Tüm alıştırma soruları

During hourly rounding on an orthopedic unit, the nurse evaluates a client recovering from a total hip arthroplasty performed 6 hours ago. The client's pain is being managed with a continuous bupivacaine epidural infusion. The client states, 'My lips feel completely numb, and I have a strange metallic taste in my mouth.' The client also mentions a persistent ringing sound in their ears. Which action should the nurse take first?

A nurse is leading a health promotion seminar at a senior center. A 72-year-old attendee expresses concern about their risk for type 2 diabetes due to a strong family history and asks how to proactively prevent the condition. Which statement by the nurse provides the most appropriate guidance regarding lifestyle choices?

An 85-year-old client residing in a long-term care facility suddenly exhibits severe agitation, disorientation, and disorganized thinking. The unlicensed assistive personnel reports that the client was completely alert, oriented, and calm earlier in the shift. In what order should the nurse perform the following assessment actions to evaluate this acute change? Arrange the steps from first (highest) priority to last (lowest) priority.

Following a right total hip arthroplasty via a posterior approach, an older adult requires assistance with activities of daily living, elimination, and positioning. To ensure safety and promote comfort during the recovery period, which of the following actions should be incorporated into the client's daily care routine? Select all that apply.

While caring for a client who is receiving intravenous antibiotics for acute pyelonephritis, the nurse monitors for systemic complications. Which assessment finding provides the earliest physiological indication that the client is developing septic shock?

During the night shift, a registered nurse is called to the room of an 84-year-old client admitted with community-acquired pneumonia. The client has suddenly become severely agitated, is pulling at the intravenous (IV) tubing, and is attempting to get out of bed unassisted. Which of the following is the most appropriate initial nursing action?

A client admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD) has the following arterial blood gas (ABG) results: pH 7.26, PaCO₂ 58 mm Hg, and HCO₃⁻ 24 mEq/L. Based on these physiological values, which acid-base imbalance is the client experiencing?

A critical care nurse is monitoring a client admitted with severe acute necrotizing pancreatitis. The client's central venous pressure (CVP) has decreased from 8 mm Hg to 2 mm Hg over the last four hours. Which of the following assessment findings indicate the client is developing hypovolemic shock secondary to massive third-spacing of fluids? Select all that apply.

A client is admitted to the intensive care unit with a severe intra-abdominal infection. The nurse is monitoring the client's hemodynamic parameters to assess for the development of early (hyperdynamic) septic shock. Which clinical and hemodynamic findings indicate that the client is experiencing this specific physiological state? Select all that apply.

A client is receiving care in the intensive care unit 48 hours after sustaining a complete spinal cord transection at the T3 level. The bedside monitor suddenly alarms. Assessment reveals a blood pressure of 72/40 mm Hg, a heart rate of 42 beats/minute, and profoundly warm, flushed skin below the level of the injury. The client is lethargic but maintains a patent airway. Which intervention should the nurse implement first?

A client with a systemic fungal infection has a double-lumen peripherally inserted central catheter (PICC). The proximal lumen is dedicated to a continuous total parenteral nutrition (TPN) infusion. The distal lumen is infusing 0.9% sodium chloride with 20 mEq of potassium chloride at 75 mL/hr. The healthcare provider prescribes a daily intermittent intravenous (IV) infusion of amphotericin B deoxycholate. Which of the following actions by the nurse demonstrates the correct technique for administering this medication?

A nurse is caring for a client with acute decompensated heart failure who weighs $198 \text{ lbs}$. The healthcare provider prescribes a continuous intravenous (IV) infusion of milrinone at $0.375 \text{ mcg/kg/min}$. The pharmacy supplies milrinone as $20 \text{ mg}$ in $100 \text{ mL}$ of $5\% \text{ Dextrose}$ in water (D5W). At what rate, in $\text{mL/hr}$, should the nurse set the IV infusion pump? (Record answer to the nearest tenth.)

A nurse at an outpatient primary care clinic is planning health promotion interventions for several clients on the daily schedule. Which nursing action correctly demonstrates a secondary level of disease prevention?

The charge nurse on a medical-surgical unit is reviewing the electronic health records of four assigned clients. Which client requires the most immediate assessment to reduce the risk of severe physiological deterioration?

A nurse is evaluating a $65$-year-old client admitted for a severe acute exacerbation of chronic obstructive pulmonary disease (COPD). The client is currently prescribed oxygen at $2$ L/min via nasal cannula. During the latest assessment, the nurse discovers that the client is extremely lethargic, difficult to arouse, and breathing at a shallow rate of $10$ breaths/min. The results of a stat arterial blood gas (ABG) draw are as follows:

* pH: $7.22$
* PaCO $_2$: $74$ mm Hg
* PaO $_2$: $58$ mm Hg
* HCO $_3^-$: $29$ mEq/L

To mitigate the risk of impending physiological decompensation, which of the following is the priority nursing action?

A nurse is caring for a client at 40 weeks gestation who is receiving a continuous transcervical amnioinfusion for the management of recurrent, severe variable decelerations. The nurse evaluates the electronic fetal monitor and intrauterine pressure catheter (IUPC) data. The fetal heart rate baseline is 145 bpm with moderate variability, and the variable decelerations have ceased. However, the nurse observes that the uterine resting tone has steadily increased from 15 mm Hg to 45 mm Hg over the past 20 minutes, and the client's perineal underpads are completely dry. Which of the following is the nurse's priority action?

An adult client receiving volume-controlled mechanical ventilation suddenly exhibits profound clinical deterioration. The ventilator triggers continuous high peak airway pressure alarms. Simultaneously, the cardiac monitor displays a heart rate of $142$ beats per minute, and the arterial line shows a precipitous blood pressure drop to $68/38 \text{ mmHg}$. Arrange the following emergency nursing actions in the correct chronological sequence for managing this acute crisis.

A client receiving an intravenous infusion of vincristine reports severe pain and burning at the peripheral intravenous site. The nurse observes swelling and blanching around the insertion site. Arrange the following nursing actions in the correct sequence.

An $78$-year-old client with a history of heart failure is receiving a continuous intravenous (IV) infusion of furosemide and is scheduled for an intermittent IV push dose of digoxin. During the morning assessment, the client reports nausea, anorexia, and seeing "yellow halos" around the lights in the room. The nurse assesses an irregular apical heart rate of $52 \text{ beats/min}$. Based on these findings, which of the following is the priority nursing action?

A nurse is caring for a client with a confirmed pulmonary embolism who is receiving a continuous intravenous (IV) infusion of heparin at $18 \text{ units/kg/hr}$ through a single-lumen peripheral venous catheter. The healthcare provider prescribes a scheduled dose of IV levofloxacin $500 \text{ mg}$ to infuse over $60 \text{ minutes}$ for a concurrent bacterial pneumonia. Upon reviewing a pharmacological reference, the nurse discovers that heparin and levofloxacin are physically incompatible. Which of the following is the most appropriate action by the nurse?