Tüm alıştırma soruları

Following a diagnostic lumbar puncture to analyze cerebrospinal fluid, a client arrives on the medical-surgical unit. To effectively mitigate the risk of a post-dural puncture complication, which intervention is most appropriate for the nurse to implement?

A community health nurse is planning care for a multi-generational family during a home visit. The household consists of a 68-year-old with stage 3 chronic kidney disease, a 42-year-old female, a 26-year-old who is 28 weeks pregnant, and a 4-month-old infant. Which of the following nursing actions planned for this visit represents primary disease prevention?

A nurse is formulating a comprehensive care plan for an 82-year-old client with advanced Alzheimer's disease, severe osteoarthritis, and dysphagia who is currently receiving treatment for aspiration pneumonia. The client is confined to bed, requires continuous intravenous (IV) fluid therapy, and intermittently attempts to remove the IV catheter. Which of the following interventions should the nurse include in the plan of care to address the client's basic care and comfort needs? Select all that apply.

An interdisciplinary team is preparing to discharge a client who recently experienced a left-hemisphere cerebrovascular accident (CVA) with resulting right-sided hemiparesis. The primary nurse is finalizing the client's independent living and self-care directives. Which of the following interventions should the nurse incorporate into the plan of care? Select all that apply.

Following a percutaneous liver biopsy, a client is transferred back to the medical-surgical unit for recovery. To minimize the risk of hemorrhage from the puncture site, what is the most appropriate position for the nurse to place the client in?

A 52-year-old client is admitted to the recovery area immediately after a percutaneous liver biopsy. The client is currently drowsy but responds appropriately to verbal stimuli. Which nursing interventions must be implemented to minimize the risk of complications? Select all that apply.

During a scheduled home visit, a community health nurse is evaluating a 79-year-old client who lives independently. The client's adult children have expressed anxiety about recent alterations in their parent's overall condition, asking what changes represent normal aging. Which of the following clinical observations should the nurse recognize as an acute pathophysiological event demanding immediate medical evaluation?

A nurse is admitting a new client to an inpatient addiction treatment unit for the management of severe opioid use disorder. Arrange the following nursing actions in the correct sequence from first to last.

A 72-year-old client is 48 hours post-operative following a right above-the-knee amputation (AKA). The client is experiencing intermittent confusion, reports a "burning" sensation in the right foot, and frequently attempts to touch the surgical dressing. Which nursing action is most appropriate to promote the client's basic care, comfort, and safety?

A gravid client at $37$ weeks gestation is admitted with severe preeclampsia and requires magnesium sulfate therapy to prevent eclampsia, along with oxytocin for labor induction. The healthcare provider's orders include:

- Strict total intravenous fluid restriction of $125\text{ mL/hour}$.
- Magnesium sulfate maintenance infusion at $2\text{ grams/hour}$ (supplied as $20\text{ grams}$ in $500\text{ mL}$ of $0.9\%$ sodium chloride).
- Oxytocin continuous infusion at $12\text{ milliunits/minute}$ (supplied as $30\text{ units}$ in $500\text{ mL}$ of Lactated Ringer's).
- A primary intravenous line of Lactated Ringer's to run at a rate that maintains the exact total hourly fluid restriction.

What should the nurse set the infusion rate for the primary line of Lactated Ringer's to, in $\text{mL/hour}$? Record your answer as a whole number.

A home health nurse is developing a comprehensive care plan for a 72-year-old client who is recovering from a recent ischemic stroke. The nurse incorporates interventions representing various levels of disease prevention. Which of the following planned nursing actions specifically demonstrates a secondary prevention strategy?

During a mobility assessment, a client with left-sided hemiparesis needs to be moved from their bed to a sitting position in a wheelchair. What is the correct sequence of actions the nurse should take to execute this transfer safely?

A pediatric nurse is caring for a 7-year-old client admitted with a severe asthma exacerbation. The client's parents, who are undergoing a contentious divorce, begin arguing loudly at the bedside about custody arrangements. The client starts crying, and the nurse observes increased work of breathing and audible wheezing. Which nursing action is the priority?

While caring for a client requiring intravenous antibiotics, the nurse needs to initiate a secondary intermittent infusion (piggyback) through an active primary IV line. Assuming the secondary tubing has already been primed, arrange the following setup actions in the correct sequence.

A nurse preceptor is observing a newly licensed nurse care for a client who completed an intravenous chemotherapy infusion 24 hours ago. Which action by the newly licensed nurse indicates proper handling of the client's hazardous bodily fluids?

A nurse is teaching a client who has a prescribed non-weight-bearing status on the right leg how to ascend stairs using crutches. In what order should the nurse instruct the client to perform the following steps? Arrange the actions in the correct sequence.

A nurse on a dual-diagnosis unit is evaluating several clients who were recently admitted. Which client presentation requires the most immediate priority action by the nurse?

A client is admitted with profound hypokalemia, exhibiting a serum potassium level of 2.4 mEq/L (2.4 mmol/L). The healthcare provider prescribes an intravenous (IV) potassium replacement. The prescription reads: 'Potassium chloride 20 mEq in 100 mL of 0.9% sodium chloride IV to infuse over 30 minutes.' The client's only vascular access is a 20-gauge peripheral IV catheter in the right forearm. Which of the following is the priority nursing action?

A nurse is monitoring a 58-year-old client who returned to the medical-surgical unit one hour ago following a percutaneous left renal biopsy. Which of the following assessment findings indicates an impending physiological complication and requires the most immediate risk mitigation action by the nurse?

A public health nurse is conducting a home visit for a newly relocated client who reports severe insomnia, daily fatigue, and overwhelming stress related to adapting to the new cultural environment. The client tearfully states, "Everything here is too difficult, and I feel like I will never belong." Which of the following is the priority nursing action?