Tüm alıştırma soruları

A nurse is preparing to administer furosemide $80 \text{ mg}$ intravenous (IV) push to a client experiencing acute pulmonary edema. The medication is available in a vial labeled $10 \text{ mg/mL}$. Which of the following is the most appropriate action for the nurse to take?

A nurse is caring for a client who is immobilized in skeletal traction following a fractured right femur. The client reports sacral discomfort from prolonged bed rest. Which nursing intervention is most appropriate to promote comfort and maintain skin integrity?

A nurse is preparing to administer a large-volume cleansing enema to an adult client who is experiencing severe constipation. In what order should the nurse perform the following actions? (Arrange the steps in the correct sequence from first to last.)

A nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation with a positive end-expiratory pressure (PEEP) of $15 \text{ cm H}_2\text{O}$. Suddenly, the ventilator's high-pressure alarm activates. The nurse observes that the client's blood pressure has decreased from $122/76 \text{ mm Hg}$ to $82/48 \text{ mm Hg}$, heart rate has increased from $94 \text{ /min}$ to $138 \text{ /min}$, and oxygen saturation has dropped to $86\%$. Which action is the nurse's priority?

An intensive care nurse is configuring an infusion pump for a client requiring deep sedation. The new medication order specifies remifentanil to run at $0.05\text{ mcg/kg/min}$. The client's admission weight is $230\text{ lb}$. The available medication on the unit is a pre-mixed bag containing $2\text{ mg}$ of remifentanil dissolved in $250\text{ mL}$ of normal saline ($0.9\%\text{ NaCl}$). Calculate the required pump setting in $\text{mL/hr}$. (First, convert and round the client's weight to the nearest tenth of a kilogram. Then, perform your calculations and round the final answer to the nearest tenth.)

A nurse is caring for a client who underwent a percutaneous liver biopsy 4 hours ago. The client is currently positioned on their right side. The client's vital signs are heart rate 116 beats/minute, blood pressure 104/82 mm Hg, respiratory rate 24 breaths/minute, and temperature 98.8°F (37.1°C). The client reports a new onset of right shoulder pain and states, 'I must have slept on my arm wrong.' Which of the following is the most appropriate initial nursing action?

A nurse is evaluating a client admitted with a severe exacerbation of chronic obstructive pulmonary disease (COPD). The client's most recent arterial blood gas (ABG) analysis on room air reveals the following results: $pH$ of $7.25$, $PaCO_2$ of $74$ mm Hg, $HCO_3^-$ of $32$ mEq/L, and $PaO_2$ of $52$ mm Hg. Based on these physiological values, which clinical manifestations should the nurse anticipate during the physical assessment? Select all that apply.

A client with suspected bacterial meningitis is admitted to the intensive care unit. The healthcare provider prescribes a stat dose of intravenous ceftriaxone and a continuous infusion of $0.9\% \text{ Sodium Chloride}$ at $100 \text{ mL/hr}$. The client arrives from the emergency department with a single peripheral intravenous catheter currently infusing Lactated Ringer's solution at $100 \text{ mL/hr}$. Based on these findings, which of the following is the priority action by the nurse?

A client is admitted to the emergency department with an active upper gastrointestinal bleed. The client's vital signs are blood pressure 84/52 mmHg, heart rate 126 beats per minute, and respiratory rate 22 breaths per minute. The client has a single 18-gauge peripheral intravenous catheter currently infusing 5% dextrose in water (D5W) at 100 mL/hr. The healthcare provider prescribes a stat transfusion of one unit of packed red blood cells (PRBCs) and intravenous pantoprazole. Which action should the nurse take first?

A triage nurse in the emergency department is assessing a client who presents with an acute asthma exacerbation. Which of the following clinical findings indicate the client is experiencing impending respiratory failure and requires immediate life-saving intervention? Select all that apply.

A nurse is planning care for a client who has left lower extremity weakness and is learning to ambulate with a standard pick-up walker. Which of the following interventions should the nurse include in the plan of care?

A client with a history of chronic kidney disease is brought to the emergency department after missing three scheduled hemodialysis treatments. The client reports severe muscle weakness and abdominal cramping. Assessment reveals a heart rate of 54 bpm, respiratory rate of 22 breaths/min, and blood pressure of 92/58 mm Hg. The cardiac monitor displays a prolonged PR interval, wide QRS complexes, and tall, peaked T waves. Which of the following interventions should the nurse implement first?

The registered nurse is developing a comprehensive care profile for an 82-year-old client who exhibits profound immobility, frequent episodes of urinary incontinence, and an elevated risk for pressure injuries. Which of the following interventions should the nurse incorporate into the management plan? Select all that apply.

A nurse is monitoring a client at $36$ weeks of gestation who is receiving a continuous intravenous (IV) infusion of magnesium sulfate for the management of severe preeclampsia. Which of the following assessment findings indicate potential magnesium toxicity or impaired clearance, requiring immediate intervention by the nurse? Select all that apply.

A nurse is caring for a $45$-year-old client receiving total parenteral nutrition via a right subclavian central venous access device. While the nurse is changing the intravenous tubing, the catheter temporarily disconnects from the infusion line. The client immediately reports severe chest pain, shortness of breath, and a sense of impending doom. The client's heart rate is $128$ bpm, blood pressure is $86/52$ mmHg, and oxygen saturation is $82\%$ on room air. The nurse immediately clamps the catheter. Which of the following is the priority nursing action?

A client in the intensive care unit with septic shock is receiving a continuous intravenous infusion of norepinephrine via the proximal lumen of a triple-lumen central venous catheter. The healthcare provider prescribes a stat dose of intravenous sodium bicarbonate to treat severe metabolic acidosis. Upon checking a drug reference guide, the nurse discovers that norepinephrine and sodium bicarbonate are chemically incompatible. Which action by the nurse is the most appropriate?

A nurse is monitoring a client who is receiving a continuous intravenous infusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion begins, the client reports sudden lower back pain, chills, and dyspnea. Place the following nursing actions in the correct order of performance. (All steps must be used).

A nurse is monitoring a client diagnosed with Guillain-Barré syndrome who reports increasing weakness in the upper body. The client's forced vital capacity (FVC) has decreased from 40 mL/kg to 14 mL/kg over the past shift. The most recent arterial blood gas (ABG) results on room air reveal a pH of 7.29, PaCO2 of 58 mm Hg (7.7 kPa), PaO2 of 64 mm Hg (8.5 kPa), and HCO3- of 25 mEq/L (25 mmol/L). Based on these findings, what is the priority nursing action?

A client who recently experienced a cerebrovascular accident requires an intermittent bolus enteral feeding through an established nasogastric (NG) tube. Place the following nursing actions in the correct sequence for safely delivering this nutrition. (Arrange the steps in chronological order.)

A healthcare provider prescribes an intermittent intravenous vancomycin infusion of $15\text{ mg/kg}$ for a client with a severe bacterial infection. The client weighs $154\text{ lb}$. To prevent red man syndrome, institutional guidelines require vancomycin to be administered at a maximum rate of $10\text{ mg/min}$. Calculate the minimum safe infusion time in minutes for this dose. Record your answer as a whole number.