Tüm alıştırma soruları

While evaluating a 79-year-old client who was admitted to a medical-surgical floor overnight, the oncoming nurse reviews the morning assessment data. Which documented observations represent expected physiological adaptations of senescence? Select all that apply.

A nurse on a medical-surgical unit is caring for a client who is confused and repeatedly attempting to remove a newly placed percutaneous endoscopic gastrostomy (PEG) tube. After multiple alternative safety measures have failed, the healthcare provider prescribes bilateral soft wrist restraints. Which action by the nurse ensures the safe use of these restraints?

A client recovering from abdominal surgery requires pain management. The provider orders morphine sulfate $6 \text{ mg}$ IV push every 4 hours as needed for severe pain. The medication is available in a vial containing $10 \text{ mg}/\text{mL}$. How many milliliters should the nurse administer for a single dose?

The triage nurse in a busy adult emergency department is concurrently evaluating four walk-in clients. Based on the principles of prioritization and triage, arrange the clients in the order they must be medically evaluated, from highest priority (first) to lowest priority (last).

An intensive care unit nurse is preparing to enter the negative-pressure isolation room of a client who has both active pulmonary tuberculosis and a heavily draining abdominal wound infected with methicillin-resistant *Staphylococcus aureus* (MRSA) that requires irrigation. Arrange the following steps for donning the required personal protective equipment (PPE) in the correct sequential order.

Before providing morning care to a client with confirmed disseminated varicella-zoster virus, a nurse must don full personal protective equipment (PPE) for Airborne and Contact Precautions. Arrange the following actions for applying the required PPE in the correct chronological sequence.

A nursing coordinator at a regional medical center is directing workflow for a team comprising a registered nurse (RN), a licensed practical nurse (LPN/VN), and an unlicensed assistive personnel (UAP). Which task delegation by the coordinator demonstrates the safest practice?

A nurse is reviewing the physical assessment data of several older adult clients in a primary care clinic. Which documented finding should the nurse identify as an expected physiological change associated with the aging process?

A nurse is providing care for a client in a semi-private room. Behind the drawn privacy curtain, the other client in the room is discussing their recent human immunodeficiency virus (HIV) diagnosis and treatment plan with a physician. The nurse's client overhears the conversation, becomes visibly anxious, and asks the nurse, "What is wrong with the person next to me? Am I going to catch something dangerous?" Which of the following is the most appropriate response by the nurse?

During a routine home visit, a palliative care registered nurse assesses an 84-year-old client diagnosed with severe dementia. The nurse notes several distinct, blistered circular lesions on the client's posterior thorax. The family caregiver explains, "We applied heated glass cups to draw out the toxins causing their back pain." The client winces when the area is touched but cannot verbally communicate. Which of the following represents the most appropriate ethical and legal nursing action?

A registered nurse (RN) is developing a plan of care for a critically ill client who is mechanically ventilated. The client is experiencing acute agitation and has repeatedly attempted to pull at the endotracheal tube despite maximum pharmacological sedation, verbal reorientation, and the continuous presence of a sitter. The healthcare provider has prescribed bilateral soft wrist restraints to prevent self-extubation. Which of the following nursing interventions should the RN include in the care plan? Select all that apply.

A registered nurse (RN) is supervising an unlicensed assistive personnel (UAP) on a medical-surgical unit. The RN observes the UAP preparing to feed a client who has a history of dysphagia, but the client's bed is completely flat. Arrange the RN's actions in the priority order they should be performed, from first to last.

A nurse is providing care for an older adult client. While attempting to get out of bed, the client suddenly reports feeling dizzy and lightheaded. Arrange the following nursing actions in the prioritized order of performance, from first to last.

During the night shift, a nurse responds to a bed alarm and finds an older adult client who has abruptly become disoriented. The client is restless, attempting to climb over the bed rails, and pulling forcefully at their indwelling urinary catheter. Which action should the nurse take first to protect the client from injury?

During a night shift, a client recovering from a complicated bowel resection becomes profoundly restless and starts forcefully pulling at their wound vacuum dressing and peripheral intravenous line. Sequence the following nursing actions from the initial priority intervention to the most restrictive emergency measure.

A client admitted with acute amphetamine intoxication exhibits severe paranoia and suddenly becomes physically combative, striking a staff member and throwing medical equipment. Verbal de-escalation and environmental modifications have failed to calm the client. The healthcare provider prescribes bilateral physical restraints for violent behavioral management. Which action by the primary nurse is correct?

During a comprehensive safety audit on an acute care unit, a clinical nurse leader evaluates various staff practices for compliance with injury prevention protocols. Which action by a staff member demonstrates correct adherence to environmental and client safety standards?

During a shift assessment, a registered nurse evaluates a client who is receiving a continuous intravenous (IV) heparin infusion for a deep vein thrombosis. The client, who has a history of stroke with residual dysphagia, is additionally on contact precautions for a methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse notes the client has become acutely disoriented, highly agitated, and is repeatedly attempting to climb out of bed unassisted. Which of the following interventions should the nurse implement to maintain a safe care environment? Select all that apply.

During a routine clinic visit, an older adult client describes their current sleep habits to the nurse. Which of the following statements by the client indicates an expected age-related physiological change?

A 35-year-old client with end-stage renal disease is admitted to the medical-surgical unit. The client is alert, oriented, and calmly informs the nurse of the decision to discontinue all future hemodialysis treatments. The client articulates a clear understanding that this decision will lead to death. The client's adult sibling becomes extremely upset and demands that the nurse administer a sedative to the client so that dialysis can be forcibly initiated. Which action by the nurse represents the most appropriate ethical practice?