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Soru 221Soru →

A nurse is preparing to perform Leopold maneuvers on a pregnant client to determine fetal presentation and position. Place the steps of this assessment in the correct chronological order.

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Cevap

The correct sequence for Leopold maneuvers is: palpating the fundus, palpating the sides of the abdomen, grasping the lower abdomen above the symphysis pubis, and finally facing the client's feet to palpate for fetal descent.
Leopold maneuvers follow a systematic, four-step approach to determine fetal lie, presentation, position, and attitude. The nurse starts at the top of the uterus (fundus) while facing the client to identify the fetal pole. Next, the nurse palpates down the sides to find the fetal back. Then, the nurse grasps the lower abdomen to identify the presenting part. Finally, the nurse turns to face the client's feet and palpates the lower abdomen to assess fetal descent and attitude.

Adım Adım Çözüm

1
Identify the first maneuver.
Palpate the uterine fundus.
This step establishes which fetal pole (head or buttocks) is situated in the upper abdomen to determine fetal presentation.
2
Identify the second maneuver.
Palpate the sides of the abdomen.
This step locates the smooth, firm contour of the fetal back versus the irregular small parts (limbs).
3
Identify the third maneuver.
Grasp the lower abdomen above the symphysis pubis.
This step confirms the presenting part and determines whether it is movable or has engaged in the maternal pelvis.
4
Identify the fourth maneuver.
Face the client's feet and palpate the lower abdomen.
This step assesses the fetal attitude and verifies the degree of descent into the pelvis.

Anahtar Kavram

Leopold Maneuvers Assessment Sequence
Soru 222Soru →

An adult client recovering from a traumatic brain injury is experiencing severe psychomotor agitation and repeatedly attempts to remove their nasogastric feeding tube. The nurse is implementing measures to protect the medical device while adhering to safety guidelines. Arrange the following interventions in the correct sequence from least restrictive to most restrictive.

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Cevap

The correct sequence of interventions from least restrictive to most restrictive is: Assess for physiological triggers, provide a diversionary activity, camouflage the medical tubing, initiate continuous observation, and finally apply prescribed soft mitt restraints.
In accordance with safety and legal guidelines, restraints must be the intervention of last resort. The nurse must systematically exhaust less restrictive alternatives, beginning with physiological assessment to rule out treatable causes of delirium, progressing through environmental modifications and camouflaging devices, moving to direct human supervision, and only applying physical restraints when all other methods have proven ineffective.

Adım Adım Çözüm

1
Analyze the clinical scenario.
The client is experiencing psychomotor agitation and attempting to remove an essential medical device, requiring interventions to protect the device while honoring client rights.
Establishing the clinical priority determines the trajectory of nursing care.
2
Apply the principle of the least restrictive alternative.
Interventions must progress from non-invasive, autonomous actions to increasingly restrictive measures.
Federal regulations and nursing standards mandate that restraints are an intervention of strict last resort.
3
Sequence the interventions based on the restriction hierarchy.
Assessment must precede environmental modification, followed by device camouflage, human supervision, and ultimately physical restraint application.
This sequence systematically rules out physiological causes and attempts all less restrictive measures before limiting the client's physical freedom.

Anahtar Kavram

Least Restrictive Restraint Alternatives
Soru 223Soru →

A nurse is preparing to draw up a prescribed intravenous medication from a glass ampule. Arrange the following steps in the correct chronological order to ensure safe preparation.

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Cevap

The correct chronological order for preparing medication from an ampule is: tap the ampule to clear the fluid from the neck, wrap the neck with a protective pad, snap the neck away from the body, withdraw the medication using a filter needle, and finally replace the filter needle with a standard injection needle.
Safe preparation of medication from a glass ampule follows a strict chronological sequence to prevent injury to the nurse and client. Tapping the ampule ensures the entire dose is in the lower chamber. Wrapping the neck provides a physical barrier, and snapping away from the body protects against flying glass. Using a filter needle is mandatory to prevent glass aspiration, and replacing it before administration ensures glass particles are not injected into the client.

Adım Adım Çözüm

1
Tap the top of the ampule lightly.
The medication in the top of the ampule moves into the bottom chamber.
This ensures the full dose of the medication is available and prevents spilling when the ampule is opened.
2
Wrap a sterile gauze pad or unopened alcohol swab around the ampule neck.
A physical barrier is created around the scored glass.
This protects the nurse's fingers from cuts when the glass breaks.
3
Snap the ampule neck quickly and firmly away from the body.
The ampule is opened safely.
Directing the breaking force away from the body prevents glass shards from flying toward the nurse's face or eyes.
4
Attach a filter needle to a syringe and withdraw the medication.
The medication is drawn into the syringe without glass shards.
The filter needle catches any microscopic glass particles that may have fallen into the liquid when the ampule was snapped.
5
Remove the filter needle and attach an appropriate injection needle.
The syringe is safely prepared for administration to the client.
Filter needles are for drawing up only; using them for administration could inject trapped glass particles into the client.

Anahtar Kavram

Safe medication preparation from a glass ampule requires protecting the nurse from glass cuts and protecting the client from glass shards by using a filter needle.
Soru 224Soru →

An acutely agitated adult client is continuously attempting to pull out a life-saving central venous catheter. The nurse determines that all less restrictive measures have failed and emergency bilateral soft wrist restraints are necessary to prevent immediate injury. Arrange the following nursing actions in the correct chronological sequence.

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The correct sequence prioritizes immediate client safety by applying and securing the restraints, immediately verifying safe application with a two-finger check, obtaining the required provider prescription, and finally documenting the emergency event.
In an emergency behavioral or medical situation where a client poses an immediate threat to themselves (such as pulling out a life-saving device) and all alternative measures have failed, the nurse must intervene first to secure safety. This sequence involves first applying the restraints to stop the behavior, safely securing them to a movable bed part with a quick-release knot, and immediately checking for a safe fit (two-finger method). Once the client is physically safe, the nurse must contact the provider to obtain the required emergency prescription (typically required within 1 hour), followed by comprehensive documentation of the event.

Adım Adım Çözüm

1
Apply the soft wrist restraints directly to the client's wrists.
Prevents immediate harm and protects the life-saving central venous catheter.
In an emergency where less restrictive measures fail, stopping the immediate physical threat is the absolute first priority.
2
Secure the restraint straps to the movable portion of the bed frame using a quick-release tie.
Safely anchors the restraints.
Securing to the movable frame ensures restraints do not tighten if the bed is adjusted, and a quick-release tie allows for rapid removal in an emergency.
3
Insert two fingers under the secured restraints to verify appropriate fit.
Ensures the restraints are not too tight.
Verifying fit immediately prevents neurovascular compromise and skin breakdown.
4
Contact the healthcare provider to evaluate the client and obtain a formal emergency prescription.
Initiates the legal and clinical requirement for restraint use.
Emergency application requires an evaluation and formal order from the provider, typically within 1 hour of applying the restraints.
5
Document the client's behavior, the alternatives attempted, and the exact time of restraint application.
Completes the medical record and provides legal protection.
Comprehensive documentation must follow the physical stabilization of the client and notification of the provider.

Anahtar Kavram

Emergency Physical Restraint Implementation Sequence
Soru 225Soru →

A registered nurse is preparing to safely move a client who has right-sided hemiparesis from the hospital bed into a wheelchair. In what sequence should the nurse perform the following interventions?

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The correct sequence prioritizes environmental safety by placing the chair on the strong side, prevents orthostatic hypotension by dangling, secures the client with a gait belt and footwear, stabilizes the weak leg during standing, and executes the pivot toward the strong side.
The correct sequence ensures client safety by addressing environmental, physiological, and mechanical risks in a logical order. The nurse must first prepare the environment by placing the chair on the strong side. Next, the nurse addresses physiological safety by allowing the client to dangle to prevent orthostatic hypotension. Mechanical safety is then established by applying a gait belt and non-skid footwear. Finally, the nurse provides physical support by bracing the weak side during the stand and directing the pivot toward the strong side.

Adım Adım Çözüm

1
Place the wheelchair on the client's strong (left) side and lock the wheels.
The environment is secured for a safe transfer path.
Transferring toward the unaffected side ensures the client can use their strong leg to pivot and bear weight safely.
2
Sit the client on the edge of the bed and allow their legs to dangle.
The client is acclimated to an upright posture.
This allows baroreceptors to adjust, preventing orthostatic hypotension and dizziness before standing.
3
Apply the transfer belt and put on non-skid footwear.
The client is properly equipped for physical movement.
The belt provides the nurse with a secure grip to prevent falls, and the footwear provides traction.
4
Brace the client's weak (right) leg while holding the transfer belt.
The client's hemiparetic side is fully supported.
This prevents the weakened knee from buckling under the client's weight during the standing phase.
5
Pivot the client to the left and lower them into the chair.
The client is safely transferred into the wheelchair.
Using the strong arm and leg allows the client to control their descent and maintain balance during the final step.

Anahtar Kavram

Safe client transfer techniques for hemiparesis
Tahmini Süre:1m 30s
Soru 226Soru →

A nurse is preparing to remove a non-tunneled central venous catheter (CVC) from the subclavian vein of an alert, cooperative adult client. Arrange the following actions in the correct chronological order to minimize the risk of a venous air embolism and bleeding. (First action to last action)

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The correct sequence for removing a central venous catheter is to first position the client supine, instruct them to perform the Valsalva maneuver, withdraw the catheter during the maneuver, apply immediate firm pressure, and finally apply an air-occlusive dressing.
Removing a central venous catheter (CVC) carries a high risk of venous air embolism and bleeding. To minimize these risks, the nurse must manipulate pressure gradients to ensure venous pressure is higher than atmospheric pressure. Positioning the client supine increases central venous pressure. Instructing the client to perform the Valsalva maneuver (bearing down) further raises intrathoracic pressure. Withdrawing the catheter during this positive-pressure state prevents air from entering the vein. Immediately applying firm pressure stops bleeding and seals the tract, and finally, placing an air-occlusive dressing ensures the site remains sealed while the skin and vein heal.

Adım Adım Çözüm

1
Position the client flat in a supine position.
Central venous pressure increases in the upper body.
Keeping the insertion site at or below the level of the heart prevents a negative pressure gradient that could draw air into the vein.
2
Instruct the client to take a deep breath, hold it, and bear down.
Intrathoracic pressure is temporarily increased.
This Valsalva maneuver creates positive pressure within the venous system, actively pushing against atmospheric pressure.
3
Withdraw the catheter smoothly and continuously.
The catheter is removed from the vein.
Removing the catheter while the client holds their breath ensures air cannot enter the open venous tract.
4
Apply firm manual pressure to the insertion site with sterile gauze.
Bleeding is controlled and the tract is sealed.
Firm pressure for at least 5 to 10 minutes achieves hemostasis and physically prevents air entry.
5
Secure an air-occlusive dressing over the site.
The insertion site is completely sealed from the environment.
An occlusive dressing prevents delayed air entry while the tissue tract heals.

Anahtar Kavram

Prevention of Venous Air Embolism During CVC Removal
Soru 227Soru →

A nurse is preparing to administer an intramuscular (IM) injection of iron dextran using the Z-track method to an adult client. Arrange the following steps of the procedure in the correct chronological order.

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The correct sequence is to first cleanse the site, displace the skin laterally, insert the needle at a 90-degree angle, inject the medication slowly, wait 10 seconds, and finally withdraw the needle while releasing the displaced skin.
The Z-track method is designed to prevent irritating medications, such as iron dextran, from leaking into the subcutaneous tissue. Proper technique requires establishing the track by displacing the skin first, then inserting the needle and injecting. Waiting 10 seconds allows for dispersion within the muscle, and releasing the skin only after the needle is completely withdrawn seals the track.

Adım Adım Çözüm

1
Identify and cleanse the injection site.
The skin over the target muscle is disinfected.
This is the foundational step of infection control prior to breaking the skin barrier.
2
Displace the skin and subcutaneous tissue laterally.
The tissue layers are shifted out of their normal alignment.
This sets up the Z-track path, which is required before the needle is introduced.
3
Insert the needle at a 90-degree angle.
The needle penetrates through the displaced skin and subcutaneous tissue into the muscle.
A 90-degree angle ensures the medication is delivered deep into the muscle, not the subcutaneous layer.
4
Inject the medication slowly.
The medication is deposited into the muscle tissue.
Slow injection minimizes tissue distention and discomfort.
5
Wait for 10 seconds with the needle in place.
The medication begins to absorb and disperse.
Waiting prevents the medication from immediately seeking the path of least resistance (the needle track) when the needle is removed.
6
Withdraw the needle and release the skin.
The tissue layers slide back to their normal anatomical position.
This traps the medication in the muscle, preventing it from leaking into subcutaneous tissue and causing irritation.

Anahtar Kavram

Z-track Method for Intramuscular Injections
Soru 228Soru →

A nurse is caring for a 65-year-old client who is receiving an intravenous infusion of alteplase (rtPA) for an acute ischemic stroke. Thirty minutes into the infusion, the client reports a sudden, severe headache, becomes intensely nauseous, and exhibits a new unilateral pupillary dilation. To reduce the risk of catastrophic neurological deterioration, arrange the following nursing actions in the correct priority order from first to last.

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The correct sequence is to first stop the alteplase infusion, then assess the airway and hemodynamics, notify the healthcare team, send the client for an emergent CT scan, and finally draw blood for coagulation studies.
The physiological integrity of the client is best preserved by immediately eliminating the source of harm (stopping alteplase). Once the immediate risk is mitigated, the nurse secures the airway and stabilizes hemodynamics. Following stabilization, communicating with the medical team allows for orders that direct diagnostic confirmation (CT scan) and subsequent supportive care preparation (drawing blood for coagulation factors).

Adım Adım Çözüm

1
Discontinue the intravenous alteplase infusion immediately.
The delivery of the fibrinolytic agent is halted.
Symptoms such as sudden severe headache, nausea, and pupillary changes during alteplase administration strongly indicate hemorrhagic conversion. Stopping the drug minimizes further coagulopathy and limits expanding intracranial hemorrhage.
2
Assess airway patency, breathing, and hemodynamic stability.
Immediate life threats regarding oxygenation, ventilation, and perfusion are identified.
An expanding intracranial hemorrhage can cause rapid depression of the central nervous system, leading to loss of airway reflexes. This assessment determines if immediate intubation or cardiovascular support is required.
3
Notify the rapid response team and the neurologist.
Advanced medical support and targeted interventions are mobilized.
The provider must evaluate the client and order emergency diagnostics and pharmacological reversal agents.
4
Transport the client for an emergent non-contrast head CT scan.
The presence of intracranial bleeding is confirmed or ruled out.
A non-contrast CT is the gold standard for rapidly identifying acute hemorrhage, which dictates the subsequent medical or surgical management.
5
Draw blood for a stat coagulation profile and type and screen.
Laboratory data is obtained to guide blood product administration.
Preparing for the administration of cryoprecipitate, platelets, or antifibrinolytic agents requires baseline coagulation values and blood typing.

Anahtar Kavram

Prioritization of interventions for life-threatening complications of fibrinolytic therapy requires immediately removing the causative agent before assessing ABCs and escalating care.
Soru 229Soru →

A nurse is preparing to assist a client who has dysphagia and right-sided facial weakness with a meal. Arrange the following nursing actions in the correct chronological sequence to ensure safe oral intake and prevent aspiration. All options must be used.

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First, elevate the head of the bed. Second, place food on the left side. Third, instruct the client to tuck their chin. Fourth, assess for pocketed food. Finally, maintain an upright position.
Safe oral feeding for a client with dysphagia and hemiparesis requires a systematic approach prioritizing airway protection. Upright positioning must occur before any food is introduced. Food is then placed on the unaffected side to maximize control, followed by a chin-tuck maneuver to physically protect the airway during the swallow. Immediate post-swallow assessment ensures clearance, and prolonged upright positioning prevents subsequent reflux or delayed aspiration.

Adım Adım Çözüm

1
Establish safe positioning.
The head of the bed is elevated to 90 degrees.
Gravity assists swallowing and severely reduces the initial risk of aspiration.
2
Introduce food appropriately.
Food is placed on the strong (left) side of the mouth.
The unaffected side has intact motor control and sensation, allowing the client to safely manipulate the bolus.
3
Protect the airway during the swallow.
The client performs a chin-tuck maneuver.
This physical positioning narrows the airway opening and prevents food from entering the trachea.
4
Verify oral clearance.
The oral cavity is checked for residual food.
Weak facial muscles can lead to food pocketing on the right side, which can be aspirated later if not removed.
5
Prevent post-meal complications.
The client remains in an upright position for at least 30 minutes.
This sustained posture prevents gastroesophageal reflux and silent aspiration of residual particles.

Anahtar Kavram

Aspiration precautions and feeding techniques for clients with dysphagia and unilateral facial weakness.
Tahmini Süre:1m 30s
Soru 230Soru →

A nurse is providing care for a client recovering from a traumatic brain injury who is becoming increasingly restless and repeatedly attempting to pull out their enteral feeding tube. To ensure client safety while following the legal and ethical principle of least restrictive interventions, arrange the following nursing actions in the correct sequence from first to last.

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Cevap

The correct sequence begins with assessment to identify reversible causes, followed by escalating interventions from the least restrictive (environmental modifications and disguising the tube) to continuous observation, and finally ending with the most restrictive intervention (obtaining a prescription for physical restraints).
Safe restraint use requires strict adherence to the nursing process and the legal principle of least restrictive interventions. Assessment always comes first to rule out immediately reversible physiological causes (like a full bladder or hypoxia). Once physiological needs are met, the nurse must exhaust a hierarchy of alternatives: general environmental safety (alarms, quiet room), targeted device protection (binders, sleeves), and direct human supervision (sitter). Only when all these have failed to keep the client safe can the nurse legally request a prescription for physical restraints.

Adım Adım Çözüm

1
Assess for underlying physiological causes of agitation.
Identifies reversible issues like pain or hypoxia.
The nursing process requires assessment first; treating the root cause often eliminates the need for any safety restrictions.
2
Modify the client's environment.
Reduces overstimulation and alerts staff to movement via bed alarms.
This is the most basic, least restrictive safety measure.
3
Conceal the targeted medical device.
Removes the visual and tactile stimulus triggering the pulling behavior.
Disguising tubes is a targeted, non-restrictive alternative to tying down the client's hands.
4
Initiate continuous one-to-one observation.
Provides immediate physical redirection without mechanical restriction.
A sitter is the final step in the least-restrictive hierarchy before applying physical restraints.
5
Obtain a prescription for physical restraints.
Authorizes the legal application of soft wrist restraints.
Restraints are the absolute last resort when all other documented alternatives have failed to protect the client.

Anahtar Kavram

The principle of least restrictive interventions and restraint escalation protocols.
Soru 231Soru →

A client with a history of heart failure is admitted to the progressive care unit. During the night shift, the client suddenly awakens with severe dyspnea, a productive cough with frothy pink sputum, and an oxygen saturation of 84% on room air. The nurse observes profound jugular venous distention and hears diffuse coarse crackles upon auscultation. Arrange the following nursing actions in the correct order of priority from first to last.

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The correct priority sequence is to first position the client upright with legs dependent, then apply high-flow oxygen, followed by administering intravenous furosemide, and finally inserting an indwelling urinary catheter.
In acute cardiogenic pulmonary edema, the priority is to immediately improve oxygenation and reduce cardiac workload. Positioning the client in a high-Fowler's position with legs dependent uses gravity to decrease venous return (preload) and allows the lungs to expand more fully. This is the fastest, most immediate independent nursing intervention. Next, applying high-flow oxygen addresses the severe hypoxemia caused by fluid in the alveoli. Once the client's airway and breathing are acutely supported, intravenous furosemide is administered to initiate rapid diuresis, thereby removing fluid and further reducing preload. Finally, inserting a urinary catheter is necessary to accurately track the massive diuresis expected from the furosemide, making it the logical final step in this sequence.

Adım Adım Çözüm

1
Evaluate the client's immediate physiological needs based on ABCs (Airway, Breathing, Circulation).
The client is determined to be in acute respiratory distress due to fluid overload (flash pulmonary edema).
Establishing the primary threat to life dictates the prioritization of all subsequent nursing interventions.
2
Prioritize mechanical respiratory and hemodynamic interventions.
Positioning the client upright with legs dependent is selected as the immediate first action.
Sitting the client up immediately decreases venous return to the heart (reducing preload) and allows for maximum diaphragmatic excursion to ease breathing.
3
Address the acute hypoxemia.
Applying oxygen via a non-rebreather face mask is prioritized as the second action.
The client's oxygen saturation is 84%, requiring immediate high-concentration oxygen therapy to prevent severe tissue hypoxia.
4
Administer pharmacological treatment for the underlying fluid overload.
Intravenous furosemide is given.
Loop diuretics reduce the circulating fluid volume, thereby decreasing pulmonary congestion, but they must be administered after immediate airway and breathing stabilization.
5
Implement necessary monitoring tools for the pharmacological intervention.
An indwelling urinary catheter is inserted.
Accurate measurement of urine output is critical to evaluate the effectiveness of the rapid-acting loop diuretic.

Anahtar Kavram

Prioritization of care in acute cardiogenic pulmonary edema follows the principles of immediate preload reduction and airway management, beginning with physical positioning, followed by oxygenation, pharmacological diuresis, and precise fluid monitoring.
Soru 232Soru →

A nurse has completed wound care for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) of the lower extremity and influenza. The client is appropriately placed on contact and droplet precautions. The nurse is currently wearing an isolation gown, a surgical mask, a face shield, and clean gloves. Arrange the following steps for removing (doffing) the personal protective equipment in the correct chronological sequence to prevent self-contamination.

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Cevap

The correct doffing sequence is: 1) Remove gloves, 2) Remove face shield, 3) Remove gown, 4) Remove mask, 5) Perform hand hygiene.
According to standard infection control guidelines, the removal of personal protective equipment must proceed from the most contaminated items to the least contaminated to prevent self-inoculation. Gloves are removed first, followed by eyewear (handling only the clean earpieces). The gown is then removed and rolled inside-out. The mask is removed last to maintain respiratory protection during the preceding steps. Finally, hand hygiene is strictly performed to eliminate any bacteria or viruses that may have been transferred to the skin.

Adım Adım Çözüm

1
Remove gloves.
Hands are now bare.
Gloves are the most heavily contaminated item and must be removed first.
2
Remove the face shield.
Eye protection is safely removed.
Protects the face from contamination; it is removed from the back to avoid touching the contaminated front.
3
Remove the isolation gown.
Gown is contained.
Rolled inside-out to trap pathogens and prevent uniform or environmental contamination.
4
Remove the surgical mask.
Airway protection is removed.
Removed last to ensure respiratory protection is maintained while handling the other contaminated PPE.
5
Perform hand hygiene.
Hands are decontaminated.
Removes any transient pathogens that may have transferred to the hands during the doffing process.

Anahtar Kavram

Proper doffing sequence of personal protective equipment (PPE)
Soru 233Soru →

A client with right-sided hemiparesis requires assistance moving from the bed to a sitting position in a wheelchair. In which order should the nurse perform the following actions to safely complete this transfer?

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The correct sequence is to first position the wheelchair on the strong side, lock all brakes, assist the client to sit and dangle, apply the gait belt, and finally have the client pivot on their strong leg.
Safe client transfers require sequential preparation to minimize fall risk. The environment must first be set up correctly by placing the wheelchair on the client's unaffected (strong) side and locking all brakes. Once the environment is secure, the client is brought to a seated position to stabilize blood pressure (dangling). A gait belt is then applied for physical support before the actual physical movement occurs. Finally, the client uses their strong side to bear weight and pivot into the wheelchair.

Adım Adım Çözüm

1
Position the wheelchair on the left side at a 45-degree angle.
The destination is prepared optimally.
Placing the wheelchair on the strong side ensures the client can use their unaffected side to guide the transfer.
2
Lock the brakes on the bed and wheelchair.
The equipment is immobilized.
Prevents shifting of the bed or wheelchair, significantly reducing the risk of a fall.
3
Assist the client to sit on the edge of the bed and dangle.
The client is sitting safely on the bed edge.
Allows for assessment of orthostatic hypotension and stabilizes blood pressure before standing.
4
Apply a gait belt around the waist.
The nurse has a secure way to hold the client.
Provides a safe handhold for the nurse to control the client's center of gravity during the pivot.
5
Instruct the client to bear weight on the left leg and pivot.
The client safely completes the transfer into the wheelchair.
Bearing weight on the strong (left) leg compensates for the right-sided hemiparesis and prevents the knee from buckling.

Anahtar Kavram

Safe client transfer techniques and mobility assistance for hemiparesis.
Soru 234Soru →

A nurse is preparing to perform Leopold maneuvers on a client at 36 weeks of gestation to determine fetal presentation and position. Arrange the following steps of the procedure in the correct chronological order, from first to last.

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Cevap

The correct chronological sequence begins with client preparation (emptying the bladder), followed by the first maneuver (palpating the fundus), the second maneuver (palpating the lateral sides), the third maneuver (grasping the lower uterine segment), and concludes with the fourth maneuver (facing the client's feet to palpate the lower abdomen).
Leopold maneuvers must be performed in a specific, systematic sequence to accurately determine fetal position, presentation, and attitude. The client must first empty their bladder to ensure accurate palpation and prevent discomfort. The first maneuver involves palpating the fundus to identify fetal lie. The second maneuver involves palpating the lateral sides of the uterus to locate the smooth fetal back and the irregular extremities. The third maneuver involves grasping the lower uterine segment to confirm the presenting part and assess for engagement. Finally, the fourth maneuver requires the nurse to change positioning and face the client's feet to palpate the lower abdomen, assessing the cephalic prominence and fetal attitude.

Adım Adım Çözüm

1
Identify the necessary preparation before performing abdominal palpation.
Instruct the client to empty their bladder before the assessment.
Ensures client comfort and accuracy of the examination by preventing a full bladder from displacing the uterus.
2
Determine the first maneuver of Leopold's assessment.
Palpate the uterine fundus to determine which fetal part is located in the upper pole.
Identifies fetal lie and the presenting part in the fundus.
3
Determine the second maneuver.
Palpate the lateral sides of the abdomen to locate the fetal back and extremities.
Locates the fetal back for optimal placement of the fetal monitor and auscultation of the fetal heart rate.
4
Determine the third maneuver.
Grasp the lower uterine segment just above the symphysis pubis to confirm the presenting part.
Confirms the presenting part and determines if the fetal head has engaged in the pelvic inlet.
5
Determine the fourth maneuver.
Face the client's feet and palpate the lower abdomen to assess the cephalic prominence.
Evaluates fetal attitude and the degree of head flexion, which requires a shift in the nurse's positioning.

Anahtar Kavram

Leopold Maneuvers Sequence
Soru 235Soru →

A nurse is caring for an alert and oriented client with diabetes mellitus who suddenly reports sweating, palpitations, and feeling hungry. Arrange the following nursing actions in the correct order to manage this acute situation.

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Cevap

The correct sequence is to first assess the blood glucose, then administer 15 grams of a fast-acting carbohydrate, reassess the blood glucose in 15 minutes, and finally provide a snack with complex carbohydrates and protein.
The correct sequence follows the standard protocol for managing acute hypoglycemia in a conscious client. The nurse first assesses the blood glucose to confirm the condition. Next, 15 grams of a fast-acting carbohydrate is given for rapid absorption. After 15 minutes, the nurse reassesses to evaluate the intervention's effectiveness. Finally, once the glucose level is stable, a complex carbohydrate and protein snack is provided to prevent a secondary hypoglycemic event.

Adım Adım Çözüm

1
Confirm the client's condition.
The capillary blood glucose level is assessed to verify hypoglycemia.
Assessment must precede intervention to ensure the correct protocol is followed.
2
Provide rapid treatment.
15 grams of a fast-acting simple carbohydrate is administered.
A simple carbohydrate quickly absorbs into the bloodstream to rapidly raise the blood glucose level.
3
Evaluate the treatment's effectiveness.
The blood glucose level is reassessed 15 minutes after the fast-acting carbohydrate is given.
Monitoring is required to determine if the blood glucose is rising to a safe level or if the initial treatment needs to be repeated.
4
Sustain the blood glucose level.
A snack containing a complex carbohydrate and protein is provided.
Complex carbohydrates and proteins take longer to digest, which helps maintain the blood glucose level and prevents another sudden drop.

Anahtar Kavram

The 15/15 Rule for Acute Hypoglycemia Management
Soru 236Soru →

A client who was admitted for diabetic ketoacidosis (DKA) now has a closed anion gap and a blood glucose of 180 mg/dL180 \text{ mg/dL} (10.0 mmol/L10.0 \text{ mmol/L}). The healthcare provider prescribes transitioning the client from the continuous intravenous regular insulin infusion to a subcutaneous insulin regimen. To reduce the risk of physiological decompensation, in what order should the nurse perform the following actions? Arrange the actions from first to last.

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The correct sequence is: Confirm the meal is at the bedside, administer the subcutaneous insulin, assist the client to eat, maintain the IV insulin for 1 to 2 hours, and finally discontinue the IV insulin.
When transitioning a client with resolved diabetic ketoacidosis (DKA) from intravenous (IV) to subcutaneous (SQ) insulin, the primary risk reduction goal is preventing a relapse of DKA while avoiding hypoglycemia. Because IV regular insulin has a half-life of only minutes, stopping it abruptly causes immediate insulin deficiency. The nurse must first ensure food is present, give the SQ insulin, have the client eat, and then crucially maintain the IV infusion for an overlap period of 11 to 22 hours. This allows the SQ insulin to reach a therapeutic level before the IV supply is removed.

Adım Adım Çözüm

1
Assess the client's readiness to eat and ensure the meal is physically present at the bedside.
Hypoglycemia risk is mitigated before administering rapid-acting insulin.
Subcutaneous rapid-acting insulin has an onset of 1010 to 1515 minutes. Administering it without guaranteed immediate oral intake risks severe hypoglycemia.
2
Administer the prescribed subcutaneous dose of insulin.
The subcutaneous insulin depot is created.
This initiates the transition process, but the subcutaneous insulin will take time to absorb and reach therapeutic blood levels.
3
Instruct the client to consume the meal.
Carbohydrate absorption matches the onset of the rapid-acting insulin.
Provides glucose to prevent hypoglycemia as the insulin begins to peak.
4
Maintain the continuous intravenous regular insulin infusion for 11 to 22 hours.
Continuous insulin coverage is maintained during the subcutaneous absorption phase.
Intravenous regular insulin has a half-life of only minutes. An overlap period is required to prevent a critical gap in insulin coverage, which would cause rapid rebound hyperglycemia and potentially reopen the anion gap.
5
Discontinue the intravenous regular insulin infusion.
The transition to subcutaneous insulin is safely completed.
The subcutaneous insulin has now reached a therapeutic level, making the intravenous infusion unnecessary and preventing late hypoglycemia.

Anahtar Kavram

Diabetic Ketoacidosis (DKA) Intravenous to Subcutaneous Insulin Transition Protocol
Soru 237Soru →

A nurse is assisting a client during the second stage of labor. After the fetal head is delivered, it immediately retracts firmly against the maternal perineum. Arrange the following nursing actions in the correct order of priority from first to last.

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The correct sequence for managing shoulder dystocia is to first call for help, then instruct the client to stop pushing, followed by assisting with the McRoberts maneuver, applying suprapubic pressure, and finally documenting the event.
When shoulder dystocia occurs (indicated by the 'turtle sign' where the head retracts), the immediate priority is to summon help, often remembered by the 'H' in the HELPERR mnemonic. Next, the nurse must prevent further impaction by instructing the client not to push. The first-line physical intervention is the McRoberts maneuver, which resolves a large percentage of dystocias by altering pelvic angles. If this fails, suprapubic pressure is applied to manually push the shoulder under the pubic bone. Finally, after the newborn is delivered and the acute emergency is managed, meticulous documentation of the timing of the head delivery and all maneuvers is required.

Adım Adım Çözüm

1
Summon additional help.
Obstetric and neonatal teams are notified of the emergency.
Shoulder dystocia requires a coordinated team approach for maternal maneuvers and potential neonatal resuscitation.
2
Halt maternal pushing efforts.
The client stops bearing down.
Pushing worsens the impaction of the fetal shoulder against the maternal pelvis.
3
Implement the McRoberts maneuver.
The client's thighs are hyperflexed to the abdomen.
This alters the maternal pelvic geometry, straightening the sacrum and opening the pelvic outlet.
4
Apply suprapubic pressure.
Downward pressure is applied over the symphysis pubis.
This helps manually dislodge the anterior fetal shoulder from behind the pubic bone.
5
Record the sequence of events.
Times and specific maneuvers are documented.
Meticulous documentation is required for the medical record, but only after the acute crisis is managed.

Anahtar Kavram

Nursing priorities during an obstetric emergency (Shoulder Dystocia)
Soru 238Soru →

A clinical nurse is guiding a client with generalized deconditioning on how to safely transfer from a seated position in a standard armchair to a standing position using a rolling walker. Place the following instructions and actions in the correct sequential order to prevent injury.

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The correct sequence is to first apply the transfer belt, have the client scoot to the edge of the chair, place their hands on the chair's armrests, push up to a standing position, and finally grasp the walker handles once balanced.
Safe transferring with a walker requires strict adherence to biomechanics and device safety rules. The nurse must first apply a transfer belt to ensure client safety during the movement. Next, the client must scoot to the edge of the chair to bring their center of gravity forward. Crucially, the client must push up from the chair's armrests rather than pulling on the walker. Pulling on a wheeled walker can cause it to tip or roll, leading to a severe fall. Once the client has pushed up, is standing upright, and has established equilibrium, they can safely transfer their hands one at a time to the walker.

Adım Adım Çözüm

1
Apply the transfer belt.
The nurse has a secure handhold on the client.
Applying the belt first ensures safety is established before initiating any movement.
2
Instruct the client to scoot to the edge of the chair.
The client's center of gravity is brought forward.
This reduces the distance the client must lift their body weight and prepares them for an efficient transfer.
3
Direct the client to place hands on the chair armrests.
The client's arms are positioned to provide upward thrust.
Using the stable chair for leverage prevents the dangerous mistake of pulling on the lightweight walker.
4
Have the client push up to stand.
The client transitions from sitting to full standing.
Combining the forward lean with arm and leg extension safely elevates the client against gravity.
5
Instruct the client to grasp the walker handles.
The client is fully stabilized with the assistive device.
Waiting until balance is achieved ensures the client does not rely on the walker while in a vulnerable, off-balance position.

Anahtar Kavram

Assistive Device Safety and Proper Transfer Biomechanics
Tahmini Süre:1m 0s
Soru 239Soru →

A nurse is monitoring a client who is receiving an intravenous transfusion of packed red blood cells (PRBCs). Ten minutes into the transfusion, the client develops sudden, severe lower back pain, tachycardia, and hypotension. Place the following nursing actions in the correct priority order to manage this complication.

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The correct sequence is: Stop the transfusion, disconnect the blood tubing, attach new saline tubing, assess the client, notify the healthcare provider and blood bank, and return the blood product to the blood bank.
In the event of a severe transfusion reaction, the priority is minimizing harm. The sequence follows the nursing process adapted for emergencies: intervene to stop harm (stop transfusion, disconnect tubing, maintain access with new saline), assess the impact (vital signs), communicate for further orders (notify HCP), and perform follow-up diagnostics (return product to blood bank).

Adım Adım Çözüm

1
Stop the continuous flow of the packed red blood cells.
The client receives no further incompatible or contaminated blood.
Lower back pain, tachycardia, and hypotension are classic signs of a life-threatening acute hemolytic transfusion reaction. Immediate cessation is the most critical intervention.
2
Disconnect the existing blood administration set from the IV hub.
The source of the reaction is physically separated from the client's vascular access.
Leaving the tubing connected risks inadvertently pushing more of the reactant into the bloodstream during subsequent flushes.
3
Connect a new IV tubing setup primed with normal saline.
Intravenous access is maintained for emergency medications and volume expansion.
Normal saline must be infused through new tubing to prevent clotting of the IV site and to treat the resulting hypotension.
4
Perform a focused physiological assessment.
Baseline data during the reaction is obtained.
The nurse needs current vital signs, airway status, and hemodynamic parameters to accurately report the client's condition.
5
Communicate with the healthcare provider and blood bank.
Emergency medical orders are obtained and the facility's reaction protocol is activated.
Medical intervention (such as vasopressors, antihistamines, or diuretics) is required, and the blood bank must investigate the cause.
6
Package and send the blood bag, tubing, and required lab specimens.
Diagnostic testing can determine the exact cause of the reaction.
Analyzing the remaining product and the client's post-reaction blood and urine is necessary for root-cause analysis.

Anahtar Kavram

Management of Acute Hemolytic Transfusion Reactions
Soru 240Soru →

A nurse is caring for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache and blurred vision. The nurse observes profuse facial diaphoresis and records a blood pressure of 215/115 mm Hg. In what order should the nurse perform the following interventions? Arrange from first to last action.

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The correct sequence of interventions is: 1) Elevate the head of the bed, 2) Loosen constrictive clothing, 3) Inspect the urinary catheter, 4) Administer antihypertensive medication, and 5) Document the event.
In the management of autonomic dysreflexia, the nurse must prioritize actions that immediately reduce the risk of a catastrophic complication, such as a hemorrhagic stroke. Elevating the head of the bed is the fastest and most effective first step to lower blood pressure orthostatically. Subsequent steps focus on systematically removing noxious stimuli, starting with quick external fixes (loosening clothing) followed by assessing internal causes (bladder distention). Pharmacological intervention is reserved for refractory hypertension, and documentation occurs only after complete stabilization.

Adım Adım Çözüm

1
Elevate the head of the bed to a high Fowler's position.
The client's upper body is raised to a 90-degree angle.
This is the most critical first step because it leverages gravity to induce orthostatic hypotension, rapidly pooling blood in the lower extremities to lower the dangerously high systemic blood pressure and protect the brain.
2
Loosen any constrictive clothing or tight abdominal binders.
External physical pressure on the client's body is relieved.
Tactile or physical restrictions below the level of the spinal cord injury act as noxious stimuli that trigger the reflex. Removing them quickly helps mitigate the autonomic response.
3
Inspect the indwelling urinary catheter tubing for kinks and ensure dependent drainage.
The primary internal trigger for the dysreflexic episode is evaluated and resolved if present.
Bladder distention is the most frequent cause of autonomic dysreflexia. Ensuring patency of the urinary catheter removes this internal noxious stimulus.
4
Administer the prescribed PRN rapid-acting intravenous antihypertensive medication.
Pharmacological agents are introduced into the bloodstream to lower blood pressure.
If mechanical interventions (positioning, loosening clothing, bladder/bowel management) do not resolve the severe hypertension, medications must be given to prevent life-threatening complications.
5
Document the clinical presentation, interventions performed, and the client's physiological response.
The event is permanently recorded in the client's electronic health record.
Documentation is critical but is always performed last, after the acute, life-threatening emergency has been fully managed and the client is safe.

Anahtar Kavram

Prioritization of care for a client experiencing autonomic dysreflexia, focusing on immediate reduction of blood pressure followed by the elimination of noxious stimuli.
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