Tüm alıştırma soruları

An overnight registered nurse is planning care for a client who has Clostridioides difficile (C. diff) infection, is experiencing acute delirium, and is frequently attempting to pull out their intravenous (IV) catheter. Which interventions should the nurse include in the safety and care plan? Select all that apply.

A triage nurse receives a client with type 1 diabetes mellitus who presents with deep, rapid breathing, a fruity breath odor, and increasing lethargy. The initial point-of-care blood glucose is $512$ mg/dL ($28.4$ mmol/L). Arrange the following nursing interventions in the priority order they should be implemented.

A nurse is caring for a $62$-year-old client who returned to the telemetry unit $2$ hours ago following a percutaneous coronary intervention (PCI) via the right femoral artery. Which of the following assessment findings require immediate follow-up by the nurse? Select all that apply.

A nurse is caring for a client with diabetic ketoacidosis (DKA) who is receiving a continuous intravenous (IV) infusion of regular insulin at $0.1\text{ units/kg/hr}$. The client's most recent laboratory results reveal a blood glucose of $215\text{ mg/dL}$ ($11.9\text{ mmol/L}$), a serum potassium of $3.1\text{ mEq/L}$ ($3.1\text{ mmol/L}$), and an anion gap of $18\text{ mEq/L}$. The current maintenance IV fluid is $0.45\%$ sodium chloride infusing at $150\text{ mL/hr}$. Which of the following is the priority nursing action?

A nurse is monitoring a client 4 hours after a complex open abdominal surgery. The client's baseline preoperative vital signs were blood pressure 126/78 mm Hg, heart rate 72 beats/min, and respiratory rate 14 breaths/min. Which combination of current assessment findings provides the most definitive early indication of compensatory hypovolemic shock?

A nurse is evaluating a client who is $2$ hours postpartum following the vaginal delivery of a $4,100\text{ g}$ newborn. The client has saturated a perineal pad in $30$ minutes. Which of the following assessment findings should the nurse recognize as early indicators of hemorrhagic shock? (Select all that apply.)

A nurse is caring for a client who has just returned to the medical-surgical unit following a percutaneous liver biopsy. Which of the following interventions should the nurse include in the client's immediate plan of care to reduce the risk of post-procedure complications? Select all that apply.

A nurse is assisting with field triage following a roof collapse at a local warehouse. Using the START (Simple Triage and Rapid Treatment) method, the nurse assesses an adult client who is sitting on the ground. The client has an obvious deformity of the right lower leg and reports severe pain. The client is unable to walk. The respiratory rate is 22 breaths/minute, the radial pulse is strong and regular, and the client correctly follows the command to squeeze the nurse's hand. Which triage category should the nurse assign to this client?

A nurse is caring for a client receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes after the infusion begins, the client develops sudden chills, severe lower back pain, and dyspnea. Arrange the following nursing actions in the priority order they should be performed, from first action to last.

A nurse is planning hygiene and comfort measures for a client with a severe traumatic brain injury and continuously monitored increased intracranial pressure (ICP). The client is mechanically ventilated and requires a full bed bath, linen change, and repositioning. Which of the following nursing interventions is the most appropriate?

A nurse is caring for an adult client with a serum potassium level of $2.5 \text{ mEq/L}$ who is prescribed $40 \text{ mEq}$ of intravenous (IV) potassium chloride (KCl) to be administered via a peripheral IV line. Which action must the nurse take to ensure safe administration?

A client presents to the emergency department with a sudden onset of high fever, severe headache, photophobia, and nuchal rigidity. The healthcare provider suspects bacterial meningitis. Which of the following actions should the nurse include in the client's plan of care? Select all that apply.

A nurse is caring for a client who is $4$ hours post-cardiac catheterization via the right femoral artery. The client begins reporting new, severe discomfort in the lower back and flank area, along with mild dizziness. Current vital signs reveal a blood pressure of $96/54$ mm Hg and a heart rate of $114$ beats per minute. The femoral insertion site dressing is completely dry and intact. Which action should the nurse take first to address the client's risk of physiological decompensation?

A telephone triage nurse at an obstetrical practice is reviewing voicemail messages left by four different clients. Which client condition requires the most immediate callback?

A nurse is monitoring an adult client who is receiving a transfusion of packed red blood cells for symptomatic anemia. Twenty minutes after the infusion begins, the client suddenly reports severe lower back pain, chills, and a sensation of chest tightness. In what order should the nurse perform the following interventions to minimize the client's risk of physiological deterioration?

A public health nurse is conducting a disaster preparedness drill for newly hired emergency department staff. The nurse is reviewing the Simple Triage and Rapid Treatment (START) algorithm for adult mass casualty incidents. Place the following triage assessment actions in the correct sequential order from first to last.

An adult client is transferred to the neurology observation unit following a diagnostic lumbar puncture. Thirty minutes after arrival, the client complains of a severe, throbbing headache that intensifies noticeably whenever they attempt to sit upright. Vital signs reveal a blood pressure of $118/74$ mmHg, a heart rate of $78$ beats/min, and an oxygen saturation of $98\%$ on room air. Which intervention should the nurse prioritize to manage this post-procedure complication?

A client recovering from a severe traumatic brain injury (TBI) is experiencing acute post-traumatic agitation. The client is highly restless, attempting to remove their cervical collar, and repeatedly trying to climb over the bed rails. Which intervention should the nurse prioritize to safeguard this client from harm?

A nurse is closely monitoring a client who sustained blunt abdominal trauma in a motor vehicle collision 2 hours ago. The client's baseline vital signs upon admission were: blood pressure 138/76 mm Hg, heart rate 80 beats per minute, and respiratory rate 16 breaths per minute. Which of the following current vital sign profiles provides the strongest evidence that the client is experiencing early compensatory hypovolemic shock?

A client admitted with acute decompensated heart failure is receiving a continuous intravenous (IV) infusion of milrinone through a single peripheral IV catheter. The healthcare provider prescribes a stat dose of furosemide via IV push. The nurse consults a drug compatibility reference and notes that furosemide and milrinone are incompatible. Which of the following is the priority nursing action?