Tüm alıştırma soruları

Following an emergent bronchoscopy with a transbronchial lung biopsy, a 65-year-old client is transferred to the progressive care unit for continuous monitoring. Which of the following assessment findings indicate that the client is experiencing a severe post-procedure complication requiring immediate intervention? Select all that apply.

A nurse is assessing a client who is receiving a continuous peripheral intravenous (IV) infusion of a vesicant antineoplastic agent. The client suddenly reports severe burning pain at the IV insertion site. The nurse observes local swelling, erythema, and a lack of blood return upon aspiration. In what order should the nurse perform the following interventions? Arrange the actions in the correct sequence.

A patient admitted with a hypertensive emergency requires a continuous intravenous infusion of nitroglycerin. The provider orders a rate of $25 \text{ \mu g/min}$. The pharmacy delivers a standard premixed glass bottle containing $50 \text{ mg}$ of nitroglycerin in $250 \text{ mL}$ of $0.9\% \text{ sodium chloride}$.

Calculate the correct electronic infusion pump setting in $\text{mL/hr}$. (Record your answer rounding to the nearest tenth.)

A client in the intensive care unit is receiving a continuous intravenous (IV) infusion of dopamine hydrochloride via a peripheral venous catheter. The client reports a severe, stinging pain at the insertion site. Upon assessment, the nurse observes that the surrounding tissue is blanched, edematous, and cold to the touch. Which of the following is the nurse's most appropriate initial action?

A nurse is monitoring a client who is receiving an intravenous transfusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion is initiated, the client suddenly reports severe lower back pain, shortness of breath, and a feeling of impending doom. Arrange the following nursing actions in the correct priority sequence. All options must be used.

A client presents to the emergency department in status epilepticus. The healthcare provider prescribes an immediate intravenous loading dose of phenytoin. The client has one established 20-gauge peripheral intravenous (IV) catheter, which is currently infusing a continuous solution of 5% dextrose in water (D5W) at 75 mL/hr. Which action outlines the safest and most appropriate method for the nurse to administer the prescribed medication?

An adult client is treated in the emergency department for a severe asthma attack. Following one hour of continuous bronchodilator therapy, the client becomes markedly lethargic. Assessment reveals a "silent chest" with absent wheezing on auscultation and a respiratory rate that has decreased to $10$ breaths/minute. Laboratory analysis shows an arterial $pH$ of $7.28$, $PaCO_2$ of $60 \text{ mm Hg}$, $PaO_2$ of $62 \text{ mm Hg}$, and $HCO_3^-$ of $24 \text{ mEq/L}$. Based on these clinical findings, which action is the priority?

A client is being managed in the intensive care unit following a severe closed head injury. Over the past hour, the nurse notes a significant change in the client's vital signs: the blood pressure has shifted from 124/82 mmHg to 180/58 mmHg, the heart rate has decreased from 86 to 48 beats/minute, and the respirations have become increasingly irregular with brief periods of apnea. Which of the following is the most appropriate initial nursing action?

An older adult client with moderate dementia is hospitalized for the treatment of pneumonia. During the night shift, the client becomes restless, is frequently incontinent of urine, and repeatedly attempts to remove their intravenous (IV) catheter. Which basic care and comfort interventions should the nurse include in the plan of care? Select all that apply.

A nurse is managing the care of a client admitted with diabetic ketoacidosis (DKA) who is receiving a continuous intravenous infusion of regular insulin. The client's current arterial blood gas (ABG) values are pH 7.31, PaCO2 32 mm Hg, and HCO3 15 mEq/L. Which actions should the nurse include in the plan of care to minimize potential complications? Select all that apply.

A nurse in the coronary care unit is caring for a client admitted with an acute inferior wall ST-segment elevation myocardial infarction (STEMI) with right ventricular involvement. The client is restless, diaphoretic, and reports substernal chest pain rated 7 on a 0 to 10 scale. Current vital signs are blood pressure 80/52 mm Hg, heart rate 112 beats/minute, and respiratory rate 20 breaths/minute. Lung sounds are clear bilaterally, and marked jugular venous distention is present. Which of the following prescribed interventions should the nurse implement first?

A critically ill client with distributive shock is being supported by a continuous norepinephrine infusion via a dedicated single-lumen central venous catheter. While the nurse is performing an assessment, the client abruptly exhibits generalized tonic-clonic seizure activity. An emergency prescription for immediate intravenous lorazepam is received. Which action by the nurse represents the safest practice for administering this medication?

An 81-year-old client is on the surgical unit for their first postoperative day following a right total hip arthroplasty via a posterior approach. The client requires help with morning hygiene, meals, and general comfort measures. Which action by the nurse demonstrates the safest and most appropriate care?

A nurse is evaluating a client who was admitted 12 hours ago with a severe traumatic brain injury (TBI). The client is intubated, mechanically ventilated, and being closely monitored for increased intracranial pressure (ICP). Which of the following assessment findings or clinical observations indicate a potential complication or an increased risk of physiological decompensation requiring immediate intervention? Select all that apply.

A nurse is caring for a client who is 4 hours postoperative following a bowel resection. The client's preoperative blood pressure was 132/78 mm Hg and heart rate was 76 beats/min. The nurse now notes a blood pressure of 108/88 mm Hg, a heart rate of 116 beats/min, a respiratory rate of 22 breaths/min, and an oxygen saturation of 97% on room air. The client reports incisional pain as 5 on a 0 to 10 scale. Which of the following is the priority nursing action?

A 54-year-old client with a history of chronic hepatitis C has just returned to the medical-surgical unit following a percutaneous liver biopsy. The client's initial vital signs are stable, and they report mild tenderness at the right upper quadrant biopsy site. Which nursing action is the highest priority to reduce the risk of a severe post-procedure complication?

A client admitted with a deep vein thrombosis is receiving a continuous intravenous infusion of heparin through a single-lumen peripheral catheter. The client is experiencing severe pain from an unrelated surgical incision, and the healthcare provider prescribes an as-needed dose of intravenous morphine. After consulting a drug reference guide and determining that morphine and heparin are chemically incompatible at the Y-site, which of the following actions should the nurse take?

A nurse is preparing to administer a large-volume cleansing enema to a client experiencing severe constipation. Arrange the following steps in the correct sequence from first to last. All options must be used.

A nurse is caring for a client who is receiving continuous total parenteral nutrition (TPN) via a single-lumen peripherally inserted central catheter (PICC). The client is newly prescribed a scheduled dose of intravenous (IV) ceftriaxone. What is the most appropriate action for the nurse to take?

A nurse is preparing to remove a client's non-tunneled central venous catheter (CVC). To minimize the risk of a potential air embolism and ensure client safety, arrange the following nursing actions in the correct chronological sequence.