Tüm alıştırma soruları

A localized tornado strike has caused massive structural damage to a community center during a crowded event, resulting in numerous casualties. The first-responding nurse is applying the Simple Triage and Rapid Treatment (START) algorithm to prioritize care. Which individual should the nurse classify as requiring immediate, life-saving intervention (Red tag)?

The unit educator is observing a newly licensed nurse provide care for a confused client who requires bilateral soft wrist restraints to prevent the removal of a central venous catheter. Which action by the newly licensed nurse indicates a need for immediate intervention by the educator?

An adult client is transferred to the medical-surgical unit immediately after a percutaneous liver biopsy. To mitigate the risk of internal bleeding from the puncture site, which positioning strategy is most appropriate for this client?

An older adult client is hospitalized for treatment of a severe urinary tract infection. The client becomes acutely confused and continuously attempts to pull out their peripheral intravenous (IV) catheter. A colleague suggests obtaining a prescription for physical restraints. Which action should the nurse take first?

An older adult client with a history of severe bilateral peripheral arterial disease (PAD) reports intense, burning pain in the lower extremities that wakes them during the night. The client's lower extremities are hairless, with thin, dry skin that is cool to the touch. The nurse is planning basic care to promote comfort and sleep. Which nursing action is most appropriate?

A nurse is preparing to remove a client's non-tunneled percutaneous central venous catheter (CVC). To minimize the risk of an air embolism, in what order should the nurse perform the following actions? Arrange the steps in the correct sequence from first to last.

A client recovering from an ischemic stroke with expressive aphasia repeatedly attempts to pull out their nasogastric (NG) feeding tube. After documenting the failure of multiple less restrictive interventions, the healthcare provider prescribes bilateral soft wrist restraints. Which actions should the nurse include in the client's plan of care? Select all that apply.

The healthcare team is managing a client diagnosed with active pulmonary tuberculosis who also exhibits acute delirium and a high risk for falls. Which actions should the registered nurse include in the comprehensive safety plan? Select all that apply.

A nurse is preparing to assist a healthcare provider with a bedside lumbar puncture for a client admitted with suspected bacterial meningitis. Which nursing actions are appropriate to ensure client safety and prevent procedure-related complications? Select all that apply.

A client weighing $105\text{ kg}$ is admitted to the emergency department with an acute ischemic stroke. The healthcare provider prescribes intravenous alteplase therapy at $0.9\text{ mg/kg}$. Which of the following nursing actions are required for the safe administration and monitoring of this pharmacological therapy? (Select all that apply.)

A hazardous chemical leak occurs at an industrial site, and several contaminated victims arrive on foot outside the hospital's main entrance. The facility's Emergency Operations Plan for a hazardous materials (HAZMAT) incident is activated. Which of the following actions should the designated nursing response team take? Select all that apply.

An older adult client who underwent a right total hip arthroplasty (posterior approach) 2 days ago has developed acute delirium. The client is restless, frequently attempts to get out of bed unassisted, and requires assistance with activities of daily living. When updating the client's plan of care, what interventions should the nurse implement to safely address the client's basic care and comfort needs? Select all that apply.

A registered nurse is managing the care of a young adult diagnosed with diabetic ketoacidosis. The individual has been receiving a continuous intravenous drip of regular insulin alongside isotonic saline for several hours. A recent metabolic panel and arterial blood gas analysis show a pH of 7.26, PaCO2 of 28 mm Hg, bicarbonate of 14 mEq/L, and a serum potassium level of 3.2 mEq/L. Electrocardiogram monitoring reveals flattened T waves and emerging U waves. Current hemodynamics demonstrate a systolic pressure of 108 mm Hg, diastolic of 70 mm Hg, and a pulse of 110 beats per minute. Which of the following clinical interventions should the nurse prioritize?

A critically ill client is admitted to the intensive care unit with a diagnosis of severe diabetic ketoacidosis. Initial laboratory results reveal a serum glucose of $815$ mg/dL ($45.2$ mmol/L), an arterial pH of $7.08$, and a serum potassium of $3.0$ mEq/L ($3.0$ mmol/L). The client exhibits profound lethargy, deep and rapid respirations, and poor skin turgor. Arrange the following therapeutic interventions in the correct physiological priority sequence to safely manage this client's acute decompensation.

A nurse in the emergency department evaluates the arterial blood gas (ABG) results of a client who intentionally ingested a toxic amount of acetylsalicylic acid 8 hours ago. The client is lethargic, diaphoretic, and breathing deeply at a rate of 34 breaths/minute.

ABG results (on room air):
- pH: 7.42
- PaCO2: 24 mm Hg
- HCO3-: 14 mEq/L
- PaO2: 95 mm Hg

Based on these clinical findings, which conclusion about the client's physiological acid-base status is most accurate?

A nurse is caring for a client experiencing a severe asthma exacerbation. The client is highly agitated, visibly using accessory muscles to breathe, and has a respiratory rate of $34 \text{ breaths/min}$ and a heart rate of $118 \text{ beats/min}$. The most recent arterial blood gas (ABG) results on room air are:

Based on these findings, which of the following is the priority nursing action?

A nurse evaluates a client with severe acute pancreatitis who has become increasingly restless over the last $4$ hours. Current vital signs are: blood pressure $88/46 \text{ mm Hg}$, heart rate $124 \text{ beats/min}$, respiratory rate $28 \text{ breaths/min}$, and temperature $101.8^\circ\text{F}$ ($38.8^\circ\text{C}$). The nurse suspects the client is manifesting early distributive shock secondary to systemic inflammatory response syndrome (SIRS). Which of the following clinical and diagnostic findings are consistent with this specific early physiological state? Select all that apply.

A client is being treated in the emergency department for a severe asthma exacerbation. Upon admission, the client was highly anxious, tachypneic, and audibly wheezing. Initial arterial blood gas (ABG) results were: pH 7.52, PaCO2 28 mm Hg, HCO3- 24 mEq/L, and PaO2 68 mm Hg. Two hours later, the nurse notes that the client has become lethargic and the respiratory effort is shallow. A repeat ABG reveals: pH 7.36, PaCO2 44 mm Hg, HCO3- 24 mEq/L, and PaO2 58 mm Hg. Which of the following is the priority nursing action?

Following a complex cystoscopy procedure, a client develops a systemic infection. While performing a reassessment, the nurse notes several changes in the client's clinical presentation. Which assessment findings should alert the nurse that the client is experiencing the early, hyperdynamic phase of septic shock? Select all that apply.

An adult client is admitted to the surgical step-down unit following a motor vehicle collision involving blunt abdominal trauma. During the initial shift assessment, the nurse notes the client has become increasingly restless and diaphoretic, and is reporting new-onset pain in the left shoulder. The client's vital signs are heart rate $118$ bpm, blood pressure $98/62$ mmHg, and respiratory rate $24$/min. Which of the following is the priority nursing action to reduce the client's risk for physiological deterioration?