Tüm alıştırma soruları

While conducting hourly rounds, a nurse evaluates a client who sustained a T4 spinal cord injury three weeks ago. The client suddenly reports a severe, throbbing headache and blurred vision. The nurse notes profuse diaphoresis above the level of the injury and a blood pressure of 215/115 mm Hg. Arrange the following clinical interventions in the prioritized sequence they should be performed.

A home health nurse is evaluating an older adult client with significant mobility deficits. The nurse notes unexplained, patterned bruising on the client's upper extremities. The client becomes visibly fearful when their adult child, who acts as the primary caregiver, enters the room. When the caregiver briefly steps away, the client whispers to the nurse, "Please do not report anything. It will only make my situation worse." Which of the following actions demonstrates the most appropriate ethical nursing response?

An infection control clinical nurse specialist is conducting unannounced surveillance rounds across multiple high-acuity medical-surgical units. Which of the following observed actions by the healthcare team represent a breach in infection control protocols that requires immediate intervention? Select all that apply.

A nurse is planning care for a client who is severely agitated, disoriented, and repeatedly attempting to remove a newly placed central venous catheter (CVC). The client has disseminated herpes zoster and is in a negative-pressure isolation room. Which of the following is the most appropriate initial action by the nurse to prevent patient injury and ensure environmental safety?

A charge nurse is auditing the infection control protocols for a newly admitted client who has frequent, severe diarrhea testing positive for *Clostridioides difficile*, as well as a chronic productive cough with pending sputum cultures for suspected *Mycobacterium tuberculosis*. Which of the following actions are appropriate for the nurse to include in the plan of care? (Select all that apply.)

An emergency department nurse is sorting clients who have self-evacuated from a nearby industrial fire. A client approaches the triage desk walking independently and reports a minor burn on their left hand. Which of the following disaster triage tag colors should the nurse assign to this client?

A nurse on a neurological step-down unit is caring for a client recovering from a traumatic brain injury. The client is restless, disoriented to place, and persistently picking at their peripheral intravenous (IV) line and surgical dressings. Which of the following is the most appropriate initial nursing action to protect the client from self-injury?

A client admitted to the emergency department with suspected substance-induced psychosis becomes physically violent toward staff, throwing equipment and attempting to strike the triage nurse. After verbal de-escalation and pharmacological interventions fail, the healthcare team applies four-point mechanical restraints. Which nursing action demonstrates strict adherence to safety and legal standards for violent restraints?

A nurse is preparing to contact the healthcare provider regarding a client who is 2 days postoperative following a right total knee arthroplasty and suddenly develops acute dyspnea, tachycardia, and a dropping oxygen saturation. The nurse uses the SBAR (Situation, Background, Assessment, Recommendation) communication tool. Arrange the following statements in the correct chronological order as they should be delivered during the report.

Several victims of an agricultural pesticide transport spill arrive unannounced outside the facility's emergency department. The clients are conscious, coughing continuously, and have an unknown liquid visible on their clothing. Which intervention is the priority for the nursing staff?

A nursing supervisor is observing a newly licensed nurse delegate tasks to an unlicensed assistive personnel (UAP) on a busy gastroenterology unit. Which of the following delegated tasks indicates a need for the supervisor to intervene?

A client is admitted to the medical-surgical unit with night sweats, hemoptysis, and a recent positive stool assay for *Clostridioides difficile*. The healthcare provider suspects active pulmonary tuberculosis. Which of the following infection control interventions should the nurse implement? Select all that apply.

The infection control nurse is reviewing isolation protocols for four high-acuity clients. Match each client's clinical scenario to the most appropriate and comprehensive transmission-based precaution intervention required.

While organizing the morning workflow on an acute care floor, a registered nurse (RN) must assign interventions among available staff members, including a licensed practical/vocational nurse (LPN/VN) and an assistive personnel (AP). Which specific client care activities fall within the safe scope of practice to delegate to the LPN/VN? Select all that apply.

A nurse is preparing to transfer a client who has right-sided hemiparesis from the bed to a wheelchair. To prevent injury and ensure a safe transfer, arrange the following nursing actions in the correct chronological sequence.

A nurse is prioritizing care for a group of clients on a medical-surgical unit. Which of the following client findings mandate immediate intervention? Select all that apply.

A nurse is responding to a small paper fire in the staff break room. The fire alarm has been activated, and all personnel have been safely evacuated. The nurse retrieves a nearby fire extinguisher to contain the flames. Arrange the steps for operating the fire extinguisher in the correct priority sequence.

A home health nurse is establishing a plan of care for an older adult client who recently experienced a right hemisphere stroke, resulting in left-sided hemiplegia, unilateral neglect, and mild dysphagia. Which of the following safety interventions should the nurse include in the care plan? (Select all that apply.)

A client with progressing multiple sclerosis is transitioning to a home health care program. The client's spouse reports that the client frequently drops utensils due to hand tremors and struggles with buttoning clothes, though chewing and swallowing remain intact. Which interdisciplinary collaboration or action should the home health nurse prioritize to address these specific challenges?

A quality assurance nurse is reviewing incident reports related to infection control practices on a medical-surgical unit. Which documented event represents a breach in transmission-based precaution protocols?