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Soru 621Soru →

A rehabilitation nurse is providing discharge education to a female client with a spinal cord injury who will be managing a neurogenic bladder. The nurse is teaching the client how to perform clean intermittent self-catheterization (CISC) at home. In which order should the client perform the following steps? Arrange the actions in the correct chronological sequence.

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Cevap

The correct sequence is: Wash hands and gather supplies; Position and cleanse the meatus; Lubricate and insert the catheter; Drain completely and withdraw; Clean and store the equipment.
The correct sequence prioritizes medical asepsis and logical skill progression for home self-catheterization. Hand hygiene and supply preparation must occur first. Cleansing the perineum from front to back occurs immediately prior to insertion to prevent introducing bacteria into the urethra. The catheter is then lubricated and inserted until urine flows. Complete drainage is allowed before slow withdrawal, and the final step involves the hygienic maintenance of the reusable equipment to promote continued safe self-care.

Adım Adım Çözüm

1
Wash hands and gather supplies.
The client is prepared for the procedure with a reduced risk of transmitting pathogens.
Medical asepsis begins with proper hand hygiene before touching any self-care equipment.
2
Position comfortably and cleanse the meatus from front to back.
The periurethral area is clean and ready for catheter insertion.
Cleansing from front to back prevents the introduction of fecal bacteria into the urinary tract.
3
Lubricate the catheter tip and insert it until urine flows.
The catheter safely enters the bladder to begin drainage.
Water-soluble lubricant prevents tissue trauma, and urine flow confirms correct placement.
4
Allow complete drainage and slowly withdraw the catheter.
The bladder is fully emptied of residual urine.
Slow withdrawal ensures that urine pooled at the base of the bladder is also drained.
5
Wash, dry, and store the reusable catheter.
The equipment is maintained for future safe use.
Home self-catheterization utilizes clean technique, requiring thorough washing of reusable supplies to prevent bacterial overgrowth.

Anahtar Kavram

Clean Intermittent Self-Catheterization (CISC) Technique and Home Self-Care Maintenance
Soru 622Soru →

A nurse is preparing to transfer a client from the bed to a wheelchair. The client has a history of severe orthostatic hypotension and right-sided hemiparesis following a cerebrovascular accident. Arrange the following steps in the correct chronological order to ensure a safe and hemodynamically stable transfer.

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The correct sequence prioritizes environmental preparation, followed by gradual physiological adaptation to upright posture, and concludes with a mechanically safe pivot transfer.
This sequence synthesizes two critical nursing priorities: proactive environmental safety and hemodynamic adaptation. By placing the wheelchair on the strong (left) side first, the nurse ensures the client is never left unsupported while symptomatic. Gradual elevation and dangling prevent orthostatic syncope. Finally, using a gait belt and pivoting on the strong leg ensures maximum biomechanical stability.

Adım Adım Çözüm

1
Position the wheelchair at a 45-degree angle on the client's left side and lock the wheels.
The environment is safely prepared before the client is moved.
Equipment must be secured on the strong side to prevent leaving a potentially dizzy or unstable client unsupported while retrieving the chair.
2
Elevate the head of the bed to a high-Fowler's position.
The client's body begins to adapt to an upright posture.
Gradual elevation mitigates the hemodynamic effects of severe orthostatic hypotension.
3
Assist the client to a sitting position with their legs dangling over the edge of the bed.
The client is seated safely at the bedside.
Dangling allows the cardiovascular system to further equalize and stabilizes blood pressure before weight-bearing.
4
Assess the client for dizziness and apply a transfer belt securely around their waist.
The client is confirmed stable and physically secured for the transfer.
Confirming the absence of orthostatic symptoms ensures readiness, and the gait belt provides a safe mechanical hold point.
5
Instruct the client to bear weight on their left leg and pivot smoothly into the wheelchair.
The client is safely transferred into the chair.
Pivoting on the unaffected (left) side maximizes the client's strength and maintains balance during the movement.

Anahtar Kavram

Principles of safe mobility and transfer for clients with hemiparesis and orthostatic hypotension.
Tahmini Süre:2m 30s
Soru 623Soru →

A nurse is preparing to administer an intermittent enteral tube feeding to a client via a percutaneous endoscopic gastrostomy (PEG) tube. Place the following nursing actions in the correct sequence to ensure safe administration.

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The correct sequence is: elevate the head of the bed, check the gastric residual volume, flush the tube, administer the feeding formula, and finally flush the tube again.
Safe administration of enteral feeding requires a logical progression prioritizing client safety. Positioning the client upright comes first to prevent aspiration. Next, measuring residual volume confirms gastrointestinal tolerance. An initial flush verifies tube patency, followed by the actual formula administration. Finally, a post-feeding flush clears the tube to maintain future patency.

Adım Adım Çözüm

1
Elevate the head of the bed to 30 to 45 degrees.
The client is placed in a semi-Fowler's position.
This is the most important initial safety step to prevent aspiration of stomach contents into the lungs.
2
Check the gastric residual volume.
The amount of undigested formula left in the stomach is measured.
This step determines if the client is tolerating the feedings and prevents overfilling the stomach.
3
Flush the tube with 30 mL of water.
The tube is cleared and confirmed to be patent.
Checking patency before administering the formula ensures the feeding will flow smoothly without blockages.
4
Administer the prescribed enteral feeding formula.
The client receives their prescribed nutrition.
Nutrition can be safely delivered once all safety and patency checks are complete.
5
Flush the tube again with 30 mL of water.
The tube is cleared of all formula residue.
Formula left in the tube can dry, cause occlusions, and serve as a medium for bacterial growth.

Anahtar Kavram

Safe administration of enteral tube feedings
Soru 624Soru →

A nurse is conducting hourly rounds on an inpatient dual-diagnosis unit and discovers a client unresponsive with cyanotic lips, pinpoint pupils, and a respiratory rate of 6 breaths per minute. The client has a documented history of severe opioid use disorder. Arrange the following nursing actions in the correct order of priority.

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The correct sequence is to first determine unresponsiveness and call for help, then check the pulse and breathing, initiate ventilations to correct hypoxia, administer naloxone to reverse the overdose, and finally monitor for recurrent respiratory depression.
According to basic life support and emergency guidelines for a suspected opioid overdose, the absolute first priority is to assess responsiveness and call for help to activate the emergency response system. Next, the nurse must simultaneously check for a pulse and breathing. Upon identifying severe respiratory depression (6 breaths per minute) with a likely pulse, the immediate physiological need is oxygenation; therefore, the nurse must open the airway and provide ventilations. Once breathing is mechanically supported, the nurse administers naloxone to reverse the opioid effects. Finally, continuous reassessment is critical because the half-life of naloxone is often shorter than the opioid ingested, putting the client at high risk for a recurrence of respiratory depression.

Adım Adım Çözüm

1
Determine unresponsiveness and call for immediate help.
Activates the emergency response team.
Ensures adequate personnel and equipment (such as a crash cart) are en route before beginning physical interventions.
2
Simultaneously check the carotid pulse and observe for breathing.
Identifies whether the client requires full CPR or solely respiratory support.
Guides the appropriate progression of the basic life support algorithm based on circulatory status.
3
Open the airway and initiate bag-valve-mask ventilations.
Provides immediate oxygenation to the client.
Reversing severe hypoxia is the primary physiological priority. Interventions for oxygenation must not be delayed.
4
Administer the prescribed dose of intravenous naloxone.
Reverses the opioid-induced central nervous system and respiratory depression.
Treats the underlying toxicological cause of the respiratory failure once the airway is supported.
5
Reassess the client continuously for recurrent respiratory depression.
Monitors the sustained effectiveness of the reversal agent.
Naloxone has a shorter half-life than many opioids, meaning the client could slip back into a comatose, apneic state.

Anahtar Kavram

Priority Management of Acute Opioid Overdose
Tahmini Süre:1m 30s
Soru 625Soru →

A nurse is preparing to remove and dispose of bed linens heavily soiled with feces from a client diagnosed with a Clostridioides difficile (C. diff) infection. Arrange the following actions in the correct sequence to ensure safe handling of infectious materials.

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The proper sequence is: don personal protective equipment, gently roll the soiled linens away from the body, place them in a leak-proof biohazard bag, remove the protective equipment, and finally wash hands with soap and water.
Handling infectious linens requires a strict sequential protocol to maintain environmental safety and prevent cross-contamination. The nurse must first protect themselves by donning appropriate personal protective equipment (PPE). Next, the linens must be handled gently and rolled away from the body to prevent aerosolizing spores. The contaminated linens are immediately secured in a leak-proof biohazard laundry bag to contain the infectious material. Finally, the nurse removes their contaminated PPE and performs hand hygiene specifically with soap and water, because alcohol-based sanitizers do not eradicate C. difficile spores.

Adım Adım Çözüm

1
Don a fluid-resistant isolation gown and clean gloves.
The nurse is protected from exposure to infectious bodily fluids.
Personal protective equipment must be donned prior to contact with the contaminated environment.
2
Roll the soiled linens carefully away from the body without shaking them.
The contaminated surface is folded inward, containing the infectious material.
This minimizes the aerosolization of spores and prevents the soiled linens from touching the nurse's uniform.
3
Place the rolled linens directly into a designated leak-proof biohazard laundry bag.
The infectious material is secured and contained.
Immediate containment in a designated bag prevents environmental contamination and protects laundry handling staff.
4
Remove and discard the gown and gloves into the appropriate infectious waste receptacle.
Contaminated protective gear is safely disposed of.
Doffing equipment inside the patient's room prevents the spread of pathogens outside the isolation area.
5
Perform hand hygiene by washing hands thoroughly with soap and water.
Hands are mechanically cleansed of pathogens.
Soap and water must be used because alcohol-based hand sanitizers cannot kill Clostridioides difficile spores.

Anahtar Kavram

Safe handling of infectious materials and contact precautions for Clostridioides difficile require minimizing environmental contamination, immediate containment of biohazards, and mechanical removal of spores via handwashing with soap and water.
Soru 626Soru →

A nurse at an outpatient wellness center is creating a targeted health promotion initiative to increase influenza vaccination compliance among older adult clients. In what order should the nurse perform the following actions?

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The correct sequence follows the nursing process framework for health promotion: Assessment, Diagnosis, Planning, Implementation, and Evaluation.
The nursing process (ADPIE) provides a systematic framework for health promotion. The nurse must first assess baseline data and barriers. Next, the data is analyzed to identify the specific deficit (Diagnosis). Then, the nurse establishes measurable goals (Planning). Following this, the educational outreach is executed (Implementation). Finally, the nurse compares the post-intervention data against the baseline to measure success (Evaluation).

Adım Adım Çözüm

1
Identify the assessment phase.
The nurse must first analyze baseline data and survey clients to understand the current situation.
Assessment (data collection) is always the foundational first step in planning any health promotion initiative.
2
Identify the diagnosis/analysis phase.
The nurse identifies the primary health promotion deficit, such as a lack of awareness.
Once data is collected, it must be analyzed to define the specific problem to be targeted.
3
Identify the planning phase.
The nurse establishes a measurable target goal to increase vaccination rates by 20%.
Before acting, clear and measurable objectives must be set based on the identified problem.
4
Identify the implementation phase.
The nurse distributes educational pamphlets and makes reminder calls.
Implementation is the active execution of the strategies developed during the planning phase.
5
Identify the evaluation phase.
The nurse compares post-intervention rates with the baseline data.
Evaluation determines if the implemented actions successfully met the established goals.

Anahtar Kavram

Application of the nursing process (ADPIE) to population health promotion and primary disease prevention.
Tahmini Süre:1m 0s
Soru 627Soru →

A nurse is caring for a client receiving intravenous (IV) fluids. The client suddenly develops shortness of breath, a cough, and crackles in the lung bases. Arrange the following nursing actions in the priority order they should be performed.

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Cevap

The correct sequence is to elevate the head of the bed, decrease the IV fluid rate, administer oxygen, and then notify the healthcare provider.
In acute decompensation from fluid volume overload, the nurse must follow the airway, breathing, and circulation (ABC) prioritization framework. Elevating the head of the bed immediately improves breathing mechanics. Stopping or slowing the IV fluid prevents further circulatory overload. Administering oxygen supports gas exchange. Finally, notifying the provider is essential to obtain further medical orders once initial stabilization is complete.

Adım Adım Çözüm

1
Elevate the head of the bed to a high-Fowler's position.
Improves lung expansion and decreases venous return.
Airway and breathing are the highest priority. Sitting the client up provides the fastest relief for dyspnea.
2
Decrease the intravenous fluid infusion rate.
Stops the infusion of excess volume.
Circulation is the next priority. Slowing the IV fluids prevents the fluid overload from becoming more severe.
3
Administer supplemental oxygen.
Increases oxygen saturation in the blood.
Hypoxia must be treated to ensure adequate tissue perfusion.
4
Notify the healthcare provider.
Facilitates further medical intervention.
Once the client is temporarily stabilized, the provider must be informed to obtain prescriptions for medications like loop diuretics.

Anahtar Kavram

Prioritization of care for acute fluid volume overload
Tahmini Süre:1m 0s
Soru 628Soru →

A nurse is instructing a client who is non-weight-bearing on the left leg due to a fractured tibia on how to safely ascend a flight of stairs using crutches. Arrange the following steps of a three-point gait in the correct sequential order.

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Cevap

The correct sequence is to place weight on the crutches, step up with the unaffected right leg, transfer weight to the right leg, bring the crutches and affected left leg up, and finally re-establish a stable tripod base.
When teaching a client to ascend stairs with a three-point gait, the nurse must emphasize the principle of 'up with the good.' The safe sequence begins by the client placing full weight on the crutches. Next, the unaffected (right) leg is advanced up to the stair. The client then transfers their body weight onto the strong right leg. Following this, the crutches and the affected (left) leg are brought up together to the same step. Finally, the client must ensure a stable tripod position is re-established before taking the next step. This sequence ensures safety, maintains balance, and prevents accidental weight-bearing on the affected limb.

Adım Adım Çözüm

1
Place body weight entirely onto the crutches.
The client's weight is fully supported by the upper body.
This removes weight from both legs, allowing the strong leg to move freely.
2
Advance the unaffected right leg up onto the step.
The right foot is securely placed on the higher surface.
The strong leg must go up first to provide the power needed to lift the body's center of gravity ('up with the good').
3
Transfer body weight from the crutches to the unaffected right leg.
The right leg now bears the body's weight.
Shifting weight to the planted strong leg allows the client to lift the crutches and the affected limb safely.
4
Bring the crutches and the affected left leg up to the same step.
Both feet and the crutches are now on the same stair.
The crutches and the affected leg move together as a single unit to ensure continuous support and protection of the injured limb.
5
Establish a stable tripod base of support before initiating the next step.
The client achieves stable equilibrium.
A proper tripod stance prevents falls and prepares the client's alignment for the subsequent step.

Anahtar Kavram

Ascending stairs with crutches requires the 'up with the good' sequence, utilizing the unaffected leg to lift the body's weight.
Soru 629Soru →

A nurse is preparing to administer a large-volume cleansing enema to an adult client to relieve constipation. Arrange the following procedural steps in the correct chronological order from first to last.

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The correct sequence is: Position the client, lubricate the tubing, insert the tubing, elevate the container to administer fluid, and finally withdraw the tube while encouraging retention.
Administering a cleansing enema requires a systematic approach to ensure safety and effectiveness. The nurse must first place the client in the left lateral Sims position to align the sigmoid colon with gravity. Next, the equipment is prepared by lubricating the tip to prevent mucosal trauma. The tube is then inserted 3 to 4 inches into the rectum, aiming toward the umbilicus to follow the bowel's contour safely. Following correct placement, the fluid container is elevated 12 to 18 inches above the anus to initiate a steady, low-pressure flow. Finally, the tube is removed, and the client is instructed to retain the fluid to maximize the therapeutic outcome.

Adım Adım Çözüm

1
Position the client in a left lateral Sims position with the right knee flexed.
The client's gastrointestinal anatomy is optimally aligned for the procedure.
This position allows gravity to help the fluid flow smoothly into the descending colon and sigmoid colon.
2
Lubricate the distal 2 to 3 inches of the enema tubing tip.
The tubing is prepared for atraumatic insertion.
Lubrication reduces friction and prevents mucosal tearing or irritation.
3
Insert the enema tube gently 3 to 4 inches into the rectum, directing it toward the umbilicus.
The tube successfully and safely bypasses both the external and internal anal sphincters.
This depth and angle respect adult anatomy and prevent accidental bowel perforation.
4
Elevate the fluid container 12 to 18 inches above the client's anus and unclamp the tubing.
The enema fluid begins to flow into the rectum at a safe, controlled rate.
This specific height provides adequate pressure for infusion without causing painful bowel spasms.
5
Withdraw the tube smoothly and encourage the client to retain the enema fluid as prescribed.
The procedure concludes, allowing the fluid to take therapeutic effect.
Retaining the fluid provides necessary time for the stool to soften and for the bowels to be stimulated for evacuation.

Anahtar Kavram

Safe administration of a large-volume cleansing enema
Soru 630Soru →

A nurse is caring for a client receiving total parenteral nutrition (TPN) via a central venous catheter (CVC). During a tubing change, the CVC accidentally disconnects from the injection cap. The client suddenly gasps, reports sharp chest pain, and exhibits dyspnea with cyanosis. Arrange the following risk-reduction actions in the chronological order the nurse must perform them to manage this complication.

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Cevap

The correct chronological sequence is: 1) Occlude the catheter, 2) Position in left lateral Trendelenburg, 3) Administer 100% oxygen, 4) Activate the rapid response team, and 5) Monitor vital signs continuously.
In the event of a suspected air embolism from a disconnected CVC, the nurse's priority sequence is designed to stop the embolus, trap it safely, treat the systemic effects, and get advanced help. Clamping the line directly stops the source of air entry. The left lateral Trendelenburg position mechanically traps the air in the right ventricle. Oxygen therapy then treats hypoxemia and helps dissolve the nitrogen in the air bubble. Finally, escalating care and monitoring are required for advanced management.

Adım Adım Çözüm

1
Identify the complication as a suspected air embolism.
The client's sudden dyspnea, chest pain, and cyanosis upon CVC disconnection strongly indicate an air embolism.
Recognizing the life-threatening complication dictates the immediate emergency response.
2
Prioritize interventions that mechanically stop further harm.
Clamping the catheter is identified as the first and most critical action.
According to strict prioritization principles, stopping the source of ongoing injury takes precedence over all other interventions.
3
Determine the next mechanical intervention to prevent the embolus from causing a blockage.
Positioning the client in the left lateral Trendelenburg position is selected.
This specific position utilizes gravity and cardiac anatomy to keep the air bubble trapped in the right ventricle, away from the pulmonary valve.
4
Address the client's severe oxygenation needs.
Administering 100% oxygen is the third action.
Once the physical threat of further air entry and movement is mitigated, treating the hypoxemia and promoting nitrogen resorption is critical.
5
Summon advanced help and provide ongoing assessment.
Activating the rapid response team, followed by continuous monitoring, completes the immediate sequence.
Advanced interventions require a healthcare provider, and continuous monitoring ensures further physiological decompensation is caught immediately.

Anahtar Kavram

Management of a suspected air embolism in a central venous catheter requires immediate mechanical occlusion, specific anatomical positioning to trap the air, high-flow oxygen administration, and rapid escalation of care.
Soru 631Soru →

A nurse is preparing to administer a prescribed intravenous (IV) piggyback dose of a reconstituted antibiotic. The client has a continuous primary IV infusion of 0.9%0.9\% sodium chloride running via an electronic infusion pump. Arrange the following steps in the correct chronological order to safely prepare and initiate the secondary IV piggyback infusion. All steps must be used.

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Cevap

The correct sequence for IV piggyback setup is to first reconstitute the medication, inject it into the secondary dilution bag, prime the secondary tubing, asepticize the proximal Y-site port, and finally connect the tubing while lowering the primary fluid bag.
Establishing a secondary IV piggyback infusion requires a precise chronological workflow to ensure pharmacological safety and mechanical function. The medication must first be reconstituted from its powder form and then injected into the secondary bag for proper dilution. Before connecting anything to the patient's existing line, the secondary tubing must be spiked and primed to eliminate air. Aseptic technique dictates scrubbing the proximal Y-site port (above the pump, to ensure the pump regulates the rate) before attachment. Finally, the mechanical principles of gravity-fed infusion require lowering the primary fluid bag so the higher secondary bag exerts greater hydrostatic pressure, ensuring the pump draws the medication first.

Adım Adım Çözüm

1
Reconstitute the antibiotic powder.
The solid medication is transformed into a concentrated liquid solution.
Lyophilized powders must be dissolved in a sterile diluent before they can be added to larger fluid volumes.
2
Inject the reconstituted drug into the secondary IV bag.
The medication reaches the appropriate therapeutic concentration for infusion.
Direct administration of concentrated reconstituted medication can cause severe phlebitis or speed shock; it requires proper dilution.
3
Prime the secondary IV tubing.
Air is completely removed from the secondary line.
Purging air from the tubing is an essential safety requirement to prevent a potentially fatal air embolism.
4
Scrub the primary tubing Y-site port above the pump.
The connection site is sterilized.
Accessing any IV port without rigorous disinfection introduces a high risk of bloodstream infections.
5
Attach the secondary line, lower the primary bag, and open the clamp.
The secondary infusion is ready to be delivered by the pump.
Because the pump draws fluid from the highest source, the primary bag must be positioned lower than the secondary bag for the piggyback medication to infuse first.

Anahtar Kavram

Safe intravenous piggyback (IVPB) administration requires sequential reconstitution, dilution, line priming, aseptic connection at a proximal port, and gravity-assisted flow prioritization.
Soru 632Soru →

A nurse is preparing to administer an intravenous (IV) push medication through a client's peripheral IV saline lock. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence.

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Cevap

The correct sequence is to perform hand hygiene and don gloves, scrub the injection port, flush the line with normal saline to check patency, inject the medication over the prescribed time, and finally flush the line again with normal saline.
The standard and safest sequence for administering an IV push medication through a saline lock follows strict infection control protocols and the established SAS (Saline-Administer-Saline) method. The nurse must first perform hand hygiene and don gloves to protect both the patient and themselves. Next, the injection port is scrubbed to prevent introducing pathogens. The initial flush with normal saline is critical to confirm the line is patent and not infiltrated. After patency is established, the medication is safely injected at the prescribed rate. Finally, a subsequent saline flush is necessary to clear the medication from the line, ensuring the patient receives the complete dose and preventing catheter occlusion.

Adım Adım Çözüm

1
Ensure infection control.
Hand hygiene is performed and clean gloves are donned.
This is the fundamental first step in any invasive procedure to maintain standard precautions.
2
Disinfect the access point.
The IV injection port is scrubbed with an antiseptic swab.
Prevents the introduction of microorganisms into the patient's bloodstream.
3
Assess IV patency.
The IV catheter is flushed with 0.9% sodium chloride.
Ensures the vein is viable, the line is not occluded, and prevents administering medication into infiltrated tissue.
4
Administer the therapeutic agent.
The medication is injected over the recommended duration.
Delivers the required dose safely and minimizes the risk of speed shock or localized irritation.
5
Clear the line and ensure full dosing.
A final flush of 0.9% sodium chloride is administered.
Pushes the remaining medication in the extension tubing into the systemic circulation and locks the line to maintain future patency.

Anahtar Kavram

Safe administration of IV push medications via a saline lock using the SAS (Saline-Administer-Saline) method.
Soru 633Soru →

The nurse is preparing to obtain a capillary blood glucose measurement for a client with diabetes mellitus. To ensure accurate results and reduce the risk of infection, in what order should the nurse perform the following actions? Arrange the steps in the correct sequence.

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Cevap

The correct sequence is to first clean and dry the site, puncture the lateral fingertip, wipe away the first drop of blood, apply the second drop to the test strip, and finally apply pressure to the site.
Obtaining a capillary blood glucose measurement requires strict adherence to technique to ensure both client safety (infection prevention) and clinical accuracy (preventing altered readings). The site must first be cleaned and completely dried. Puncturing the lateral side of the finger minimizes pain. Wiping away the first drop of blood is a critical step because it may be diluted with serous fluid or remaining alcohol. The second drop is then applied to the test strip for a highly accurate reading, followed immediately by applying pressure to the site to stop bleeding and prevent bruising.

Adım Adım Çözüm

1
Clean the selected puncture site with an alcohol swab and allow it to air dry.
The skin is sanitized and free of wet alcohol.
Reduces infection risk and prevents alcohol from chemically altering the glucose reading.
2
Puncture the lateral aspect of the fingertip with a sterile lancet.
A small capillary puncture is created.
The lateral side of the finger is less painful for the client due to fewer nerve endings.
3
Wipe away the first drop of blood using a clean, dry gauze pad.
The initial, potentially diluted blood drop is removed.
The first drop may contain interstitial fluid or alcohol residue, causing inaccurate glucose results.
4
Apply the second drop of blood to the reagent test strip.
An accurate blood sample is collected for testing.
The second drop provides a pure capillary sample for the most accurate measurement.
5
Apply direct pressure to the puncture site with a cotton ball or gauze pad.
Bleeding is stopped.
Maintains skin integrity and prevents continued bleeding or localized bruising.

Anahtar Kavram

Capillary Blood Glucose Monitoring and Risk Reduction
Soru 634Soru →

A nurse is preparing to administer an intermittent secondary intravenous (IV) piggyback medication using a new sterile administration set. The client is currently receiving a continuous primary IV fluid infusion via an electronic pump. Arrange the following actions in the correct sequence.

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Cevap

The correct sequence is to verify medication compatibility, close the secondary tubing's roller clamp, spike the bag and prime the tubing, cleanse the primary tubing's upper Y-port, and finally connect the secondary tubing while lowering the primary IV fluid bag.
Administering a secondary intravenous (IV) piggyback medication requires a systematic approach to ensure patient safety and medication efficacy. First, the nurse must verify the compatibility of the secondary medication with the continuous primary IV fluid to prevent dangerous precipitates from forming. Next, the nurse closes the roller clamp on the new secondary tubing to prevent fluid from freely flowing out when the bag is spiked. The bag is then spiked, and the tubing is primed to expel all air, which prevents an air embolism. Following preparation of the tubing, the nurse maintains strict asepsis by cleansing the upper Y-port (the port above the infusion pump) on the primary line with an antimicrobial swab. Finally, the secondary tubing is connected to the cleansed port, and the primary fluid bag is lowered using an extension hanger. Because the secondary bag is hung higher, gravity allows it to exert greater hydrostatic pressure, ensuring the secondary medication infuses first while temporarily halting the primary infusion until the secondary bag is empty.

Adım Adım Çözüm

1
Verify compatibility.
Ensures the secondary medication will not form a precipitate when it mixes with the primary IV fluid.
Patient safety is the highest priority; incompatible medications can cause life-threatening complications.
2
Close the roller clamp.
The secondary tubing is closed off to fluid flow.
Prevents the medication from immediately spilling out when the fluid bag is spiked.
3
Spike the bag and prime the tubing.
Air is completely removed from the secondary tubing.
Expelling air from the intravenous line prevents an air embolism from reaching the client's vascular system.
4
Cleanse the upper Y-port.
The connection site above the infusion pump is disinfected.
Vigorously scrubbing the needleless port maintains asepsis and prevents the introduction of pathogens into the bloodstream.
5
Connect the tubing and lower the primary bag.
The secondary medication is ready to infuse first.
Gravity causes the fluid in the higher bag (secondary) to exert greater hydrostatic pressure, allowing it to infuse while temporarily halting the flow of the lowered primary bag.

Anahtar Kavram

Safe administration of intravenous piggyback (IVPB) medications
Tahmini Süre:1m 30s
Soru 635Soru →

A client with a complete T4 spinal cord injury suddenly reports a severe, pounding headache and profound nasal congestion. The nurse observes profuse diaphoresis above the level of the injury and a suddenly elevated blood pressure of 218/114 mm Hg. Arrange the following nursing actions in the priority order they should be performed. (Place the first action at the top and the final action at the bottom.)

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The correct sequence prioritizes immediate mechanical reduction of blood pressure (elevating the head of the bed), followed by removing external triggers (loosening clothing), addressing internal triggers (checking the bladder/catheter), administering medications if needed, and finally documenting the event.
Autonomic dysreflexia is a medical emergency characterized by uncontrolled sympathetic nervous system activation below the level of the spinal cord injury, leading to life-threatening hypertension. The immediate, first-line priority is to lower the blood pressure by utilizing orthostasis (raising the head of the bed). After this initial stabilizing action, the nurse should remove external restrictive stimuli, investigate and resolve the most common internal triggers (such as a kinked catheter or distended bladder), administer antihypertensives if the noxious stimulus cannot be found or resolved, and finally document the event.

Adım Adım Çözüm

1
Recognize the signs of an acute medical emergency.
Autonomic dysreflexia is identified.
A pounding headache, severe hypertension, and diaphoresis above the injury level in a client with a T4 spinal cord injury are classic indicators of a dysreflexic crisis.
2
Prioritize immediate physiological safety by altering the client's position.
The head of the bed is elevated to a high Fowler's position.
Sitting the client upright induces orthostatic hypotension, which rapidly lowers the dangerously high blood pressure and reduces stroke risk.
3
Remove secondary external triggers from the client.
Restrictive clothing and binders are loosened.
Cutaneous and tactile stimuli can further aggravate the uninhibited sympathetic response.
4
Identify and resolve the primary internal trigger.
The bladder and urinary catheter are assessed.
Bladder distention or a kinked catheter is the most common precipitating cause of autonomic dysreflexia.
5
Administer targeted pharmacological therapy if symptoms do not resolve.
Antihypertensive medication is given.
Medications are required if removing the noxious stimulus fails to lower the blood pressure safely.

Anahtar Kavram

Autonomic Dysreflexia Emergency Management
Tahmini Süre:1m 30s
Soru 636Soru →

A nurse is preparing to transfer a client who has right-sided weakness from the bed to a wheelchair. Arrange the following nursing actions in the correct sequence to ensure a safe transfer.

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The correct sequence is to first prepare the wheelchair on the strong side, then assist the client to sit on the edge of the bed, apply the transfer belt and footwear, help the client stand, and finally instruct them to pivot and sit in the wheelchair.
Safe transfer of a client with unilateral weakness requires a systematic approach prioritizing environmental safety, physiological readiness, and mechanical support. By placing the chair on the strong side first, the client can use their unaffected limbs to assist in the transfer. Dangling allows cardiovascular adjustment to prevent syncope. The transfer belt and footwear provide essential safety measures. Finally, pivoting on the strong leg and reaching for the armrests ensures a controlled descent into the wheelchair.

Adım Adım Çözüm

1
Prepare the environment and wheelchair.
The wheelchair is locked and positioned correctly on the client's unaffected side.
Ensures the equipment is stable and positioned to maximize the client's use of their strong side.
2
Assist the client to a dangling position.
The client is safely sitting on the side of the bed.
Allows the nurse to assess for orthostatic hypotension and ensures the client has their balance before standing.
3
Apply the transfer belt and non-slip footwear.
The client is properly equipped for a safe weight-bearing transfer.
Provides a secure point of contact for the nurse and prevents the client from slipping on the floor.
4
Assist the client to a standing position.
The client is upright and bearing weight primarily on the strong leg.
Initiates the physical transfer toward the wheelchair while maintaining safety and control.
5
Instruct the client to pivot and reach for the armrests.
The client safely transitions into the wheelchair seat.
Reaching for the armrests provides stability and prevents the client from missing the chair or falling during the descent.

Anahtar Kavram

Safe Client Transfer and Mobility
Soru 637Soru →

A telehealth nurse is consulting with a young adult client who mentions smoking electronic cigarettes and occasional traditional cigarettes. The nurse decides to implement the evidence-based brief intervention framework for tobacco cessation. Arrange the nurse's actions in the correct sequential order.

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The correct sequence follows the 5 A's model: Ask, Advise, Assess, Assist, and Arrange.
The '5 A's' is an evidence-based clinical intervention framework for smoking cessation. It must be implemented sequentially to maximize effectiveness. The nurse must first identify the habit (Ask), then provide a clinical recommendation (Advise). Once the recommendation is made, the nurse evaluates the client's readiness to change (Assess). If the client is ready, the nurse helps them formulate a strategy (Assist), and finally establishes ongoing support to prevent relapse (Arrange).

Adım Adım Çözüm

1
Identify the first action in the framework.
The nurse must first 'Ask' about tobacco use.
Without knowing the extent and nature of the client's tobacco use, further intervention is not possible.
2
Determine the subsequent clinical recommendation.
The nurse should 'Advise' the client to quit.
Once tobacco use is established, the healthcare provider has a duty to provide a strong, personalized recommendation to quit.
3
Evaluate the client's receptiveness.
The nurse must 'Assess' the client's readiness to change.
The intervention strategy changes depending on whether the client is ready to quit now or needs motivational interviewing.
4
Provide actionable support.
The nurse will 'Assist' the client with a quit plan.
For clients ready to make an attempt, providing resources, counseling, and pharmacotherapy planning is essential for success.
5
Ensure continuity of care.
The nurse will 'Arrange' follow-up contact.
Relapse rates are high during the first week of quitting, making early follow-up a critical component of successful cessation.

Anahtar Kavram

The 5 A's Model for Tobacco Cessation
Soru 638Soru →

A registered nurse is caring for a gravid client in active labor when spontaneous rupture of membranes occurs. The fetal heart rate suddenly drops to 80 beats per minute80\text{ beats per minute}, and the nurse visualizes the umbilical cord protruding from the introitus. In what sequence should the nurse perform the following actions? Arrange the interventions from first to last.

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The correct sequence for managing an umbilical cord prolapse is to first call for assistance, followed immediately by manually elevating the fetal presenting part off the cord. Next, the client should be repositioned into a knee-chest or Trendelenburg position, followed by the administration of oxygen, and finally, preparing the client for an emergency cesarean birth.
The priority in an umbilical cord prolapse is to restore fetal oxygenation while preparing for rapid delivery. The nurse must first call for help to mobilize the surgical team. Instantly following this, the nurse must manually elevate the presenting part to remove life-threatening pressure from the cord. Maternal repositioning utilizes gravity to sustain this relief. Providing high-flow oxygen treats the systemic fetal hypoxia. Finally, preparing for surgical delivery serves as the ultimate resolution to the emergency.

Adım Adım Çözüm

1
Call for immediate assistance.
Additional healthcare personnel are alerted to the obstetrical emergency.
The nurse must not leave a client with a prolapsed cord; extra staff are required to gather supplies, notify the provider, and prepare the operating room while the primary nurse stabilizes the fetus.
2
Elevate the fetal presenting part manually.
Mechanical pressure is removed from the prolapsed umbilical cord.
Cord compression blocks oxygenated blood flow to the fetus, causing immediate hypoxia. Relieving this compression is the most critical life-saving physical intervention.
3
Reposition the client into a knee-chest or extreme Trendelenburg position.
Gravity shifts the fetus toward the maternal diaphragm and away from the pelvic inlet.
This positional change assists in keeping the fetal presenting part off the umbilical cord, reinforcing the manual elevation.
4
Administer high-flow oxygen via a nonrebreather mask.
Maternal systemic oxygenation is increased.
Maximizing maternal oxygen saturation ensures that any blood flowing through the partially compromised umbilical cord carries the highest possible concentration of oxygen to the fetus.
5
Prepare for an emergency cesarean birth.
The client is readied for immediate surgical delivery.
Because vaginal delivery is no longer safe when the cord precedes the fetus, rapid surgical delivery is the definitive medical treatment.

Anahtar Kavram

Prioritization of care in obstetrical emergencies (Umbilical Cord Prolapse)
Soru 639Soru →

A rapid response team is called to an inpatient unit for a client who is experiencing a generalized tonic-clonic seizure. The seizure activity has been continuous for 12 minutes without the client regaining consciousness. Upon arrival, the nurse notes circumoral cyanosis and audible gurgling respirations. Arrange the following emergent interventions in the priority sequence they must be executed.

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The correct sequence prioritizes immediate airway clearance and safety (lateral position), followed by oxygenation, establishing access, stopping the active seizure with a rapid-acting agent, and finally preventing recurrence with a long-acting agent.
The correct sequence follows the fundamental principles of resuscitation: Airway, Breathing, Circulation, and then targeted pharmacological therapy. In status epilepticus, the physical airway is compromised by patient position and secretions, making lateral positioning the first action. Once the airway is open, providing oxygen treats the immense cerebral metabolic demand and cyanosis. Next, circulation and access must be verified to safely administer medications. The immediate pharmacological goal is to break the seizure using a rapid-acting benzodiazepine. Finally, a long-acting antiepileptic drug is given to provide sustained seizure prophylaxis.

Adım Adım Çözüm

1
Turn the client onto a lateral decubitus position and protect the head from trauma.
The airway is cleared of pooling secretions, reducing aspiration risk, and the head is protected from concussive injury.
Airway patency and safety are the most immediate life-saving priorities in an actively seizing client.
2
Apply high-flow supplemental oxygen via a non-rebreather mask.
Hypoxemia (evidenced by cyanosis) is treated, and cerebral oxygen delivery is maximized.
Status epilepticus significantly increases cerebral oxygen consumption; oxygen must be applied immediately after the airway is physically cleared.
3
Verify the patency of the client's existing intravenous catheter.
A secure route for emergency medication administration is confirmed.
Intravenous access must be verified before administering vesicant or critical care medications to avoid delays or extravasation.
4
Administer the prescribed rapid-acting intravenous lorazepam.
The continuous seizure activity is pharmacologically aborted.
Benzodiazepines are the evidence-based first-line therapy to stop status epilepticus, minimizing further neurological damage.
5
Initiate a prescribed intravenous loading dose of fosphenytoin.
Therapeutic levels of an antiepileptic drug are established in the bloodstream.
A long-acting antiepileptic is required following a benzodiazepine to prevent the seizure from recurring once the short-acting agent wears off.

Anahtar Kavram

Prioritization in Status Epilepticus Management
Soru 640Soru →

A nurse is preparing to administer prescribed oral medications to an older adult client who experiences age-related changes in swallowing (presbyphagia). The client reports occasional coughing during meals. In what order should the nurse implement the following interventions to ensure safe medication administration?

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The correct sequence prioritizes immediate airway safety (positioning), followed by assessment of function (swallow screen), safe intervention (administering pills individually), verification of swallowing (checking for pocketing), and prevention of delayed complications (maintaining upright posture).
This sequence follows the nursing process and prioritizes airway safety. The nurse must first establish physical safety (positioning), assess capability (swallow screen), intervene safely (single pill administration), evaluate the intervention (checking for pocketing), and implement post-intervention safety measures (remaining upright).

Adım Adım Çözüm

1
Position the client in a high-Fowler's position at a 90-degree angle.
The client is sitting upright, maximizing airway protection.
An upright position uses gravity to help clear the bolus and prevents anatomical structures from compromising the airway, which is the essential first step before any oral intake.
2
Conduct a bedside swallow evaluation using a small sip of water.
The nurse confirms the client can swallow without coughing or choking.
Due to age-related presbyphagia and a history of coughing, assessing the swallow reflex with water is necessary before attempting to give solid medications.
3
Administer the prescribed oral medications one at a time.
The client swallows each medication safely.
Giving pills one at a time prevents overwhelming a weakened swallowing mechanism, reducing the risk of choking.
4
Inspect the inside of the client's mouth to check for pocketed pills.
The nurse confirms no medications are hidden in the cheeks.
Older adults may have decreased oral sensitivity and muscle strength, leading to asymptomatic pocketing of pills which could later be aspirated.
5
Maintain the client in an upright position for at least 30 minutes.
The client safely digests the medications without reflux.
Age-related relaxation of the lower esophageal sphincter increases reflux risk; staying upright prevents delayed aspiration of regurgitated stomach contents.

Anahtar Kavram

Prioritization of care for older adults with presbyphagia (age-related swallowing changes).
Tahmini Süre:1m 0s
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