Tüm alıştırma soruları

A nurse is preparing to transfer a client who has bilateral lower extremity weakness from a hospital bed to a wheelchair using a one-person assist technique. Place the following steps in the sequence the nurse should perform them.

A triage nurse in a community health clinic evaluates a pediatric client presenting with a high fever, cough, coryza, and a widespread maculopapular rash that started on the forehead and is spreading downward. The accompanying caregiver states the child has not received any routine immunizations. Which immediate infection control and safety actions should the nurse implement? Select all that apply.

A nurse is monitoring a client who is 15 minutes into a packed red blood cell (PRBC) transfusion. The client suddenly reports severe lower back pain, chills, and a feeling of impending doom. The nurse observes that the client's urine in the Foley catheter tubing has become dark red. Arrange the following nursing interventions in the correct order of priority from first to last.

A nurse is developing a plan of care for an 80-year-old client who has right-sided hemiplegia and dysphagia following a recent cerebrovascular accident (CVA). Which interventions should the nurse include in the client's plan of care to promote basic care, comfort, and safety? Select all that apply.

A 68-year-old client is receiving mechanical ventilation in the intensive care unit following a coronary artery bypass graft. The client's oxygen saturation drops to 89%, and auscultation reveals coarse crackles over the mainstem bronchi. The nurse prepares to perform open endotracheal suctioning. To reduce the risk of severe hypoxia and mucosal trauma, arrange the following procedural steps in the correct sequence.

A nurse is evaluating a client who returned to the neurological unit 30 minutes ago following a lumbar puncture. Which of the following assessment findings or observations require immediate intervention by the nurse? (Select all that apply.)

A nurse is caring for an older adult client who has right-sided hemiplegia and severe dysphagia following a recent cerebrovascular accident. Which of the following actions should the nurse take when managing the client's nutritional intake?

A registered nurse is observing an unlicensed assistive personnel (UAP) provide care for a client who is on enteric contact precautions due to an active *Clostridioides difficile* (*C. difficile*) infection. Which action by the UAP requires immediate intervention by the nurse?

A nurse is caring for a conscious client with diabetes mellitus who suddenly becomes diaphoretic, tachycardic, and reports feeling shaky. In what order should the nurse perform the following actions? Arrange the actions in the correct sequence from first to last.

A nurse is reviewing the medication administration records for four newly admitted clients. Which prescribed parenteral therapy should the nurse question immediately?

A nurse is monitoring a client who has sustained severe bleeding and is at risk for hypovolemic shock. Which of the following vital sign changes should the nurse identify as an early indicator of this condition?

A nurse is evaluating the continuous electronic fetal heart rate (FHR) tracing of a client in active labor. Which of the following FHR patterns indicate potential fetal compromise and require the nurse to initiate corrective interventions? Select all that apply.

During a shift, a nurse is preparing to administer a scheduled dose of intermittent intravenous (IV) ciprofloxacin to a client. The client has only one peripheral IV catheter, which is currently being used for a continuous IV infusion of pantoprazole. Which action is the priority for the nurse to take?

During a shift assessment, a client with a history of severe chronic obstructive pulmonary disease (COPD) is found to be lethargic and responds only to painful stimuli. The client was admitted earlier in the day for an acute respiratory exacerbation and is receiving continuous oxygen therapy at 4 L/min via nasal cannula. Stat arterial blood gas (ABG) results reveal a pH of 7.24, PaCO2 of 71 mm Hg, PaO2 of 65 mm Hg, and HCO3 of 32 mEq/L. Which action should the nurse prioritize?

A nurse is titrating a continuous intravenous infusion of sodium nitroprusside for a client experiencing a hypertensive emergency. The client weighs $198 \text{ lbs}$. The medication is supplied as $50 \text{ mg}$ of sodium nitroprusside mixed in $250 \text{ mL}$ of 5% dextrose in water ($D_5W$). The client's current infusion rate is set at $15 \text{ mL/hr}$. The healthcare provider prescribes an increase in the continuous infusion dose by $0.5 \text{ mcg/kg/min}$. What is the new infusion pump setting in $\text{mL/hr}$? (Record answer to the nearest tenth.)

A nurse in the obstetrical triage unit has just received a shift report and must prioritize the initial assessments of four pregnant clients. Based on the provided information, which of the following clients should the nurse assess first?

A nurse is educating a client who sustained a right fractured tibia and is prescribed non-weight-bearing status on the affected leg. The client is learning how to ascend a flight of stairs using a three-point crutch gait. Arrange the following instructions in the correct chronological sequence.

A nurse is removing a client's central venous access device (CVAD). As the catheter is withdrawn, the client suddenly gasps, reports severe chest pain, and becomes acutely dyspneic. The oxygen saturation drops abruptly to 83%. Suspecting a venous air embolism, in what order should the nurse perform the following actions? (Arrange the items in the correct sequence from first to last.)

At exactly 5 minutes after birth, a transition nurse completes a physiological assessment on a newly delivered term infant. The nurse documents an apical heart rate of 96 beats per minute. The infant is exhibiting a weak, gasping cry. When the soles of the feet are gently flicked, the infant responds with a slight grimace but no active withdrawal. The infant's muscle tone reveals flaccid extremities. The skin color is centrally pink with noticeably blue hands and feet.

What is the infant's 5-minute Apgar score?

A client is admitted to the intensive care unit with a sudden onset of high fever, nuchal rigidity, photophobia, and a petechial rash. A lumbar puncture is performed, and preliminary cerebrospinal fluid results strongly suggest *Neisseria meningitidis*. Which of the following infection control interventions are appropriate for this client? (Select all that apply.)