Tüm alıştırma soruları
862 soru
Soru 561Soru →
A public health nurse is responding to a newly identified cluster of active tuberculosis (TB) cases within a crowded metropolitan homeless shelter. To effectively manage the outbreak and apply principles of disease prevention, arrange the following nursing actions in the most appropriate sequence of priority from first to last.
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Cevap
The correct sequence prioritizes immediate infection control, followed by legal reporting, targeted screening, prophylactic treatment, and finally, broad population-based education.
In an acute outbreak of a highly contagious airborne pathogen, the nurse must prioritize actions based on the severity of the immediate threat. The sequence begins with immediate source control (isolation) to halt transmission. Once the immediate environment is secured, legal mandates dictate reporting the outbreak to public health authorities. Subsequently, the focus shifts to secondary prevention (screening exposed individuals) and targeted intervention (treating latent infections). Finally, broad primary prevention strategies (education) are deployed to mitigate future risks.
Adım Adım Çözüm
1
Isolate the individuals demonstrating active respiratory symptoms.
Halts ongoing exposure to the airborne pathogen.
Immediate source control is the highest priority for public health safety and primary prevention of new cases.
2
Notify the local public health department.
Triggers an official epidemiological response.
Mandatory reporting ensures legal compliance and unlocks necessary resources for large-scale outbreak management.
3
Initiate contact tracing and administer screening tests.
Identifies individuals who have been exposed and infected.
Secondary prevention via early detection is necessary after the initial exposure source is contained.
4
Facilitate prophylactic therapy for latent infections.
Eradicates the dormant mycobacteria in exposed individuals.
Pharmacological intervention prevents latent TB from progressing to active disease, acting as a secondary/tertiary preventive measure.
5
Implement a shelter-wide educational campaign.
Increases community awareness and future prevention capabilities.
Primary health promotion is most effective and appropriate once the immediate acute outbreak is stabilized.
Anahtar Kavram
Prioritization of Disease Prevention and Outbreak Management
Tahmini Süre:2m 0s
Soru 562Soru →
A nurse is preparing to administer an intravenous (IV) antibiotic piggyback to a client receiving a compatible continuous primary infusion of 0.9% sodium chloride. Place the following steps for setting up the secondary infusion in the correct chronological order.
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Cevap
The correct chronological sequence is to close the secondary roller clamp, spike and prime the secondary line, cleanse the primary access port, connect the lines, and hang the primary bag lower than the secondary bag.
Following the proper chronological sequence for an IV piggyback setup ensures patient safety by preventing fluid loss, avoiding air embolisms, maintaining strict asepsis, and utilizing gravity correctly for the secondary infusion.
Adım Adım Çözüm
1
Close the roller clamp on the secondary IV tubing.
The tubing is sealed.
Prevents medication from freely running out of the tubing when the bag is spiked.
2
Spike the secondary medication bag and prime the tubing.
The line is filled with fluid and devoid of air.
Removes atmospheric air from the line to prevent an air embolism.
3
Scrub the uppermost access port of the primary tubing with an antiseptic swab.
The access port is disinfected.
Maintains strict aseptic technique to prevent catheter-related bloodstream infections.
4
Connect the primed secondary IV tubing to the cleansed primary line port.
The secondary line is integrated into the primary infusion system.
Establishes a continuous, secure pathway for the medication to reach the patient.
5
Hang the primary IV fluid bag lower than the secondary medication bag.
The secondary bag has greater hydrostatic pressure.
Utilizes gravity so the pump draws fluid from the highest bag (the medication) until it is empty.
Anahtar Kavram
Intravenous Piggyback (IVPB) Setup Sequence
Soru 563Soru →
A nurse discovers that a urinary catheter drainage bag has detached from a client receiving intravesical Bacillus Calmette-Guérin (BCG) therapy for bladder cancer. The fluid containing the live attenuated mycobacteria is actively leaking onto the floor. Arrange the following actions in the correct sequence to safely manage this hazardous biological spill.
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Cevap
The correct sequence for managing a BCG biological spill is to secure the area, don appropriate PPE including an N95 respirator, contain the active leak, cover the spill with absorbent materials, and apply a tuberculocidal disinfectant for the required contact time.
When managing a hazardous biological spill involving live mycobacteria (BCG), the nurse must prioritize safety systematically. Securing the area prevents unintended exposures. Donning PPE, specifically including an N95 respirator, protects the nurse from aerosolized bacteria. Containing the active source of the leak prevents the spill from worsening. Applying absorbent materials before the disinfectant prevents splashing, and allowing the proper contact time ensures the tuberculocidal agent destroys the pathogens before final cleanup.
Adım Adım Çözüm
1
Secure the immediate area and restrict access to the room to prevent tracking of the infectious fluid.
The risk of exposure to patients, visitors, and other staff is minimized.
Safety protocols require isolating the hazard immediately to prevent tracking or accidental contact with bloodborne or infectious pathogens.
2
Don personal protective equipment (PPE), including an N95 respirator, gown, face shield, and utility gloves.
The nurse is fully protected from chemical and biological hazards, including aerosolized mycobacteria.
BCG contains live Mycobacterium bovis. Occupational safety guidelines require respiratory protection in addition to contact and eye protection when cleaning a spill due to aerosolization risks.
3
Clamp the urinary catheter and reattach or replace the drainage bag to stop the active leak.
The active source of the biohazard leak is safely contained.
The ongoing leak must be stopped before attempting to clean the surrounding spill to prevent continuous environmental contamination.
4
Cover the spilled fluid with absorbent paper towels to prevent splashing and minimize aerosolization.
The biological spill is contained and prepared for disinfection.
Pouring liquids directly onto a biological spill can cause splashing and aerosolization of pathogens; covering it first with absorbent material mitigates this risk.
5
Apply an EPA-registered tuberculocidal disinfectant over the towels and wait the required contact time.
Pathogens are effectively destroyed, and the area is safe for normal use.
Disinfectants require a specific wet dwell time to ensure complete eradication of the mycobacteria before physical removal.
Anahtar Kavram
Management of intravesical Bacillus Calmette-Guérin (BCG) spills requires specialized biohazard protocols, including airborne respiratory protection (N95) and tuberculocidal disinfectants, due to the aerosolization risk of the live attenuated mycobacterium.
Soru 564Soru →
A nurse is preparing to provide oral hygiene to an unconscious client. Arrange the following steps of the procedure in the chronological order the nurse should perform them to ensure client safety.
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Cevap
The correct chronological sequence prioritizes assessment first, followed by safe positioning to prevent aspiration, preparation of the immediate environment, the cleaning procedure, and finally suctioning to clear the airway.
The nursing process dictates that assessment comes first to identify risks, such as the absence of a gag reflex. Because aspiration is the greatest risk during oral care for an unconscious client, placing the client in a side-lying position is the immediate safety priority before introducing any fluids. Once the airway is protected by gravity, the nurse prepares the area with a towel and basin, performs the cleaning, and finally suctions the mouth to ensure all fluids and loosened secretions are safely removed.
Adım Adım Çözüm
1
Assess the client's respiratory status and presence of a gag reflex.
Determines the client's risk for aspiration.
The nursing process always begins with assessment to ensure individualized and safe care before implementing any interventions.
2
Place the client in a side-lying position with the face turned slightly downward.
Allows gravity to facilitate the drainage of oral secretions out of the mouth.
Unconscious clients cannot swallow effectively. This position is the primary intervention to prevent choking and aspiration of fluids.
3
Place a protective towel and an emesis basin under the client's chin.
Protects the client's skin, gown, and bed linens.
Setting up the environment after safe positioning ensures that any immediate drainage is caught and hygiene is maintained.
4
Clean the teeth, gums, and inner cheeks using a moistened soft foam swab.
Removes plaque, crusts, and debris from the oral cavity.
Promotes oral hygiene, prevents infection, and maintains the integrity of the oral mucosa.
5
Suction the oral cavity to remove any remaining fluids and loosened secretions.
Clears the airway and oral cavity of excess moisture.
Ensures that the client does not aspirate any residual fluids introduced during the cleaning process.
Anahtar Kavram
Oral Care for the Unconscious Client
Soru 565Soru →
A nurse is caring for a client who is receiving continuous enteral nutrition via a nasogastric tube. The client suddenly begins coughing vigorously, becomes tachypneic, and their oxygen saturation drops to 88% on room air. Arrange the following nursing actions in the correct order of priority to mitigate the risk of further respiratory compromise.
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The correct priority sequence is to stop the feeding, position the client, suction the airway, administer oxygen, assess vital signs, and finally notify the healthcare provider.
When a client aspirates enteral feeding, the nurse must rapidly apply the principles of Airway, Breathing, and Circulation (ABC) to reduce the risk of severe complications such as hypoxic respiratory failure and aspiration pneumonia. The first action must always be to eliminate the cause by stopping the feeding pump. Next, the airway must be protected via positioning and cleared via suctioning. Once the airway is patent, breathing is supported with supplemental oxygen. Only after the client is stabilized should the nurse complete a comprehensive assessment and communicate the findings to the healthcare provider.
Adım Adım Çözüm
1
Stop the enteral feeding pump.
Halts the infusion of formula.
Prevents additional fluid from entering the compromised airway, directly reducing the risk of worsening aspiration.
2
Reposition the client.
Protects the airway using gravity.
High-Fowler's or side-lying positioning prevents pooling of secretions and facilitates the clearing of aspirated material.
3
Suction the airway.
Removes formula and pulmonary secretions.
Clears the mechanical obstruction from the oropharynx to restore breathing and gas exchange.
4
Administer oxygen.
Increases circulating oxygen levels.
Addresses the acute desaturation (88%) now that the airway has been secured and cleared.
5
Assess the client.
Evaluates the extent of physiological damage.
Auscultating breath sounds and taking vital signs provides crucial data on the client's current status.
6
Notify the provider.
Communicates the critical change in condition.
Allows the provider to prescribe follow-up interventions, such as a chest x-ray to assess for aspiration pneumonia.
Anahtar Kavram
Prioritization of care for enteral feeding complications using the Airway, Breathing, Circulation (ABC) framework.
Tahmini Süre:1m 30s
Soru 566Soru →
A nurse on an acute psychiatric unit is reviewing the protocol for managing clients who exhibit escalating, aggressive behavior. According to the principle of least restrictive intervention, arrange the following nursing actions in the correct sequence from least restrictive to most restrictive.
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Cevap
The correct sequence from least to most restrictive is: verbally engaging the client, modifying the environment, offering voluntary oral medication, administering emergency intramuscular medication, and finally utilizing a locked seclusion room.
The correct sequence adheres to the legal and ethical mandate to use the least restrictive measures first. The hierarchy strictly progresses from independent communication (verbal), to spatial management (environment), to collaborative medical treatment (oral meds), to non-collaborative medical treatment (IM meds), and finally to total restriction of movement (seclusion).
Adım Adım Çözüm
1
Identify the foundational principle of behavioral crisis management.
The nurse must always start with the least restrictive and least invasive interventions before progressing to more restrictive measures.
This approach protects the client's autonomy, dignity, and legal rights while maintaining a safe therapeutic milieu.
2
Evaluate the restrictiveness of the non-pharmacological interventions.
Verbal engagement is the least restrictive, followed by environmental modifications (moving to a quiet area).
Verbal techniques rely completely on client cooperation without limiting movement. Environmental changes begin to limit the client's spatial freedom slightly but do not alter their physiology.
3
Evaluate the restrictiveness of the pharmacological and physical interventions.
Voluntary oral medication is less restrictive than emergency intramuscular medication, and physical seclusion is the most restrictive overall.
Voluntary medications maintain consent. Chemical restraints (IM) override physical autonomy. Seclusion completely eliminates freedom of movement and isolates the client, serving only as the absolute last resort.
Anahtar Kavram
The hierarchy of least restrictive behavioral interventions
Soru 567Soru →
A registered nurse is preparing to initiate a continuous intravenous (IV) regular human insulin infusion for a client admitted with diabetic ketoacidosis (DKA). Arrange the following nursing actions in the correct sequence.
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Cevap
The correct sequence is: Review baseline laboratory values, prepare the insulin mixture, prime the tubing and discard the waste volume to saturate binding sites, connect to the proximal injection port, start the electronic infusion pump, and evaluate the blood glucose level in 1 hour.
The proper sequence for initiating an intravenous insulin infusion heavily prioritizes client safety and advanced pharmacological principles. Assessment (verifying blood glucose and potassium) must occur first to ensure the intervention will not cause harm, such as severe hypokalemia. Next, preparation and specialized priming are required. Priming the tubing with a waste volume is a critical pharmacological step because insulin adsorbs to PVC plastic; saturating the tubing ensures the client receives the actual ordered dose. Finally, connecting the line to a proximal port minimizes dead space, allowing the pump-controlled infusion to act quickly, followed by strict hourly reassessment to guide titration.
Adım Adım Çözüm
1
Review the client's most recent serum potassium and blood glucose levels.
The nurse confirms the need for insulin therapy and verifies that the serum potassium is at a safe level to proceed.
Assessment must precede implementation. Insulin causes intracellular shifts of potassium; administering it to a hypokalemic client can induce lethal cardiac dysrhythmias.
2
Prepare the prescribed concentration of regular human insulin in 0.9% sodium chloride.
The intravenous insulin solution is properly mixed and ready for administration.
Once safety parameters are confirmed, the nurse prepares the specific medication. Regular insulin is the standard formulation approved for continuous intravenous use.
3
Prime the IV administration set, allowing 20 to 50 mL of the insulin solution to flow through and be discarded.
The polyvinyl chloride (PVC) binding sites within the inner lumen of the tubing are saturated with insulin.
Insulin strongly adsorbs to standard plastic IV tubing. Discarding this initial volume ensures the fluid that ultimately reaches the client contains the correct, prescribed concentration of insulin rather than a diluted dose.
4
Connect the IV tubing to the injection port closest to the client's venous access site.
The IV tubing is securely attached to the most proximal port on the client's access line.
High-alert continuously titrated medications must be connected as close to the client as possible to minimize dead space and ensure rapid physiological response to rate changes.
5
Begin the continuous infusion via an electronic infusion pump at the prescribed weight-based rate.
The client begins receiving the insulin at a strictly controlled and precise rate.
An electronic infusion pump is mandatory for continuous insulin administration to prevent accidental rapid boluses and ensure accurate metabolic management.
6
Evaluate the client's capillary blood glucose level 1 hour after initiation.
The nurse assesses the client's physiological response to the initial hour of insulin therapy.
Frequent monitoring (typically hourly) is critical to evaluate the therapeutic efficacy of the infusion and to promptly titrate the rate to prevent dangerous hypoglycemia.
Anahtar Kavram
Initiating a continuous IV insulin infusion requires a baseline assessment of serum potassium, specialized priming of the IV tubing with 20 to 50 mL of the solution to saturate plastic PVC binding sites, and connection to a proximal port to ensure accurate and safe drug delivery.
Soru 568Soru →
A nurse is caring for a client in the active phase of dying. The client begins to exhibit loud, gurgling respiratory secretions. The client's family members are at the bedside, visibly distressed, and state, "Please help, they are choking!" Arrange the following nursing actions in the priority order they should be performed.
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Cevap
The correct priority sequence is: 1) Assess the client, 2) Reposition the client, 3) Administer anticholinergic medication, 4) Explain the sounds to the family, 5) Perform oral care.
In end-of-life care, prioritizing actions follows the nursing process (ADPIE) and physiological needs. Assessment is always the first step. Next, non-pharmacological physical interventions (such as repositioning) provide immediate relief for terminal secretions. Pharmacological interventions (like anticholinergics) follow to address the underlying symptom medically. Once the client's physical needs are stabilized, the nurse addresses the psychosocial needs of the family through education and reassurance. Finally, routine comfort measures like oral hygiene are provided.
Adım Adım Çözüm
1
Assess the client's level of consciousness and signs of respiratory distress.
The nurse establishes baseline data and confirms the presence of terminal secretions.
The nursing process always begins with assessment to ensure interventions are appropriate for the client's current condition.
2
Reposition the client into a lateral or semi-Fowler's position.
Secretions drain via gravity, reducing the gurgling sound.
Immediate non-pharmacological interventions for airway clearance take priority over medications or family education.
3
Administer the prescribed sublingual anticholinergic medication.
Secretions are pharmacologically dried up over time.
Anticholinergics (such as atropine or scopolamine) are standard pharmacological treatments to manage 'death rattle' once immediate physical positioning is complete.
4
Explain the physiological cause of the sounds to the family to alleviate their distress.
The family understands that the client is not suffocating, which reduces their anxiety.
Psychosocial support and education for the family are crucial in end-of-life care but are secondary to the client's immediate physical airway needs.
5
Perform gentle oral care using moistened swabs.
The client's mouth remains clean and comfortable.
Routine comfort measures follow acute symptom management and family support.
Anahtar Kavram
Prioritization of care for terminal secretions (death rattle) utilizing the nursing process.
Soru 569Soru →
A triage nurse in the emergency department receives a 26-year-old client who was found unresponsive in a public restroom. The client presents with pinpoint pupils, perioral cyanosis, and a respiratory rate of 5 breaths per minute. A used syringe is visible in the client's pocket. Arrange the following nursing actions in the correct sequential order of priority from first to last.
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Cevap
The correct sequence is to first initiate manual ventilation, followed by administering intravenous naloxone, placing the client in a lateral recovery position, assessing for acute opioid withdrawal, and finally providing harm reduction education.
The correct sequence strictly adheres to the nursing process and the ABCs (Airway, Breathing, Circulation) framework. Manual ventilation addresses the immediate respiratory failure (Breathing). Naloxone administration directly counteracts the pharmacological cause of the respiratory depression. Positioning the client laterally is an anticipatory safety measure to protect the airway from aspiration, a common complication of naloxone-induced emesis. Once stable, the nurse monitors for the adverse effects of reversal (acute withdrawal). Finally, secondary prevention via harm reduction education is provided when the client is fully alert and stable.
Adım Adım Çözüm
1
Address immediate life-threatening physiological needs first.
Initiate manual ventilation using a bag-valve-mask device.
Airway and breathing take absolute precedence in an unresponsive, cyanotic client with severe bradypnea (5 breaths/minute).
2
Administer the pharmacological antidote.
Administer the prescribed dose of intravenous naloxone.
Once the airway is secured and oxygenation is supported, reversing the underlying opioid toxicity is necessary to restore spontaneous respirations.
3
Implement safety measures to protect the airway.
Place the client in a lateral recovery position.
Opioid reversal can cause sudden awakening and vomiting; a side-lying position prevents aspiration of gastric contents.
4
Monitor for expected complications of the intervention.
Assess for manifestations of acute opioid withdrawal.
Rapid reversal of opioid intoxication often precipitates acute withdrawal symptoms, necessitating close ongoing assessment.
5
Engage in health promotion and harm reduction.
Provide education on safe injection practices and dispense a take-home naloxone kit.
Education is crucial for preventing future fatal overdoses, but it is only effective once the client is medically cleared and alert.
Anahtar Kavram
Sequential prioritization in acute intoxication emphasizing ABCs, airway protection, and subsequent harm reduction.
Soru 570Soru →
A nurse is preparing to administer a prescribed intermittent enteral tube feeding to a client. Arrange the following nursing actions in the correct chronological order.
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Cevap
The correct sequence is to first elevate the head of the bed, verify tube placement and residual volume, flush the tube to confirm patency, administer the enteral feeding, and finally flush the tube again.
Safe administration of an intermittent enteral feeding follows a specific clinical protocol to prevent severe complications such as aspiration and tube occlusion. The nurse must first elevate the head of the bed to at least 30 degrees to minimize aspiration risk. Next, tube placement and gastric residual volume are assessed to ensure gastrointestinal readiness. The tube is then flushed with water to confirm patency. After these safety measures are complete, the feeding formula is administered. Finally, a post-feeding flush is performed to clear the tubing and prevent clogging.
Adım Adım Çözüm
1
Position the client with the head of the bed elevated.
The client is in a safe, upright position.
Elevating the head of the bed to at least 30 degrees uses gravity to prevent reflux and decreases the risk of aspiration.
2
Verify tube placement and check the gastric residual volume.
Tube location is confirmed and gastric emptying is assessed.
This ensures the feeding will go directly into the stomach and that the client is safely digesting previous feedings.
3
Flush the enteral tube with 30 mL of water.
The tube is cleared and patency is confirmed.
Flushing verifies that the tube is not blocked before introducing the viscous feeding formula.
4
Administer the prescribed intermittent enteral feeding.
The client receives the required nutrition.
The formula is administered only after safety checks and patency are clearly established.
5
Flush the enteral tube again with 30 mL of water.
The tube is cleared of any remaining formula.
A post-feeding flush prevents the formula from clogging the tube and reduces the risk of bacterial growth inside the lumen.
Anahtar Kavram
Enteral Tube Feeding Administration
Soru 571Soru →
A registered nurse in a primary care clinic is conducting a comprehensive health promotion and disease prevention visit for a 60-year-old client. Arrange the following nursing actions in the most appropriate chronological order to maximize the effectiveness of the preventative care plan.
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Cevap
The correct sequence follows the nursing process: subjective assessment (family history), objective assessment (biometrics), analysis (risk calculation), planning (goal setting), and implementation (referral).
The sequence of actions in a health promotion visit must strictly follow the nursing process. The nurse first collects subjective data (family history) followed by objective data (biometrics and labs). Once all assessment data is gathered, the nurse analyzes the information to determine risk (using a risk calculator). After the risk is understood, the nurse enters the planning phase to set collaborative goals with the client. Finally, the nurse implements the plan by executing specific interventions, such as providing community referrals.
Adım Adım Çözüm
1
Identify the subjective assessment phase.
Eliciting a multi-generation family history.
The nursing process begins with gathering subjective client data to identify underlying, non-modifiable risk factors.
2
Identify the objective assessment phase.
Obtaining biometrics and reviewing lab panels.
Objective data collection completes the assessment phase by determining the client's current physiological baseline.
3
Identify the analysis phase.
Utilizing a validated cardiovascular risk calculator.
The nurse synthesizes both subjective and objective data to evaluate the overall risk for disease before planning interventions.
4
Identify the planning phase.
Collaborating to establish a dietary goal.
Based on the synthesized risk analysis, the nurse and client collaboratively plan mutually acceptable health promotion goals.
5
Identify the implementation phase.
Providing a referral to an exercise program.
Specific preventative interventions and referrals are implemented to achieve the established health promotion goals.
Anahtar Kavram
Application of the nursing process (Assessment, Analysis, Planning, Implementation, Evaluation) to health promotion and disease prevention strategies.
Soru 572Soru →
A pediatric nurse is educating new parents about the expected physical development of their child during the first year of life. Arrange the following gross motor milestones in the chronological order that they are typically achieved by an infant, from earliest to latest.
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Cevap
The correct chronological order of gross motor milestone achievement is: demonstrating no head lag (4 months), rolling from abdomen to back (5 months), sitting independently (8 months), creeping on hands and knees (9 months), and cruising while holding furniture (11 months).
Gross motor development follows a predictable cephalocaudal (head-to-toe) progression. The typical sequential timeline for the milestones presented is: establishing head control with no head lag (4 months), rolling from the abdomen to the back (5 months), sitting independently without support (8 months), creeping on hands and knees (9 months), and finally cruising while holding onto furniture (11 months).
Adım Adım Çözüm
1
Identify the earliest gross motor milestone presented in the options.
Demonstrating no head lag when pulled to sit typically occurs first, around 4 months of age.
Head control is one of the initial major gross motor skills acquired, following the cephalocaudal (head-to-toe) pattern of physical development.
2
Determine the next milestone achieved in the first half of the infant's first year.
Rolling from the abdomen to the back typically occurs next, at 5 months of age.
Truncal strength develops after head control, allowing the infant to roll over. Rolling from the front to the back usually precedes rolling from the back to the front.
3
Identify the milestone associated with core stability and independent posture.
Sitting upright independently without support typically occurs around 8 months of age.
Progressing down the body, the infant gains sufficient lower back and core strength to maintain a sitting posture without relying on external support.
4
Determine the milestone related to independent floor mobility.
Creeping on hands and knees bearing weight typically occurs around 9 months of age.
After mastering sitting, infants learn to coordinate their arms and legs to bear weight and achieve crawling/creeping mobility.
5
Identify the latest milestone in the sequence prior to independent walking.
Cruising sideways while holding onto furniture typically occurs at 11 months of age.
Leg strength and balance development culminate in the ability to pull to a stand and cruise, which immediately precedes unassisted, independent walking.
Anahtar Kavram
Infant gross motor development follows a predictable, chronological, cephalocaudal (head-to-toe) pattern throughout the first year of life.
Soru 573Soru →
A nurse is caring for a client with acute delirium who is experiencing severe sensory overload. The client is highly agitated, attempting to climb over the bed rails, and shouting at shadows on the wall while the room's television is blaring. In what order should the nurse prioritize the following interventions? Arrange the actions from first (highest priority) to last (lowest priority).
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Cevap
The correct sequence is to first ensure physical safety, second reduce environmental stimuli, third approach the client calmly, fourth provide verbal reorientation, and fifth administer medication as a last resort.
The correct sequence follows the nursing process and prioritization frameworks. The nurse must first ensure immediate physical safety to prevent injury from falling. Next, the nurse addresses the root cause of the immediate distress by eliminating excessive sensory stimuli (turning off the TV, adjusting lights). Once the environment is calm, the nurse can safely approach the client in a non-threatening manner. After establishing a presence, verbal reorientation using simple terms is appropriate. Finally, if these less restrictive, non-pharmacological interventions are ineffective at managing the severe agitation, PRN medication is administered as a last resort.
Adım Adım Çözüm
1
Prioritize immediate physical safety.
The client is prevented from falling or sustaining physical injury.
According to prioritization principles, preventing imminent physical harm is always the first action.
2
Modify the environment to reduce sensory overload.
The blaring television is turned off and shadows are minimized.
Sensory overload exacerbates delirium and agitation. Removing noxious stimuli is necessary before effective communication can occur.
3
Initiate non-threatening therapeutic contact.
The nurse approaches calmly and speaks softly.
A calm presence helps de-escalate the situation and models controlled behavior for the agitated client.
4
Reorient the client verbally.
The client receives simple, clear information about reality.
Cognitive impairment requires brief, concrete statements to help anchor the client to their actual surroundings.
5
Utilize pharmacological interventions as a last resort.
Medication is administered only if agitation persists.
The principle of least restrictive interventions dictates that environmental and verbal strategies must be attempted before chemical restraints.
Anahtar Kavram
Prioritization of care for a client experiencing acute sensory overload and delirium, utilizing the principles of safety, least restrictive interventions, and environmental modification.
Tahmini Süre:1m 30s
Soru 574Soru →
A clinic nurse is preparing to conduct an intimate partner violence (IPV) screening for a young adult client who arrived at the healthcare facility with their spouse. Arrange the following nursing actions in the correct sequence to safely and effectively perform the screening.
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Cevap
The correct sequence is: Ensure privacy, explain universal screening, ask direct questions, validate disclosure, and evaluate immediate safety.
The priority in IPV screening is client safety, meaning the nurse must first establish a secure, private environment away from any accompanying individuals. Next, introducing the screening as a universal, routine practice reduces stigma and defensiveness. The nurse then asks direct, objective screening questions. If the client discloses abuse, the immediate psychosocial priority is to therapeutically validate their experience. Finally, the nurse must assess for immediate danger and lethality to determine if an urgent safety plan is needed before the client leaves the facility.
Adım Adım Çözüm
1
Ensure privacy
The client is separated from their spouse in a secure room.
Screening must never occur with a partner present due to the high risk of retaliation and compromised confidentiality.
2
Introduce universal screening
The nurse explains that IPV screening is routinely done for all clients.
Normalizing the assessment prevents the client from feeling singled out and reduces defensiveness.
3
Conduct the screening assessment
Direct, non-judgmental questions about abuse are asked.
Clear and specific questions are necessary to accurately identify experiences of violence.
4
Validate the client's disclosure
The nurse provides an affirming statement that the abuse is not the client's fault.
Therapeutic validation builds trust and provides crucial emotional support immediately following disclosure.
5
Assess immediate safety
The nurse evaluates the risk for imminent lethality or harm.
Once the client's experience is validated, determining immediate danger dictates the urgency and type of safety planning required before the client leaves.
Anahtar Kavram
Intimate Partner Violence (IPV) Screening Sequence
Soru 575Soru →
A nurse is preparing to change a two-piece ostomy appliance for a client with a newly established descending colostomy. In which order should the nurse perform the following actions? Arrange the steps from first to last.
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Cevap
The correct sequence for changing an ostomy appliance is: removing the old appliance, cleaning and drying the skin, measuring the stoma, cutting the barrier to the appropriate size, and applying the new barrier and pouch.
The procedure for changing an ostomy pouch requires a logical progression focused on skin integrity and maintaining a proper seal. The nurse must first gently remove the old equipment by pushing the skin away from the adhesive to prevent epidermal stripping. Next, the skin is cleaned with warm water (avoiding soaps that leave residue) and thoroughly dried. Because the stoma size fluctuates, especially in the postoperative period, the nurse must measure it accurately after cleaning and drying the area. The wafer is then carefully cut approximately 1/8 inch larger than the stoma to ensure it does not compress the stomal tissue while still protecting the surrounding skin from effluent. Finally, the newly cut barrier and pouch are applied.
Adım Adım Çözüm
1
Remove the soiled appliance.
Exposes the stoma and peristomal skin.
Necessary to begin the care process while minimizing skin trauma.
2
Cleanse and dry the area.
Removes effluent and prepares a clean, dry surface.
Feces can cause severe skin breakdown, and moisture prevents the new adhesive from sticking properly.
3
Measure the stoma.
Provides the exact current dimensions of the stoma.
Stoma size changes over time, especially postoperatively, requiring accurate measurement during each change.
4
Cut the skin barrier 1/8 inch larger than the stoma.
Creates a customized opening in the wafer.
A correct fit prevents stoma strangulation and protects the surrounding skin from corrosive stool.
5
Apply the new barrier and pouch.
Secures the appliance to the client.
Completes the procedure, restoring the closed system for effluent collection.
Anahtar Kavram
Ostomy Care and Peristomal Skin Management
Soru 576Soru →
A nurse is preparing to safely transfer a client who has generalized weakness from the bed to a wheelchair. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence from first to last.
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Cevap
The correct sequence is: Position and lock the wheelchair, assist the client to sit on the edge of the bed, apply the transfer belt, assist the client to stand, and finally pivot to the wheelchair.
A safe bed-to-chair transfer prioritizes client stability and proper nursing body mechanics. First, the environment must be prepared by positioning the wheelchair on the client's strong side and locking the brakes to prevent movement. Next, the client is assisted to a dangling position to prevent orthostatic hypotension. The transfer belt is then applied while the client is seated to ensure a snug fit. Once secured, the nurse assists the client to stand. Finally, the nurse and client pivot together, allowing the client to reach for the wheelchair armrests and safely sit.
Adım Adım Çözüm
1
Position the wheelchair on the strong side and lock the brakes.
The equipment is safely prepared.
Ensures the wheelchair will not move during the transfer, preventing falls.
2
Assist the client to sit on the edge of the bed.
The client is seated upright.
Allows the client to stabilize and prevents injury from orthostatic hypotension (dizziness).
3
Apply the transfer belt securely.
The nurse has a safe grasping point.
Provides stability and allows the nurse to support the client's center of gravity without pulling on their arms.
4
Assist the client to a standing position.
The client is safely standing.
Transitions the client to a weight-bearing position using the support of the transfer belt.
5
Pivot and guide the client into the wheelchair.
The client is safely seated in the wheelchair.
Completes the transfer with minimal twisting of the nurse's spine and safe seating for the client.
Anahtar Kavram
Safe Client Transfer and Mobility
Soru 577Soru →
A client has recently passed away on a medical-surgical unit. The provider has pronounced the death and confirmed that an autopsy is not indicated. The family is currently waiting in the lounge to view the body. Arrange the following post-mortem care actions in the correct chronological sequence.
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Cevap
The correct sequence is: Position a pillow beneath the head, close the eyes and mouth, remove intravenous lines and tubes, wash the body and apply a clean gown, and finally remove unnecessary medical equipment from the room.
Post-mortem care is performed systematically to maintain the dignity of the deceased and support the grieving family. The immediate physical priority is preventing facial discoloration by elevating the head, followed quickly by closing the eyes before rigor mortis occurs. Next, removing medical devices (when autopsy is not required) and bathing the body restores a natural appearance. Finally, modifying the environment completes the preparation before the family enters.
Adım Adım Çözüm
1
Prevent post-mortem physical changes.
The nurse positions a pillow under the head and raises the bed slightly.
Doing this immediately prevents blood from pooling in the face (livor mortis), preventing permanent discoloration.
2
Ensure a natural facial appearance.
The nurse gently closes the eyes and mouth.
This must be completed quickly before rigor mortis begins, as stiffening will make it difficult to adjust the facial features later.
3
Prepare the body physically for the family.
The nurse removes all medical lines, tubes, and catheters.
Since the provider confirmed no autopsy is needed, invasive devices are removed so the client looks more natural and less institutionalized.
4
Perform hygienic care.
The nurse washes the body and dresses the client in a clean gown.
Cleansing removes any bodily fluids and the fresh gown restores the client's dignity prior to the viewing.
5
Optimize the therapeutic environment.
The nurse removes excess medical supplies and equipment.
A clean, decluttered room creates a peaceful atmosphere that supports the grieving family during their final visitation.
Anahtar Kavram
Post-Mortem Care Sequence
Soru 578Soru →
While completing evening rounds on a behavioral health unit, a nurse observes a client clenching their fists, breathing rapidly, and shouting obscenities at another staff member. The nurse recognizes that the client is experiencing acute agitation. In what order should the nurse implement the following interventions? Arrange the actions from first to last.
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Cevap
The correct sequence is to first secure the environment by removing bystanders, then attempt verbal de-escalation, followed by offering voluntary oral medication, administering IM medication if aggression escalates, and finally applying physical restraints as an absolute last resort.
The management of an agitated client follows a strict hierarchy prioritizing safety and utilizing the least restrictive interventions first. Ensuring the safety of bystanders is the immediate priority. Once the area is clear, verbal de-escalation is the least restrictive direct approach. If this fails, offering voluntary oral medication gives the client a chance to retain autonomy and participate in their care. Involuntary intramuscular medication (chemical restraint) is used only if the client continues to pose a severe threat. Physical restraints are the most restrictive option and are reserved as a final measure when all other alternatives have been exhausted and imminent harm is highly likely.
Adım Adım Çözüm
1
Ensure environmental safety
Remove bystanders from the area.
Protects others from potential harm and reduces the audience, which can sometimes fuel aggressive behavior.
2
Attempt verbal de-escalation
Speak calmly from a safe distance.
Provides the least restrictive method to help the client regain self-control without utilizing physical or chemical interventions.
3
Offer voluntary pharmacological support
Provide PRN oral medication.
Offers a less restrictive medical intervention if verbal methods are insufficient, preserving client autonomy.
4
Administer chemical restraint
Give IM medication.
Manages imminent danger when the client refuses oral medication and continues to escalate.
5
Apply physical restraints
Use mechanical restraints.
Serves as the absolute last resort for preventing immediate physical harm to the client or staff when all other options have been exhausted.
Anahtar Kavram
Hierarchy of Least Restrictive Behavioral Interventions
Soru 579Soru →
A nurse is preparing to enter the room of a client who has disseminated herpes zoster and is on airborne and contact precautions. In what order should the nurse don the required personal protective equipment (PPE)? Arrange the following steps in the correct sequence.
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Cevap
The correct sequence for donning PPE is: perform hand hygiene, put on the isolation gown, put on the N95 respirator, put on the face shield or goggles, and finally put on the gloves.
According to standard infection control guidelines, the sequence for donning personal protective equipment (PPE) begins with hand hygiene to prevent contaminating the clean equipment. Next, the isolation gown is put on to cover the torso and arms, and it is tied securely. Following the gown, the N95 respirator is placed and seal-checked to protect against airborne pathogens. Eye protection (goggles or a face shield) is then applied over the respirator straps. Finally, clean gloves are donned last, ensuring they extend over the cuffs of the gown to provide a continuous, secure barrier against contact transmission.
Adım Adım Çözüm
1
Perform hand hygiene using an alcohol-based hand rub or soap and water.
Hands are clean and ready to handle sterile or clean PPE.
Prevents the transfer of pathogens to the clean PPE during the donning process.
2
Put on a clean isolation gown and fasten the ties securely at the neck and waist.
The torso, arms, and clothing are covered and protected.
The gown provides the largest surface area of protection and must be secured before facial PPE.
3
Put on a fit-tested N95 respirator and perform a user seal check.
The respiratory tract is protected from airborne particles.
The respirator is secured before eye protection to ensure the straps lie flat on the head and the seal is tight.
4
Put on a face shield or goggles.
The mucous membranes of the eyes are protected.
Eye protection is placed over the respirator to ensure it does not break the seal of the N95.
5
Put on clean gloves, ensuring they extend over the cuffs of the isolation gown.
The hands and wrists are completely covered.
Gloves must be placed last so they can wrap over the gown cuffs, eliminating exposed skin at the wrists.
Anahtar Kavram
Personal Protective Equipment (PPE) Donning Sequence
Tahmini Süre:1m 0s
Soru 580Soru →
A nurse is preparing to hang an intravenous infusion of cyclophosphamide when the bag accidentally drops, spilling the liquid antineoplastic medication onto the floor. Arrange the following nursing actions in the correct sequence to safely manage this incident.
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Cevap
The correct sequence for managing a hazardous drug spill is: 1) Secure the perimeter to protect others, 2) Retrieve the specialized spill kit, 3) Don appropriate PPE, 4) Contain the spill with absorbent materials, 5) Decontaminate the floor surface, and 6) Dispose of all cleanup materials and PPE in a bulk hazardous waste bin.
The correct sequence prioritizes immediate bystander safety, followed by preparation (getting the kit), self-protection (donning PPE), execution of cleanup (containment and decontamination), and finally, safe disposal according to OSHA and ONS guidelines.
Adım Adım Çözüm
1
Secure the immediate area
Prevents inadvertent exposure to others
Safety of bystanders and clients is the absolute first priority in any hazardous material incident. Leaving an unmonitored spill to get supplies can lead to tracking of the chemical.
2
Obtain the spill kit
Provides the necessary tools for safe cleanup
Specialized equipment, such as specific absorbents and chemical-rated PPE, is required to safely handle antineoplastic agents.
3
Don PPE
Protects the nurse from toxic exposure
The nurse must be fully protected (double gloves, gown, face/respiratory protection) before approaching the concentrated hazardous material.
4
Contain the liquid spill
Stops the physical spread of the medication
Absorbent pads prevent the drug from contaminating a larger surface area and make the bulk cleanup safer.
5
Decontaminate the surface
Removes hazardous chemical residue
Detergent and water (or kit-provided neutralizing agents) lift any remaining microscopic drug particles from the floor.
6
Dispose of waste safely
Completes the hazardous spill protocol
All items that touched the drug are now considered hazardous waste and require specialized disposal to protect environmental services workers.
Anahtar Kavram
Management of hazardous antineoplastic medication spills requires a strict sequence of securing the area, protecting the healthcare worker with specific PPE, containing the chemical, decontaminating the environment, and properly disposing of hazardous waste.