Tüm alıştırma soruları

A client in the intensive care unit is receiving a continuous intravenous (IV) infusion of norepinephrine at $12 \text{ mcg/min}$ via a single-lumen peripherally inserted central catheter (PICC) for septic shock. The client's current mean arterial pressure (MAP) is $64 \text{ mmHg}$. The healthcare provider prescribes a stat dose of IV push hydrocortisone. Which action by the nurse is the most appropriate?

A nurse is evaluating the arterial blood gas (ABG) results for a client who is experiencing shallow breathing and lethargy following abdominal surgery. The laboratory report displays a pH of $7.26$, a $\text{PaCO}_2$ of $58\text{ mm Hg}$, and an $\text{HCO}_3^-$ of $24\text{ mEq/L}$. Which of the following acid-base imbalances should the nurse identify to initiate appropriate risk-reduction interventions?

A nurse is caring for a client who is receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes after the transfusion begins, the client reports sudden lower back pain, chills, and shortness of breath. In which order should the nurse perform the following actions? Arrange the actions from first to last.

A nurse is teaching a client with a left tibial fracture, who is prescribed non-weight-bearing status on the left leg, how to safely stand up from a seated position in a chair using axillary crutches. Arrange the following instructional steps in the correct chronological order.

While performing a clinical assessment on a client who underwent an open splenectomy four hours ago, the nurse reviews the electronic health record. The baseline vital signs recorded upon arrival to the surgical unit were: blood pressure 128/72 mm Hg, heart rate 76 beats/min, and respiratory rate 16 breaths/min. Which of the following current clinical findings should the nurse interpret as the earliest sign of impending physiological decompensation that necessitates immediate risk mitigation?

A nurse at a menopause specialty clinic is evaluating a 54-year-old client's understanding of lifestyle modifications aimed at osteoporosis risk reduction. Which statements by the client indicate effective learning? Select all that apply.

A nurse is caring for an older adult client who is 1 day post-operative following an abdominal surgery. The provider has prescribed knee-high antiembolism stockings to promote venous return. Which of the following actions should the nurse take?

A nurse is evaluating a client at 35 weeks gestation who arrived at the emergency department following a high-speed motor vehicle collision. The client reports mild, continuous abdominal discomfort but denies any visible vaginal bleeding. Which of the following assessment findings should the nurse identify as indicators of a concealed placental abruption and impending hemorrhagic shock? Select all that apply.

Five minutes after a spontaneous vaginal delivery, while awaiting the expulsion of the placenta, the client suddenly grasps her chest and states, 'I can't breathe, and I feel like I'm going to die.' The client's skin rapidly becomes ashen and cyanotic. The bedside monitor reveals a sudden drop in oxygen saturation to 81% and a heart rate of 134 beats/min. Which sequence of immediate nursing actions is the highest priority?

An orthopedic unit nurse is updating the care plan for a geriatric client recovering from a right-sided posterior total hip arthroplasty. The client has developed unexpected episodes of nighttime restlessness and loss of bladder control. Which nursing actions are appropriate to ensure optimal hygiene, comfort, and safety? Select all that apply.

A registered nurse is evaluating a nursing student's knowledge regarding the physiological adaptations of the respiratory system in older adults. The nurse asks the student to describe expected findings for an 83-year-old client who has no acute or chronic illness. Which statement by the student indicates an accurate understanding of normal senescence?

A nurse is preparing to administer a prescribed intravenous (IV) push medication through a client's peripheral saline lock. Place the following steps in the correct chronological order for safe administration.

A clinic nurse is utilizing the '5 R's' motivational intervention for a client who currently smokes but is not ready to quit. Arrange the nursing actions in the correct chronological sequence according to this evidence-based model.

A nurse is monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs). Fifteen minutes into the transfusion, the client reports sudden lower back pain, chills, and shortness of breath. Arrange the following nursing actions in the correct order of priority, from first to last.

A critical care nurse is removing a non-tunneled central venous catheter (CVC) from a client's right subclavian vein. Immediately after the catheter is withdrawn, the client gasps, reports sudden severe chest pain, and becomes pale and tachycardic. Suspecting a venous air embolism, arrange the following actions in the exact priority sequence the nurse must perform them to reduce the risk of fatal cardiopulmonary collapse.

A client in the trauma intensive care unit is receiving a massive transfusion protocol for severe hemorrhagic shock following a pelvic crush injury. After the rapid administration of 8 units of packed red blood cells and 6 units of fresh frozen plasma, the client's continuous electrocardiogram reveals a newly prolonged QT interval of 0.54 seconds. The nurse observes circumoral tingling and muscle fasciculations. Current vital signs include a heart rate of 112 beats per minute, blood pressure of 86/48 mm Hg, and a central venous pressure (CVP) of 9 mm Hg. Which of the following is the priority nursing action?

A client with septic shock is receiving a continuous intravenous (IV) infusion of norepinephrine via a single-lumen peripherally inserted central catheter (PICC). The client's blood pressure is $88/54 \text{ mmHg}$ and the mean arterial pressure (MAP) is $65 \text{ mmHg}$. The healthcare provider prescribes a stat dose of IV pantoprazole and a continuous IV infusion of regular insulin. The nurse is unable to establish additional peripheral IV access due to severe generalized edema. Which of the following actions should the nurse take? (Select all that apply.)

A multidisciplinary care team prescribes continuous total parenteral nutrition (TPN) alongside a separate $20\%$ intravenous lipid emulsion for a client recovering from an extensive bowel resection. The client currently has a single-lumen peripherally inserted central catheter (PICC). The primary TPN infusion set includes a standard $0.22\text{-micron}$ in-line filter. To safely administer both solutions concurrently, which action must the nurse implement?

A community health nurse is preparing to conduct an initial health screening and risk assessment for a 45-year-old client who recently immigrated and has limited English proficiency. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence from first to last.

A 78-year-old client residing in a skilled nursing facility suddenly develops acute confusion, agitation, and new-onset urinary incontinence. The nurse enters the client's room and observes the client attempting to climb over the bed rails. In what order should the nurse prioritize the following actions? (Arrange the actions from highest to lowest priority.)