The IV tubing is stretched taut. Which action should the nurse take first?

A nurse preceptor on a medical-surgical unit is evaluating the clinical decision-making of a newly licensed registered nurse (RN). Which actions by the newly licensed RN demonstrate appropriate adherence to legal rights and responsibilities? Select all that apply.

A nurse is participating in an interdisciplinary care conference for a 7-year-old client with spastic cerebral palsy who is nearing discharge after treatment for pneumonia. The parents express profound exhaustion, stating they must feed, dress, and bathe the child entirely because the child struggles significantly with grasping utensils and manipulating clothing fasteners. Which recommendation by the nurse demonstrates the most appropriate interdisciplinary collaboration to address this specific concern?

A nurse is caring for a client with acute confusion who is repeatedly attempting to remove a surgical wound drain. Arrange the following nursing interventions in the correct sequence, starting from the least restrictive measure to the most restrictive.

An emergency department triage nurse evaluates an adult who reports a persistent cough, drenching night sweats, and blood-tinged sputum. While awaiting further medical evaluation for suspected active tuberculosis, which immediate isolation action is most appropriate for the nurse to implement?

After receiving the handoff report on a pediatric acute care unit, the nurse prepares to assess four assigned clients. Which client should the nurse evaluate first?

During bedside rounds, a nurse observes that a postoperative client is confused and continuously grasping at their indwelling urinary catheter tubing. To prevent premature removal of the device, which action should the nurse take first?

The nursing care team is preparing a room for a client diagnosed with epilepsy who experiences frequent, unpredictable generalized tonic-clonic seizures. Which environmental modifications and safety practices should be established immediately? Select all that apply.

The nurse is assessing a client admitted to the medical-surgical unit with acute pancreatitis. Which of the following clinical findings indicate a life-threatening complication and require immediate clinical follow-up? Select all that apply.

A registered nurse is navigating situations that require balancing client confidentiality under HIPAA regulations with legal mandates and interdisciplinary care. Which of the following actions by the nurse demonstrate appropriate management of protected health information (PHI)? Select all that apply.

A nurse is preparing to provide morning care for a client admitted with frequent, watery stools who has just tested positive for Clostridioides difficile. Which of the following infection control interventions should the nurse implement? Select all that apply.

A nurse is caring for a client who is receiving a unit of packed red blood cells (PRBCs). Fifteen minutes after the transfusion is initiated, the client suddenly reports severe lower back pain, chills, and dyspnea. Place the following nursing interventions in the correct order of priority from first to last.

A nurse is coordinating the care plan for a client recovering from a right hemispheric cerebrovascular accident (CVA). The client exhibits left-sided hemiparesis, unilateral neglect, and impulsive behavior. The family expresses severe distress because the client frequently chokes when drinking liquids and becomes highly agitated when struggling to grasp eating utensils. Which action by the nurse demonstrates the most appropriate interdisciplinary collaboration and care management?

A client with mild cognitive impairment is repeatedly pulling at their intravenous (IV) tubing. Which less restrictive interventions should the nurse implement to protect the IV line before considering physical restraints? Select all that apply.

An older adult client is admitted to the medical-surgical unit with pneumonia. During the night shift, the client becomes acutely confused and repeatedly attempts to pull out their peripheral intravenous (IV) catheter. Which initial nursing action is the most appropriate to prevent injury and maintain the integrity of the IV line?

A registered nurse is finalizing the transition plan for a 19-year-old client with a recently acquired C7 complete spinal cord injury who is preparing to transfer to an inpatient rehabilitation facility. The client requires intermittent catheterization, struggles to grasp feeding utensils, and expresses intense feelings of hopelessness regarding the future. While coordinating comprehensive care, which of the following actions by the nurse are appropriate? Select all that apply.

A registered nurse is caring for a client with early-stage Alzheimer's disease on a telemetry unit. The client is scheduled for an elective permanent pacemaker insertion. The healthcare provider has completed the explanation of the procedure's risks, benefits, and alternatives. When the nurse approaches to witness the consent, the client states, 'I understand that I need this pacemaker to fix my abnormally slow heart rate.' The client's adult child intervenes, stating, 'My parent is naturally confused from old age and should not sign anything; I will sign the form.' Which of the following actions should the nurse take? Select all that apply.

A registered nurse is providing care to a client with a traumatic brain injury who repeatedly attempts to dislodge a newly inserted nasogastric tube. After securing a provider's prescription for physical limb restraints, which action should the nurse take to ensure client safety?