Tüm alıştırma soruları

A nurse enters a client's room and discovers that the intravenous tubing has accidentally disconnected from the client's central venous catheter (CVC) hub. The client is suddenly dyspneic, coughing, tachypneic, and grasping their chest. In which order should the nurse perform the following actions to minimize the client's risk for complications? (Arrange the actions from first to last.)

An adult client is recovering on the cardiac telemetry unit 3 hours after a percutaneous coronary intervention (PCI) via the right femoral artery. The client suddenly reports severe, continuous lower back pain. The nurse notes the client's blood pressure has dropped from a baseline of 134/76 mm Hg to 108/86 mm Hg, and the heart rate has increased from 78 to 114 beats/min. The femoral insertion site dressing remains dry and intact. Which of the following is the priority nursing action?

The nurse is developing a basic care and comfort plan for an 82-year-old client who is recovering from a right-sided modified radical mastectomy. The client has a baseline of mild cognitive impairment. Which interventions should the nurse include in the plan of care? Select all that apply.

A client with hepatic cirrhosis and severe ascites undergoes a therapeutic paracentesis, resulting in the removal of 4.5 liters of peritoneal fluid. Thirty minutes after the procedure, the client's heart rate increases from 84 to 118 bpm, and blood pressure decreases from 128/74 to 92/56 mm Hg. Which action should the nurse implement first to mitigate the risk of a life-threatening complication?

During the bedside placement of a left subclavian central venous catheter, the client suddenly becomes extremely restless and diaphoretic, reporting severe chest tightness. The cardiac monitor reveals sinus tachycardia at 135 beats/min. Hemodynamic assessment demonstrates a blood pressure drop from 138/82 mm Hg to 86/74 mm Hg, and a respiratory rate of 28 breaths/min. The nurse notes that the neck veins remain markedly distended when the head of the bed is elevated to 45 degrees, and heart tones are difficult to auscultate. Which of the following immediate interventions are indicated? (Select all that apply.)

A nurse is planning care for a client who has just returned to the medical-surgical unit following a lumbar puncture to rule out meningitis. Which of the following nursing actions are appropriate to reduce the risk of post-procedure complications? Select all that apply.

A nurse is removing a central venous catheter (CVC) from a client's right subclavian vein. Immediately after the catheter is withdrawn, the client suddenly gasps for air, becomes profoundly cyanotic, and reports severe chest pain. In which order should the nurse perform the following emergency interventions? Arrange the actions from first (highest priority) to last (lowest priority).

A nurse is assessing a client who is 12 hours post-operative following an open surgical repair of an abdominal aortic aneurysm (AAA). Which of the following findings indicate a potential post-operative complication requiring immediate intervention? (Select all that apply.)

A nurse is preparing to administer furosemide $40 \text{ mg}$ via intravenous (IV) push through a peripheral saline lock to a client with an exacerbation of heart failure. To prevent ototoxicity, institutional guidelines require administering the medication slowly over at least $2 \text{ minutes}$. Which action demonstrates the safest and most appropriate administration technique?

A nurse is caring for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache. The nurse observes profuse diaphoresis above the level of the spinal injury, facial flushing, and a blood pressure of 214/114 mm Hg. In what order should the nurse perform the following interventions? Arrange the actions from first to last.

A $52$-year-old client is in the post-anesthesia care unit (PACU) $45$ minutes after an open hernia repair under general anesthesia, having received intravenous fentanyl for pain control. The nurse notes the client is extremely lethargic and difficult to arouse. Vital signs are: heart rate $68 \text{ bpm}$, blood pressure $112/70 \text{ mm Hg}$, and respiratory rate $6 \text{ breaths/min}$ with shallow depth. An arterial blood gas (ABG) analysis reveals: pH $7.24$, $\text{PaCO}_2$ $66 \text{ mm Hg}$, $\text{PaO}_2$ $55 \text{ mm Hg}$, and $\text{HCO}_3^-$ $24 \text{ mEq/L}$. Which action should the nurse take first?

The nurse is caring for an 78-year-old client who recently experienced a cerebrovascular accident (CVA) resulting in right-sided facial weakness and dysphagia. Which of the following nursing interventions should the nurse include in the client's care plan to promote safe oral intake? Select all that apply.

While working in the emergency department, a registered nurse receives a prescription for a stat dose of intravenous phenytoin for a client experiencing seizure activity. The client's only venous access is a peripheral catheter currently infusing $5\%$ dextrose in water ($D_5W$) at $100 \text{ mL/hr}$. Which protocol must the nurse implement to safely administer this medication?

A nurse is caring for a client who is receiving positive pressure mechanical ventilation for acute respiratory distress syndrome (ARDS). The client's most recent arterial blood gas (ABG) results are:

- pH: 7.28
- PaCO2: 58 mm Hg
- PaO2: 54 mm Hg
- HCO3-: 26 mEq/L

Over the last 15 minutes, the ventilator's high-pressure alarm has sounded, indicating the peak inspiratory pressure (PIP) has increased from 28 cm H2O to 48 cm H2O. The nurse auscultates the lungs and notes absent breath sounds on the right side. The client's current vital signs are BP 112/90 mm Hg (previously 124/72 mm Hg) and HR 118 beats/min. Which action is the priority for the nurse?

An adult client was transferred to the telemetry unit following a percutaneous coronary intervention (PCI) utilizing a right femoral approach. Baseline vital signs at admission were blood pressure 134/84 mmHg and heart rate 72 bpm. Two hours later, the client complains of a continuous, dull ache in the right flank and lower back. The current vital signs demonstrate a blood pressure of 102/60 mmHg and a heart rate of 110 bpm. Examination of the right femoral insertion site reveals a dry, intact dressing with no visible swelling or external bleeding. Based on these clinical findings, what is the most appropriate initial action by the nurse?

A nurse is caring for a client who underwent a right transfemoral cardiac catheterization two hours ago. The client reports a new onset of dull, aching pain in the lower right back. Which of the following actions should the nurse take first?

A nurse is preparing to administer an intermittent bolus enteral feeding to a client via a gastrostomy tube. Place the following nursing actions in the correct chronological order.

A client receiving parenteral nutrition via a right subclavian central venous access device (CVAD) suddenly reports severe chest pain, shortness of breath, and a feeling of impending doom. The nurse observes that the intravenous tubing has become disconnected from the catheter hub. Which of the following immediate interventions should the nurse implement? (Select all that apply.)

A nurse is caring for a client who returned to the medical-surgical unit one hour ago following a diagnostic cardiac catheterization via the right femoral artery approach. The client reports mild lower back discomfort and requests a change in position. Which of the following positioning interventions is most appropriate for this client?

The healthcare team is preparing to perform a bed bath and linen change for a client receiving continuous enteral nutrition via a nasogastric tube. Which action should the registered nurse take to maintain safety during this care?