Tüm alıştırma soruları

A nurse is caring for a client who is 4 hours postoperative following a coronary artery bypass grafting (CABG) procedure. The client suddenly exhibits profound hypotension, pronounced jugular venous distention, muffled heart sounds, and a precipitous drop in mediastinal chest tube drainage. Arrange the following nursing actions in the priority order they should be executed.

A client is admitted to the medical unit with a history of peptic ulcer disease and reports of passing dark, tarry stools for the past two days. The client is currently resting in a supine position.

Vital signs upon admission (3 hours ago): Blood pressure $138/80$ mm Hg, heart rate $78$ beats/min, respiratory rate $14$ breaths/min.

Current assessment findings:
- Blood pressure $112/84$ mm Hg
- Heart rate $112$ beats/min
- Respiratory rate $24$ breaths/min
- SpO $_2$ $96\%$ on room air
- The client reports feeling restless and slightly lightheaded.
- Arterial Blood Gas (ABG): pH $7.49$, PaCO $_2$ $29$ mm Hg, PaO $_2$ $92$ mm Hg, HCO $_3^-$ $23$ mEq/L

Based on these findings, which of the following is the priority nursing intervention?

A client is receiving care in the intensive care unit four days after a severe subarachnoid hemorrhage. The client, previously alert and oriented, suddenly becomes extremely restless and confused. Current assessment findings include a blood pressure of 82/46 mm Hg, heart rate of 126 beats/minute, and a central venous pressure (CVP) of 1 mm Hg. The client's urine output over the past 4 hours was 1,600 mL.

The nurse reviews the most recent laboratory results:

Based on these findings, which of the following prescribed interventions is the highest priority for the nurse to implement?

A nurse is caring for a multiparous client who experienced a precipitous vaginal delivery of a macrosomic newborn 4 hours ago. The nurse asks the unlicensed assistive personnel (UAP) to obtain the client's vital signs. The UAP reports a blood pressure of 108/86 mmHg, heart rate of 114 beats/min, and respiratory rate of 20 breaths/min. The client reports feeling slightly lightheaded when attempting to sit up. Which of the following is the priority nursing action?

A registered nurse is preparing to admit a client diagnosed with disseminated herpes zoster. Which of the following transmission-based precaution interventions should the nurse implement? Select all that apply.

A registered nurse realizes that an incorrect intravenous (IV) high-alert medication has just been initiated for an adult client. Arrange the following nursing actions in the priority sequence the nurse should perform them to mitigate harm and manage the error.

During the continuous electronic fetal monitoring of a client in active labor, the nurse observes recurrent, abrupt decreases in the fetal heart rate that drop 30 beats per minute below the baseline. These decreases reach their lowest point in less than 30 seconds, return to baseline rapidly, and do not demonstrate a consistent relationship with the onset of uterine contractions. Which action should the nurse take first?

A nurse working at the emergency department triage desk receives a telephone call from an unknown individual stating that an explosive device has been placed in the hospital. Arrange the following actions in the correct priority sequence the nurse should take according to standard emergency response protocols. (Order from first action to last action)

A nurse is planning care for a client who is 48 hours post-operative following a right above-the-knee amputation (AKA) due to complications of peripheral arterial disease. Which of the following positioning interventions is most appropriate to include in the client's plan of care?

A nurse is caring for a client at $31$ weeks of gestation who is experiencing preterm labor. The healthcare provider prescribes a continuous intravenous infusion of magnesium sulfate at a rate of $3\text{ g/hr}$ for fetal neuroprotection. The pharmacy dispenses a premixed IV bag containing $20\text{ g}$ of magnesium sulfate in $500\text{ mL}$ of sterile water. At what rate in $\text{mL/hr}$ should the nurse set the intravenous infusion pump? (Record your answer as a whole number.)

While attending an off-duty community event at a large indoor stadium, a structural collapse occurs, resulting in mass casualties. A nurse establishes a preliminary triage area for the victims. Based on the START (Simple Triage and Rapid Treatment) algorithm, which individual should the nurse classify as an immediate priority?

A nurse is caring for a client who is receiving continuous enteral tube feedings and requires repositioning every 2 hours to prevent pressure injuries. Which of the following actions is the most appropriate for the nurse to take when turning the client?

An acute care facility activates its emergency response plan after receiving a tornado warning indicating a severe storm is imminent. The charge nurse on a progressive care unit is coordinating immediate safety measures. Which of the following actions should the nurse implement? Select all that apply.

A nurse is evaluating a client who had an open abdominal surgery 6 hours ago. The client reports feeling dizzy, anxious, and extremely thirsty. The nurse assesses the vital signs: heart rate 124 beats/min, blood pressure 98/74 mm Hg (baseline 130/80 mm Hg), and respiratory rate 24 breaths/min. The client's skin is pale and cool to the touch. Which of the following is the priority nursing action?

While evaluating the labor progress of a gravida 2, para 1 client receiving oxytocin augmentation, the nurse identifies a gradual, symmetric decrease in the fetal heart rate that begins consistently after the peak of successive contractions. The heart rate returns to baseline only after the contraction has fully resolved. Which intervention is the most appropriate initial action?

A nurse is establishing a plan of care for an older adult client who is recovering from a right-sided modified radical mastectomy with axillary lymph node dissection. Which nursing intervention best addresses the client's basic care and comfort needs while preventing complications?

A registered nurse is preparing to enter the airborne infection isolation room (AIIR) of a client admitted with disseminated varicella-zoster virus. The client requires both airborne and contact precautions. Arrange the following steps for donning personal protective equipment (PPE) in the correct chronological order from first to last.

A specialized medical task force arrives at the site of a severe passenger train derailment. As part of the initial disaster response team utilizing the Simple Triage and Rapid Treatment (START) algorithm, which casualty should the nurse categorize as requiring immediate, life-saving intervention?

A nurse is assisting with the delivery of a newborn. Immediately after birth, the newborn is apneic and limp. Arrange the following neonatal resuscitation interventions in the correct chronological sequence according to standard clinical guidelines.

A nurse is caring for a client who just underwent a percutaneous liver biopsy and is now prescribed a packed red blood cell (PRBC) transfusion for acute blood loss. Which interventions are essential for the nurse to implement to prevent accidents, errors, and injury? Select all that apply.