Tüm alıştırma soruları

A nurse is caring for a client who is 12 hours postoperative following an open abdominal surgery. Which interventions should the nurse implement to reduce the client's risk of developing a venous thromboembolism (VTE)? Select all that apply.

An emergency department nurse is managing a client in a hypertensive crisis. The client weighs $85\text{ kg}$ and is currently receiving a continuous intravenous (IV) infusion of sodium nitroprusside at $25\text{ mL/hr}$. The IV bag contains $50\text{ mg}$ of sodium nitroprusside mixed in $250\text{ mL}$ of $5\%$ Dextrose in Water ($D_5W$). According to the facility protocol, the nurse must titrate the infusion upward by $0.5\text{ mcg/kg/min}$ if the mean arterial pressure (MAP) remains above $80\text{ mm Hg}$. The client's current MAP is $94\text{ mm Hg}$. After increasing the dosage by one increment, what will be the new infusion pump rate in $\text{mL/hr}$? Record your answer to the nearest tenth.

A charge nurse at a skilled rehabilitation center responds to a room where an 84-year-old client is experiencing a sudden, acute onset of severe confusion and hyperactivity, which is a stark change from their baseline. Arrange the following nursing actions in the priority order they should be implemented.

A client is prescribed an intravenous (IV) dose of phenytoin for seizure management. The client has a single peripheral IV access site with a continuous primary infusion of $5\%$ dextrose in water (D5W). Which action should the nurse take to safely administer the phenytoin?

A nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving positive-pressure mechanical ventilation. The client's high-pressure ventilator alarm begins sounding continuously, and the nurse notes that the client has become highly agitated. The latest arterial blood gas (ABG) results show a pH of $7.21$, $\text{PaCO}_2$ of $72\text{ mm Hg}$, $\text{PaO}_2$ of $52\text{ mm Hg}$, and $\text{HCO}_3^-$ of $25\text{ mEq/L}$. Over the last 10 minutes, the client's blood pressure has dropped from $122/76\text{ mm Hg}$ to $84/42\text{ mm Hg}$, and the heart rate has increased from $98\text{ bpm}$ to $136\text{ bpm}$. Auscultation reveals absent breath sounds over the right lung field. Which action is the highest priority for the nurse to take to reduce the risk of cardiovascular collapse?

Following a craniotomy, a hospitalized individual develops postoperative delirium and forcefully tugs at their external ventricular drain. After determining that environmental modifications, a bed alarm, and verbal redirection are ineffective, the care team decides that physical safety devices are necessary to prevent life-threatening tube dislodgment. Which nursing action demonstrates adherence to proper safety protocols for this intervention?

A nurse is formulating a basic care and comfort plan for an 82-year-old client who experienced a right hemispheric ischemic stroke 48 hours ago. The client exhibits left-sided hemiparesis, impulsive behavior, moderate dysphagia, and new-onset urinary incontinence. Which intervention is the most appropriate for the nurse to include in the plan of care?

A nurse is caring for a client newly admitted to the intensive care unit with diabetic ketoacidosis (DKA). The client is lethargic and exhibits deep, rapid respirations. Initial laboratory results reveal a serum blood glucose of 680 mg/dL (37.7 mmol/L), an arterial pH of 7.12, and a serum potassium of 2.7 mEq/L (2.7 mmol/L). In what order should the nurse implement the collaborative interventions? Arrange the actions from first to last.

A nurse in an outpatient clinic is conducting a clinical risk evaluation for a 75-year-old community-dwelling client to promote healthy aging and prevent fall-related injuries. Arrange the following nursing actions in the correct sequential order according to the nursing process.

A registered nurse (RN) is planning morning hygiene care for a client who has right-sided hemiparesis and is receiving continuous enteral nutrition. The RN is delegating parts of the care to an unlicensed assistive personnel (UAP). Which instruction provided by the RN is the most appropriate?

Following the removal of $1,500$ mL of pleural fluid via a right-sided thoracentesis, a client suddenly develops acute respiratory distress. The continuous monitor displays a heart rate of $128$ beats/minute and a blood pressure of $84/52$ mm Hg. Physical examination reveals absent breath sounds on the right side and a leftward tracheal shift. Which of the following is the priority nursing action?

A nurse is evaluating the electronic fetal monitoring tracing of a client at 39 weeks gestation who is in active labor. The client has not received any systemic medications. The tracing reveals a baseline fetal heart rate of 135 beats/min. Over the past 25 minutes, the tracing demonstrates a smooth, undulating, sine wave-like pattern with an amplitude of 15 beats/min and a frequency of 4 cycles per minute. There are no accelerations, and baseline variability is absent. Which action is the priority for the nurse?

A nurse is monitoring a client who is at risk for internal hemorrhage following a percutaneous liver biopsy. Which of the following vital sign trends represents the earliest physiological adaptation to intravascular fluid loss?

The nurse receives the shift report for four clients on a medical-surgical unit. Which client should the nurse assess first?

A nurse is preparing to administer a large-volume cleansing enema to an adult client who is experiencing severe constipation. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence.

A nurse is admitting a client presenting with a severe headache, nuchal rigidity, and photophobia. The healthcare provider suspects Neisseria meningitidis. Additionally, the client reports experiencing frequent, watery diarrhea over the past two days, and a stool sample has been sent for Clostridioides difficile testing. Which of the following infection control interventions should the nurse include in the client's plan of care? (Select all that apply.)

During the administration of a first dose of intravenous ceftriaxone, the client suddenly grasps their neck, stating their throat is closing, and severe expiratory wheezing is noted. Place the following crisis management actions in the correct priority sequence from first to last.

A community health nurse is conducting a home assessment for a 76-year-old client. The client mentions several recent physical and cognitive changes. Which of the following client statements should the nurse identify as an expected physiological change of aging rather than a manifestation of acute pathology?

An adult client with acute decompensated heart failure is admitted to the cardiac intensive care unit. The client is currently receiving a continuous intravenous (IV) infusion of dobutamine at $10 \text{ \mu g/kg/min}$ via a dedicated single-lumen peripheral IV catheter. During the shift, the client suddenly develops severe dyspnea, and the nurse auscultates coarse bilateral crackles. The healthcare provider immediately prescribes a stat dose of furosemide $40 \text{ mg}$ IV push. Which of the following is the most appropriate action by the nurse?

An emergency department nurse is caring for an older adult client who presents with profound lethargy and confusion. The client has a known medical history of heart failure with a severely reduced ejection fraction. The client's family reports a three-day history of dysuria, chills, and fever prior to admission.

Current vital signs:
- Blood pressure: 76/48 mm Hg (MAP 57 mm Hg)
- Heart rate: 134 bpm
- Respiratory rate: 32 breaths/min
- Temperature: 39.2 °C (102.6 °F)
- Oxygen saturation: 88% on 4 L/min via nasal cannula

Physical assessment reveals prominent jugular venous distention at a 45-degree angle, cool and mottled extremities, and coarse crackles auscultated bilaterally up to the mid-lung fields.

Based on the client's clinical presentation and laboratory data, which of the following prescribed interventions is the highest priority for the nurse to implement?