Tüm alıştırma soruları

Two hours following a diagnostic lumbar puncture, a client reports intense hunger and requests the lunch tray that was just delivered. The provider has prescribed strict flat bed rest for six hours. Which action is the most appropriate for the nurse to take?

A nurse is providing care for an older adult client who has just returned to the unit following a diagnostic lumbar puncture. The client reports a headache, and family members express concern that the client is suddenly exhibiting mild confusion. Which of the following is the most appropriate nursing action?

A nurse is establishing a plan of care for an older adult client who requires bilateral eye patches and strict bed rest following complex ophthalmic surgery. The client reports feeling highly anxious and "disconnected from reality." Which interventions should the nurse include in the plan of care to address the client's sensory and perceptual alterations? Select all that apply.

An occupational health nurse evaluates a 48-year-old manufacturing worker who reports waking up multiple times nightly to urinate and experiencing continuous excessive thirst. The worker dismisses these symptoms, stating, "My body is just changing as I get older." Based on the epidemiological framework of prevention, which nursing action represents the priority secondary prevention strategy?

Following a diagnostic lumbar puncture, a client is transferred back to the clinical unit. Which action should the nurse implement to reduce the client's risk of developing a post-dural puncture headache?

A clinic nurse is providing education to a pregnant client at 10 weeks of gestation who reports using cannabis daily to manage severe morning sickness. The client states, "It is a natural plant, so I feel it is much safer for my baby than taking prescription chemicals." Which of the following responses by the nurse are appropriate? (Select all that apply.)

A nurse at a university health clinic is evaluating a 20-year-old client who requests a prescription for HIV pre-exposure prophylaxis (PrEP). During the risk assessment, the client discloses engaging in condomless transactional sex and sharing needles for unlicensed cosmetic injections. Which of the following is the priority nursing action?

During a mealtime on a secure mental health unit, a client becomes suddenly hostile, throws a food tray across the room, points aggressively at the wall, and yells about the food being poisoned by spies. Which of the following initial actions should the nurse implement? (Select all that apply.)

During bedside shift report, the nurse assesses a client who underwent a percutaneous coronary intervention via the right femoral artery four hours ago. The client suddenly reports acute, deep lower back pain. The nurse notes a heart rate of 118 beats per minute and a blood pressure of 92/58 mm Hg, compared to baseline vital signs of 78 beats per minute and 124/76 mm Hg. The right groin dressing remains dry and intact. Which of the following is the most appropriate initial action by the nurse?

Prior to an endoscopic procedure, a client requires the administration of a large-volume cleansing enema. The supplies are at the bedside, and the client's identity has been verified. In what sequence should the nurse perform the administration steps? Arrange the actions from first to last.

A client is receiving continuous total parenteral nutrition (TPN) through a single-lumen central venous catheter. The healthcare provider issues a new prescription for an intravenous (IV) antibiotic. What is the safest action for the nurse to take regarding the administration of this new medication?

A nurse is planning basic care and comfort measures for an older adult client receiving palliative care who has severe cachexia, intractable bone pain, and a stage 3 sacral pressure injury. Which interventions should the nurse include in the plan of care? Select all that apply.

An older adult client is prescribed strict supine bed rest following a diagnostic lumbar puncture. When assisting the client with basic comfort and daily needs, which actions should the nurse implement? Select all that apply.

An educator is evaluating a group of newly hired nurses on the safe handling of hazardous antineoplastic medications. Which statements by the orientees indicate a correct understanding of the safety protocols? Select all that apply.

A nurse is caring for a client who is $24$ hours postoperative following an open reduction and internal fixation (ORIF) of a right femoral shaft fracture. The client suddenly becomes intensely restless and confused. Assessment reveals a respiratory rate of $32$ breaths/minute, a heart rate of $122$ bpm, and a pinpoint red rash over the anterior chest. Arterial blood gas (ABG) results on room air are as follows:

Which action should the nurse perform FIRST to reduce the risk of severe physiological deterioration?

A critical care nurse is evaluating a client who has been receiving a continuous intravenous infusion of sodium nitroprusside at $3\text{ mcg/kg/min}$ for the management of a hypertensive emergency. The client's renal function has deteriorated over the last $48$ hours, evidenced by a urine output of $15\text{ mL/hr}$ and a serum creatinine level of $3.1\text{ mg/dL}$. The client now presents with profound confusion, muscle twitching, and a mixed venous oxygen saturation ($SvO_2$) of $88\%$ (normal range: $60\% - 80\%$). Based on these assessment data, which of the following pharmacological interventions should the nurse anticipate immediately?

During an annual wellness visit at a primary care clinic, a nurse evaluates a septuagenarian client who reports several new physical changes over the past six months. Which documented finding indicates an abnormal pathological process that requires prompt provider evaluation, rather than an expected age-related physiological change?

An adult client is recovering on the medical-surgical unit two hours after a percutaneous liver biopsy. The nurse observes that over the last hour, the client's heart rate has increased from 76 to 114 bpm, and the blood pressure has shifted from 128/80 mm Hg to 110/88 mm Hg. The client reports feeling "restless" and has mild right upper quadrant discomfort. Which action should the nurse take immediately to minimize the risk of a severe complication?

A client is admitted to the medical-surgical unit directly after undergoing a percutaneous liver biopsy. Which of the following nursing interventions should be implemented to minimize the risk of post-procedure complications? Select all that apply.

An oncology client with severe mucositis has developed distributive shock secondary to a suspected bloodstream infection. The client has a double-lumen peripherally inserted central catheter (PICC) in place with the following active infusions:

- Distal port: Continuous infusion of norepinephrine to sustain a mean arterial pressure (MAP) above 65 mm Hg.
- Proximal port: Continuous infusion of total parenteral nutrition (TPN) with added regular insulin.

The provider issues a stat order to administer a 100 mL intravenous bag of a broad-spectrum antibiotic over 30 minutes. Which intervention demonstrates the most appropriate clinical judgment regarding the administration of this antibiotic?