Tüm alıştırma soruları

3881 soru

Soru 2721Soru →

A client who underwent a cardiac catheterization via the right femoral artery is currently on strict bed rest. The nurse observes that the client has been incontinent of urine and needs immediate perineal care and a linen change. Which of the following is the most appropriate action for the nurse to take?

Cevabı ve açıklamayı göster

Cevap: Assist the client to turn onto the left side while maintaining the right leg in a straight, neutral position.

Cevap

The most appropriate action is to assist the client to turn onto the left side while maintaining the right leg in a straight, neutral position.
Following a cardiac catheterization via the femoral artery, the client must remain on bed rest with the affected extremity kept completely straight to prevent hematoma formation and bleeding. When basic care such as a linen change is required, the safest and most appropriate approach is for the nurse to gently assist the client to turn toward the unaffected side (the left side) while strictly maintaining the affected right leg in a straight, neutral position. This provides access for hygiene while protecting the vascular access site.

Adım Adım Çözüm

1
Identify the client's post-procedure requirements.
The client had a right femoral cardiac catheterization and requires strict bed rest with the affected right leg kept completely straight.
To prevent hemorrhage and hematoma formation at the high-pressure arterial puncture site.
2
Evaluate the basic care task required.
The client needs immediate perineal care and a linen change due to urinary incontinence.
To maintain skin integrity, prevent infection, and provide basic comfort.
3
Determine the safest method to execute the care.
The client can be turned to the unaffected (left) side by the nurse, as long as the right leg is kept completely straight and supported.
This approach successfully balances the physiological need for arterial site protection with the basic care need for hygiene.

Anahtar Kavram

Post-Cardiac Catheterization Basic Care and Positioning
Soru 2722Soru →

A pediatric clinic nurse is assessing the development of several young clients. Arrange the following fine motor and play milestones in the chronological order in which a typically developing child achieves them, from earliest to latest.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct chronological order of fine motor skill acquisition is: holding hands open and briefly grasping, followed by voluntary palmar grasp, transferring objects between hands, using a neat pincer grasp, and finally building a two-block tower.
Fine motor development in children proceeds in a proximodistal pattern (from the center of the body outward) and goes from gross, uncoordinated movements to fine, precise movements. Infants first lose the involuntary grasp reflex (2-3 months), then learn to voluntarily rake or grasp with the whole hand (4-5 months). Later, they develop bilateral coordination to transfer objects between hands (6-7 months), refine their grasp to use just the thumb and index finger (10-12 months), and finally develop the precise voluntary release and spatial control needed to stack objects (15 months).

Adım Adım Çözüm

1
Identify the earliest milestone associated with fading reflexes.
Holding hands open and briefly grasping a placed object is placed first (2-3 months).
This marks the transition from involuntary newborn reflexes to the beginning of purposeful movement.
2
Determine the next milestone involving voluntary reaching and gross hand use.
The palmar grasp is placed second (4-5 months).
Infants learn to use the entire hand to pull objects toward themselves before refining individual finger control.
3
Identify when bilateral coordination emerges.
Transferring an object from one hand to the other is placed third (6-7 months).
This requires crossing the body's midline and coordinating both hands simultaneously.
4
Identify the milestone involving refined, distal finger control.
The neat pincer grasp is placed fourth (10-12 months).
Fine motor skills progress proximodistally; using the tips of the thumb and index finger represents advanced distal refinement.
5
Identify the milestone requiring precise voluntary release.
Building a two-block tower is placed last (15 months).
Stacking objects requires not just grasping, but the complex cognitive and motor skill of letting go of an object at a precise location.

Anahtar Kavram

Pediatric Fine Motor Development Sequence
Soru 2723Soru →

A client arrives at the behavioral health center for inpatient treatment of major depressive disorder. During the intake interview, the individual mentions consuming a 'couple of drinks' nightly to manage insomnia, with the most recent beverage consumed approximately 12 hours prior. The client currently exhibits restlessness, continuous pacing, and complains of nausea along with a mild headache. What is the priority nursing action at this time?

Cevabı ve açıklamayı göster

Cevap: Initiate a standardized alcohol withdrawal assessment protocol.

Cevap

The priority action is to initiate a standardized alcohol withdrawal assessment protocol.
The client's history of daily alcohol consumption, combined with the timeline of their last drink and current symptoms (restlessness, nausea, headache), strongly suggests the onset of early alcohol withdrawal. Using the nursing process, the priority is to formally assess the severity of these physiological symptoms using a validated scale (such as CIWA-Ar) to determine the need for medication and safety precautions.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and timeline.
The client has a history of daily alcohol use, consumed their last drink 12 hours ago, and is now showing restlessness, pacing, nausea, and headache.
Establishing the timeline of last substance use is critical for predicting the onset of withdrawal symptoms.
2
Correlate the findings with known substance use disorder pathophysiology.
The symptoms align perfectly with the early stages of alcohol withdrawal, which typically begins 6 to 24 hours after cessation.
Recognizing early withdrawal prevents progression to severe complications like seizures or delirium tremens.
3
Determine the priority nursing intervention based on the nursing process.
Assessment is the first step. The nurse must formally evaluate the severity of the withdrawal using a validated tool.
A standardized assessment guides the appropriate administration of pharmacological treatments.

Anahtar Kavram

Recognizing and assessing early signs of alcohol withdrawal
Soru 2724Soru →

A nurse is preparing to administer an intravenous (IV) push medication through a client's established peripheral intermittent infusion device (saline lock). Arrange the following actions in the correct chronological sequence from first to last.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is to clean the access port, flush the catheter with normal saline to check patency, administer the medication, and then flush the catheter again with normal saline.
The standard procedure for administering an IV push medication through a saline lock follows the SAS method: Saline flush, Administer medication, Saline flush. Before any connection is made, the port must be thoroughly cleaned with an antimicrobial swab to maintain asepsis. The initial flush verifies IV patency. The medication is then administered. The final flush ensures the entire dose enters the bloodstream and clears the line to prevent occlusion.

Adım Adım Çözüm

1
Clean the access port of the infusion device with an antimicrobial swab.
The surface of the port is disinfected.
Prevents the introduction of microorganisms into the client's bloodstream during access.
2
Attach a syringe of normal saline and flush the peripheral intravenous catheter.
The IV line is assessed for patency and proper placement.
Ensures the medication will enter the vein safely and not infiltrate surrounding tissues.
3
Administer the prescribed medication at the recommended rate of injection.
The therapeutic agent is delivered to the client.
Provides the required pharmacological treatment while preventing rapid administration complications.
4
Flush the intravenous catheter again with normal saline.
The medication is cleared from the tubing.
Ensures the client receives the complete prescribed dose and helps maintain catheter patency for future use.

Anahtar Kavram

Safe administration of intravenous medications via a saline lock relies on the standard SAS (Saline, Administer, Saline) procedure combined with strict aseptic technique.
Soru 2725Soru →

A nurse is caring for a client who is receiving continuous enteral nutrition via a nasogastric tube. Which of the following positions is the most appropriate for this client to prevent complications?

Cevabı ve açıklamayı göster

Cevap: Semi-Fowler's position with the head of the bed elevated 30 to 45 degrees

Cevap

Semi-Fowler's position with the head of the bed elevated 30 to 45 degrees
Elevating the head of the bed to 30 to 45 degrees (semi-Fowler's position) is a foundational standard of care for clients receiving continuous enteral feedings. This position uses gravity to keep the formula in the stomach, thereby reducing the risk of gastric reflux and life-threatening aspiration pneumonia.

Adım Adım Çözüm

1
Identify the client's current treatment and the primary associated risk.
The client is receiving continuous enteral nutrition via a nasogastric tube. The major complication associated with this therapy is pulmonary aspiration of the feeding formula.
Recognizing the most critical safety risk determines the priority nursing intervention.
2
Determine the physiological mechanism needed to mitigate the risk.
Gravity must be utilized to keep the liquid formula within the stomach and prevent it from traveling back up the esophagus.
Non-pharmacological positioning is the standard first-line defense against aspiration.
3
Select the client position that best achieves this gravitational benefit.
Elevating the head of the bed to a 30 to 45-degree angle (semi-Fowler's position) provides the necessary elevation to prevent reflux.
This specific angle safely prevents aspiration while maintaining client comfort and minimizing shear forces on the sacral skin.

Anahtar Kavram

Prevention of aspiration during enteral feeding via proper positioning
Tahmini Süre:45s
Soru 2726Soru →

A client with end-stage renal disease has made the decision to discontinue hemodialysis and transition to hospice care. The client's parent is visibly distraught, approaches the nurse in the hallway, and states, "You have to talk some sense into them! They cannot just give up and die." Which response by the nurse is the most therapeutic?

Cevabı ve açıklamayı göster

Cevap: It sounds like you are feeling completely overwhelmed by this decision. Let's sit down and talk about it.

Cevap

The most therapeutic response reflects the parent's feelings of being overwhelmed and offers the nurse's presence to talk about those feelings.
The correct answer acknowledges the parent's emotional state without judgment and offers the nurse's time and presence. This approach builds trust and allows the parent to process their grief, which is a critical nursing intervention in end-of-life care.

Adım Adım Çözüm

1
Analyze the parent's statement and underlying emotion.
The parent is expressing intense distress, grief, and a feeling of loss of control over the client's decision to stop life-prolonging treatment.
Identifying the core emotion is necessary to choose a response that validates the parent's feelings rather than arguing facts.
2
Evaluate the options for therapeutic and non-therapeutic communication techniques.
The correct response must use validating, open-ended techniques. Options that use 'why', give advice, or deflect the conversation are incorrect.
Therapeutic communication in end-of-life care focuses on active listening, empathy, and offering self.

Anahtar Kavram

Therapeutic Communication in End of Life Care
Soru 2727Soru →

An adult client is currently receiving a transfusion of packed red blood cells (PRBCs) through a 20-gauge peripheral intravenous catheter to treat acute blood loss anemia following a surgical procedure. During the transfusion, the client experiences a sudden episode of severe post-operative nausea and vomiting. The healthcare provider prescribes an immediate dose of intravenous ondansetron. The client currently has no other vascular access. Which of the following actions is the most appropriate way to safely administer the medication?

Cevabı ve açıklamayı göster

Cevap: Establish a new peripheral intravenous catheter in a different vein to administer the medication.

Cevap

Establish a new peripheral intravenous catheter in a different vein to administer the medication.
The correct action is to initiate a secondary intravenous line. Blood products must infuse through a dedicated line using specialized Y-tubing. To prevent red blood cell lysis, medication incompatibility, and contamination, no medications may be mixed with packed red blood cells or injected into the blood administration set. Because the client needs immediate relief for severe nausea and vomiting, establishing a new access point is the only safe intervention that allows prompt treatment without compromising the blood product.

Adım Adım Çözüm

1
Evaluate the current intravenous access and the prescribed therapy.
The client has only one IV line, which is currently dedicated to a packed red blood cell transfusion.
Before administering any medication, the nurse must ensure there is safe and compatible vascular access.
2
Determine the compatibility rules for blood product administration.
Blood products are incompatible with almost all medications and intravenous solutions, except for 0.9%0.9\% sodium chloride. Medications cannot be mixed into blood tubing.
Mixing medications with blood can cause red blood cell lysis (hemolysis), precipitation, and severe patient harm.
3
Prioritize the client's immediate physiological needs.
The client has severe nausea and active vomiting, requiring immediate intervention to prevent distress and aspiration.
Delaying treatment for active vomiting is unsafe, meaning the medication must be given promptly rather than waiting hours for the transfusion to finish.
4
Select the safest intervention that addresses both constraints.
Initiating a second peripheral IV line allows for the immediate administration of the antiemetic without interrupting or compromising the ongoing blood transfusion.
Establishing secondary access adheres to infection control, medication compatibility standards, and acute symptom management protocols.

Anahtar Kavram

Safe Administration of Blood Products and Intravenous Medications
Soru 2728Soru →

A 28-year-old client is brought to the emergency department after heavily using cocaine at a party. The client is profoundly agitated, diaphoretic, and reporting severe, crushing chest pain. Place the following nursing interventions in the correct order of priority.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence prioritizes immediate cardiovascular assessment and circulatory access, followed by targeted pharmacological de-escalation of the hyperadrenergic state, diagnostic evaluation of the chest pain, and environmental modification.
In the setting of acute cocaine intoxication with severe agitation and chest pain, the priority is to assess the cardiovascular status and establish a route for medication. The immediate pharmacological treatment of choice is intravenous benzodiazepines to control the hyperadrenergic state. Once the client is calmed and hemodynamically stabilized, a 12-lead ECG can be accurately obtained to evaluate for myocardial ischemia. Finally, environmental modifications support continued stabilization.

Adım Adım Çözüm

1
Prioritize immediate assessment.
Applying continuous cardiac monitoring and assessing vital signs.
Cocaine is a potent sympathomimetic that causes severe vasoconstriction, tachycardia, and hypertension. Immediate cardiovascular assessment is critical.
2
Prepare for pharmacological intervention.
Establishing peripheral IV access.
Rapid administration of emergency medications is required to stabilize the client's vital signs and control agitation.
3
Administer targeted therapy.
Administering an intravenous benzodiazepine.
Benzodiazepines are the treatment of choice for cocaine-induced agitation and cardiovascular toxicity, as they blunt the excessive sympathetic outflow and prevent seizures.
4
Perform diagnostic evaluation.
Obtaining a 12-lead ECG.
An ECG is necessary to evaluate the chest pain, but the client must be chemically calmed first to obtain an accurate, artifact-free tracing.
5
Modify the environment.
Dimming the lights and minimizing noise.
Reducing sensory input prevents further escalation of agitation and sympathetic response after acute medical stabilization.

Anahtar Kavram

Prioritization in Acute Stimulant Intoxication
Soru 2729Soru →

A registered nurse in a pediatric clinic is preparing to administer the first dose of the live-attenuated measles, mumps, and rubella (MMR) vaccine to a 12-month-old infant. Arrange the following nursing actions in the correct chronological order to ensure safe and effective practice.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence for administering the MMR vaccine is: 1) Screening for contraindications, 2) Providing the Vaccine Information Statement (VIS), 3) Obtaining informed consent, 4) Reconstituting the vaccine, 5) Administering it subcutaneously, and 6) Documenting the procedure.
The nursing process dictates that assessment must occur first to ensure client safety. After confirming medical eligibility, the nurse must educate the client (or parent) by providing the Vaccine Information Statement (VIS). This education is a prerequisite for obtaining informed consent. Only after consent is granted should the nurse prepare the medication, as live vaccines degrade quickly upon reconstitution and would be wasted if prepared prior to a parent's refusal. Following preparation, the medication is administered using the correct clinical route (subcutaneously). Finally, documentation must occur immediately after administration to maintain an accurate and legal health record.

Adım Adım Çözüm

1
Screen the infant's health record for contraindications.
Identifies any absolute or relative contraindications to the vaccine.
Ensures client safety, as live vaccines can cause severe complications in immunocompromised individuals or those with recent passive immunity.
2
Provide the Vaccine Information Statement (VIS) and address questions.
Educates the parent on the specific risks and benefits of the vaccine.
This is a federally mandated step that must precede consent to ensure the parent's decision is fully informed.
3
Obtain informed consent from the parent or legal guardian.
Secures legal permission to perform the medical intervention.
Consent must follow education and precede any physical preparation or administration of the medication to respect client autonomy.
4
Reconstitute the lyophilized vaccine with the specific diluent.
Prepares the active medication for immediate injection.
Live vaccines like MMR degrade quickly once reconstituted and should only be mixed when the nurse is ready to administer.
5
Administer the vaccine subcutaneously into appropriate tissue.
Delivers the immunization effectively.
The subcutaneous route is the evidence-based standard for the MMR vaccine to ensure proper systemic absorption and immune response.
6
Document the administration details in the medical record.
Creates a permanent and legal record of the immunization.
Documentation must always occur immediately after the intervention, never before, to maintain medical record integrity and prevent errors.

Anahtar Kavram

Principles of Safe Immunization Administration and the Nursing Process
Soru 2730Soru →

A nurse in an outpatient clinic is interviewing a 72-year-old client who presents with dysuria and genital lesions. The client recently moved into an active senior living community and reports having multiple new sexual partners. The client states, "I don't use any protection because pregnancy is no longer a concern at my age." Which response by the nurse is the most appropriate?

Cevabı ve açıklamayı göster

Cevap: While pregnancy is not a risk, barrier methods remain essential to protect against sexually transmitted infections.

Cevap

The nurse should directly address the client's misconception by providing factual information about the ongoing risk of sexually transmitted infections (STIs) regardless of age, while avoiding judgmental language.
The correct answer provides factual, non-judgmental education that directly addresses the client's specific knowledge deficit. Rates of STIs in older adults are rising, and nurses must actively advocate for primary prevention (such as barrier methods) regardless of a client's reproductive capacity.

Adım Adım Çözüm

1
Analyze the client's statement to identify the core knowledge deficit.
The client incorrectly believes that preventing pregnancy is the sole reason to use protection during sexual intercourse.
Identifying the specific misconception allows the nurse to target health promotion education effectively.
2
Evaluate the nursing responses based on therapeutic communication and primary prevention principles.
The response addressing STI risk provides accurate, non-judgmental health education.
Older adults remain at high risk for STIs, and primary prevention via barrier methods is the most effective harm reduction strategy.

Anahtar Kavram

Harm Reduction and Primary Prevention in Older Adults
Tahmini Süre:1m 15s
Soru 2731Soru →

A clinic nurse is assessing a 21-year-old client during an annual wellness visit. The nurse should identify that which client statements indicate high-risk behaviors requiring targeted education? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: I occasionally take my roommate's prescription amphetamine to help me stay awake and study for exams.; When I go out on weekends, I mix liquor with caffeinated energy drinks so I do not feel as tired.; I rely on the withdrawal method as my primary form of contraception because condoms are uncomfortable.

Cevap

The statements regarding using a roommate's prescription amphetamine, mixing alcohol with energy drinks, and relying on the withdrawal method indicate high-risk behaviors.
High-risk behaviors in young adults often involve substance misuse and unsafe sexual practices. Taking unprescribed medications, such as a roommate's amphetamine, is a direct form of substance misuse that carries risks of dependency and adverse cardiovascular events. Mixing alcohol with caffeinated energy drinks is highly dangerous because the caffeine masks the natural depressant effects of alcohol, which often leads to overconsumption and severe alcohol toxicity. Relying on the withdrawal method for contraception is a high-risk sexual practice because it is highly ineffective at preventing unintended pregnancies and provides absolutely no barrier protection against sexually transmitted infections (STIs). These three behaviors require immediate, targeted harm-reduction education.

Adım Adım Çözüm

1
Analyze the client's statement regarding taking a roommate's prescription amphetamine.
This is identified as substance misuse, which is a high-risk behavior.
Using unprescribed controlled substances carries significant physiological and legal risks.
2
Analyze the client's statement about mixing liquor with caffeinated energy drinks.
This is identified as a dangerous polysubstance practice and a high-risk behavior.
Caffeine masks alcohol-induced drowsiness, preventing the client from realizing their level of intoxication and increasing the risk of alcohol toxicity.
3
Analyze the client's statement about relying on the withdrawal method for contraception.
This is identified as an unsafe sexual practice and a high-risk behavior.
The withdrawal method has a high failure rate for pregnancy prevention and provides zero barrier protection against STIs.
4
Evaluate the remaining statements regarding physical exams and rideshare verification.
These are identified as health-promoting and safety-conscious behaviors, respectively.
Routine screenings and personal safety checks decrease risk and represent positive coping and maintenance strategies.

Anahtar Kavram

High Risk Behaviors
Soru 2732Soru →

A client who recently experienced a cerebrovascular accident has dense left-sided hemiplegia. The nursing team is establishing a schedule to maintain body alignment, prevent joint deformities, and ensure skin integrity. Which action is the most appropriate to include in this client's daily care?

Cevabı ve açıklamayı göster

Cevap: Place a trochanter roll alongside the lateral aspect of the client's left thigh.

Cevap

The most appropriate action is to place a trochanter roll alongside the lateral aspect of the client's left thigh.
Placing a trochanter roll along the lateral aspect of the paralyzed leg prevents external rotation of the hip, which is a common and debilitating complication in clients with hemiplegia. This intervention maintains proper anatomical alignment, protects the joint capsule, and promotes overall comfort as part of basic care.

Adım Adım Çözüm

1
Analyze the client's condition and the goals of care.
The client has left-sided hemiplegia (paralysis) and needs interventions for joint alignment and skin integrity.
Understanding the deficits guides the selection of safe and therapeutic comfort measures.
2
Evaluate the physiological impact of hemiplegia on the lower extremities.
A paralyzed leg naturally tends to roll outward (external rotation) due to gravity and lack of muscle tone.
Identifying the natural pathological tendency highlights the need for a mechanical counter-measure.
3
Determine the correct positioning intervention.
A trochanter roll placed laterally along the thigh physically prevents the hip from rotating outward.
This maintains neutral anatomical alignment, preventing permanent joint deformities and promoting comfort.

Anahtar Kavram

Therapeutic Positioning and Alignment for Hemiplegia
Soru 2733Soru →

A nurse enters a client's room and observes the client cowering in the corner, covering their head, and shouting about a traumatic event from their past. The client is experiencing an active flashback with severe sensory and perceptual dissociation. Arrange the following nursing interventions in the correct order of priority from first to last.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence prioritizes immediate physical safety, followed by verbal orientation, visual grounding, active cognitive sensory engagement, and finally physiological regulation.
When a client experiences a flashback, their sensory perception is profoundly altered, causing them to re-experience trauma as if it is occurring in the present. The priority sequence aligns with trauma-informed care: first ensure safety and avoid triggers by maintaining distance (no touch), then orient verbally using their name. Next, guide the client to process current sensory input by opening their eyes, followed by actively naming objects to break the dissociation. Finally, address physiological symptoms with breathing exercises once they are fully grounded in the present.

Adım Adım Çözüm

1
Maintain distance and avoid physical touch.
Prevents startling the client and ensures physical safety.
During a flashback, the client's sensory perception is altered, and they may interpret unexpected touch as a physical attack.
2
Use the client's name and state they are safe.
Introduces present-day reality through auditory channels.
Calm, verbal reassurance begins the process of pulling the client's perception out of the traumatic memory and into the present.
3
Direct the client to open their eyes and look around.
Breaks the internal visual memory loop.
Visualizing the current environment replaces the traumatic imagery with accurate, present sensory data.
4
Engage the client in identifying specific objects.
Completes the grounding process by requiring active cognitive processing.
Describing objects forces the brain to focus on concrete, present sensory input, effectively resolving the severe perceptual alteration.
5
Initiate deep breathing exercises.
Lowers heart rate and promotes physiological relaxation.
Breathing exercises are most effective after the perceptual distortion has ended, as the client can now comprehend and follow instructions.

Anahtar Kavram

Prioritization of nursing interventions for severe sensory and perceptual alterations related to dissociative episodes and trauma.
Soru 2734Soru →

A school nurse is developing an educational program about bicycle safety for a group of 8-year-old students. Based on Piaget's theory of cognitive development, which teaching strategy is most appropriate for this specific age group?

Cevabı ve açıklamayı göster

Cevap: Supplying physical bicycle helmets for the students to manipulate and practice fitting on themselves.

Cevap

The most appropriate strategy is supplying physical bicycle helmets for the students to manipulate and practice fitting on themselves.
The strategy of supplying physical bicycle helmets is correct because an 8-year-old is in Piaget's concrete operational stage of cognitive development. During this stage (ages 7 to 11), children transition from the magical thinking of early childhood to logical thought. However, their logic is primarily applied to physical, tangible objects. They learn best through direct, hands-on manipulation, return demonstrations, and concrete examples rather than abstract theories.

Adım Adım Çözüm

1
Identify the client's developmental age.
The clients are 8-year-old students.
Age is the primary determinant for selecting the correct developmental stage framework.
2
Match the age to the corresponding stage in Piaget's theory of cognitive development.
An 8-year-old is in the concrete operational stage (which typically spans ages 7 to 11).
Understanding the specific stage reveals how the child processes information.
3
Determine the cognitive characteristics and optimal teaching methods for the concrete operational stage.
Children in this stage use logical thought applied to physical, concrete objects and learn best through hands-on activities.
Aligning the teaching strategy with the child's cognitive abilities ensures the education is effective and comprehended.
4
Evaluate the provided options against the characteristics of the concrete operational stage.
Providing physical helmets for hands-on practice directly supports concrete learning, whereas the other options target either younger (preoperational) or older (formal operational) stages.
This confirms the correct nursing intervention.

Anahtar Kavram

Piaget's Stages of Cognitive Development (Concrete Operational Stage)
Tahmini Süre:1m 0s
Soru 2735Soru →

Following a vaginal delivery at 41 weeks gestation complicated by thick meconium-stained fluid, the neonate is completely flaccid, apneic, and deeply cyanotic. To adhere to current Neonatal Resuscitation Program (NRP) standards, arrange the designated resuscitative interventions in the exact chronological order they must be performed.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence prioritizes establishing an airway and ventilation before circulation: complete initial steps (warm/clear/dry/stimulate), initiate positive-pressure ventilation (PPV), perform ventilation corrective steps if needed, commence chest compressions, and finally administer epinephrine.
The correct ordering strictly follows the evidence-based Neonatal Resuscitation Program (NRP) algorithm. Neonatal transition failures are almost exclusively respiratory in origin. Therefore, the sequence mandates attempting spontaneous respiration through initial steps, mechanically inflating the lungs via PPV, ensuring that PPV is effective via corrective steps, and only then moving to circulatory support with compressions and ultimately pharmacological support with epinephrine.

Adım Adım Çözüm

1
Perform initial resuscitation steps (warm, clear airway, dry, stimulate).
The infant is warmed and the airway is clear of immediate obstruction.
Prevents cold stress and removes upper airway meconium. Current standards strictly advise against routine intubation for meconium to prevent delays in ventilation.
2
Initiate Positive-Pressure Ventilation (PPV).
Air is forced into the lungs, establishing functional residual capacity.
The primary cause of neonatal compromise is hypoxia. Apnea requires immediate mechanical assistance to expand the lungs and begin gas exchange.
3
Implement ventilation corrective steps.
Effective ventilation is confirmed by visible, bilateral chest rise.
Subsequent steps (compressions/medications) will fail if the lungs remain unexpanded. Correcting the mask seal or airway position ensures oxygen actually reaches the alveoli.
4
Begin coordinated chest compressions with 100% oxygen.
Artificial cardiac output is generated to perfuse vital organs.
Required when the heart rate remains below 60 bpm despite 30 seconds of effective ventilation, indicating profound hypoxic myocardial depression.
5
Administer epinephrine.
Coronary artery perfusion pressure is chemically increased.
Used as a last resort when the myocardium is too ischemic to recover with ventilation and compressions alone.

Anahtar Kavram

Current Neonatal Resuscitation Program (NRP) algorithms prioritize establishing effective ventilation over routine endotracheal suctioning, even in the presence of meconium-stained fluid, progressing to circulatory support only after ventilation is optimized.
Soru 2736Soru →

A nurse is preparing to assist a healthcare provider with a bedside thoracentesis for an adult client with a large pleural effusion. To ensure client safety and reduce the risk of procedural complications, arrange the following nursing actions in the correct chronological order.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is: Verify informed consent, properly position the client, provide intra-procedure safety instructions, apply an occlusive dressing, and finally obtain a post-procedure chest radiograph.
The correct sequence follows the logical progression of care for an invasive bedside procedure: pre-procedure legal verification, anatomical preparation (positioning), intra-procedure safety management, immediate post-procedure site care, and subsequent monitoring for potential iatrogenic complications.

Adım Adım Çözüm

1
Verify informed consent.
Legal and ethical prerequisites are met.
Informed consent is mandatory before any invasive diagnostic procedure begins.
2
Position the client appropriately.
The client is sitting upright, leaning forward over a bedside table.
This specific orthopneic position maximizes the intercostal spaces and provides optimal access to the pleural cavity while reducing the risk of organ puncture.
3
Provide safety instructions during the procedure.
The client understands to avoid coughing or moving.
Movement during needle insertion can cause the needle to lacerate the lung, leading to a pneumothorax.
4
Apply an occlusive sterile dressing.
The puncture site is immediately sealed.
Sealing the site prevents air from being drawn into the negative-pressure pleural space as the client breathes.
5
Obtain a follow-up chest radiograph.
Diagnostic imaging is performed.
An x-ray confirms the removal of pleural fluid and rules out complications such as pneumothorax or hemothorax.

Anahtar Kavram

Thoracentesis Safety and Risk Reduction
Soru 2737Soru →

A nurse is preparing to initiate a continuous enteral tube feeding for an immobile client. To effectively reduce the risk of potentially life-threatening respiratory complications, which action must the nurse take?

Cevabı ve açıklamayı göster

Cevap: Maintain the head of the bed elevated at 30 to 45 degrees throughout the infusion.

Cevap

The nurse must maintain the head of the bed elevated at 30 to 45 degrees throughout the continuous enteral feeding.
Elevating the head of the bed to at least 30 to 45 degrees is a fundamental nursing intervention that uses gravity to keep enteral formula within the stomach. This significantly reduces the risk of regurgitation and subsequent pulmonary aspiration, which is a common and highly dangerous complication of tube feedings.

Adım Adım Çözüm

1
Identify the primary physiological risk associated with continuous enteral tube feedings.
The most significant risk is regurgitation of the liquid formula leading to pulmonary aspiration.
Immobile clients have a diminished ability to clear their airway if stomach contents back up into the esophagus.
2
Determine the most effective nursing intervention to physically prevent this complication.
Positioning the client upright utilizes gravity to contain the fluid.
Maintaining the head of the bed at 30 to 45 degrees ensures formula stays in the stomach, directly reducing the risk potential for aspiration.

Anahtar Kavram

Aspiration Prevention in Enteral Feedings
Soru 2738Soru →

A nurse is caring for a hemodynamically unstable client with severe sepsis who has a blood pressure of 82/40 mm Hg. The client is receiving a continuous intravenous (IV) infusion of norepinephrine through the distal port of a newly placed triple-lumen central venous catheter (CVC). The provider prescribes a 500 mL bolus of 0.9% sodium chloride and pantoprazole 40 mg IV push. Which of the following actions represent safe parenteral medication administration and physiological management for this client? (Select all that apply.)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Initiate the 0.9% sodium chloride bolus through a separate peripheral IV or a different central line lumen rather than the one infusing norepinephrine.; Aspirate for a brisk blood return from the selected central venous catheter lumen to confirm patency prior to administering the pantoprazole.; Verify the Y-site compatibility of pantoprazole with any other continuous infusions if a shared central line lumen must be utilized.

Cevap

The correct actions are: initiating the fluid bolus through a separate line, aspirating for blood return prior to IV push administration, and verifying Y-site compatibility before using a shared lumen.
Safe parenteral therapy in critical care demands that high-risk continuous infusions like norepinephrine remain uninterrupted and un-bolused. Using a separate line for fluid resuscitation prevents speed shock. Verifying blood return ensures the central line is intravascular and safe for use, while checking Y-site compatibility prevents catheter occlusion from drug precipitation.

Adım Adım Çözüm

1
Evaluate the implications of the client's hemodynamic status (BP 82/40 mm Hg) on positioning.
Determine that high-Fowler's position is contraindicated because it decreases venous return and exacerbates hypotension.
Maintaining adequate preload is essential in septic shock.
2
Analyze the safety risks of manipulating a central line lumen currently infusing a high-alert vasopressor (norepinephrine).
Identify that flushing or bolusing through this specific lumen is prohibited.
Flushing pushes the residual vasopressor in the catheter rapidly into the bloodstream, causing a dangerous spike in blood pressure.
3
Determine the correct administration protocols for central lines and IV push pantoprazole.
Confirm that aspirating for blood return, verifying compatibility, and pushing the medication slowly (over 2 minutes) are required.
These steps ensure the medication enters the vein safely without precipitating or causing adverse rapid-infusion reactions.

Anahtar Kavram

Safe administration of parenteral therapies in critically ill clients requires meticulous line management, strict adherence to infusion rates, verification of compatibility, and physiological considerations such as positioning for shock.
Soru 2739Soru →

A 75-year-old client tells the clinic nurse, "I have started drinking two glasses of red wine every night before bed. My cultural tradition says it is good for the heart, and since I am getting older, it helps me fall asleep despite my arthritis pain." Which response by the nurse is the priority?

Cevabı ve açıklamayı göster

Cevap: While alcohol may help you fall asleep initially, it disrupts the deeper stages of sleep and significantly increases your risk of nighttime falls.

Cevap

The response that educates the client on how alcohol disrupts deep sleep stages and increases the risk of nighttime falls.
Alcohol initially decreases sleep onset latency due to its depressive effects on the central nervous system. However, as blood alcohol levels decline during the night, it causes a 'rebound effect,' leading to sympathetic nervous system activation, REM sleep suppression, and frequent awakenings. For an older adult with arthritis (impaired mobility), waking up frequently in the dark significantly elevates the risk for falls and subsequent injury. The priority is providing evidence-based education regarding this high-risk lifestyle choice.

Adım Adım Çözüm

1
Analyze the client's stated lifestyle choice and rationales.
The client is using alcohol nightly as a sleep aid and pain management tool, justifying it with cultural beliefs and aging.
Identifying the root cause of the behavior is necessary to provide targeted education.
2
Evaluate the physiological impact of this lifestyle choice on this specific demographic.
Alcohol acts as a rapid central nervous system depressant but causes REM sleep rebound and fragmentation later in the night. In a 75-year-old with arthritis, waking up disoriented increases fall risk.
Nursing priorities must center on safety and evidence-based physiological principles.
3
Select the response that best addresses the safety priority while maintaining therapeutic communication.
Educating the client about the sleep disruption and fall risk directly addresses the most imminent danger without being judgmental.
Patient education regarding lifestyle modifications must be factual, safety-oriented, and therapeutic.

Anahtar Kavram

Impact of alcohol consumption on sleep architecture and safety in older adults
Soru 2740Soru →

A nurse is formulating a plan of care for a client who has just returned to the nursing unit following a bronchoscopy with a transbronchial lung biopsy under conscious sedation. Which nursing interventions should be included in the plan of care to reduce the risk of post-procedure complications? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Withhold all oral food and fluids until the return of the client's gag reflex is verified.; Assess respiratory effort, continuous oxygen saturation, and bilateral lung sounds.; Reassure the client that a small amount of blood-streaked sputum is an expected finding.

Cevap

The appropriate risk-reduction interventions are to withhold all oral intake until the gag reflex returns, assess the respiratory status continuously, and reassure the client that a small amount of blood-streaked sputum is normal.
Appropriate risk reduction following a bronchoscopy prioritizes airway safety by delaying oral intake until the gag reflex returns, monitoring closely for pneumothorax through frequent lung assessments, and applying correct clinical judgment by recognizing that minor blood-tinged sputum is an expected consequence of a lung biopsy.

Adım Adım Çözüm

1
Analyze the specific procedure and identify the associated physiological risks.
The client underwent a bronchoscopy with a transbronchial biopsy under conscious sedation. The primary risks include aspiration, pneumothorax, hypoxia, and severe hemorrhage.
Identifying procedure-specific risks is essential for determining the most appropriate monitoring and complication prevention strategies.
2
Evaluate each intervention to determine if it directly mitigates the identified risks within the nursing scope of practice.
Withholding fluids successfully prevents aspiration, assessing lung sounds rapidly detects pneumothorax, and recognizing blood-streaked sputum as an expected finding prevents unnecessary patient alarm.
Interventions must be clinically accurate and directly address the physiological vulnerabilities created by the procedure.
3
Identify contraindicated actions and incorrect clinical interpretations among the distractors.
Supine positioning, delegating initial post-operative vital signs to a UAP, and treating a normal PaCO2 level (42 mm Hg) as an emergency are all incorrect and potentially unsafe actions.
These actions either increase the risk of complications (such as aspiration or missed clinical instability) or demonstrate poor interpretation of standard diagnostic data.

Anahtar Kavram

Post-procedure care and complication prevention following an invasive respiratory procedure (bronchoscopy with biopsy).
ÖncekiSayfa 137 / 195Sonraki
Tüm alıştırma soruları — NCLEX-RN | Examkin