Tüm alıştırma soruları

A client weighing $198\text{ lb}$ is receiving a continuous intravenous (IV) heparin infusion for the treatment of a deep vein thrombosis. The client's morning activated partial thromboplastin time (aPTT) is reported as $42\text{ seconds}$. According to the facility's weight-based heparin protocol, for this aPTT result, the nurse must administer an IV push bolus of $40\text{ units/kg}$ and increase the continuous infusion rate by $2\text{ units/kg/hr}$. The continuous IV infusion is currently running at $14\text{ units/kg/hr}$. The pharmacy provides a premixed heparin bag containing $25,000\text{ units}$ in $250\text{ mL}$ of $0.9\%$ sodium chloride, and a separate heparin vial containing $1,000\text{ units/mL}$ for the bolus dose.

After administering the required bolus, at what rate in $\text{mL/hr}$ should the nurse set the IV pump for the new continuous infusion? (Record your answer to the nearest tenth.)

A nurse is preparing to administer a large-volume cleansing enema to an adult client who is experiencing severe constipation. Arrange the following steps of the procedure in the correct chronological order.

A nurse in a pediatric acute care unit is caring for a 9-year-old child admitted with a vaso-occlusive sickle cell crisis. The child's divorced parents are at the bedside, loudly blaming each other for the child's recent illness. The child begins to cry and reports a sudden increase in pain. In what order should the nurse take the following actions to manage this family dynamic and care for the child? (Arrange the actions from first to last.)

A public health nurse is conducting a wellness consultation for a 22-year-old client who regularly attends multi-day outdoor music festivals. The client confides in the nurse, stating, "I sometimes take MDMA so I have enough energy to dance all night, but I am careful to only take a small amount." Which response by the nurse demonstrates the most appropriate harm reduction strategy?

A community health nurse is evaluating a client's progression through the Transtheoretical Model of Change regarding weight management and cardiovascular risk reduction. Place the following client statements in chronological order representing the progression of behavioral change, from the earliest stage to the latest stage.

A nurse is preparing to assess an adult client for orthostatic hypotension to determine their risk for falls. In what order should the nurse perform the following actions to ensure accurate results?

A community health clinic nurse is working with a client who presents in a state of acute situational crisis following a sudden, unexpected job loss. The client appears highly distressed and overwhelmed. Arrange the following nursing interventions in the correct chronological order according to standard crisis intervention principles.

A 68-year-old male client presents to the outpatient clinic for an annual health maintenance visit. The client's past medical history includes essential hypertension and a 25-pack-year smoking history, though he reports successfully quitting smoking five years ago. When formulating the client's care plan, which action by the nurse represents an appropriate secondary disease prevention strategy specifically indicated for this client's demographic and risk profile?

A nurse is caring for a client with severe hyponatremia who becomes acutely confused and begins forcefully grasping at a newly inserted central venous catheter. To prevent a life-threatening hemorrhage, the nurse must initiate a medical-surgical restraint protocol. Arrange the following nursing actions in the correct chronological sequence from the initial clinical response to the final resolution.

A pediatric nurse is conducting a developmental assessment on a 6-month-old infant during a well-child visit. The infant was born at term with no prenatal complications. Which observation should the nurse identify as a potential developmental delay requiring further evaluation?

A 68-year-old client with severe osteoarthritis arrives on the orthopedic unit after undergoing a right total hip arthroplasty using a posterior surgical approach. The client is drowsy but responsive, with stable vital signs. Which action must the nurse prioritize to prevent dislocation of the new joint prosthesis?

A clinic nurse is assessing a 45-year-old client who brings in their 78-year-old parent with moderate Alzheimer's disease for a routine check-up. The client, who also has two teenagers at home, appears exhausted and tearful. The client states, 'I feel like I am failing everyone. I snap at my kids, and I lose my patience with my parent constantly.' Which of the following is the most appropriate initial action by the nurse?

A nurse at a student health center is caring for a young adult client who ingested a hallucinogenic substance and is experiencing acute panic, paranoia, and severe psychomotor agitation. Arrange the following nursing interventions in the most appropriate order of priority to safely manage and de-escalate the situation.

A client admitted to the medical-surgical unit is severely confused and continuously attempts to pull out a newly placed continuous bladder irrigation (CBI) catheter. After multiple alternative safety measures prove ineffective, the healthcare provider prescribes bilateral soft wrist restraints. Which action by the nurse regarding the management of these restraints is legally and clinically appropriate?

A nurse is evaluating a newly hired colleague who is preparing to administer an intravenous (IV) push medication into a client's existing primary IV line. Which actions by the newly hired colleague demonstrate safe parenteral medication administration? (Select all that apply.)

A nurse is caring for a client who is receiving intravenous fluid therapy via a subclavian central venous catheter. The nurse enters the room and observes that the intravenous tubing has disconnected from the catheter hub. The client is suddenly grasping their chest, gasping for air, and appears cyanotic. Arrange the following nursing interventions in the priority sequence they should be performed, from first to last.

A 31-week gestation client is admitted with preterm prelabor rupture of membranes (PPROM). The client is receiving a continuous intravenous infusion of magnesium sulfate for fetal neuroprotection, intravenous prophylactic ampicillin, and has recently received the first dose of intramuscular betamethasone. During the current assessment, the nurse notes the following findings: Maternal temperature is 38.3°C (100.9°F), blood pressure is 110/68 mmHg, heart rate is 118 bpm, and deep tendon reflexes are 1+. The fetal heart rate tracing reveals a baseline of 175 bpm with minimal variability and occasional early decelerations. The client reports new-onset diffuse abdominal tenderness. Based on these findings, which of the following is the priority nursing action?

A client receiving continuous enteral nutrition via a nasogastric (NG) tube has just returned to the medical-surgical unit following a diagnostic lumbar puncture. The healthcare provider has prescribed strict flat bed rest for 6 hours to minimize the risk of a post-dural puncture headache. Which nursing action safely integrates the client's continuous nutritional requirements with the prescribed post-procedure positioning?

A client on a medical-surgical unit has a hemoglobin level of 6.8 g/dL (68 g/L) and is prescribed a transfusion of packed red blood cells (PRBCs). The client has a single 20-gauge peripheral intravenous (IV) catheter, which is currently infusing a continuous maintenance fluid of 5% dextrose in water (D5W) at 75 mL/hr. What is the most appropriate action by the nurse?

A nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation. The ventilator settings include a positive end-expiratory pressure (PEEP) of 15 cm $H_2O$. The most recent arterial blood gas (ABG) analysis indicates a pH of $7.29$, $PaCO_2$ of $54$ mm Hg, $HCO_3^-$ of $25$ mEq/L, and $PaO_2$ of $62$ mm Hg. Over the last $10$ minutes, the client's blood pressure drops rapidly from $115/72$ mm Hg to $82/48$ mm Hg, and the heart rate increases from $95$ to $132$ bpm. Which action should the nurse implement first to reduce the client's risk of imminent physiological collapse?