Tüm alıştırma soruları

A 28-year-old client is mechanically ventilated in the intensive care unit following a severe traumatic brain injury. The client is sedated and receiving continuous intracranial pressure (ICP) monitoring. Current assessment findings include:

- Vital signs: Blood pressure 155/85 mm Hg, Heart rate 62 bpm, SpO2 98%.
- Current ICP: 24 mm Hg (Baseline for this client: 12 mm Hg).
- Arterial Blood Gas (ABG) results: pH 7.31, PaCO2 54 mm Hg, PaO2 95 mm Hg, HCO3 26 mEq/L.

Which action should the nurse prioritize to reduce the client's risk for neurological deterioration?

A nurse is receiving a client at 36 weeks gestation in the emergency department immediately following a severe motor vehicle collision. The client is immobilized flat on a rigid backboard with a cervical collar applied. The client's blood pressure is 88/50 mmHg and heart rate is 112 beats/minute. Which action should the nurse take first?

A nurse is coordinating care for an older adult client who is recovering from a right middle cerebral artery (MCA) infarction. The client exhibits left-sided hemiplegia, moderate dysphagia, and episodes of evening agitation. Which intervention demonstrates the correct application of basic care and comfort principles?

The nurse is preparing a client for a bedside abdominal paracentesis. In what order should the nurse perform the following actions to ensure client safety and reduce the risk of complications? Arrange the actions in the correct chronological sequence.

An adult client being treated for severe sepsis has a double-lumen central venous catheter in place. One lumen is dedicated to a continuous infusion of total parenteral nutrition, and the other lumen is delivering a continuous infusion of norepinephrine. The provider prescribes an immediate intravenous dose of vancomycin. What is the safest action by the nurse?

A client presents to a crowded emergency department triage desk reporting a sudden onset of high fever, severe muscle pain, and unexplained epistaxis. The client reports returning three days ago from a region currently experiencing a high-consequence viral hemorrhagic fever outbreak. Activate the facility's emergency response plan by arranging the following immediate nursing actions in the correct priority sequence.

A nurse is evaluating a client who is $2\text{ hours}$ post-procedure following a right-sided cardiac catheterization via the femoral artery. Which of the following clinical findings indicate a developing complication and require immediate intervention? Select all that apply.

An adult client who is $24\text{ hours}$ postoperative following a small bowel resection remains NPO (nothing by mouth). The primary healthcare provider prescribes a continuous intravenous (IV) infusion of $1000\text{ mL}$ of lactated Ringer's solution to be administered over an $8\text{-hour}$ period.

At what rate in milliliters per hour (mL/hr) should the nurse set the electronic IV infusion pump? Record your answer as a whole number.

A severe thunderstorm causes a massive regional power outage, and the hospital immediately transitions to emergency backup generator power. A nurse is providing care for a group of hemodynamically unstable clients in the intensive care unit (ICU). Which actions should the nurse take during this internal utility emergency? Select all that apply.

A client weighing $154\text{ lbs}$ is experiencing continuous generalized tonic-clonic seizures. The healthcare provider orders a loading dose of intravenous phenytoin $18\text{ mg/kg}$ to be administered at the maximum safe rate. The client currently has a single 20-gauge peripheral IV in the right forearm with a continuous infusion of $5\%$ dextrose in $0.45\%$ sodium chloride (D5 1/2 NS) running at $100\text{ mL/hr}$. Phenytoin is supplied in $50\text{ mg/mL}$ vials.

Which action by the nurse represents the safest and most appropriate administration technique?

A client is admitted to the medical-surgical unit following a right-hemispheric stroke. The client exhibits severe left-sided neglect, impulsive behavior, and impaired judgment. Despite having dense left-sided hemiparesis, the client repeatedly attempts to stand up and walk unassisted. Which intervention is the most appropriate initial action to prevent injury?

A nurse is preparing to mix and administer a prescribed dose of Regular insulin and NPH insulin in a single syringe. Arrange the steps of this procedure in the correct sequence from first to last.

Following an industrial explosion resulting in a mass casualty incident, the hospital activates its Emergency Operations Plan (EOP) to surge capacity. The charge nurse on a medical-surgical unit is evaluating current clients for early discharge to make beds available for incoming victims. Which of the following clients is the safest candidate to recommend for immediate discharge?

During an interdisciplinary case review, the healthcare team evaluates several clients exhibiting challenging behaviors on a medical unit. According to regulatory standards and safety guidelines, for which client is the application of physical restraints clinically justified?

A nurse is providing morning care for a client who is in balanced suspension skeletal traction for a fractured right femur. Which action by the nurse demonstrates the correct application of basic care and comfort principles?

A nurse hears a loud noise from a client's room and enters to find the client lying on the floor. Arrange the following nursing actions in the correct chronological order from first to last.

Thick, black smoke begins pouring from a linen storage room on a medical-surgical floor. The fire alarm is activated, and the charge nurse initiates a horizontal evacuation to the adjacent fire compartment. In what order should the nurse direct the evacuation of the following clients? Arrange the clients from first to be evacuated to last.

A nurse is caring for a client who underwent a right transfemoral (above-the-knee) amputation 24 hours ago. Which positioning strategy should be incorporated into the daily routine to ensure optimal joint mobility for future prosthesis use?

An interdisciplinary healthcare team is coordinating care for a newly admitted client presenting with generalized, weeping vesicular lesions diagnosed as disseminated herpes zoster. When establishing the infection control and safety protocols for this client, which of the following actions are appropriate? Select all that apply.

A client with stage 5 chronic kidney disease (CKD) arrives at the emergency department after missing three consecutive hemodialysis sessions. The client is lethargic and exhibits deep, rapid respirations at a rate of $34 \text{ breaths/min}$. An electrocardiogram (ECG) reveals tall, peaked T waves. The most recent arterial blood gas (ABG) shows a pH of $7.22$, PaCO2 of $28 \text{ mm Hg}$, PaO2 of $96 \text{ mm Hg}$, and HCO3- of $12 \text{ mEq/L}$. To reduce the risk of imminent physiological collapse, which prescribed action should the nurse implement FIRST?