Tüm alıştırma soruları

3881 soru

Soru 2861Soru →

A pediatric clinic nurse is structuring a health promotion protocol for parents of toddlers (aged 1 to 3 years). When integrating evidence-based risk reduction, which nursing intervention represents a primary prevention strategy that specifically targets the leading cause of mortality for this developmental cohort?

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Cevap: Educating parents on installing four-sided isolation fencing around residential swimming pools

Cevap

The correct answer is educating parents on installing four-sided isolation fencing around residential swimming pools.
Unintentional injuries, such as drowning, are the leading cause of mortality in children aged 1 to 3 years. Educating caregivers about environmental safety measures, like isolation pool fencing, represents primary prevention because it involves taking proactive, structural steps to prevent a specific catastrophic injury from occurring in the first place.

Adım Adım Çözüm

1
Identify the leading cause of mortality for the specified developmental cohort (toddlers aged 1 to 3 years).
Unintentional injuries (including drowning, motor vehicle accidents, and poisoning) are the leading cause of death in this age group.
Health promotion must prioritize the highest statistical risks to the specific population being served.
2
Define the characteristics of primary disease prevention.
Primary prevention involves proactive interventions aimed at preventing disease or injury before it ever occurs.
The question specifically asks for a primary prevention strategy, eliminating secondary (screening) and tertiary (management) interventions.
3
Evaluate the options to find the one that is both primary prevention and addresses unintentional injury.
Educating parents on pool fencing prevents drowning (unintentional injury) before it happens.
This aligns perfectly with both requirements of the clinical prompt.

Anahtar Kavram

Levels of Disease Prevention and Developmental Health Risks
Soru 2862Soru →

An intensive care nurse is managing the basic care needs of an adult client who is mechanically ventilated for severe acute respiratory distress syndrome (ARDS). The client is currently placed in the prone position to optimize oxygenation and is receiving continuous enteral nutrition via an orogastric tube. To provide safe and effective basic care, which combination of interventions is most appropriate for the nurse to implement?

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Cevap: Place the bed in a reverse Trendelenburg tilt of at least 30 degrees, apply protective foam dressings to the client's facial prominences, and position the lower legs so the toes are suspended off the mattress.

Cevap

The nurse should utilize a reverse Trendelenburg tilt to prevent aspiration, apply prophylactic foam dressings to facial pressure points, and ensure the toes are suspended off the mattress.
When a client is positioned prone, the traditional method of elevating the head of the bed (bending the frame at the waist) causes severe spinal hyperextension and restricts lung expansion. To safely prevent aspiration from continuous enteral feedings, the entire bed must be tilted into a reverse Trendelenburg position (typically 30 degrees). Basic care also requires aggressive pressure injury prevention for anterior surfaces, which involves utilizing prophylactic foam dressings on facial prominences (chin, cheeks, forehead) and positioning the client so their toes are suspended off the edge of the mattress to prevent both pressure ulcers and plantar flexion contractures.

Adım Adım Çözüm

1
Analyze the primary risks associated with the client's current status and therapies.
The client faces competing risks: aspiration from continuous enteral feeding while prone, and severe pressure injuries to atypical bony prominences (face, chest, toes).
Identifying the physiological challenges of prone positioning dictates the priorities for basic care and comfort.
2
Determine the appropriate positioning modification to prevent aspiration without compromising spinal alignment.
A reverse Trendelenburg position of at least 30 degrees is selected instead of standard head-of-bed elevation.
Standard head elevation (bending the mattress at the waist) causes harmful lumbar hyperextension in a prone client. Reverse Trendelenburg elevates the head relative to the stomach while keeping the spine entirely straight.
3
Select evidence-based hygiene and mobility interventions for skin preservation in the prone position.
Protective dressings are applied to the face, and toes are suspended off the edge of the mattress.
The face bears unusual weight during proning, requiring prophylactic protection. Suspending the toes prevents both direct pressure ulcers on the digits and the development of plantar flexion contractures (footdrop).

Anahtar Kavram

Basic care management of the prone, mechanically ventilated client receiving enteral nutrition.
Soru 2863Soru →

A nurse on a medical-surgical unit has received the shift report for four clients. Which client should the nurse assess first to reduce the risk of a potential life-threatening complication?

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Cevap: A 68-year-old client who had a thoracentesis 1 hour ago and is exhibiting new-onset restlessness with a heart rate of 118 beats/min

Cevap

The client who had a thoracentesis 1 hour ago and is exhibiting new-onset restlessness with a heart rate of 118 beats/min.
The client who recently underwent a thoracentesis is presenting with new-onset restlessness and tachycardia. These are critical early indicators of physiological decompensation, potentially signaling a pneumothorax, internal bleeding, or severe hypoxia. Because this client is exhibiting an acute, unexpected change in respiratory and circulatory status, they represent the highest priority and must be assessed immediately to mitigate life-threatening risks.

Adım Adım Çözüm

1
Analyze the clinical presentation of the client who recently underwent a thoracentesis.
The client is demonstrating new-onset restlessness and a heart rate of 118 beats/min.
Recognizing early physiological signs of decompensation (such as hypoxia or shock) is necessary to catch potential post-procedure complications like a pneumothorax or hemothorax.
2
Evaluate the clinical status and stability of the other three clients.
The client with COPD has fully compensated respiratory acidosis, the lumbar puncture client is in the correct preventative position, and the DVT client has expected localized pain.
Prioritization requires distinguishing between expected, chronic, or stable findings versus acute, unstable changes that threaten the airway, breathing, or circulation.
3
Determine the highest priority client based on the ABCs (Airway, Breathing, Circulation).
The thoracentesis client represents an acute change in breathing and circulation and must be seen immediately.
Acute, unexpected changes post-procedure take precedence over chronic stable findings and expected care routines.

Anahtar Kavram

Prioritization and early recognition of post-procedure complications
Soru 2864Soru →

A healthcare provider prescribes ceftriaxone 1 gram1 \text{ gram} in 50 mL50 \text{ mL} of 0.9%0.9\% sodium chloride to be infused intravenously over 30 minutes30 \text{ minutes}. The nurse will use an electronic infusion pump. At what rate, in mL/hr\text{mL/hr}, should the nurse set the infusion pump? Record your answer as a whole number.

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Cevap: 100

Cevap

100
To determine the correct setting for an electronic infusion pump in mL/hr\text{mL/hr}, the nurse must first ensure the time is converted to hours. Thirty minutes is equal to 0.50.5 hours. Next, divide the total volume (50 mL50 \text{ mL}) by the time (0.50.5 hours) to find the correct rate of 100 mL/hr100 \text{ mL/hr}.

Adım Adım Çözüm

1
Convert the given infusion time from minutes to hours.
30 minutes=0.5 hours30 \text{ minutes} = 0.5 \text{ hours}
Infusion pumps are typically programmed in mL/hr, so the administration time must be expressed in hours.
2
Divide the total medication volume by the infusion time in hours to determine the hourly rate.
50 mL÷0.5 hours=100 mL/hr50 \text{ mL} \div 0.5 \text{ hours} = 100 \text{ mL/hr}
This calculation provides the necessary rate to deliver the full volume exactly within the prescribed time window.

Anahtar Kavram

Intravenous medication infusion rate calculation using an electronic pump
Soru 2865Soru →

A rehabilitation nurse is providing discharge education to a female client with a spinal cord injury who will be managing a neurogenic bladder. The nurse is teaching the client how to perform clean intermittent self-catheterization (CISC) at home. In which order should the client perform the following steps? Arrange the actions in the correct chronological sequence.

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Cevap

The correct sequence is: Wash hands and gather supplies; Position and cleanse the meatus; Lubricate and insert the catheter; Drain completely and withdraw; Clean and store the equipment.
The correct sequence prioritizes medical asepsis and logical skill progression for home self-catheterization. Hand hygiene and supply preparation must occur first. Cleansing the perineum from front to back occurs immediately prior to insertion to prevent introducing bacteria into the urethra. The catheter is then lubricated and inserted until urine flows. Complete drainage is allowed before slow withdrawal, and the final step involves the hygienic maintenance of the reusable equipment to promote continued safe self-care.

Adım Adım Çözüm

1
Wash hands and gather supplies.
The client is prepared for the procedure with a reduced risk of transmitting pathogens.
Medical asepsis begins with proper hand hygiene before touching any self-care equipment.
2
Position comfortably and cleanse the meatus from front to back.
The periurethral area is clean and ready for catheter insertion.
Cleansing from front to back prevents the introduction of fecal bacteria into the urinary tract.
3
Lubricate the catheter tip and insert it until urine flows.
The catheter safely enters the bladder to begin drainage.
Water-soluble lubricant prevents tissue trauma, and urine flow confirms correct placement.
4
Allow complete drainage and slowly withdraw the catheter.
The bladder is fully emptied of residual urine.
Slow withdrawal ensures that urine pooled at the base of the bladder is also drained.
5
Wash, dry, and store the reusable catheter.
The equipment is maintained for future safe use.
Home self-catheterization utilizes clean technique, requiring thorough washing of reusable supplies to prevent bacterial overgrowth.

Anahtar Kavram

Clean Intermittent Self-Catheterization (CISC) Technique and Home Self-Care Maintenance
Soru 2866Soru →

A home health nurse is conducting an initial assessment of a family providing full-time care for a 5-year-old child who requires continuous mechanical ventilation via a tracheostomy. Which findings indicate to the nurse that the parents are experiencing caregiver role strain? Select all that apply.

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Cevap: The primary caregiver reports chronic fatigue and has canceled their own routine medical appointments.; The primary caregiver exhibits a flat affect and states they no longer enjoy previously pleasurable activities.; The parents state they have stopped communicating with friends because no one understands their situation.

Cevap

The findings indicating caregiver role strain include self-neglect (canceling personal medical appointments), signs of depression (flat affect and anhedonia), and social isolation (withdrawing from friends).
Caregiver role strain occurs when the demands of providing care compromise the caregiver's physical, emotional, or social well-being. Canceling personal medical appointments indicates physical self-neglect. A flat affect and loss of interest in activities are signs of clinical depression and emotional exhaustion. Stopping communication with friends demonstrates severe social isolation. All of these are maladaptive responses signaling that the caregivers are overwhelmed and require additional support interventions.

Adım Adım Çözüm

1
Analyze the clinical scenario to identify the primary nursing concern.
The nurse must evaluate for caregiver role strain in a high-stress home care environment involving a technology-dependent child.
Families caring for children with complex medical needs are at high risk for physical, emotional, and social exhaustion.
2
Differentiate between adaptive coping mechanisms and maladaptive signs of burnout.
Identify actions that promote family functioning versus actions that compromise the caregiver's well-being.
Accurate assessment guides appropriate nursing interventions and referrals.
3
Select the options that represent maladaptive responses to chronic stress.
Self-neglect, depressive symptoms, and social withdrawal are identified as clear indicators of strain.
These findings require immediate nursing intervention to support the family system and ensure continued safe care for the child.

Anahtar Kavram

Caregiver Role Strain and Maladaptive Coping
Soru 2867Soru →

A client admitted with bacterial pneumonia is prescribed an intermittent intravenous (IV) antibiotic. The client currently has a continuous peripheral IV infusion of dextrose 5% in water (D5W) running at a low rate. Which actions are required by the nurse to ensure safe administration of the medication? Select all that apply.

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Cevap: Assess the IV insertion site for signs of infiltration or phlebitis before attaching the antibiotic.; Verify the client's identity using two unique identifiers, such as the full name and date of birth.; Review the client's health record to confirm there are no documented allergies to the prescribed medication class.

Cevap

The correct actions are assessing the IV site, verifying the client's identity using two unique identifiers, and checking the health record for documented allergies.
Safe parenteral therapy requires strict adherence to the rights of medication administration, including verifying the right patient with two identifiers, checking for allergies, and assessing the physical IV site to prevent complications like extravasation.

Adım Adım Çözüm

1
Verify patient safety standards before administration.
Confirming the patient's identity with two identifiers and checking for medication allergies ensures the 'right patient' and 'right medication' principles are met.
These are non-negotiable standards of practice for all pharmacological therapies to prevent medical errors.
2
Assess the physical route of administration.
Inspecting the peripheral IV site confirms patency and absence of complications.
Administering medications into an infiltrated or inflamed vein can cause severe local tissue damage or systemic complications.
3
Identify unsafe clinical practices.
Recognize that estimating drip rates, relying on visual fluid checks for compatibility, and delegating initial assessments are unsafe.
Evidence-based practice requires precise mathematical calculations, the use of approved compatibility resources, and RN-level clinical judgment for initial assessments.

Anahtar Kavram

Safe Administration of Parenteral Therapies
Soru 2868Soru →

A registered nurse is planning oral care for an unresponsive elderly client admitted with a severe ischemic stroke. To promote comfort and minimize physiological risk, which intervention is most appropriate for the nurse to implement?

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Cevap: Turn the client into a lateral position facing the nurse and ensure that a working suction apparatus is immediately accessible.

Cevap

The most appropriate action is to turn the client into a lateral position facing the nurse and ensure a working suction apparatus is accessible.
For an unresponsive client, the greatest physiological risk during oral care is aspiration of fluids or debris. Turning the client into a lateral (side-lying) position allows secretions to pool in the dependent side of the mouth and safely drain out via gravity. Having a suction apparatus immediately accessible ensures any excess fluid can be promptly removed to protect a compromised airway.

Adım Adım Çözüm

1
Analyze the client's clinical status.
The client is unresponsive following a severe ischemic stroke.
An unresponsive state indicates absent or diminished gag and swallowing reflexes, creating a high risk for aspiration during oral care.
2
Determine the safest positioning for the procedure.
A lateral (side-lying) position is identified as the safest orientation.
Positioning the client laterally allows oral fluids and debris to drain out of the mouth via gravity, rather than backward into the airway.
3
Identify necessary safety equipment.
A functional suction apparatus must be immediately available.
Suction is required to rapidly clear the oral cavity if fluids begin to pool, further protecting the respiratory tract.

Anahtar Kavram

Aspiration Prevention During Unresponsive Oral Care
Soru 2869Soru →

A nurse in a university health clinic is developing a health promotion plan for a 21-year-old female client. The client is sexually active, reports drinking four to five alcoholic beverages on weekend nights, and has a strong family history of type 2 diabetes mellitus. Which of the following nursing interventions represent primary prevention strategies for this client? (Select all that apply.)

Geçerli olan tümünü seçin

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Cevap: Administering the human papillomavirus (HPV) vaccine.; Educating the client on the consistent use of barrier contraceptives.; Discussing the physiological risks of binge drinking and strategies for harm reduction.

Cevap

The correct primary prevention strategies include administering the HPV vaccine, educating on barrier contraceptives, and discussing the risks of binge drinking.
Primary prevention involves actions taken prior to the onset of disease, which intercept its causation or modify its course before clinical manifestation. Administering immunizations (like the HPV vaccine) and providing health education to alter high-risk behaviors (such as teaching about barrier contraceptives and discussing alcohol use) actively prevent the occurrence of illness or injury, fulfilling the criteria for primary prevention.

Adım Adım Çözüm

1
Recall the definitions of the levels of prevention.
Primary prevention prevents disease before it occurs; secondary prevention involves early detection and screening; tertiary prevention focuses on rehabilitation and preventing complications of existing disease.
Understanding these definitions is required to correctly classify each clinical intervention.
2
Analyze the selected interventions.
Vaccinations, safer sex education, and alcohol harm reduction counseling all aim to prevent a health problem from developing in the first place.
These interventions clearly match the definition of primary prevention.
3
Analyze the rejected interventions.
Pap tests, fasting blood glucose checks, and breast self-examinations are all screening tools designed to catch disease early.
These interventions are classified as secondary prevention and must be excluded from the answer.

Anahtar Kavram

Levels of Disease Prevention: Primary, Secondary, and Tertiary
Soru 2870Soru →

A client is in the post-anesthesia care unit (PACU) following an open abdominal surgery under general anesthesia utilizing desflurane and succinylcholine. The nurse notes new-onset masseter muscle rigidity, tachycardia of 145 beats/minute145 \text{ beats/minute}, tachypnea, and an end-tidal carbon dioxide (EtCO2EtCO_2) level of 65 mm Hg65 \text{ mm Hg}. The client's temperature is rapidly rising. Based on these findings, which of the following pharmacological and parenteral interventions should the nurse anticipate implementing? (Select all that apply)

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Cevap: Hyperventilate the client with 100%100\% oxygen using a bag-valve-mask or through the endotracheal tube.; Initiate a rapid intravenous infusion of chilled 0.9%0.9\% sodium chloride.; Administer intravenous regular insulin concurrent with 50%50\% dextrose.

Cevap

The nurse should hyperventilate the client with 100% oxygen, initiate a rapid intravenous infusion of chilled 0.9% sodium chloride, and administer intravenous regular insulin concurrent with 50% dextrose.
Malignant hyperthermia is a severe hypermetabolic state. The correct interventions address the critical pathophysiological changes: 100%100\% oxygen flushes out the massive amounts of carbon dioxide produced; chilled intravenous normal saline provides active core cooling; and the combination of regular insulin and 50%50\% dextrose drives extracellular potassium back into the cells, treating the life-threatening hyperkalemia caused by continuous muscle rigidity and breakdown.

Adım Adım Çözüm

1
Identify the clinical emergency based on the assessment findings.
The combination of exposure to desflurane and succinylcholine, new-onset masseter muscle rigidity, tachycardia, hypercarbia (EtCO2EtCO_2 65 mm Hg65 \text{ mm Hg}), and rapidly rising temperature indicates malignant hyperthermia.
Early recognition of malignant hyperthermia is essential to prevent irreversible cardiovascular collapse and death.
2
Determine the priority respiratory intervention.
Hyperventilate the client with 100%100\% oxygen.
The hypermetabolic state produces massive amounts of carbon dioxide and depletes oxygen stores, requiring immediate enhanced ventilation.
3
Determine the priority parenteral cooling intervention.
Initiate rapid intravenous infusion of chilled 0.9%0.9\% sodium chloride.
Core body temperature can rise rapidly in malignant hyperthermia, necessitating immediate active core cooling to prevent cellular death.
4
Determine the priority pharmacological intervention for the metabolic complications.
Administer intravenous regular insulin and 50%50\% dextrose.
Sustained muscle rigidity causes rhabdomyolysis and severe hyperkalemia. Insulin drives potassium back into the cells, preventing lethal cardiac arrhythmias.

Anahtar Kavram

Malignant hyperthermia is a life-threatening pharmacogenetic hypermetabolic crisis triggered by volatile anesthetics and succinylcholine, requiring immediate discontinuation of triggers, administration of dantrolene, oxygenation, active cooling, and management of hyperkalemia.
Soru 2871Soru →

A school nurse is evaluating a 17-year-old client who presents with severe insomnia, a resting heart rate of 115 beats/minute, and an unintentional 4.5 kg (10 lb) weight loss over the past month. The adolescent confides, "I have been taking unprescribed dextroamphetamine to stay awake and study for my college entrance exams. I just have to get a perfect score." Which of the following is the priority nursing action?

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Cevap: Assess the client's cardiovascular status and monitor for signs of cardiac dysrhythmias.

Cevap

The correct action is to prioritize the client's physiological safety by assessing their cardiovascular status and monitoring for dysrhythmias.
According to Maslow's Hierarchy of Needs, physiological safety is the highest priority. Dextroamphetamine is a central nervous system stimulant that can cause severe cardiovascular complications, including hypertension, tachycardia, and dysrhythmias. The client is already exhibiting a resting heart rate of 115 beats/minute, indicating significant cardiovascular stress. The nurse must first assess the client's physical stability before addressing the psychosocial aspects of the high-risk behavior.

Adım Adım Çözüm

1
Analyze the client's reported symptoms and history of substance use.
The client is exhibiting tachycardia, insomnia, and weight loss due to unprescribed stimulant use.
Identifying the physiological impact of the high-risk behavior is the first step in clinical judgment.
2
Apply Maslow's Hierarchy of Needs to prioritize nursing interventions.
Physiological needs (cardiovascular stability) take precedence over psychosocial needs (education, communication).
Stimulant toxicity can lead to life-threatening cardiac dysrhythmias or severe hypertension.
3
Evaluate the remaining options against therapeutic communication and legal standards.
Asking 'why' is non-therapeutic, primary prevention teaching is not the immediate priority, and reporting to an academic board breaches confidentiality.
Maintaining trust and focusing on immediate health risks aligns with nursing standards of care.

Anahtar Kavram

Prioritization of Care in Substance Misuse
Soru 2872Soru →

A nurse is preparing to transfer a client from the bed to a wheelchair. The client has a history of severe orthostatic hypotension and right-sided hemiparesis following a cerebrovascular accident. Arrange the following steps in the correct chronological order to ensure a safe and hemodynamically stable transfer.

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Cevap

The correct sequence prioritizes environmental preparation, followed by gradual physiological adaptation to upright posture, and concludes with a mechanically safe pivot transfer.
This sequence synthesizes two critical nursing priorities: proactive environmental safety and hemodynamic adaptation. By placing the wheelchair on the strong (left) side first, the nurse ensures the client is never left unsupported while symptomatic. Gradual elevation and dangling prevent orthostatic syncope. Finally, using a gait belt and pivoting on the strong leg ensures maximum biomechanical stability.

Adım Adım Çözüm

1
Position the wheelchair at a 45-degree angle on the client's left side and lock the wheels.
The environment is safely prepared before the client is moved.
Equipment must be secured on the strong side to prevent leaving a potentially dizzy or unstable client unsupported while retrieving the chair.
2
Elevate the head of the bed to a high-Fowler's position.
The client's body begins to adapt to an upright posture.
Gradual elevation mitigates the hemodynamic effects of severe orthostatic hypotension.
3
Assist the client to a sitting position with their legs dangling over the edge of the bed.
The client is seated safely at the bedside.
Dangling allows the cardiovascular system to further equalize and stabilizes blood pressure before weight-bearing.
4
Assess the client for dizziness and apply a transfer belt securely around their waist.
The client is confirmed stable and physically secured for the transfer.
Confirming the absence of orthostatic symptoms ensures readiness, and the gait belt provides a safe mechanical hold point.
5
Instruct the client to bear weight on their left leg and pivot smoothly into the wheelchair.
The client is safely transferred into the chair.
Pivoting on the unaffected (left) side maximizes the client's strength and maintains balance during the movement.

Anahtar Kavram

Principles of safe mobility and transfer for clients with hemiparesis and orthostatic hypotension.
Tahmini Süre:2m 30s
Soru 2873Soru →

A 38-year-old client is admitted to the medical-surgical unit for treatment of acute pancreatitis. The health history reveals chronic daily consumption of liquor. The client states their last alcoholic beverage was approximately 14 hours ago. During the initial shift assessment, the nurse notes the client is restless, has a heart rate of 112 beats per minute, and exhibits fine bilateral hand tremors. Which nursing action is most appropriate?

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Cevap: Initiate the prescribed withdrawal medication protocol and implement strict seizure precautions.

Cevap

Initiate the prescribed withdrawal medication protocol and implement strict seizure precautions.
The client is exhibiting classic early signs of alcohol withdrawal, which include tachycardia, restlessness, and fine tremors, typically beginning 6 to 24 hours after the last drink. Initiating a withdrawal protocol (often involving benzodiazepines) and establishing seizure precautions are the priority actions to prevent the condition from progressing to severe, life-threatening complications like delirium tremens or withdrawal seizures.

Adım Adım Çözüm

1
Analyze the client's history and current clinical presentation.
The client has a history of chronic alcohol use, stopped drinking 14 hours ago, and presents with restlessness, tachycardia, and fine tremors.
Identifying the timeline of last substance use is essential to anticipate withdrawal syndromes.
2
Correlate the assessment findings with potential complications.
The onset of tremors, elevated heart rate, and agitation 6 to 24 hours after the last drink are hallmark early signs of alcohol withdrawal.
Early recognition prevents progression to life-threatening complications such as seizures or delirium tremens.
3
Determine the highest priority nursing intervention.
The nurse must provide immediate medical intervention (administering withdrawal protocol medications like benzodiazepines) and ensure client safety (seizure precautions).
Patient safety and physiological stabilization take precedence over routine care or delegation.

Anahtar Kavram

Early Recognition and Management of Alcohol Withdrawal
Tahmini Süre:1m 0s
Soru 2874Soru →

A client with suspected active pulmonary tuberculosis (TB) needs to provide a sputum sample for diagnostic testing. During the collection and packaging of this infectious material, which action demonstrates proper safety adherence?

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Cevap: Placing the tightly sealed specimen container into a plastic biohazard bag that has a separate outer pouch for the requisition form.

Cevap

The specimen container should be placed into a biohazard transport bag, ensuring the requisition form is kept in the separate outer pocket to prevent contamination.
Proper management of infectious laboratory specimens requires placing the sealed container into a secondary biohazard transport bag. Keeping the laboratory requisition form in the separate outer pouch prevents it from becoming contaminated if the primary container leaks, protecting laboratory personnel from exposure.

Adım Adım Çözüm

1
Identify the transmission risk associated with the suspected pathogen.
Tuberculosis requires airborne precautions, and sputum is a highly infectious material.
Understanding the pathogen dictates the appropriate personal protective equipment and handling protocols.
2
Determine the proper packaging for infectious laboratory specimens.
The specimen must be secured in a leak-proof primary container and placed in a secondary biohazard transport bag.
Double-layering protects the environment and personnel from accidental exposure during transport.
3
Ensure the safety of the laboratory requisition documentation.
The paperwork is placed in the separate outer pocket of the biohazard bag.
Keeping paperwork separated from the specimen prevents the documentation from becoming contaminated in the event of a leak.

Anahtar Kavram

Handling Infectious Materials and Biohazard Packaging
Soru 2875Soru →

An adult client is receiving total parenteral nutrition (TPN) via a single-lumen peripherally inserted central catheter (PICC). The healthcare provider prescribes a scheduled dose of intravenous (IV) famotidine. Which action is most appropriate for the nurse to take?

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Cevap: Establish a new peripheral intravenous access site to administer the prescribed medication.

Cevap

Establish a new peripheral intravenous access site to administer the prescribed medication.
Total parenteral nutrition (TPN) must be administered through a strictly dedicated intravenous line. Because the client has a single-lumen PICC, no other medications, fluids, or blood products can be administered through this line or its ports. Establishing a new peripheral IV site is the only safe and appropriate way to administer the prescribed famotidine without compromising client safety.

Adım Adım Çözüm

1
Identify the type of continuous infusion the client is currently receiving.
The client is receiving total parenteral nutrition (TPN) through a single-lumen central line.
Recognizing the specific fluid is crucial because TPN has strict, highly specialized administration guidelines.
2
Determine the compatibility and administration rules for the primary infusion.
TPN requires a dedicated line and cannot be mixed or Y-sited with other medications.
TPN solutions are highly complex, hypertonic, and prone to life-threatening precipitation and bacterial contamination when mixed with other substances.
3
Select the safest method to administer the newly prescribed medication without compromising the primary infusion.
A separate peripheral intravenous line must be started to administer the famotidine.
Using a separate line ensures the medication is delivered safely while maintaining the integrity and sterility of the client's TPN line.

Anahtar Kavram

Total Parenteral Nutrition (TPN) lines must be dedicated solely to TPN administration to prevent dangerous drug incompatibilities and reduce the risk of central line-associated bloodstream infections.
Soru 2876Soru →

A nurse is creating a care plan for a client with an acute exacerbation of multiple sclerosis who has bilateral lower extremity paralysis and frequent bowel incontinence. Which interventions should the nurse include to maintain skin integrity and promote basic comfort? Select all that apply.

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Cevap: Cleanse the perineal region with a pH-balanced no-rinse cleanser and apply a moisture barrier.; Employ a mechanical lift or a friction-reducing slide sheet when moving the client up in bed.; Position a supportive pad under the lower legs from the mid-calf to the ankle to suspend the heels.

Cevap

The appropriate interventions are: cleansing the perineum with a pH-balanced cleanser and applying a moisture barrier; employing a friction-reducing device for movement; and positioning a supportive pad under the calves to suspend the heels.
The correct interventions for maintaining skin integrity and promoting comfort in an immobile client include using a pH-balanced cleanser with a moisture barrier to prevent incontinence-associated dermatitis. Additionally, using friction-reducing devices during repositioning minimizes destructive shear forces on the skin. Suspending the heels by placing support under the lower legs completely offloads pressure from the vulnerable heel areas, preventing localized pressure injuries.

Adım Adım Çözüm

1
Evaluate the client's specific risk factors for skin breakdown.
The client is identified as high risk due to immobility from paralysis and constant moisture exposure from bowel incontinence.
Identifying specific physiological risk factors allows the nurse to select targeted, evidence-based preventive measures.
2
Select interventions that manage moisture and protect the epidermal barrier.
Using a pH-balanced, no-rinse cleanser and applying a moisture barrier are chosen to protect the perineum.
Alkaline soaps can strip the skin's natural oils, while moisture barriers protect the epidermis from the corrosive, macerating effects of feces.
3
Select interventions that minimize shear, friction, and localized pressure on bony prominences.
Using a friction-reducing slide sheet and completely offloading the heels are appropriate. Donut cushions and continuous high Fowler's positioning are rejected as inherently harmful.
Shear and intense localized pressure are the primary mechanical causes of pressure injuries; ring cushions and high backrest angles exacerbate these destructive forces.
4
Determine appropriate delegation of care tasks for this high-risk client.
The task of assessing and documenting skin integrity is retained by the RN rather than being assigned to the UAP.
Initial assessment, ongoing evaluation, and clinical judgment are strictly within the scope of practice of the registered nurse.

Anahtar Kavram

Pressure Injury Prevention and Safe Delegation
Tahmini Süre:2m 0s
Soru 2877Soru →

A nurse is caring for an older adult client who recently began experiencing mild confusion. The client's two adult children are arguing loudly at the bedside about long-term care plans. One child turns to the nurse and asks, 'Don't you agree that our parent needs to go to a nursing home immediately because of this decline?' What is the most appropriate response by the nurse?

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Cevap: It sounds like you both are very concerned about your parent's safety. Let's arrange a family meeting with the care team to discuss all available options.

Cevap

The most appropriate response acknowledges the family's underlying emotions, avoids taking sides in their conflict, and suggests an interdisciplinary family meeting.
This response is highly therapeutic because it uses empathy and reflection to validate the family's underlying emotional distress ('concerned about your parent's safety') without taking a side in their argument. By suggesting a family meeting, the nurse establishes professional boundaries, avoids being triangulated into the conflict, and guides the family toward a safe, interdisciplinary approach to decision-making.

Adım Adım Çözüm

1
Analyze the family dynamic and the client's situation.
The family is exhibiting conflict and attempting to triangulate the nurse by asking the nurse to take a side regarding the client's placement.
Identifying triangulation is critical to avoiding non-therapeutic engagement.
2
Evaluate the nurse's role in the family conflict.
The nurse must remain neutral, establish boundaries, and address the underlying emotion (concern for safety) rather than answering the direct, polarizing question.
Taking sides escalates family conflict and breaks therapeutic boundaries.
3
Select the response that promotes therapeutic communication and collaborative care.
Suggesting a family meeting with the interdisciplinary team provides a structured, supportive environment for decision-making.
Complex discharge planning and family disagreements are best managed collaboratively with social services, case management, and the provider.

Anahtar Kavram

Family Triangulation and Therapeutic Boundaries
Soru 2878Soru →

A nurse is caring for a client who has just returned to the medical-surgical unit following an esophagogastroduodenoscopy (EGD) performed with a topical anesthetic spray to the throat. Which action is the priority for the nurse to take to reduce the client's risk of a potential complication?

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Cevap: Assess for the return of the gag reflex prior to offering ice chips or water

Cevap

The nurse must assess for the return of the gag reflex before offering any oral fluids.
The correct action directly addresses the highest priority risk: aspiration. Because the throat is numbed with a topical anesthetic during an EGD, the gag reflex is temporarily absent. The nurse must verify its return before offering any oral intake to protect the client's airway and prevent aspiration pneumonia.

Adım Adım Çözüm

1
Identify the physiological effects of the procedure.
During an EGD, a topical anesthetic spray is used to numb the throat to suppress the gag reflex and allow scope insertion.
Understanding the procedure's localized effects is essential for anticipating post-operative safety risks.
2
Determine the primary risk associated with a numb throat.
An absent or diminished gag reflex significantly increases the risk of pulmonary aspiration if food or liquid is ingested.
Aspiration is a severe, potentially life-threatening complication that must be prevented.
3
Select the nursing intervention that directly mitigates this risk.
The nurse must verify that the topical anesthetic has worn off by assessing the gag reflex before allowing oral intake.
This specific assessment ensures the airway is protected during swallowing.

Anahtar Kavram

Prevention of aspiration following procedures involving topical throat anesthesia.
Soru 2879Soru →

A public health nurse is designing a comprehensive cardiovascular health program for a rural community. The nurse's specific objective for the upcoming quarter is to implement secondary disease prevention measures. Which of the following actions should the nurse include to meet this objective?

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Cevap: Conducting mobile screening events to check blood pressure and lipid profiles in asymptomatic residents.

Cevap

Conducting mobile screening events to check blood pressure and lipid profiles in asymptomatic residents.
Secondary prevention focuses on early detection, screening, and prompt intervention for diseases in their earliest stages, often before symptoms appear. Conducting blood pressure and lipid screenings for asymptomatic residents directly aligns with this goal by identifying individuals who may have undetected cardiovascular issues.

Adım Adım Çözüm

1
Analyze the question to determine the required level of prevention.
The scenario specifically asks for 'secondary disease prevention measures'.
Identifying the target prevention level is necessary to select the correct intervention.
2
Evaluate each option against the definitions of primary, secondary, and tertiary prevention, as well as safe nursing practice.
Screening asymptomatic individuals is secondary prevention. Education is primary. Rehabilitation is tertiary. Delegating interpretation of results is an unsafe practice.
Systematically categorizing each intervention ensures the correct level is selected and unsafe actions are eliminated.

Anahtar Kavram

Levels of Disease Prevention
Soru 2880Soru →

A client is recovering on the surgical unit 24 hours after a right-sided modified radical mastectomy with an axillary lymph node dissection. The client has a closed-suction drain in place and reports incisional pain. What actions should the nurse implement to optimize the client's basic care and comfort? Select all that apply.

Geçerli olan tümünü seçin

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Cevap: Elevate the client's right arm on a pillow to promote lymphatic drainage and prevent lymphedema.; Instruct the client to perform finger, wrist, and elbow flexion exercises on the affected side.; Assist the client to a semi-Fowler's position with the back and unaffected side supported by pillows.

Cevap

The nurse should elevate the affected right arm on a pillow, instruct the client to perform distal arm exercises (finger, wrist, and elbow), and position the client in a semi-Fowler's position.
Elevating the right arm promotes lymphatic and venous drainage to prevent lymphedema. Performing distal exercises (finger, wrist, elbow) maintains joint mobility and enhances circulation without straining the chest wall incision. Assisting the client to a semi-Fowler's position with support on the unaffected side reduces incisional tension, facilitates optimal lung expansion, and enhances overall client comfort.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client is in the early post-operative phase following a right mastectomy with lymph node dissection, has a surgical drain, and is experiencing pain.
Understanding the surgical procedure and time frame is essential to determine appropriate positioning, mobility, and safety needs.
2
Evaluate positioning and mobility interventions for basic care.
Elevating the right arm and performing distal joint exercises are indicated to prevent lymphedema and maintain mobility. The semi-Fowler's position reduces incisional tension.
These actions directly promote lymphatic return, prevent contractures, and provide non-pharmacological comfort.
3
Assess the remaining interventions for safety and delegation appropriateness.
Positioning on the operative side, delegating site evaluation to unlicensed assistive personnel, and applying physical restraints are identified as contraindicated actions.
These actions violate principles of post-operative positioning, the scope of practice for delegation, and safe restraint usage guidelines.

Anahtar Kavram

Post-Mastectomy Basic Care and Comfort
Tahmini Süre:2m 0s
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Tüm alıştırma soruları — NCLEX-RN | Examkin