Tüm alıştırma soruları

The charge nurse is rounding on a medical-surgical unit. Which observation of client care requires the charge nurse to intervene immediately to reduce the risk of a severe physiological complication?

A severe hurricane has caused catastrophic structural damage and total power failure at a long-term care and rehabilitation center. The incident commander orders an immediate, full-scale facility evacuation. Arrange the following client evacuation steps in the order the nursing supervisor should prioritize them, from first to last.

A nurse has just completed suctioning the tracheostomy of a client infected with methicillin-resistant Staphylococcus aureus (MRSA) in the sputum. The client is on contact and droplet precautions. The nurse is wearing a gown, gloves, a face shield, and a surgical mask. Place the following steps for removing personal protective equipment (PPE) in the correct chronological order.

A nurse is preparing to provide a complete bed bath for a client who is receiving continuous enteral nutrition via a nasogastric tube. The procedure requires lowering the head of the bed to a supine position. Which of the following actions is the most appropriate for the nurse to take to ensure client safety?

A client with diabetic ketoacidosis (DKA) is receiving a continuous intravenous infusion of regular insulin. Which nursing interventions are appropriate when managing this parenteral therapy? Select all that apply.

While monitoring a client 6 hours after an open cholecystectomy, the nurse notes several subtle physiological changes and suspects the development of early (compensatory) hypovolemic shock due to internal bleeding. Which of the following assessment findings support this physiological adaptation? (Select all that apply)

A client with acute kidney injury is admitted to the intensive care unit. The client's serum potassium level is $7.5$ mEq/L ($7.5$ mmol/L), and the bedside cardiac monitor shows a widened QRS complex with tall, peaked T waves. The healthcare provider prescribes several interventions. In what order should the nurse execute these actions? Arrange the sequence from first to last.

A nurse is assessing a client who sustained multiple injuries in a motor vehicle crash and is at risk for hypovolemic shock. Which assessment findings should the nurse identify as early indicators of the compensatory stage of shock? Select all that apply.

While providing care during the day shift, the interdisciplinary healthcare team encounters clients with various infectious diseases. Which of the following staff actions demonstrate the correct application of transmission-based precautions? Select all that apply.

A critically ill client is receiving a continuous intravenous (IV) infusion of norepinephrine for the management of severe septic shock. The client's mean arterial pressure (MAP) is currently maintained at 68 mm Hg. Arterial blood gas results reveal severe metabolic acidosis, and the healthcare provider prescribes a stat intravenous bolus of sodium bicarbonate. The client currently has a single-lumen central venous catheter and no peripheral IV access. Which action by the nurse represents the safest and most appropriate clinical judgment?

A nurse is preparing to transfer a client with right-sided weakness from the bed to a wheelchair. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence.

A 72-year-old client with a history of severe chronic obstructive pulmonary disease (COPD) is admitted to the progressive care unit with a respiratory infection. The client is lethargic and confused. Vital signs are: blood pressure 86/52 mmHg, heart rate 122 beats/min, respiratory rate 32 breaths/min, and oxygen saturation 83% on room air. The arterial blood gas (ABG) results are: pH 7.25, PaCO2 68 mmHg, HCO3 29 mEq/L, and PaO2 50 mmHg. To reduce the risk of further physiological decompensation, which actions should the nurse take? Select all that apply.

A registered nurse is developing a care plan for an older adult client who is recovering from a recent cerebrovascular accident (stroke) and has been diagnosed with new-onset dysphagia. Which of the following actions should the nurse include in the client's mealtime plan of care?

A client receiving mechanical ventilation for severe acute respiratory distress syndrome (ARDS) has the following ventilator settings and clinical data:

- Ventilator settings: Assist-control (AC) mode, $\text{FiO}_2$ $0.80$, respiratory rate $18 \text{ breaths/min}$, tidal volume $400 \text{ mL}$, positive end-expiratory pressure (PEEP) $15 \text{ cm H}_2\text{O}$.
- Arterial blood gas (ABG) results: pH $7.27$, $\text{PaCO}_2$ $59 \text{ mm Hg}$, $\text{PaO}_2$ $54 \text{ mm Hg}$, $\text{HCO}_3^-$ $26 \text{ mEq/L}$.
- Vital signs: Blood pressure $82/50 \text{ mm Hg}$, heart rate $128 \text{ beats/min}$.
- Hemodynamic data: Central venous pressure (CVP) $15 \text{ mm Hg}$.
- Physical assessment: Distant breath sounds on the right anterior chest and tracheal deviation to the left.

Which of the following interventions should the nurse anticipate implementing immediately? Select all that apply.

A nurse is evaluating the clinical data and current status of several assigned clients. Which of the following situations indicate a significant risk for physiological complications and require immediate nursing intervention? Select all that apply.

A client is receiving treatment for a hyperosmolar hyperglycemic state (HHS). The initial admission serum glucose was $1,150$ mg/dL. The client is receiving a continuous intravenous regular insulin infusion and aggressive intravenous fluid resuscitation. Three hours into the treatment regimen, the repeat serum glucose is $600$ mg/dL. The nurse notes the client, who was previously alert and oriented, is now increasingly lethargic, reports a severe headache, and exhibits sluggish pupillary light reflexes. Which physiological mechanism best explains this acute neurological deterioration?

A nurse in the emergency department is evaluating a client who has sustained blunt force trauma and is exhibiting signs of early hypovolemic shock. Which of the following clinical findings should the nurse expect to observe? Select all that apply.

A nurse is reviewing the arterial blood gas (ABG) results of a client who has been experiencing severe, frequent diarrhea for the past three days. The ABG results show a pH of $7.31$, a $PaCO_2$ of $39\text{ mm Hg}$, and an $HCO_3^-$ of $18\text{ mEq/L}$. Based on these findings, which of the following acid-base imbalances is the client experiencing?

A triage nurse is performing field triage following a stage collapse at a large outdoor concert. Using the Simple Triage and Rapid Treatment (START) algorithm for a mass casualty incident, which clients should the nurse classify as "Immediate" (Red tag)? Select all that apply.

A nurse is caring for a client with a pulmonary embolism who is receiving a continuous heparin infusion through a single peripheral IV catheter. The healthcare provider has newly prescribed intermittent IV vancomycin to treat a concurrent cellulitis infection. Which of the following actions should the nurse take to safely administer these therapies? Select all that apply.