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Soru 241Soru →

During a surgical procedure under general anesthesia, the intraoperative monitor reveals a sudden, rapid rise in end-tidal carbon dioxide (ETCO2). Simultaneously, the client develops generalized muscle rigidity and unexpected severe sinus tachycardia. Recognizing a malignant hyperthermia crisis, in which order must the nurse execute or assist with the following collaborative interventions? Arrange the actions from highest priority (first) to lowest priority (last).

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The correct sequence prioritizes removing the causative agent first, followed by supporting airway/breathing, administering the definitive antidote, treating the hyperthermia symptomatically, and finally establishing monitoring for secondary complications.
In any acute emergency, the nursing process and prioritization frameworks dictate that removing the immediate life-threatening cause is paramount. For malignant hyperthermia, this means stopping the triggering anesthetics immediately. Following the ABC framework, the next priority is to support ventilation and oxygenation (Breathing) because the hypermetabolic state creates extreme oxygen demand and CO2 production. Once ventilation is supported, circulation and pharmacological reversal take precedence via the administration of dantrolene, the definitive antidote. Only after these immediate life-saving measures are taken should the team focus on symptom management (active cooling) and ongoing assessment for secondary complications (urinary catheterization for rhabdomyolysis).

Adım Adım Çözüm

1
Discontinue the administration of volatile inhaled anesthetics and succinylcholine.
The causative pharmacologic triggers are removed from the client's system.
Halting the trigger is the absolute first step in malignant hyperthermia to stop the unregulated release of calcium from the sarcoplasmic reticulum.
2
Hyperventilate the client with 100% oxygen at a high flow rate.
Hypoxemia is prevented and excess carbon dioxide is rapidly eliminated.
The hypermetabolic state causes severe oxygen consumption and CO2 production; aggressive ventilation (Breathing) immediately follows securing the trigger.
3
Administer reconstituted intravenous dantrolene sodium.
Muscle relaxation occurs and the hypermetabolic crisis is pharmacologically reversed.
Dantrolene is the only specific antidote for malignant hyperthermia and must be given promptly after airway and breathing are managed.
4
Initiate active surface cooling measures and infuse chilled intravenous fluids.
The client's rapidly rising core body temperature is systematically lowered.
Hyperthermia is a severe but secondary symptom of the metabolic crisis; cooling measures prevent brain damage but follow ABCs and antidote administration.
5
Insert an indwelling urinary catheter to monitor hourly urine output.
Urine output and color (monitoring for myoglobinuria) are continuously assessed.
Assessing for complications such as acute kidney injury secondary to rhabdomyolysis is vital but represents a lower-acuity monitoring intervention compared to acute resuscitation.

Anahtar Kavram

Prioritization of care during a malignant hyperthermia crisis strictly follows immediate removal of the triggering agent, followed by the ABCs (Airway, Breathing, Circulation/Antidote).
Soru 242Soru →

A hospitalized client is receiving a continuous infusion of a maintenance fluid through a single-lumen peripheral venous catheter. The healthcare provider has prescribed a scheduled intravenous (IV) bolus medication that is physically incompatible with the current infusion. Arrange the following actions in the correct chronological order to safely deliver the medication.

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The correct sequence for administering an incompatible IV bolus medication through a continuous infusion line is to first stop the continuous infusion, flush the line with normal saline, administer the medication, flush the line again with normal saline at the same rate the medication was given, and finally restart the continuous infusion.
When administering an IV bolus medication that is incompatible with a continuous infusion through the same line, the nurse must prevent the two fluids from mixing. This is achieved using the SAS (Saline-Administer-Saline) method. The nurse stops the continuous infusion and flushes the line with a compatible solution (like 0.9% sodium chloride) to clear the tubing. After administering the medication over the prescribed time, the nurse flushes the line again to clear the medication before restarting the incompatible continuous infusion. This prevents precipitation in the line and ensures safe drug delivery.

Adım Adım Çözüm

1
Stop the continuous intravenous infusion.
The flow of the incompatible maintenance fluid is halted.
Prevents the incompatible fluid from mixing with the medication in the intravenous line.
2
Flush the catheter with 10 mL of 0.9% sodium chloride.
The intravenous line is cleared of the incompatible maintenance fluid.
Creates a safe, neutral barrier in the tubing prior to medication administration.
3
Administer the prescribed intravenous bolus medication.
The medication is delivered to the client.
Provides the therapeutic intervention over the safe, recommended duration.
4
Flush the catheter again with 10 mL of 0.9% sodium chloride at the same administration rate.
The medication is completely cleared from the tubing.
Ensures the full dose is received and prevents rapid infusion of residual medication.
5
Restart the continuous maintenance fluid infusion.
The original fluid therapy is resumed.
Maintains the client's prescribed fluid requirements after the medication has been safely delivered.

Anahtar Kavram

Administration of an incompatible IV bolus medication via an existing continuous infusion line requires the Saline-Administer-Saline (SAS) technique to prevent drug precipitation and ensure patient safety.
Soru 243Soru →

A nurse is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, pounding headache. The nurse notes profuse diaphoresis on the client's face and neck, and a blood pressure reading of 210/115 mm Hg. Arrange the following nursing actions in the correct priority order from first to last.

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The correct sequence of actions for managing autonomic dysreflexia is to first elevate the head of the bed, then check for bladder distention, followed by checking for bowel impaction, administering antihypertensive medication if unresolved, and finally documenting the event.
Autonomic dysreflexia is a medical emergency characterized by severe hypertension triggered by a noxious stimulus below the level of the spinal cord injury. The immediate priority is to lower the blood pressure mechanically by placing the client in a high-Fowler's position. Next, the nurse must locate and remove the triggering stimulus, starting with the most common cause (bladder distention) followed by the next most common (bowel impaction). If these non-pharmacological interventions fail, antihypertensive medications are administered. Documentation occurs last, after the client is stabilized.

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 immediately induces orthostatic pooling of blood in the lower extremities, helping to lower the dangerously high blood pressure.
2
Check the urinary catheter tubing for kinks or assess the bladder for distention.
The most common trigger for autonomic dysreflexia is evaluated.
Removing the noxious stimulus is the primary treatment; bladder issues are the most frequent cause.
3
Examine the client for signs of fecal impaction.
The second most common trigger is evaluated.
If the bladder is not the source, the bowel is the next logical system to assess for a noxious stimulus.
4
Administer the prescribed rapid-acting antihypertensive medication.
Medication is delivered to artificially lower the blood pressure.
This is necessary if the stimulus cannot be removed or if the blood pressure remains dangerously high despite removing the stimulus.
5
Document the event, the interventions provided, and the client's response.
The medical record is updated with accurate information.
Administrative and legal requirements are fulfilled after the client is safe and stable.

Anahtar Kavram

Management of Autonomic Dysreflexia
Soru 244Soru →

A nurse is changing the administration set for a client's central venous catheter. The client suddenly gasps, reports sharp chest pain, and becomes profoundly dyspneic and tachycardic. Suspecting a central line-associated air embolism, arrange the following nursing actions in the correct priority sequence to minimize physiological risk.

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The correct sequence is to first clamp the catheter, then position the client in a left lateral Trendelenburg position, followed by administering high-flow oxygen, notifying the Rapid Response Team, and finally assessing continuous vital signs.
In the event of a suspected air embolism, the nurse must prioritize immediate actions that physically stop the embolism from worsening. Clamping the line prevents more air from entering. The left lateral Trendelenburg position traps the existing air in the right atrium/ventricle. Oxygen administration supports tissue perfusion and shrinks the nitrogen bubble. Only after these life-saving nursing interventions are applied should the nurse escalate the situation to the medical team and proceed with ongoing monitoring.

Adım Adım Çözüm

1
Clamp the central venous catheter tubing immediately.
Further air entry into the central circulation is halted.
Source control is the most critical first step to prevent a fatal volume of air from entering the vascular system.
2
Place the client in a left lateral Trendelenburg position.
The air embolus is localized to the right side of the heart.
This positioning prevents the air from migrating into the pulmonary artery and causing right ventricular outflow tract obstruction.
3
Administer high-flow oxygen via a non-rebreather mask.
Systemic oxygenation is supported and nitrogen absorption is accelerated.
High-flow oxygen reduces hypoxia-induced tissue damage and decreases the size of the air embolus.
4
Notify the Rapid Response Team and the healthcare provider.
Emergency medical personnel are dispatched to the client's room.
Medical intervention, such as aspiration of the air from the right ventricle, may be required.
5
Assess continuous vital signs and prepare for potential cardiopulmonary resuscitation.
The client's hemodynamic status is closely monitored for deterioration.
An air embolism can rapidly lead to cardiovascular collapse, requiring immediate resuscitation efforts.

Anahtar Kavram

Management of a central venous catheter air embolism requires immediate source control and specific client positioning to prevent circulatory collapse.
Soru 245Soru →

A nurse is preparing to administer a large-volume cleansing enema to an adult client. In what order should the nurse perform the following actions? Arrange the steps from first to last.

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The correct procedural sequence is to first position the client in the left lateral Sims position, then lubricate the enema tubing, carefully insert the tubing into the rectum, and finally raise the container to begin the infusion.
Administering a cleansing enema safely requires a logical, step-by-step approach. The nurse must first place the client in the left lateral Sims position to align with the anatomy of the lower GI tract. Next, the equipment is readied by lubricating the tubing tip. The tube is then carefully inserted. Only after the tube is securely in the rectum should the nurse raise the bag to allow the fluid to flow via gravity.

Adım Adım Çözüm

1
Assist the client into the left lateral Sims position.
The client is in the safest and most effective anatomical position.
The left lateral Sims position utilizes gravity to help the fluid flow down into the sigmoid and descending colon.
2
Lubricate the tip of the enema tubing.
The tubing is prepared for safe insertion.
Lubrication minimizes tissue friction, preventing pain or damage to the sensitive rectal mucosa.
3
Insert the tubing 3 to 4 inches into the rectum.
The tube passes the internal sphincter and rests safely in the rectum.
Inserting the tube 3 to 4 inches in an adult, directed toward the umbilicus, ensures the fluid will be delivered appropriately without risking bowel wall perforation.
4
Raise the enema container and open the clamp.
Fluid begins to instill into the colon at a controlled rate.
The height of the bag controls the pressure and flow rate of the instillation. Raising it only after secure placement prevents spills and ensures a controlled, safe procedure.

Anahtar Kavram

Basic Care and Comfort: Enema Administration
Soru 246Soru →

A home health nurse arrives at the residence of a client with paraplegia for a scheduled wound care visit. The client's spouse is pacing erratically and shouts, 'I cannot take care of this anymore!' The nurse notices three circular, crusted lesions resembling cigarette burns on the client's forearms. The client avoids eye contact and appears fearful. The spouse insists on remaining at the bedside. In what order should the nurse perform the following actions? Arrange the actions from first priority to last.

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The correct sequence prioritizes immediate safety and separation, followed by physical assessment, psychosocial interviewing, objective documentation, and finally, mandatory reporting.
In cases of suspected abuse, the nursing process prioritizes interventions based on safety and Maslow's hierarchy of needs. The absolute first step is to establish a safe environment by tactfully separating the client from the suspected perpetrator. Once safety is secured, the nurse addresses physiological needs by assessing the physical injuries. After physical assessment, the nurse addresses psychosocial needs by interviewing the client privately. Following the completion of the assessment, the nurse objectively documents all findings. Finally, using the gathered information, the nurse fulfills their legal obligation by reporting the suspected abuse to the designated authorities.

Adım Adım Çözüm

1
Ensure immediate client safety by separating them from the suspected abuser.
The spouse is removed from the room, creating a secure environment.
Safety is always the primary concern in suspected abuse situations; an accurate assessment cannot be performed while the abuser is present.
2
Assess the client's physical condition.
The nurse evaluates the burns and checks for other injuries.
Physical stabilization and identifying acute trauma take precedence over interviewing and documentation.
3
Interview the client privately about the injuries.
The nurse asks direct, non-judgmental questions to determine the cause of the injuries.
Direct communication in a safe environment is necessary to validate suspicions and assess the client's immediate risk level.
4
Document all findings objectively.
Physical descriptions, direct quotes, and behavioral observations are recorded.
Factual documentation provides the foundation for the subsequent legal report and future investigations.
5
Report the suspected abuse to the appropriate authorities.
Adult protective services is notified of the suspected dependent adult abuse.
Nurses are mandated reporters; however, this step follows safety, assessment, and documentation.

Anahtar Kavram

Prioritization of Care in Suspected Abuse
Soru 247Soru →

A nurse is caring for a client with a complete spinal cord injury at the T3 level. The client suddenly reports a severe, pounding headache. The nurse notes profuse diaphoresis on the client's face and neck, cutis anserina (goosebumps), a blood pressure of 220/115 mm Hg, and a heart rate of 52 bpm. Arrange the following nursing interventions in the priority order they should be performed.

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Cevap

1. Elevate head of bed, 2. Loosen restrictive clothing, 3. Inspect urinary catheter/bladder, 4. Assess for fecal impaction with anesthetic, 5. Administer antihypertensive medication.
Autonomic dysreflexia is a medical emergency characterized by a massive, uncompensated cardiovascular response to stimulation of the sympathetic nervous system. The absolute first priority is to decrease blood pressure immediately using gravity (sitting the client up). Subsequent steps systematically eliminate the most common noxious stimuli from least invasive/most accessible (clothing) to visceral (bladder, then bowel). Medications are a last resort if primary interventions fail.

Adım Adım Çözüm

1
Elevate the head of the bed to a high Fowler's position.
Induces orthostatic pooling of blood in the lower extremities.
This immediately reduces venous return and lowers blood pressure, mitigating the immediate threat of hypertensive stroke while other interventions are prepared.
2
Loosen any restrictive clothing or tight items.
Removes external noxious cutaneous stimuli.
Tight clothing, belts, or binders can trigger or exacerbate the sympathetic discharge. This is the fastest trigger to assess and eliminate.
3
Inspect the indwelling urinary catheter tubing for kinks and palpate the bladder.
Identifies or rules out bladder distention.
A distended bladder is the leading cause of autonomic dysreflexia. Draining the bladder often completely resolves the hypertensive crisis.
4
Apply a topical anesthetic to the rectum and gently assess for a fecal impaction.
Identifies or rules out bowel impaction safely.
Bowel impaction is the second most common trigger. The topical anesthetic is mandatory to prevent the digital stimulation from causing a further spike in blood pressure.
5
Administer a prescribed rapid-acting intravenous antihypertensive medication.
Pharmacologically lowers blood pressure.
Medications (e.g., hydralazine, nitrates) are reserved for cases where the trigger cannot be found, cannot be easily removed, or the blood pressure fails to normalize after trigger removal.

Anahtar Kavram

Management of Autonomic Dysreflexia
Soru 248Soru →

A nurse is preparing to administer an intermittent bolus enteral feeding through a client's established gastrostomy tube. Place the following steps in the correct chronological order from first to last.

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The correct sequence is: Elevate the head of the bed, aspirate to verify residual volume, administer the feeding formula, and finally flush the tube with water.
Administering an enteral tube feeding safely requires a sequence of actions that prioritize aspiration prevention and tube patency. First, the client must be positioned upright to reduce aspiration risk. Next, the nurse must measure gastric residual volume to ensure the client is adequately digesting previous feedings. Once safety parameters are met, the formula is administered. Finally, the tube is flushed with water to clear the tubing, preventing occlusion and maintaining patency.

Adım Adım Çözüm

1
Elevate the head of the bed.
The client is placed in a safe, upright position (at least 30 to 45 degrees).
This utilizes gravity to keep formula in the stomach and prevents pulmonary aspiration.
2
Check gastric residual volume.
The amount of fluid remaining in the stomach is measured.
This confirms gastrointestinal motility and absorption of prior feedings, preventing overdistention.
3
Administer the feeding formula.
Nutritional intake is delivered to the client.
This meets the client's metabolic and caloric needs as prescribed by the provider.
4
Flush the gastrostomy tube.
Water clears the tubing of any residual formula.
Flushing prevents bacterial growth and formula coagulation that could occlude the tube.

Anahtar Kavram

Safe administration of enteral tube feedings
Soru 249Soru →

A nurse is preparing a client with advanced cirrhosis for a therapeutic bedside paracentesis to relieve severe ascites. To minimize the risk of procedural complications and ensure physiological stability, arrange the following nursing actions in the correct chronological sequence.

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Cevap

The correct sequence prioritizes preventing mechanical organ injury first, establishing accurate post-void baselines second, positioning for procedural safety third, executing intra-procedural hemodynamic monitoring fourth, and providing post-procedural circulatory support last.
The priority sequence for a paracentesis focuses on a deliberate progression of risk reduction: preventing mechanical organ injury (voiding), establishing accurate clinical baselines (weighing post-void), ensuring safe anatomical needle insertion (upright positioning), monitoring for intra-procedural shock (hemodynamic assessments), and preventing post-procedural circulatory collapse (albumin administration).

Adım Adım Çözüm

1
Instruct the client to completely empty their bladder.
The bladder decompresses and retracts lower into the pelvic cavity.
This is the most critical initial step to eliminate the risk of accidental bladder perforation by the trocar during insertion into the lower abdomen.
2
Measure baseline vital signs, dry weight, and abdominal girth.
Accurate baseline physiological parameters are established.
Post-void measurements provide true data unskewed by urine volume, which is essential to evaluate the exact amount of fluid removed and detect hidden post-procedure bleeding.
3
Assist the client into an upright or high-Fowler's position.
Gravity causes the ascitic fluid to pool in the dependent lower abdominal cavity.
This position protects the intestines by allowing them to float upward, providing a safe, unobstructed fluid pocket for trocar insertion.
4
Monitor blood pressure and heart rate frequently during fluid drainage.
Early detection of hemodynamic instability is achieved.
Rapid removal of large volumes of fluid can cause profound fluid shifts from the intravascular space, leading to acute hypovolemic shock.
5
Apply a pressure dressing and administer intravenous albumin.
The puncture site is secured, and oncotic pressure is restored.
Albumin acts as a plasma volume expander to prevent post-paracentesis circulatory dysfunction (PPCD) and severe hypotension following large-volume fluid removal.

Anahtar Kavram

Paracentesis Risk Reduction and Sequential Complication Management
Soru 250Soru →

A nurse is caring for a client who is experiencing an acute asthma exacerbation. The client is tachypneic, has visible intercostal retractions, and an oxygen saturation of 86% on room air. Arrange the following nursing actions in the priority order they should be performed, from first to last.

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Cevap

The correct priority order is to first position the client to maximize lung expansion, then apply oxygen to correct hypoxia, followed by the fast-acting bronchodilator, and finally the slow-acting corticosteroid.
Based on the ABC (Airway, Breathing, Circulation) prioritization framework, the nurse must first implement the fastest interventions that require the least preparation. Positioning the client upright immediately improves breathing mechanics. Applying oxygen directly addresses the life-threatening hypoxia (SpO2 86%). Once these immediate supportive measures are in place, the nurse administers the rapid-acting bronchodilator to open the airways, followed by the slow-acting corticosteroid to address inflammation.

Adım Adım Çözüm

1
Identify the primary physiological problem.
The client has an acute airway and breathing compromise as evidenced by retractions and an oxygen saturation of 86%.
Airway and breathing are the absolute highest priorities according to the ABC framework.
2
Determine the fastest, most immediate intervention.
Place the client in a high-Fowler's position.
This independent nursing action takes seconds, immediately improves lung expansion, and requires no equipment or medication preparation.
3
Address the critical tissue hypoxia.
Apply supplemental oxygen via a non-rebreather mask.
An oxygen saturation of 86% is life-threatening and requires immediate high-flow oxygen therapy to prevent ischemic damage.
4
Relieve the acute bronchospasm.
Administer the albuterol nebulizer.
Short-acting bronchodilators act quickly to open the constricted airways and are the priority medication for an acute asthma attack.
5
Address the underlying airway inflammation.
Establish intravenous access and administer methylprednisolone.
Systemic corticosteroids are essential for resolving the exacerbation but take several hours to peak, so they follow the immediate life-saving ABC steps.

Anahtar Kavram

Airway, Breathing, Circulation (ABC) prioritization framework for acute respiratory compromise.
Soru 251Soru →

A nurse is preparing to transfer a client with left-sided hemiplegia and a history of orthostatic hypotension from the bed to a wheelchair. Arrange the following nursing actions in the correct chronological sequence.

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The correct sequence is to first position the wheelchair on the client's strong side, sit the client up to assess for orthostatic hypotension, apply the transfer belt, brace the weak knee during standing, and finally have the client pivot on their strong leg.
The correct chronological sequence prioritizes environmental preparation, physiological safety, and proper body mechanics. First, the wheelchair must be locked on the client's strong (right) side to ensure the environment is ready. Second, the client must dangle on the edge of the bed to allow their blood pressure to adapt, preventing syncope related to their history of orthostatic hypotension. Third, a transfer belt is applied to ensure a safe hold. Fourth, as the client stands, the nurse must block the affected (left) knee to prevent buckling. Finally, the client uses their strong (right) leg to bear weight and safely pivot into the wheelchair.

Adım Adım Çözüm

1
Place the wheelchair on the client's right side at a 45-degree angle and lock the wheels.
The environment is safely prepared before the client is moved.
Preparing the equipment first prevents leaving the client unattended. The wheelchair must be on the unaffected (right) side so the client can pivot toward their strong side.
2
Assist the client to sit on the edge of the bed and assess for reports of dizziness.
The client is moved to an upright position and assessed for syncope.
Because of the history of orthostatic hypotension, the client must dangle at the bedside to allow blood pressure to stabilize before further activity.
3
Apply a transfer belt securely around the client's waist.
The nurse has a secure gripping point for the transfer.
A transfer belt prevents falls and avoids unsafe lifting methods, such as pulling on the client's arms or shoulders.
4
Brace the client's left knee and foot with your own knee and foot.
The client's paralyzed leg is stabilized.
Blocking the affected (left) knee prevents it from collapsing or buckling when the client attempts to bear weight.
5
Instruct the client to bear weight on their right leg and pivot into the wheelchair.
The client safely completes the transfer into the wheelchair.
The client uses their intact strength on the right side to pivot and lower themselves safely into the chair.

Anahtar Kavram

Safe transfer techniques for hemiplegia and orthostatic hypotension
Soru 252Soru →

A nurse is caring for a client receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes after the transfusion begins, the client reports sudden chills, severe lower back pain, and dyspnea. The client's heart rate is 115 beats/min and blood pressure is 88/52 mm Hg. What is the correct sequence of priority for the nurse's actions? Arrange the following steps in the correct order.

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Cevap

The correct sequence is to first stop the transfusion, then maintain the IV with normal saline using new tubing, assess the client, notify the healthcare provider, and finally send the blood and tubing to the blood bank.
In any suspected blood transfusion reaction, the absolute highest priority is to stop the transfusion immediately to prevent further antigens from entering the client's bloodstream. The second step is to maintain the IV line with normal saline using entirely new tubing; the old tubing must be disconnected to avoid flushing remaining blood into the client. Once the source is stopped and the IV is secured, the nurse performs a thorough assessment of vital signs and respiratory status. This complete clinical picture is then communicated to the healthcare provider to obtain orders for emergency interventions. Finally, as a follow-up action, the blood bag, labels, and tubing are sent to the blood bank for investigation into the cause of the reaction.

Adım Adım Çözüm

1
Identify the primary source of harm and stop it.
The blood transfusion is stopped immediately.
Continuing the transfusion exacerbates the acute hemolytic reaction and increases the risk of mortality.
2
Maintain vascular access safely.
Normal saline is initiated using completely new IV tubing.
IV access is crucial for administering emergency medications and fluids, but old tubing contains the reactive blood product which must not be flushed into the client.
3
Evaluate the client's physiological condition.
Vital signs and respiratory status are assessed.
Accurate, up-to-date assessment data is required to determine the extent of hemodynamic compromise before communicating with the provider.
4
Communicate findings to the medical team.
The healthcare provider is notified.
The provider needs the assessment data to prescribe appropriate pharmacological interventions.
5
Follow institutional protocols for reaction investigation.
The blood bag and tubing are returned to the blood bank.
Laboratory analysis of the remaining blood and tubing is necessary to determine the exact cause of the reaction.

Anahtar Kavram

Management of acute hemolytic transfusion reactions prioritizes immediate cessation of the blood product, maintenance of IV access, and rapid clinical assessment.
Soru 253Soru →

A nurse is assessing a client who has a central venous catheter (CVC) in place. The client suddenly reports acute chest pain and shortness of breath, and the nurse observes a loose connection at the catheter hub. Suspecting a catheter-related air embolism, arrange the following nursing actions in the priority order they should be performed. (Arrange from first action to last action.)

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Cevap

The correct sequence is to first clamp the catheter, then place the client in the left lateral Trendelenburg position, administer high-flow oxygen, notify the rapid response team, and finally monitor vital signs.
An air embolism is a life-threatening complication of central venous catheters. The absolute priority is to stop more air from entering by clamping the line. Next, positioning the client on their left side with the head down (left lateral Trendelenburg) traps the air in the right ventricle, preventing it from entering the pulmonary circulation. Administering 100% oxygen helps relieve hypoxia and decreases the size of the air bubble. Calling for help ensures advanced care is on the way, and subsequent vital sign monitoring guides ongoing resuscitation efforts.

Adım Adım Çözüm

1
Stop further air entry.
Clamp the central venous catheter.
Stopping the source of the air intake is the most critical immediate step to prevent the embolism from worsening.
2
Trap the existing air bubble.
Position the client in the left lateral Trendelenburg position.
This position uses gravity to keep the air trapped in the apex of the right ventricle, preventing it from migrating into the pulmonary circulation.
3
Treat hypoxia and reduce bubble size.
Administer 100% oxygen.
High concentrations of oxygen help wash out nitrogen from the air bubble, reducing its size while simultaneously treating tissue hypoxia.
4
Summon advanced medical assistance.
Notify the rapid response team.
Advanced medical intervention is required for hemodynamic support and potential aspiration of the air.
5
Continuously assess the client.
Obtain baseline vital signs.
Ongoing monitoring establishes a baseline for the medical team and detects signs of obstructive shock or cardiac arrest.

Anahtar Kavram

Emergency Management of a Central Venous Catheter Air Embolism
Soru 254Soru →

A triage nurse in an emergency department observes a client pacing rapidly in the waiting area, speaking loudly to other visitors about the delay in seeing a physician. Arrange the following nursing actions in the most appropriate sequence to therapeutically communicate and de-escalate the situation. All options must be used.

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Cevap

The correct sequence is to first establish a safe, non-threatening physical posture, followed by validating the client's emotions, exploring their specific concerns, providing factual information about the wait, and finally offering a collaborative choice.
The correct sequence for verbal de-escalation prioritizes physical safety and non-verbal communication first. Once a non-threatening presence is established, the nurse must validate the client's feelings and explore their concerns through active listening. Only after the client's emotional intensity has decreased is it appropriate to provide logical information (like triage times) and offer collaborative choices to manage the situation.

Adım Adım Çözüm

1
Establish physical safety and non-verbal readiness.
The nurse stands at a 45-degree angle with an open posture.
Non-verbal communication sets the tone for the interaction and ensures safety for both the nurse and the client before any words are spoken.
2
Acknowledge and validate the client's emotional state.
The nurse states that they can see the client is frustrated.
Validation demonstrates empathy and helps de-escalate heightened emotions by showing the client they are seen and heard.
3
Encourage verbalization of specific concerns.
The nurse asks an open-ended question about the client's distress.
Allowing the client to vent verbally reduces physical agitation and provides the nurse with context about the core issue.
4
Provide factual information to address the root concern.
The nurse explains the triage process and wait time.
Information giving reduces the anxiety of the unknown, but it is only effective after the client's emotional state has been validated and de-escalated.
5
Collaborate on a plan to restore a sense of control.
The nurse offers to move to a quieter consultation room.
Offering choices empowers the client, redirects their behavior constructively, and removes them from the stimulating waiting room environment.

Anahtar Kavram

Therapeutic Communication: De-escalation and Crisis Intervention Sequencing
Soru 255Soru →

A registered nurse (RN) on a neurology unit is planning the sequence of care for four assigned clients. Arrange the clients in the order they should be assessed, from highest priority (first) to lowest priority (last).

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Cevap

The correct assessment order is: 1) the client with myasthenia gravis, 2) the client post-craniotomy, 3) the client with Parkinson disease, and 4) the stable client requiring assistance with breakfast.
Prioritization requires the nurse to evaluate each client's physiological stability and acuity. According to the ABC framework, the client with myasthenia gravis and new-onset dysphagia has a threatened airway, making them the absolute highest priority. The postoperative craniotomy client is the second priority due to the risk of increased intracranial pressure, a severe and unstable complication. The client with Parkinson disease requires time-sensitive medication administration to prevent symptom exacerbation, making them the third priority. Finally, the client recovering from a stroke simply requires assistance with routine activities of daily living, which is the lowest priority.

Adım Adım Çözüm

1
Identify life-threatening or airway-compromising conditions.
The client with myasthenia gravis reporting difficulty swallowing is identified.
Airway compromise (the 'A' in the ABC framework) is always the most immediate threat to life and must be addressed first.
2
Identify acute, unstable changes requiring rapid intervention.
The postoperative craniotomy client with a severe headache is identified.
This client is demonstrating signs of potential increased intracranial pressure, which is a medical emergency requiring rapid intervention.
3
Identify time-sensitive interventions in otherwise stable clients.
The client with Parkinson disease needing scheduled medication is identified.
Levodopa-carbidopa must be given on a strict schedule to prevent loss of motor function, taking precedence over non-urgent routine care.
4
Identify routine, predictable care that can be delayed or safely delegated.
The stroke client waiting for breakfast assistance is identified.
Assistance with meals is a routine activity of daily living for a stable client and represents the lowest acuity task in this scenario.

Anahtar Kavram

Prioritization of client care based on the ABC framework and physiological stability
Tahmini Süre:1m 30s
Soru 256Soru →

A registered nurse is documenting in the electronic health record (EHR) when a pop-up message appears on the screen stating that the computer has been locked and demanding a ransom payment to restore access. Arrange the nurse's subsequent actions in the correct sequence of priority.

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The correct sequence is to first disconnect the computer, then contact IT security, notify the charge nurse, initiate downtime procedures, and finally submit an incident report.
The correct sequence prioritizes the immediate physical containment of the security breach to protect the wider hospital network, followed by alerting specialized IT personnel, warning the immediate clinical team, ensuring ongoing client care, and finally completing administrative documentation.

Adım Adım Çözüm

1
Identify the active threat and disconnect the affected computer workstation from the facility's network.
The ransomware is isolated to a single device.
Containment is the absolute highest priority to prevent malicious software from spreading across the hospital network and compromising further Protected Health Information (PHI).
2
Contact the Information Technology (IT) security department.
IT professionals are alerted to the breach.
Specialized personnel must assess the attack, secure the broader network, and initiate the facility's formal cyber incident response plan.
3
Notify the charge nurse to warn other staff members.
The unit staff is made aware of the cyber threat.
Unit leadership must coordinate the clinical response and prevent other staff from logging into potentially compromised terminals, limiting further exposure.
4
Initiate facility-approved downtime procedures.
Client care and documentation continue safely without the EHR.
Nurses must maintain continuity of care using alternative methods (e.g., paper charting) when the electronic health record (EHR) is inaccessible or unsafe to use.
5
Submit a formal incident report.
The event is formally documented for internal review.
Administrative documentation is necessary for regulatory compliance and internal investigation, but must only occur after all immediate safety and operational priorities have been met.

Anahtar Kavram

Incident Response and Containment for Electronic Health Record (EHR) Breaches
Soru 257Soru →

A nurse is walking through a high-traffic unit hallway and observes a visitor looking closely at an unattended computer on wheels (COW). The screen is unlocked and displays an active electronic health record (EHR) belonging to a client. Arrange the following actions the nurse should take in the correct sequence, from first to last.

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The nurse must first stop the active breach by redirecting the visitor, then secure the computer, notify unit leadership, and finally document the event in an incident report.
In the event of an active privacy breach under HIPAA regulations, the nurse's first priority is always to mitigate the immediate harm. This is achieved by physically blocking the unauthorized view (redirecting the visitor). The second step is to secure the source of the breach (locking the screen) to prevent recurrence. Third, the nurse must follow the chain of command by notifying the charge nurse, who will coordinate with the facility's privacy officer. Finally, the nurse must complete formal documentation (an incident or variance report) while the details are fresh, but only after the immediate threat has been neutralized.

Adım Adım Çözüm

1
Politely redirect the visitor away from the terminal.
The ongoing visual exposure of the client's data is stopped.
Mitigating the immediate harm and active privacy breach is the highest priority.
2
Lock the screen or log out of the EHR.
The terminal is secured against further unauthorized access.
Securing the source of the breach prevents additional individuals from viewing the information.
3
Notify the charge nurse.
Unit leadership is informed of the privacy violation.
Supervisors must be alerted to initiate formal institutional breach protocols, which may involve the facility privacy officer.
4
Complete an incident report.
The event is formally documented in the facility's risk management system.
Creating a legal record of the HIPAA violation is required, but it should only occur after the data is secured and leadership is notified.

Anahtar Kavram

Confidentiality and Information Security
Soru 258Soru →

A registered nurse (RN) is preparing to delegate the task of obtaining routine morning vital signs for a group of stable clients to an unlicensed assistive personnel (UAP). Arrange the steps of the delegation process in the correct chronological order from first to last.

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The correct sequence for the delegation process is: Assess the client's stability, Communicate clear instructions, Supervise the UAP's performance, and Evaluate the outcomes.
The delegation process always begins with the RN assessing the client and the situation to ensure the task is appropriate to delegate. Following assessment, the RN must communicate clear directions and expectations. During the task, the RN maintains supervision. Finally, the RN evaluates the outcomes and provides feedback. This order ensures the Five Rights of Delegation are maintained.

Adım Adım Çözüm

1
Identify the standard steps of the delegation process established by nursing regulatory bodies.
The steps are Assess and Plan, Communicate, Supervise, and Evaluate.
Understanding the sequence ensures safe and effective delegation.
2
Determine the initial action required before a task can be handed over.
The RN must first assess the client's stability and the complexity of the task.
The RN retains accountability for client care and must ensure delegation is appropriate based on current client status.
3
Sequence the remaining steps that follow the initial assessment.
Communication occurs before task execution; supervision happens during execution; evaluation and feedback occur after completion.
This chronological progression aligns with the logical flow of giving instructions, monitoring the work, and reviewing the results.

Anahtar Kavram

The delegation process consists of sequential phases: assessment and planning, communication, surveillance and supervision, and evaluation and feedback.
Soru 259Soru →

A registered nurse in an oncology unit accidentally drops a glass vial of a liquid antineoplastic medication, causing it to shatter on the floor. Arrange the following actions for managing this hazardous drug spill in the correct sequence. (Place the first action at the top and the last action at the bottom.)

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The correct sequence for managing a hazardous drug spill is: restrict access to the area, don personal protective equipment from the spill kit, contain the liquid with absorbent pads, collect the broken glass with a scoop, clean the area from the outside inward, and dispose of all materials in a designated hazardous waste receptacle.
Hazardous drug spills, such as antineoplastic medications, require a strict, systematic approach to prioritize human safety and minimize environmental contamination. The protocol dictates securing the perimeter first to protect the public, protecting the healthcare worker with appropriate PPE second, containing the liquid third, safely removing sharps with a mechanical tool, decontaminating the surface using an outside-in technique, and finally ensuring safe disposal in a designated hazardous waste bin.

Adım Adım Çözüm

1
Restrict access to the immediate area.
The area is secured from foot traffic.
Prevents unauthorized individuals from stepping in the hazardous drug and tracking it throughout the unit.
2
Don PPE from the hazardous drug spill kit.
The nurse is protected from chemical exposure.
Personal safety is paramount before engaging with any hazardous chemical or bodily fluid spill.
3
Place absorbent pads over the liquid.
The spread of the antineoplastic medication is halted.
Containing the liquid first prevents the spill footprint from expanding while managing the sharps.
4
Use a scoop to collect the broken glass.
Sharps are safely removed from the spill zone.
Using a mechanical tool instead of hands eliminates the risk of contaminated sharps puncturing the gloves.
5
Clean the surface from the outside edges toward the center.
The floor is decontaminated without spreading the chemical.
Working from the least contaminated perimeter toward the most contaminated center confines the residue.
6
Dispose of all materials in a designated hazardous waste container.
Contaminants are safely isolated for proper incineration or disposal.
Antineoplastic medications require specialized disposal protocols to prevent environmental and public health hazards.

Anahtar Kavram

Hazardous Drug Spill Management
Soru 260Soru →

A nurse is preparing to provide oral hygiene to a comatose client. Arrange the following actions in the correct sequence from first to last.

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The correct sequence prioritizes airway protection by first placing the client in a side-lying position, followed by setting up the towel and basin, opening the mouth with a padded blade, cleaning the oral cavity, and finally suctioning excess fluids.
The primary safety concern when providing oral care to an unresponsive client is maintaining airway patency and preventing aspiration. Therefore, the very first step must be placing the client in a side-lying position so fluids can naturally drain from the mouth. After the client is safely positioned, the nurse prepares the immediate environment with a towel and basin. A padded tongue blade is then used to safely separate the teeth without causing injury. Once the mouth is accessible, the nurse cleans the oral cavity. Finally, suctioning is performed to remove any residual fluids or secretions that were mobilized during cleaning.

Adım Adım Çözüm

1
Place the client in a side-lying position.
The client is positioned to allow secretions to drain out by gravity.
The highest priority is to protect the airway and prevent aspiration, which is achieved by utilizing gravity in the side-lying position.
2
Place a towel under the client's head and an emesis basin under the chin.
The environment is prepared for the procedure.
This maintains the cleanliness of the client's gown and bed linens during the procedure.
3
Gently open the client's mouth using a padded tongue blade.
The oral cavity is safely accessible for cleaning.
An unresponsive client may bite down involuntarily; a padded tongue blade safely keeps the mouth open without causing trauma.
4
Clean the oral cavity using a moistened sponge swab.
The teeth, gums, and tongue are cleansed.
This removes plaque, prevents infection, and maintains the integrity of the oral mucosa.
5
Suction the oral cavity to remove excess fluid and secretions.
The oral cavity is cleared of any residual fluid.
Suctioning eliminates any pooled liquids that the comatose client cannot swallow or expectorate, further preventing aspiration.

Anahtar Kavram

Prioritization of airway patency and aspiration prevention during hygiene care for unresponsive clients.
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