Tüm alıştırma soruları

A nurse is preparing to administer a large-volume cleansing enema to an adult client experiencing severe constipation. Arrange the following nursing actions in the correct chronological sequence of execution.

A nurse is caring for a client who is receiving continuous enteral tube feedings via a nasogastric (NG) tube. Which actions should the nurse take to reduce the client's risk of aspiration? Select all that apply.

A nurse is caring for a client who is 6 hours postpartum following a forceps-assisted vaginal delivery. The client reports severe, unrelenting perineal pressure and pain that has worsened over the last hour, despite having received prescribed oral acetaminophen and ibuprofen. Assessment reveals a firm uterus located midline at the umbilicus, with scant lochia rubra. Which of the following actions should the nurse take first?

A client with severe gastroenteritis requires intravenous rehydration. The treatment plan includes $1,000\text{ mL}$ of $0.9\%$ sodium chloride to run over a $4\text{-hour}$ period. At what rate in $\text{mL/hr}$ should the nurse program the infusion pump? (Record your answer using a whole number.)

A group of ambulatory clients arrives at the emergency department walk-in entrance reporting exposure to an unknown liquid chemical from an overturned transport vehicle. Arrange the following actions the triage nurse should take in the correct chronological order.

A nurse is preparing to obtain a blood specimen for a comprehensive metabolic panel from a client's multi-lumen central venous catheter (CVC). A continuous infusion of parenteral nutrition is currently running through an adjacent lumen. To reduce the risk of pre-analytical laboratory errors and maintain line patency, in what order should the nurse perform the following actions? (Arrange the items in the correct chronological sequence.)

A nurse discovers that a client's central venous catheter (CVC) tubing has accidentally disconnected from the injection cap. The client suddenly appears extremely restless, is gasping for air, and exhibits circumoral cyanosis. Which of the following is the priority nursing action?

An older adult client is admitted with a severe exacerbation of chronic obstructive pulmonary disease (COPD). During evening rounds, the client reports extreme fatigue but states, "I cannot fall asleep because I feel like I am suffocating when I lie down." Which nursing action is most appropriate to promote comfort and facilitate rest for this client?

A client is admitted to the cardiac intensive care unit with acute decompensated heart failure and a severely elevated blood pressure. The client is receiving a continuous intravenous (IV) infusion of nitroglycerin currently running at $15\text{ mcg/min}$. The provider's prescription states: "Titrate nitroglycerin infusion upward by $5\text{ mcg/min}$ every 5 minutes until systolic blood pressure is less than $140\text{ mm Hg}$." The pharmacy provides a premixed nitroglycerin solution of $50\text{ mg}$ in $250\text{ mL}$ of $5\%$ dextrose in water (D5W). The client's blood pressure remains elevated, requiring exactly two dosage titrations over the next 10 minutes. What will the nurse set the IV infusion pump rate to in $\text{mL/hr}$ following the second titration? Record your answer as a number with one decimal place.

A client receiving a first dose of an intravenous antibiotic suddenly reports difficulty swallowing and feeling faint. The nurse observes facial swelling, audible wheezing, and a rapidly dropping blood pressure. Place the following nursing interventions in the correct sequence to manage this acute physiological emergency.

A nurse is evaluating the clinical data of a client with a small bowel obstruction who has received continuous nasogastric (NG) tube decompression for 72 hours. The client is lethargic with shallow respirations of 10 breaths/min. The cardiac monitor reveals a prolonged QT interval and frequent multifocal premature ventricular contractions (PVCs).

Morning laboratory results:
- pH: $7.56$
- $PaCO_2$: $54$ mm Hg
- $HCO_3^-$: $44$ mEq/L
- Potassium: $2.4$ mEq/L ($2.4$ mmol/L)
- Magnesium: $1.1$ mEq/L ($0.55$ mmol/L)

Which intervention must the nurse prioritize to reduce the client's risk of a life-threatening physiological complication?

A nurse is removing a non-tunneled central venous catheter (CVC) from a client's right subclavian vein. Immediately following the catheter's removal, the client suddenly gasps, exhibits severe dyspnea, clutches their chest, and their oxygen saturation rapidly drops to 84%. Suspecting an acute venous air embolism, arrange the following collaborative and nursing interventions in the priority order they must be implemented to mitigate physiological risk.

An adult client underwent a percutaneous left renal biopsy 4 hours ago. Baseline vital signs in the recovery unit included a blood pressure of 138/82 mm Hg and a heart rate of 76 beats/min. During the current assessment, the client reports a new, deep ache in the left flank and lower back. Vital signs demonstrate a blood pressure of 108/88 mm Hg, a heart rate of 115 beats/min, and a respiratory rate of 22 breaths/min. Based on these physiological changes, which intervention is the priority to minimize further client risk?

While evaluating a client who recently arrived at the surgical unit after a total abdominal hysterectomy, the nurse reviews the most recent vital signs and clinical presentation. Which assessment finding represents the earliest manifestation of internal bleeding?

An adult client in the intensive care unit is being treated for severe sepsis and metabolic acidosis. The client has a triple-lumen central venous catheter (CVC) in the right internal jugular vein. The current continuous intravenous (IV) infusions are as follows:

• Proximal port: $0.45\%$ sodium chloride with $150\text{ mEq}$ of sodium bicarbonate infusing at $150\text{ mL/hr}$.
• Medial port: Epinephrine infusing at $0.05\text{ mcg/kg/min}$ for blood pressure support.
• Distal port: Total parenteral nutrition (TPN) infusing at $75\text{ mL/hr}$.

The client's morning laboratory results indicate an ionized calcium level of $0.85\text{ mmol/L}$ (normal: $1.05\text{-}1.30\text{ mmol/L}$). The healthcare provider prescribes $1\text{ g}$ of intravenous calcium gluconate to be administered over 15 minutes. Which action by the nurse is the most appropriate?

A nurse is caring for a laboring client who is receiving an intravenous oxytocin infusion for labor augmentation. Upon reviewing the electronic fetal monitor tracing, the nurse notes a pattern of recurrent late decelerations. In which order should the nurse perform the following interventions? (Arrange the actions in the correct sequence from first to last.)

First responders are deployed to a residential apartment complex following a severe earthquake that caused widespread structural collapse. While utilizing the Simple Triage and Rapid Treatment (START) algorithm during this mass casualty incident, which client should the nurse classify as delayed (yellow tag)?

The nurse is preparing to administer an intermittent bolus enteral feeding via a gastrostomy tube to a client with dysphagia. After verifying the provider's prescription, performing hand hygiene, and donning clean gloves, arrange the following nursing actions in the correct chronological sequence.

An older adult client with a history of moderate dementia is receiving continuous enteral nutrition via a nasogastric (NG) tube. During the night shift, the client becomes acutely restless, exhibits new-onset confusion, and repeatedly attempts to pull at the NG tube. The client also requires frequent linen changes due to urinary incontinence. What nursing action demonstrates the safest approach to managing this client's basic care and comfort?

A registered nurse is preparing to provide care for a client admitted with a confirmed diagnosis of Middle East Respiratory Syndrome (MERS). The client is in a negative-pressure room requiring airborne and contact precautions. Arrange the following steps for donning the required personal protective equipment (PPE) in the correct chronological sequence prior to entering the client's room.