Tüm alıştırma soruları

During the second hour of admission to the intensive care unit, a 24-year-old client being treated for status asthmaticus exhibits a significant change in clinical status. Initially, the client presented with severe agitation, accessory muscle use, a respiratory rate of $34 \text{ breaths/minute}$, and loud bilateral expiratory wheezes. The client was placed on $4 \text{ L/min}$ supplemental oxygen via nasal cannula.

Currently, the client appears profoundly lethargic. The respiratory rate has decreased to $14 \text{ breaths/minute}$, and auscultation reveals a "silent chest" with absent wheezing. The nurse compares the initial arterial blood gas (ABG) results with the most recent draw (both drawn on the same oxygen settings):

Which of the following is the priority nursing action?

A client diagnosed with symptomatic anemia is currently receiving a transfusion of packed red blood cells via a 20-gauge peripheral intravenous catheter. Following a sudden drop in blood pressure to 85/50 mmHg, the healthcare provider prescribes a rapid bolus of Lactated Ringer's solution. Which action is most appropriate for the nurse to take?

A nurse is monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs) for severe anemia. Ten minutes after the infusion begins, the client reports sudden, intense lower back pain and a feeling of impending doom. The nurse notes that the client is tachycardic, tachypneic, and hypotensive. To safely manage this suspected acute hemolytic transfusion reaction and reduce the risk of further physiological compromise, arrange the following nursing actions in the correct priority sequence.

A nurse is assessing a client who has experienced severe vomiting and diarrhea for the past 48 hours. Which of the following assessment findings should the nurse identify as indicating fluid volume deficit? Select all that apply.

During a routine safety and assessment round on a medical-surgical unit, a nurse evaluates four clients. Which of the following observations indicates a severe physiological risk that requires immediate intervention by the nurse?

A client is recovering in the surgical unit after an open abdominal procedure. Which assessment finding provides the earliest physiological indication that the client is developing hypovolemic shock?

A critically ill client with septic shock has a triple-lumen central venous catheter (CVC) inserted in the right internal jugular vein. The client is receiving a continuous intravenous infusion of norepinephrine through the proximal lumen and a continuous intravenous infusion of propofol through the distal lumen. The medial lumen is currently saline-locked. The healthcare provider prescribes an intermittent intravenous piggyback (IVPB) dose of pantoprazole. The nurse verifies in an intravenous drug reference guide that pantoprazole is physically incompatible at the Y-site with both norepinephrine and propofol. What is the most appropriate nursing action?

A young adult client is being monitored on the trauma step-down unit $18$ hours after surgical stabilization of multiple long-bone fractures. The client suddenly exhibits profound agitation and disorientation. The nurse collects the following clinical data:

• Vital Signs: Heart rate $124\text{/min}$, respiratory rate $30\text{/min}$, blood pressure $108/68\text{ mm Hg}$, temperature $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$)
• Arterial Blood Gas (Room Air): pH $7.51$, $\text{PaCO}_2$ $28\text{ mm Hg}$, $\text{PaO}_2$ $52\text{ mm Hg}$, $\text{HCO}_3^-$ $23\text{ mEq/L}$
• Focused Assessment: Capillary refill is $2$ seconds. Small, non-blanching red macules are newly present across the axillae and conjunctivae.

Based on these findings, which intervention must the nurse execute immediately to mitigate the client's risk of physiological collapse?

A nurse is creating a plan of basic care and comfort for a 78-year-old client who is 24 hours postoperative following a right total knee arthroplasty (TKA). Which of the following interventions should the nurse include in the client's care plan? Select all that apply.

A nurse is caring for a client who returned to the telemetry unit thirty minutes ago following a percutaneous coronary intervention (PCI) via the right femoral artery. Which of the following nursing interventions are necessary to reduce the risk of physiological complications? (Select all that apply.)

A nurse is evaluating a client admitted with a severe urinary tract infection who is now increasingly confused. Current vital signs include a blood pressure of 90/72 mm Hg, a heart rate of 128/min, a respiratory rate of 28/min, and a temperature of 39.2°C (102.6°F). Arterial blood gas (ABG) analysis on room air reveals a pH of 7.28, a PaCO2 of 28 mm Hg, a HCO3- of 14 mEq/L, and a PaO2 of 88 mm Hg. Based on these findings, which of the following is the most appropriate interpretation and priority nursing action?

A conscious client with diabetes mellitus reports feeling shaky, diaphoretic, and weak. Arrange the following nursing actions in the correct chronological sequence according to the standard management of hypoglycemia.

A client is receiving care in the critical care unit following a closed head injury. The nurse is continuously monitoring the client's neurological status and physiological adaptation. Which of the following assessment findings strongly indicate that the client is losing compensatory auto-regulation and developing critically elevated intracranial pressure? Select all that apply.

A 45-year-old client is admitted to the burn unit after sustaining full-thickness thermal burns to 40% of their total body surface area. Eight hours into the emergent resuscitation phase, the nurse assesses the following: blood pressure 84/52 mm Hg, heart rate 136 beats/minute, and a cumulative urine output of 25 mL over the past two hours. Arterial blood gas results indicate a pH of 7.28, PaCO2 of 29 mm Hg, and HCO3- of 15 mEq/L. Based on these clinical indicators, what is the most accurate interpretation of the client's condition and the priority nursing intervention?

A nurse is caring for a client who is receiving a transfusion of packed red blood cells. The client suddenly reports severe lower back pain and chills. Arrange the following nursing actions in the correct order of priority to minimize physiological risk to the client.

A client is admitted to the intensive care unit with urosepsis. During the initial assessment, the client is restless with a temperature of 38.9°C (102°F), a heart rate of 115/min, a respiratory rate of 30/min, and a blood pressure of 118/68 mm Hg. Which arterial blood gas (ABG) result should the nurse anticipate as the most likely early physiological adaptation in this client?

An adult client is recovering in the surgical observation unit four hours after undergoing a left percutaneous renal biopsy. The client's pre-procedure vital signs were a blood pressure of 134/76 mm Hg, an apical pulse of 72 beats/min, and a respiratory rate of 14 breaths/min. During the current assessment, the client reports a persistent, dull ache in the left lower back that radiates toward the anterior abdomen. The nurse obtains the following data: blood pressure is 112/86 mm Hg, apical pulse is 104 beats/min, and respiratory rate is 22 breaths/min. The client's urine output via Foley catheter is 40 mL over the past hour and appears pink-tinged. An arterial blood gas (ABG) sample drawn 15 minutes ago reveals a pH of 7.44, a $PaCO_2$ of 32 mm Hg, and an $HCO_3^-$ of 21 mEq/L. Based on these assessment findings, which of the following actions should the nurse prioritize?

A registered nurse is preparing to administer an intravenous (IV) push medication through a client's accessed, but currently inactive, implanted venous port (Port-a-Cath). Based on standard facility protocol for a heparin-locked central venous device, arrange the following steps in the correct chronological order.

A nurse is performing a postoperative assessment on a client who underwent a laparotomy a few hours ago. To monitor for the onset of hypovolemic shock from potential internal bleeding, which of the following clinical findings should the nurse identify as the earliest indicator?

A nurse is caring for a client with a history of severe anemia who is receiving a transfusion of packed red blood cells. Fifteen minutes after the transfusion begins, the client reports a sudden onset of lower back pain, chills, and difficulty breathing. Arrange the following nursing interventions in the prioritized sequence from first to last action.