Tüm alıştırma soruları

3881 soru

Soru 2801Soru →

A client admitted with severe sepsis is receiving a continuous intravenous (IV) infusion of piperacillin/tazobactam through a peripheral IV catheter. The healthcare provider prescribes a scheduled dose of IV vancomycin 1,500 mg1,500\text{ mg}. The pharmacy dispenses the vancomycin in a 300 mL300\text{ mL} bag of 0.9%0.9\% sodium chloride. Institutional protocol requires vancomycin doses greater than 1,000 mg1,000\text{ mg} to be infused over a minimum of 90 minutes90\text{ minutes} to prevent adverse infusion reactions. The client has only one patent peripheral IV line. Which of the following is the most appropriate nursing action?

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Cevap: Pause the piperacillin/tazobactam infusion, flush the IV line thoroughly with 0.9%0.9\% sodium chloride, and infuse the vancomycin using a pump set at 200 mL/hr200\text{ mL/hr}.

Cevap

The correct action is to pause the primary continuous infusion of piperacillin/tazobactam, thoroughly flush the line with normal saline, infuse the vancomycin at the correctly calculated rate of 200 mL/hr200\text{ mL/hr}, and then flush again before restarting the primary infusion.
Piperacillin/tazobactam and vancomycin are physically incompatible and will form a precipitate if mixed in the same IV tubing. Because the client only has one peripheral access site, the nurse must use the stop-flush-administer-flush-restart method to ensure the medications never come into contact. Additionally, the nurse must correctly calculate the infusion rate to meet the 90-minute protocol. To administer a 300 mL300\text{ mL} volume over 90 minutes90\text{ minutes} (1.5 hours1.5\text{ hours}), the pump must be set to 200 mL/hr200\text{ mL/hr} (300÷1.5=200300 \div 1.5 = 200). This ensures the vancomycin is given safely and prevents vancomycin flushing syndrome (previously known as Red Man syndrome).

Adım Adım Çözüm

1
Evaluate the compatibility of the prescribed intravenous medications.
Vancomycin and piperacillin/tazobactam are physically incompatible at the Y-site.
When mixed, these two medications form a visible precipitate that can occlude the catheter or cause a fatal embolus, meaning they cannot run concurrently.
2
Determine the proper administration technique for a single IV line.
The nurse must use the stop-flush-administer-flush-restart sequence.
Flushing the line with a neutral compatible fluid (like 0.9%0.9\% sodium chloride) before and after the secondary medication prevents the incompatible drugs from ever coming into contact.
3
Calculate the correct infusion pump rate in mL/hr.
The pump should be set to 200 mL/hr200\text{ mL/hr}.
The formula is Total VolumeTime in hours\frac{\text{Total Volume}}{\text{Time in hours}}. Converting 90 minutes90\text{ minutes} to 1.5 hours1.5\text{ hours}: 300 mL1.5 hours=200 mL/hr\frac{300\text{ mL}}{1.5\text{ hours}} = 200\text{ mL/hr}.

Anahtar Kavram

IV Medication Incompatibility Management and Infusion Rate Calculation
Tahmini Süre:1m 30s
Soru 2802Soru →

During the management of a critically ill adult in the intensive care unit, a triple-lumen central venous catheter (CVC) is utilized for multiple continuous infusions. The client's distal lumen is infusing epinephrine to maintain hemodynamic stability, the medial lumen is reserved for continuous total parenteral nutrition (TPN), and the proximal lumen is delivering a standard heparin protocol. Suddenly, the cardiac monitor displays symptomatic supraventricular tachycardia (SVT), and the healthcare provider prescribes an immediate dose of adenosine via rapid intravenous push. Which parenteral administration technique represents the safest clinical judgment?

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Cevap: Pause the heparin infusion, aspirate blood from the proximal lumen to clear residual medication, flush with 0.9% sodium chloride, rapidly administer the adenosine followed by a 20 mL flush, and restart the heparin.

Cevap

The safest method is to pause the heparin infusion, aspirate the residual drug from the proximal lumen, flush with saline, administer the adenosine, flush again, and restart the heparin.
The option describing pausing the heparin, aspirating the line, and flushing before and after administration is correct because it identifies the only safe lumen to use. Aspiration is critical; it removes the residual heparin in the catheter's dead space, preventing an accidental bolus. A brief pause in heparin therapy will not harm the client, and this route provides the necessary central access for a drug with an ultra-short half-life like adenosine.

Adım Adım Çözüm

1
Analyze the pharmacological properties of the prescribed emergency medication.
Adenosine has an ultra-short half-life (under 10 seconds) and requires rapid IV push followed immediately by a rapid flush. Central venous access is highly advantageous for delivery directly to the heart.
Understanding the pharmacokinetic requirements dictates the need for the fastest and most direct intravenous route available.
2
Evaluate the safety of utilizing the distal lumen infusing epinephrine.
The catheter tubing (dead space) is filled with concentrated epinephrine. Flushing this line to push adenosine would simultaneously deliver a massive bolus of epinephrine into the central circulation.
Administering a bolus of a potent chronotropic/vasopressor agent to a client in symptomatic SVT could trigger a lethal hypertensive crisis or myocardial infarction. This lumen is contraindicated for flushing.
3
Evaluate the safety of utilizing the medial lumen infusing TPN.
Standard parenteral therapy protocols strictly prohibit administering IV push medications through a TPN line due to extreme incompatibility risks, lipid emulsion destabilization, and high infection rates.
Maintaining the integrity of a dedicated TPN line is a core patient safety standard.
4
Determine the optimal management of the proximal lumen infusing heparin.
Heparin has a comparatively longer half-life and does not cause immediate hemodynamic collapse if paused for one minute. By pausing the infusion and aspirating the blood/drug from the dead space, the nurse safely clears the lumen.
Aspiration prevents an unintended heparin bolus. This provides a safe, clear central pathway for the emergency administration of adenosine without delaying care to start a peripheral line.

Anahtar Kavram

Central Venous Catheter Dead Space and High-Alert Medication Compatibility
Soru 2803Soru →

A client is receiving a high therapeutic dose of radioactive iodine (I-131) for the treatment of thyroid cancer. A few hours after the dose is administered, the client accidentally spills a large amount of urine on the hospital room floor. Which action should the nurse take first?

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Cevap: Cover the spill with absorbent paper pads and immediately contact the facility's Radiation Safety Officer.

Cevap

The priority action is to cover the radioactive spill with absorbent paper pads to contain it and immediately contact the facility's Radiation Safety Officer.
When an unsealed radioactive source (like I-131 urine) is spilled, the primary goals are containment and specialized cleanup. Covering the spill with absorbent pads achieves immediate containment without spreading the liquid. The Radiation Safety Officer must then be contacted to manage the actual cleanup and testing of the area to ensure safe radiation levels.

Adım Adım Çözüm

1
Recognize the specific hazard associated with I-131 treatment.
Identify that the client's bodily fluids, particularly urine, are highly radioactive.
I-131 is an unsealed radioactive isotope excreted primarily through the renal system.
2
Determine the safest immediate intervention to manage a radioactive liquid spill.
Cover the fluid with absorbent material (such as chux pads) without attempting to wipe it up.
Covering the liquid prevents it from spreading or being tracked across the floor by foot traffic, which would expand the zone of radioactive contamination.
3
Identify the appropriate personnel to manage the radioactive decontamination.
Notify the Radiation Safety Officer (RSO).
Radioactive spills require specialized decontamination kits, dosimeter monitoring, and specific disposal protocols that must be overseen by the RSO.

Anahtar Kavram

Management of Unsealed Radioactive Spills
Soru 2804Soru →

A nurse is preparing to provide a bed bath and perineal care for a client who is receiving continuous enteral nutrition via a nasogastric tube. The procedure requires lowering the head of the bed to a flat, supine position. Which of the following is the priority action for the nurse to take?

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Cevap: Pause the continuous enteral feeding infusion pump.

Cevap

The priority action is to pause the continuous enteral feeding infusion pump.
When a client is receiving continuous enteral feedings, the head of the bed must remain elevated to at least 30 to 45 degrees to prevent gastric reflux and pulmonary aspiration. If a nursing procedure such as a bed bath or perineal care requires the client to be laid flat, the nurse must prioritize airway safety by pausing the enteral feeding pump before lowering the head of the bed.

Adım Adım Çözüm

1
Identify the client's current therapy and risks.
The client is receiving continuous enteral feeding, which places them at risk for aspiration if not positioned properly.
Recognizing aspiration risk is the first step in prioritizing safe care.
2
Determine the positioning requirement for the upcoming procedure.
A bed bath and perineal care require the head of the bed to be lowered to a flat, supine position.
Understanding the physical requirements of the nursing intervention allows the nurse to anticipate safety hazards.
3
Implement the highest-priority safety intervention.
Pause the continuous enteral feeding infusion before lowering the bed.
Pausing the feeding protects the client's airway and prevents aspiration of gastric contents while they are in a supine position.

Anahtar Kavram

Aspiration Precautions and Enteral Feeding
Soru 2805Soru →

A public health nurse is utilizing the Transtheoretical Model of Change to counsel a client regarding smoking cessation. Arrange the following nursing interventions in the chronological order that they should be implemented as the client progresses through the stages of change, from earliest to latest.

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Cevap

The correct chronological order aligns with the Transtheoretical Model of Change: Precontemplation, Contemplation, Preparation, Action, and finally Maintenance.
The Transtheoretical Model of Change requires nurses to tailor their interventions to the client's current readiness to change. The chronological progression begins with Precontemplation (building awareness by providing objective risk information), moves to Contemplation (weighing pros and cons to resolve ambivalence), then Preparation (setting a specific quit date), followed by Action (managing immediate cravings as behavior changes), and concludes with Maintenance (preventing relapse during high stress).

Adım Adım Çözüm

1
Identify the stage of change associated with providing objective health risks.
Precontemplation stage.
Clients in this stage do not intend to take action in the foreseeable future, so the nurse must raise awareness without causing defensiveness.
2
Identify the stage of change associated with exploring pros and cons.
Contemplation stage.
Clients are ambivalent in this stage; motivational interviewing techniques help resolve this ambivalence by weighing the benefits of change against the barriers.
3
Identify the stage of change associated with establishing a target quit date.
Preparation stage.
The client intends to take action in the immediate future and requires assistance in creating a specific, actionable plan.
4
Identify the stage of change associated with teaching strategies for acute nicotine cravings.
Action stage.
The client has made specific overt modifications to their lifestyle and needs immediate coping skills to sustain the cessation effort.
5
Identify the stage of change associated with discussing relapse prevention during high stress.
Maintenance stage.
The client is working to prevent relapse and consolidate the health gains attained during the action phase over a long period.

Anahtar Kavram

Applying the Transtheoretical Model (Stages of Change) to sequence nursing interventions for health promotion and lifestyle modification.
Soru 2806Soru →

A registered nurse is preparing to administer a prescribed intravenous (IV) loading dose of phenytoin to an adult client experiencing recurrent generalized seizures. Which of the following nursing actions are necessary during the preparation and administration of this parenteral medication? (Select all that apply.)

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Cevap: Administer the medication via an infusion pump at a continuous rate not exceeding 50 mg/min50\text{ mg/min}.; Attach a 0.220.22-micron in-line filter to the intravenous tubing prior to starting the infusion.; Assess the intravenous insertion site frequently for localized tissue swelling, pain, or discoloration.

Cevap

The correct actions are to administer the medication at a rate not exceeding 50 mg/min50\text{ mg/min}, attach a 0.220.22-micron in-line filter, and frequently assess the IV insertion site for signs of extravasation.
Phenytoin is a high-alert anti-seizure medication with strict administration parameters. It must be administered slowly (maximum 50 mg/min50\text{ mg/min}) to prevent life-threatening cardiovascular collapse, requires an in-line filter to catch micro-crystals, and necessitates close IV site monitoring because it is a vesicant that can cause severe tissue necrosis if extravasation occurs.

Adım Adım Çözüm

1
Identify the specific administration requirements and compatibilities for intravenous phenytoin.
Phenytoin precipitates in dextrose and requires normal saline (0.9%0.9\% NaCl) and an in-line filter.
To prevent crystallization and embolization in the vascular system.
2
Determine the maximum safe administration rate for IV phenytoin in an adult.
The maximum safe continuous rate is 50 mg/min50\text{ mg/min}.
Rapid administration of phenytoin can cause severe hypotension, bradycardia, and cardiovascular collapse.
3
Recognize the tissue toxicity risk associated with phenytoin extravasation.
The nurse must continuously and closely monitor the IV insertion site.
Phenytoin is highly alkaline and a potent vesicant that can cause Purple Glove Syndrome and severe tissue necrosis if it leaks into surrounding tissues.
4
Evaluate the safety of delegating client monitoring during high-risk intravenous infusions.
The registered nurse must retain direct responsibility for assessing hemodynamics and cardiac rhythms.
Assessing a client's physiological response to a high-alert medication requires specialized nursing knowledge and clinical judgment that cannot be delegated to unlicensed assistive personnel.

Anahtar Kavram

Safe Intravenous Administration of Phenytoin
Soru 2807Soru →

The registered nurse (RN) receives the morning shift report for a group of clients on a medical-surgical unit. Which client should the nurse assess first?

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Cevap: A client admitted 48 hours ago for a gastric ulcer with a history of heavy daily alcohol consumption, who is now experiencing new-onset anxiety, diaphoresis, and a heart rate of 118 beats/min.

Cevap

The client admitted 48 hours ago who is experiencing new-onset anxiety, diaphoresis, and tachycardia requires the most immediate assessment.
The correct answer identifies the client at the highest risk for sudden physiological deterioration. Alcohol withdrawal symptoms typically begin 6 to 8 hours after the last drink and peak between 24 and 72 hours. Anxiety, diaphoresis, and tachycardia (a heart rate of 118 beats/min) are early autonomic signs of withdrawal. Without immediate assessment and administration of cross-tolerant medications (such as benzodiazepines), this client is at high risk for progressing to withdrawal seizures or delirium tremens, which are potentially fatal medical emergencies.

Adım Adım Çözüm

1
Analyze each client's clinical presentation to determine physiological stability.
Three clients are physiologically stable or experiencing non-life-threatening conditions, while one client is exhibiting signs of a potentially fatal complication.
Safe prioritization requires identifying the client with the most immediate threat to life, circulation, or risk of severe neurological deterioration.
2
Evaluate the client with a history of heavy alcohol use exhibiting tachycardia, anxiety, and diaphoresis at 48 hours post-admission.
These findings are recognized as early autonomic indicators of acute alcohol withdrawal.
Alcohol withdrawal symptoms typically peak between 24 and 72 hours after the last drink and can rapidly progress to life-threatening withdrawal seizures or delirium tremens without prompt pharmacological intervention.

Anahtar Kavram

Prioritizing care for clients experiencing acute substance withdrawal
Soru 2808Soru →

An occupational health nurse is evaluating an employee who reports chronic headaches, recent-onset insomnia, and frequent irritability. The employee states, 'My workload has doubled over the last three months, and I feel like I am completely failing at my job and my life.' Which action should the nurse take first?

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Cevap: Determine the specific methods the employee is currently using to cope with the increased demands.

Cevap

Determine the specific methods the employee is currently using to cope with the increased demands.
In any psychosocial crisis or high-stress situation, the first step of the nursing process is assessment. The nurse must determine what coping mechanisms the client is already using to evaluate their effectiveness and identify any maladaptive behaviors. This information is essential before developing a plan of care or implementing stress management interventions.

Adım Adım Çözüm

1
Analyze the client's statement and presentation.
The client is experiencing acute occupational stress with physical and emotional manifestations (headaches, insomnia, feeling of failure).
Identifying the core issue is necessary to determine the appropriate nursing response.
2
Apply the nursing process (ADPIE) to prioritize the action.
Assessment is the first step. The nurse needs more information about the client's current state.
Before any interventions (teaching, referrals, advice) can be provided, the nurse must assess existing coping skills to identify strengths and maladaptive behaviors.
3
Evaluate the options based on therapeutic communication guidelines.
Options involving giving advice or false reassurance are non-therapeutic and should be eliminated.
Therapeutic communication focuses on exploring the client's feelings and promoting autonomous problem-solving.

Anahtar Kavram

Nursing Process in Psychosocial Care
Soru 2809Soru →

An occupational health nurse is conducting an annual wellness assessment for a 52-year-old client. According to Erikson's theory of psychosocial development, which statements by the client indicate successful mastery of the primary developmental task for this age group? Select all that apply.

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Cevap: I volunteered to serve as a professional mentor for the junior staff at my workplace.; I dedicate every Saturday morning to coaching a local youth soccer team.; I am coordinating a community garden project that involves several local families.

Cevap

The statements indicating successful mastery are volunteering as a professional mentor, coaching a youth soccer team, and coordinating a community garden project.
For a 52-year-old client (middle adulthood), the primary developmental task is Generativity vs. Stagnation. Generativity is achieved by contributing to society, guiding the next generation, and leaving a positive legacy. Statements about mentoring junior staff, coaching youth sports, and leading community projects all demonstrate active engagement in fostering the growth of others, which is the hallmark of generativity.

Adım Adım Çözüm

1
Identify the client's developmental stage based on their age.
The client is 52 years old, placing them in the middle adulthood stage according to Erikson's theory.
Developmental tasks are age-specific and form the basis for psychosocial assessment.
2
Determine the primary Erikson developmental task for middle adulthood.
The primary task for middle adulthood (ages 40-65) is Generativity vs. Stagnation.
Knowing the correct task is necessary to evaluate the client's statements.
3
Evaluate each statement to see if it aligns with generativity.
Mentoring, coaching, and coordinating community projects represent generativity (contributing to society and future generations). Finding a partner (intimacy), reflecting on life completion (ego integrity), and self-absorption (stagnation) do not.
This differentiates successful mastery of the current stage from failure, previous stages, or future stages.

Anahtar Kavram

Erikson's Stages of Psychosocial Development: Generativity vs. Stagnation
Soru 2810Soru →

A nurse is closely monitoring a client who is 4 hours postoperative following an open abdominal surgery. Which of the following assessment findings should the nurse recognize as early indicators of impending hemorrhagic shock? Select all that apply.

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Cevap: Unexplained restlessness and agitation; A progressive narrowing of the pulse pressure; Mild tachycardia with a heart rate of 110 beats per minute

Cevap

The early indicators of hemorrhagic shock include unexplained restlessness and agitation, a progressive narrowing of the pulse pressure, and mild tachycardia.
In the early (compensatory) stage of hemorrhagic shock, the sympathetic nervous system activates to maintain adequate tissue perfusion. This results in mild tachycardia to increase cardiac output. Peripheral vasoconstriction increases diastolic blood pressure, leading to a narrowed pulse pressure. Additionally, subtle decreases in cerebral perfusion manifest early as restlessness, anxiety, or agitation.

Adım Adım Çözüm

1
Identify the physiological changes associated with early (compensatory) shock.
The body activates the sympathetic nervous system in an attempt to maintain tissue perfusion and cardiac output.
Compensatory mechanisms mask significant blood pressure changes early in the process.
2
Analyze how these compensatory mechanisms manifest clinically.
Epinephrine and norepinephrine release causes an increased heart rate, peripheral vasoconstriction, and shunting of blood to vital organs.
This leads to tachycardia, cool skin, and a rising diastolic pressure (narrowing pulse pressure).
3
Differentiate between early signs and late (decompensated) signs.
Tachycardia, narrowing pulse pressure, and subtle cerebral hypoxia (restlessness) appear early. Severe hypotension and organ failure appear late.
Interventions must begin during the early phase before irreversible cellular damage occurs.

Anahtar Kavram

Early Recognition of Compensatory Shock
Soru 2811Soru →

A registered nurse is preparing to access a client's implanted venous access port (Port-a-Cath) to administer a scheduled intravenous infusion. Arrange the following steps in the correct chronological order to safely perform this procedure.

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Cevap

The correct sequence begins with standard preparation (mask, positioning, hand hygiene), followed by preparing the sterile equipment. Next, the skin is cleansed with chlorhexidine. Once dry, the nurse accesses the port with a 90-degree insertion, immediately aspirates to verify blood return, and finally flushes the line and secures the dressing.
Accessing an implanted port requires strict adherence to sterile technique and procedural sequencing to prevent central line-associated bloodstream infections (CLABSI) and mechanical complications. The sequence transitions systematically from environmental control (masks, hand hygiene) to sterile preparation (gloves, priming), then to patient preparation (chlorhexidine scrub). Once the site is prepared and dry, mechanical access is safely achieved by stabilizing the port and inserting the non-coring needle. Finally, verifying patency via aspiration must immediately precede flushing and securing the device.

Adım Adım Çözüm

1
Ensure droplet protection and hand hygiene.
The nurse and client are masked, and hands are clean.
Prevents respiratory pathogens from contaminating the central venous access site.
2
Prepare the sterile field and prime the tubing.
The non-coring needle and extension set are filled with sterile saline.
Air must be removed from the tubing to prevent a potentially fatal air embolism during access.
3
Scrub the site with chlorhexidine and let it dry.
The skin over the port is disinfected.
Friction removes surface bacteria, and drying is required for chlorhexidine to effectively eradicate microbes.
4
Access the port with the non-coring needle.
The needle is seated within the port's reservoir.
A 90-degree angle ensures the needle penetrates the self-sealing silicone septum without coring or damaging it.
5
Aspirate for blood return.
Blood is seen in the extension tubing.
Confirms the tip of the catheter is properly situated in the central circulation, ensuring safe administration of medications.
6
Flush the port and dress the site.
The line is cleared of blood and secured with a transparent dressing.
Flushing prevents fibrin buildup or clotting in the catheter, while the dressing prevents displacement and contamination.

Anahtar Kavram

Implanted Venous Access Port (Port-a-Cath) Access Procedure
Soru 2812Soru →

During a care conference, the parents of a 22-year-old client with newly diagnosed advanced lymphoma request that the healthcare team withhold the full prognosis to protect the client from emotional distress. The client is cognitively intact and has explicitly asked the nurse for complete transparency regarding the illness. Which nursing actions appropriately address this family conflict? Select all that apply.

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Cevap: Explore the parents' underlying fears and the cultural context influencing their request to withhold the prognosis.; Explain to the parents that the client's adult status requires the medical team to share all health information directly with the client.; Offer to arrange a facilitated family meeting with the provider and social worker to help the family navigate communication preferences.

Cevap

The correct actions include exploring the parents' underlying fears, explaining the legal obligation to inform the adult client, and arranging a facilitated family meeting.
Managing complex family dynamics requires balancing empathy for the family's distress with the ethical mandate to uphold the client's autonomy. Exploring the parents' concerns validates their feelings and builds trust. Clearly stating the legal and ethical boundaries ensures the adult client's rights are protected. Finally, arranging a facilitated interdisciplinary meeting promotes healthy family communication and prevents staff triangulation.

Adım Adım Çözüm

1
Analyze the family dynamic and competing needs.
Identified a conflict between the parents' protective instincts (driven by fear or grief) and the adult client's right to autonomy and truth-telling.
Understanding the root cause of the family's behavior is essential before intervening.
2
Determine the legal and ethical boundaries.
Recognized that a cognitively intact 22-year-old adult has the legal right to receive all medical information, superseding the parents' wishes.
Nurses must advocate for client autonomy and uphold the ethical principle of veracity (truth-telling).
3
Select interventions that support both the client and the family unit.
Chose actions that validate the parents' distress, educate them on legal boundaries, and utilize interdisciplinary support to facilitate healthy communication.
Effective family nursing addresses the needs of the entire family system while prioritizing the primary client.

Anahtar Kavram

Family Dynamics, Autonomy, and Therapeutic Communication
Soru 2813Soru →

An 82-year-old client is accompanied by their adult child to a primary health consultation. The child expresses concern regarding several physical changes observed since the client relocated to the child's home. The evaluating nurse must distinguish between typical senescence and indications of pathological disease. Which of the following assessment findings represent expected physiological adaptations of the aging process? Select all that apply.

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Cevap: Decreased chest wall compliance and a reduction in pulmonary vital capacity; A delayed and diminished baroreceptor reflex in response to postural changes; Decreased sensitivity to the sensation of thirst and an overall reduction in total body water

Cevap

The expected physiological adaptations of the aging process are decreased chest wall compliance with a reduction in vital capacity, a delayed baroreceptor reflex, and decreased sensitivity to thirst with an overall reduction in total body water.
Normal physiological adaptations of the aging process include a decline in homeostatic reserves across multiple systems. Decreased chest wall compliance reduces vital capacity, delayed baroreceptor reflexes increase orthostatic hypotension risk, and a diminished thirst mechanism combined with reduced total body water increases dehydration risk. These findings are expected and require anticipatory guidance rather than acute medical intervention.

Adım Adım Çözüm

1
Analyze the stem requirement.
The question asks to identify expected physiological changes of aging (senescence) as opposed to signs of pathological disease.
Differentiating normal aging from pathology is essential to prevent dismissing serious medical conditions as typical aging.
2
Evaluate the respiratory and cardiovascular options.
Decreased chest wall compliance and a diminished baroreceptor reflex are normal age-related changes. A new S3 heart sound indicates fluid overload (heart failure) and is pathological.
Structural changes like calcification and decreased elasticity are normal, but acute organ failure signs (S3 gallop) require intervention.
3
Evaluate the neurological, renal, and genitourinary options.
Decreased thirst and reduced total body water are expected changes. However, acute cognitive fluctuations (delirium) and new-onset urge incontinence are pathological.
Delirium and incontinence are common in older adults but are always considered abnormal and require investigation for underlying causes like infection.

Anahtar Kavram

Differentiating expected physiological changes of aging from pathological disease processes in older adults.
Soru 2814Soru →

An adult client with symptomatic anemia is scheduled to receive a transfusion of packed red blood cells. The healthcare provider has prescribed the blood product to be infused over two hours. Which of the following intravenous fluids must the nurse select to prime the blood administration tubing?

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Cevap: 0.9%0.9\% sodium chloride

Cevap

The correct answer is 0.9%0.9\% sodium chloride.
0.9%0.9\% sodium chloride (normal saline) is the only intravenous fluid compatible with packed red blood cells. It is an isotonic solution that does not cause red blood cells to shrink or swell, and it lacks additives that promote coagulation, making it uniquely safe for priming tubing and flushing the line before and after a transfusion.

Adım Adım Çözüm

1
Identify the required procedure.
The nurse is preparing to administer a transfusion of packed red blood cells.
Blood product administration requires strict adherence to compatibility protocols to prevent life-threatening adverse reactions.
2
Recall compatibility rules for blood transfusions.
Blood products are highly incompatible with most intravenous fluids, medications, and parenteral nutrition.
Incompatible solutions can cause the red blood cells to lyse (break open) or coagulate inside the tubing.
3
Select the appropriate priming fluid.
0.9%0.9\% sodium chloride is selected.
It is an isotonic solution without calcium or dextrose, making it the only safe option for priming and flushing blood administration lines.

Anahtar Kavram

0.9% sodium chloride (normal saline) is the only intravenous fluid approved for use with blood product transfusions to prevent cellular damage and clotting.
Soru 2815Soru →

A client has just arrived on the medical unit after undergoing a bedside lumbar puncture. To minimize the risk of developing a cerebrospinal fluid leak and subsequent headache, which of the following positioning interventions should the nurse implement?

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Cevap: Maintain the client in a supine position with the bed flat

Cevap

The correct intervention is to maintain the client in a supine position with the bed flat.
Following a lumbar puncture, maintaining the client in a flat, supine position for a prescribed period helps prevent the leakage of cerebrospinal fluid from the dural puncture site, thereby significantly reducing the risk of a post-dural puncture headache.

Adım Adım Çözüm

1
Identify the procedure performed and its primary post-procedure complication.
The client underwent a lumbar puncture, which carries a significant risk of cerebrospinal fluid (CSF) leakage and a resulting post-dural puncture headache.
Recognizing the specific risks associated with an invasive procedure is the first step in risk reduction.
2
Determine the appropriate physiological intervention to mitigate this risk.
Keeping the client supine and flat minimizes hydrostatic pressure at the dural puncture site in the lumbar spine.
Lower pressure at the puncture site allows the dural tissue to seal effectively, preventing ongoing CSF loss and avoiding the severe headache associated with decreased CSF volume.

Anahtar Kavram

Post-Lumbar Puncture Positioning and Complication Prevention
Soru 2816Soru →

A clinic nurse is developing a plan of care for a young adult client who was recently diagnosed with multiple sclerosis. The client reports feeling overwhelmed, experiencing difficulty sleeping, and states, 'I feel like I have absolutely no control over my life or my future anymore.' Which of the following nursing interventions are appropriate to promote effective stress management? Select all that apply.

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Cevap: Assist the client in identifying aspects of their daily routine that remain within their control.; Instruct the client on how to perform progressive muscle relaxation techniques before bedtime.; Encourage the client to keep a daily journal to recognize specific emotional triggers.

Cevap

The appropriate interventions are to assist the client in identifying controllable aspects of their daily routine, instruct them on progressive muscle relaxation techniques, and encourage daily journaling.
Effective stress management involves empowering the client, promoting healthy emotional processing, and utilizing physiological relaxation. Helping the client identify controllable factors restores a sense of autonomy. Progressive muscle relaxation directly targets physical tension and insomnia. Journaling provides a safe outlet for emotional expression and helps identify specific anxiety triggers.

Adım Adım Çözüm

1
Assess the client's current emotional response and primary stressors.
The client is experiencing acute stress, sleep difficulty, and a profound sense of powerlessness related to a new chronic illness diagnosis.
Understanding the specific manifestations of the client's stress is necessary to select targeted therapeutic interventions.
2
Identify interventions that promote active coping and physiological relaxation.
Journaling, progressive muscle relaxation, and focusing on controllable factors are identified as effective, therapeutic strategies.
These strategies directly address the client's sleep disturbances, emotional overwhelmingness, and perceived loss of control.
3
Eliminate interventions that utilize non-therapeutic communication techniques.
Avoiding discussion and providing false reassurance are eliminated.
These actions invalidate the client's feelings, promote emotional suppression, and block the therapeutic relationship.

Anahtar Kavram

Therapeutic interventions for stress management involve empowering the client, encouraging healthy emotional expression, and teaching physiological relaxation techniques while avoiding communication blocks.
Soru 2817Soru →

A maternity clinic nurse is conducting an initial prenatal visit for a client at 8 weeks gestation. The client confides, "I usually drink heavily on the weekends, and I had a few episodes of binge drinking before I knew I was pregnant. I am terrified that I have already caused permanent harm to my baby." Which response by the nurse is the most appropriate?

Cevabı ve açıklamayı göster

Cevap: Let us discuss how alcohol impacts fetal development and work together on a plan to help you maintain abstinence during your pregnancy.

Cevap

The most appropriate response is to discuss the impact of alcohol on fetal development and collaboratively plan for complete abstinence.
The correct response utilizes therapeutic communication by acknowledging the high-risk behavior without judgment, offering factual education regarding fetal development, and establishing a collaborative partnership to achieve the vital goal of alcohol abstinence for the remainder of the pregnancy.

Adım Adım Çözüm

1
Analyze the client's statement and emotional state.
The client is expressing severe guilt and fear regarding a high-risk behavior (binge drinking) during the highly sensitive early weeks of pregnancy.
Identifying the client's emotional distress and the clinical risk is necessary to formulate a response that is both therapeutic and clinically sound.
2
Evaluate the communication options based on therapeutic principles.
The correct response must avoid judgment, refrain from providing false reassurance, and directly address the clinical need for behavioral modification.
Therapeutic communication fosters trust and encourages honesty while promoting client safety and optimal health outcomes.
3
Select the most appropriate nursing response.
Choosing the response that offers factual education and a collaborative approach to maintaining abstinence is the best intervention.
This approach directly addresses the high-risk behavior, empowers the client, and promotes maternal-fetal health without alienating the client.

Anahtar Kavram

Therapeutic Communication in High-Risk Prenatal Care
Soru 2818Soru →

A nurse is administering an intramuscular injection to a client and sustains a percutaneous needlestick injury from the used needle. Arrange the following actions the nurse should take in the correct order of priority.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The nurse should first remove the contaminated gloves, then wash the puncture site with soap and water, notify the nursing supervisor, report to occupational health for evaluation, and finally complete the facility incident report.
According to occupational safety and CDC guidelines for bloodborne pathogen exposure, the nurse must prioritize physiological safety. The sequence begins with removing contaminated PPE (gloves) and immediately performing first aid by washing the puncture site with soap and water. Once decontamination is complete, the nurse must notify the supervisor to activate the facility's exposure protocol. This facilitates the next step of immediate medical evaluation at occupational health or the emergency department, where post-exposure prophylaxis (PEP) can be initiated if necessary. Finally, the nurse completes the incident report, as administrative tasks are the lowest priority and must not delay care.

Adım Adım Çözüm

1
Secure immediate physiological safety.
Gloves are removed and the wound is cleansed.
First aid and decontamination are the highest priorities to minimize pathogen absorption.
2
Activate the facility's post-exposure protocol.
The supervisor is informed and medical evaluation is sought.
The chain of command facilitates immediate medical care, post-exposure prophylaxis evaluation, and source client testing.
3
Fulfill administrative requirements.
An incident report is filed.
Documentation provides a legal and occupational record of the event but must not delay first aid or medical care.

Anahtar Kavram

Occupational Exposure and Bloodborne Pathogen Protocol
Soru 2819Soru →

The nurse is reviewing the care plan for a client who is 48 hours postoperative following a right below-the-knee amputation. Which interventions are appropriate to include in the client's basic care and comfort management? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Assist the client into a prone position for 30 minutes, three to four times a day.; Wash the residual limb daily with mild soap and water, ensuring the skin is patted completely dry.

Cevap

The appropriate interventions are assisting the client into a prone position several times a day and washing the residual limb daily with mild soap and water.
To prevent hip flexion contractures, which can severely impair future prosthetic use and mobility, the client should be placed in a prone position for 20 to 30 minutes, three to four times a day. Additionally, basic hygiene involving gentle washing with mild soap and water, followed by complete drying, is essential to maintain skin integrity, provide comfort, and prevent infection at the surgical site.

Adım Adım Çözüm

1
Analyze the client's postoperative timeframe and clinical needs.
The client is 48 hours post-amputation; the primary goals for basic care are preventing contractures, maintaining skin integrity, and promoting mobility.
Understanding the timeline is crucial, as certain interventions (like elevation) change after the first 24 hours.
2
Evaluate the positioning options provided.
Prone positioning prevents contractures and is correct. Elevation on pillows and prolonged sitting cause contractures and are incorrect.
Hip flexion contractures are a major complication following lower extremity amputations that impede future prosthetic use.
3
Evaluate the delegation and hygiene options.
Delegating assessment to a UAP is outside their scope of practice. Gentle washing and drying of the limb is standard, appropriate basic care.
Ensuring safe delegation and standard infection prevention are core components of basic care and comfort.

Anahtar Kavram

Post-amputation basic care and contracture prevention
Soru 2820Soru →

A registered nurse in the cardiovascular intensive care unit is caring for a client with severe decompensated heart failure.

Client data:
- Weight: 176 lb176\text{ lb}
- Current cardiac index (CI): 1.8 L/min/m21.8\text{ L/min/m}^2
- Current dobutamine infusion rate: 12 mL/hr12\text{ mL/hr}
- Intravenous fluid bag: Dobutamine 500 mg500\text{ mg} in 250 mL250\text{ mL} of 5% Dextrose in Water (D5W)5\%\text{ Dextrose in Water (D5W)}

The unit's hemodynamic titration protocol states: "If CI is <2.0 L/min/m2< 2.0\text{ L/min/m}^2, increase dobutamine infusion by 2.5 mcg/kg/min2.5\text{ mcg/kg/min} every 30 minutes until CI is ≥2.0 L/min/m2\geq 2.0\text{ L/min/m}^2. Maximum dose: 20 mcg/kg/min20\text{ mcg/kg/min}."

The nurse evaluates the client's current status and determines a titration is required. Based on the protocol, what should the nurse set the new infusion rate to in mL/hr\text{mL/hr}? Record your answer to the nearest whole number.

Cevabı ve açıklamayı göster

Cevap: 18

Cevap

18
The correct infusion rate is 18 mL/hr. This is determined by first converting the client's weight to kilograms (80 kg) and finding the medication concentration (2000 mcg/mL). The current dose is calculated by multiplying the rate (12 mL/hr) by the concentration and dividing by time and weight, yielding 5 mcg/kg/min. Based on the low cardiac index, the protocol requires a 2.5 mcg/kg/min increase, making the new target dose 7.5 mcg/kg/min. Multiplying this target dose by the client's weight (80 kg) and time (60 minutes) yields 36,000 mcg/hr. Dividing by the concentration (2000 mcg/mL) provides the final pump setting of 18 mL/hr.

Adım Adım Çözüm

1
Convert the client's weight from pounds to kilograms.
176 lb÷2.2 lb/kg=80 kg176\text{ lb} \div 2.2\text{ lb/kg} = 80\text{ kg}
Weight-based continuous medication infusions require the client's weight in kilograms for accurate dosing.
2
Calculate the concentration of the dobutamine solution in mcg/mL\text{mcg/mL}.
500 mg=500,000 mcg500\text{ mg} = 500,000\text{ mcg}; 500,000 mcg÷250 mL=2000 mcg/mL500,000\text{ mcg} \div 250\text{ mL} = 2000\text{ mcg/mL}
Establishing the concentration is necessary to convert between liquid volume (mL) and drug mass (mcg).
3
Calculate the current rate in mcg/min\text{mcg/min} to determine the current weight-based dose.
12 mL/hr×2000 mcg/mL=24,000 mcg/hr12\text{ mL/hr} \times 2000\text{ mcg/mL} = 24,000\text{ mcg/hr}; 24,000÷60=400 mcg/min24,000 \div 60 = 400\text{ mcg/min}
The protocol dictates titration based on the current dose in mcg/kg/min\text{mcg/kg/min}, requiring a reverse calculation from the current pump setting.
4
Divide the mcg/min\text{mcg/min} by the client's weight to find the current mcg/kg/min\text{mcg/kg/min}.
400 mcg/min÷80 kg=5 mcg/kg/min400\text{ mcg/min} \div 80\text{ kg} = 5\text{ mcg/kg/min}
This confirms the baseline dose before applying the hemodynamic titration protocol.
5
Determine the new target dose based on the client's cardiac index.
CI is 1.81.8 (which is <2.0< 2.0), so add 2.5 mcg/kg/min2.5\text{ mcg/kg/min}; 5+2.5=7.5 mcg/kg/min5 + 2.5 = 7.5\text{ mcg/kg/min}
The protocol mandates a specific incremental dose increase to improve cardiac output when CI is below target.
6
Calculate the total new dose required in mcg/hr\text{mcg/hr}.
7.5 mcg/kg/min×80 kg=600 mcg/min7.5\text{ mcg/kg/min} \times 80\text{ kg} = 600\text{ mcg/min}; 600×60=36,000 mcg/hr600 \times 60 = 36,000\text{ mcg/hr}
Pump rates are set in mL/hr\text{mL/hr}, so the target dose must be converted to an hourly amount.
7
Divide the hourly dose by the concentration to find the new rate in mL/hr\text{mL/hr}.
36,000 mcg/hr÷2000 mcg/mL=18 mL/hr36,000\text{ mcg/hr} \div 2000\text{ mcg/mL} = 18\text{ mL/hr}
This yields the final volume per hour to program into the intravenous infusion pump.

Anahtar Kavram

Titrating weight-based vasoactive infusions requires calculating the baseline dose from the existing rate, applying clinical parameters to determine the new target dose, and calculating forward to find the final pump setting in mL/hr.
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