Tüm alıştırma soruları

A nurse is evaluating a client who underwent a percutaneous coronary intervention (PCI) via the right femoral artery approach 4 hours ago. The femoral sheath has been removed and hemostasis was achieved. The client now reports a new onset of dull, aching pain in the right flank and lower back. Current vital signs are: blood pressure 96/60 mmHg, heart rate 114 bpm, and respiratory rate 20/min. The puncture site dressing is dry and intact, and the right pedal pulse is +2. Which of the following is the priority action by the nurse?

A client is 4 hours post-coronary artery bypass grafting (CABG) surgery with mediastinal and pleural chest tubes in place. The nurse notes that the previously steady dark red mediastinal drainage has abruptly stopped over the last hour. The client has become highly restless. Current vital signs are heart rate 118 bpm, blood pressure 92/76 mmHg, and respiratory rate 22 breaths/min. The latest arterial blood gas (ABG) on 40% FiO2 reveals: pH 7.32, PaCO2 37 mm Hg, PaO2 88 mm Hg, and HCO3 18 mEq/L. Which action should the nurse take FIRST to reduce the risk of imminent mortality?

A nurse is evaluating a client admitted 48 hours ago with severe acute pancreatitis. The client has become increasingly restless and confused. Current assessment findings include:

* Respiratory rate: 34 breaths/min and shallow
* Heart rate: 132 beats/min
* Blood pressure: 78/50 mm Hg
* **Oxygen saturation ($SpO_2$):** 84% on 4 L/min via nasal cannula
* Urine output: 10 mL over the last 2 hours
* Arterial Blood Gas (ABG): pH 7.25, $PaCO_2$ 58 mm Hg, $PaO_2$ 52 mm Hg, $HCO_3^-$ 24 mEq/L

Which of the following interventions should the nurse anticipate implementing? Select all that apply.

A nurse is planning discharge teaching regarding self-care management for a 15-year-old client recently diagnosed with type 1 diabetes mellitus. Which action by the nurse is most appropriate to promote the client's independence?

An adult client hospitalized with a deep vein thrombosis is receiving a continuous intravenous infusion of heparin. The healthcare provider prescribes a scheduled dose of intravenous vancomycin to treat a concurrent wound infection. The client currently has a single patent $20$-gauge peripheral venous catheter. Upon checking the facility drug reference, the nurse notes that heparin and vancomycin are physically incompatible at the Y-site. Which action by the nurse is the most appropriate?

The charge nurse at an inpatient neurological rehabilitation center is coordinating care for several clients recovering from brain injuries. The nursing team consists of a Registered Nurse (RN), a Licensed Practical Nurse (LPN/VN), and an Unlicensed Assistive Personnel (UAP). Which of the following task assignments are safe and appropriate? Select all that apply.

A nurse is preparing to perform open suctioning for an adult client with a tracheostomy tube. To minimize the risk of complications such as hypoxia and mucosal trauma, in what order should the nurse perform the following actions? Arrange the steps in the correct sequence.

Following a motor vehicle collision, a young adult client is admitted to the neurosurgical unit with a traumatic brain injury. The latest assessment reveals a blood pressure of 172/68 mm Hg and a heart rate of 52 beats per minute. Previous vital signs were a blood pressure of 130/82 mm Hg and a heart rate of 88 beats per minute. What is the most appropriate initial action for the nurse to perform?

A home healthcare nurse is developing a comprehensive care plan for a 68-year-old client recovering from a recent myocardial infarction. The nurse identifies several interventions to include in the plan of care to promote optimal health outcomes. Which of the following planned interventions specifically represents a secondary level of disease prevention?

A nurse is reviewing the arterial blood gas (ABG) results for a client with a long history of severe chronic obstructive pulmonary disease (COPD). Which of the following ABG findings indicates that the client's body has physiologically compensated for the chronic respiratory condition?

A client with a history of severe chronic obstructive pulmonary disease (COPD) is receiving non-invasive positive pressure ventilation (NIPPV) for an acute exacerbation. The client's initial arterial blood gas (ABG) values on admission were pH $7.24$, PaCO $_2$ $76$ mm Hg, PaO $_2$ $52$ mm Hg, and HCO $_3^-$ $34$ mEq/L. After 90 minutes of continuous NIPPV therapy, a repeat ABG reveals pH $7.31$, PaCO $_2$ $64$ mm Hg, PaO $_2$ $62$ mm Hg, and HCO $_3^-$ $34$ mEq/L. Upon entering the room to review these results, the nurse observes that the client is now difficult to arouse, moans only in response to a sternal rub, and exhibits absent gag and swallow reflexes. Which action should the nurse take immediately?

While a nurse is changing the needleless connector caps on a 65-year-old client's right subclavian central venous catheter, the client suddenly gasps for air, reports sharp chest pain, and develops peripheral cyanosis. Recognizing the signs of a potential air embolism, in what order should the nurse perform the following emergency interventions? Arrange the steps from first priority to last priority.

A nurse is preparing to administer a unit of packed red blood cells (PRBCs) to a client with symptomatic anemia. Arrange the following actions in the correct chronological sequence to ensure safe administration.

A nurse is caring for a client who is receiving a transfusion of packed red blood cells. Fifteen minutes after the transfusion begins, the client suddenly reports severe lower back pain, chills, and dyspnea. Place the following nursing interventions in the correct order of priority from first to last.

A registered nurse is preparing to apply knee-length anti-embolism stockings to a client who is on strict bed rest. Place the following nursing actions in the correct order from first to last. (All steps are required.)

A registered nurse is evaluating a newly licensed nurse's understanding of confidentiality, information security, and legal mandates in the clinical setting. Which of the following actions by the newly licensed nurse demonstrate appropriate adherence to these principles? (Select all that apply.)

During the first post-surgical shift following an exploratory laparotomy, a client's clinical parameters demonstrate a subtle but continuous shift. The client's systolic blood pressure has drifted from $138$ mm Hg to $118$ mm Hg, while the diastolic pressure has climbed from $70$ mm Hg to $88$ mm Hg. Concurrently, the resting heart rate has accelerated from $78$ to $115$ beats per minute, and the respiratory rate is currently $28$ breaths per minute. The most recent hourly urine measurement yielded $15$ mL. Which underlying pathophysiological mechanism best accounts for this symptom complex?

A client with osteoarthritis is prescribed oral ibuprofen $600 \text{ mg}$ every 8 hours as needed for joint pain. The medication is available on the unit as an oral suspension with a concentration of $100 \text{ mg} / 5 \text{ mL}$. How many milliliters ($\text{mL}$) should the nurse administer for a single dose?

A nurse is assessing a postoperative client who recently underwent major abdominal surgery. Which clinical findings should indicate to the nurse that the client is experiencing the early, compensatory stage of hypovolemic shock? Select all that apply.

An emergency department nurse initiates a prescribed sodium nitroprusside continuous intravenous infusion for a patient presenting with acute hypertensive encephalopathy and underlying renal insufficiency. To ensure patient safety during this high-alert parenteral therapy, which interventions must the nurse implement? Select all that apply.