Tüm alıştırma soruları

A nurse is caring for a client who has just returned to the medical-surgical unit following a percutaneous liver biopsy. Which of the following nursing actions should the nurse implement to reduce the risk of post-procedure complications? (Select all that apply.)

While rounding on a medical-surgical unit, a nurse assesses a client admitted with chronic heart failure. The client suddenly exhibits profound respiratory distress, orthopnea, and severe anxiety. Assessment reveals an oxygen saturation of 82% on room air, diffuse bilateral crackles, and the expectoration of pink, frothy sputum. Arrange the following collaborative and independent nursing actions in the correct order of priority. All options must be used.

An older adult client is recovering in the cardiac intensive care unit following an acute anterior myocardial infarction. During the morning assessment, the nurse suspects the client is developing early cardiogenic shock. Which of the following clinical findings support this complication? (Select all that apply.)

A nurse is caring for a client who has been receiving continuous gastric suctioning for the past 48 hours to manage a small bowel obstruction. The client reports lightheadedness and a new onset of tingling around the mouth and fingers. The most recent arterial blood gas (ABG) analysis shows a pH of 7.54, a $PaCO_2$ of 41 mm Hg, and an $HCO_3^-$ of 34 mEq/L. Based on these findings, which of the following is the priority nursing action?

During the continuous monitoring of a client admitted with a severe asthma exacerbation, the nurse observes that the client's respiratory rate has abruptly declined from 36 to 10 breaths per minute. The previously auscultated loud wheezes are now markedly diminished, and the client is increasingly somnolent. Recent arterial blood gas (ABG) analysis reveals the following results:

What is the most critical action for the nurse to take?

A nurse is caring for a client who has a right-sided chest tube for the treatment of a spontaneous pneumothorax. The client suddenly exhibits severe dyspnea, tachycardia, and extreme restlessness. The nurse observes that the trachea is deviated to the left and tidaling in the water-seal chamber has abruptly stopped. A stat arterial blood gas (ABG) reveals a pH of $7.24$, a $\text{PaCO}_2$ of $62\text{ mm Hg}$, and a $\text{PaO}_2$ of $52\text{ mm Hg}$. Which action should the nurse take first to reduce the client's risk of physiological deterioration?

A nurse is preparing to care for a postoperative client who will receive intravenous morphine sulfate via a patient-controlled analgesia (PCA) pump. Which of the following nursing actions are appropriate to ensure the safe administration of this parenteral therapy? (Select all that apply.)

A nurse is preparing to administer a mixed dose of regular insulin and NPH insulin in a single syringe for a client with diabetes mellitus. In what order should the nurse perform the following actions? Arrange the steps in the correct chronological order from first to last.

An emergency department nurse assesses a client with a history of severe chronic obstructive pulmonary disease (COPD) who presented with increased work of breathing. After receiving supplemental oxygen for two hours, the client is now profoundly somnolent and responds only to painful stimuli. The respiratory rate is $8\text{ breaths/min}$ and shallow. Recent arterial blood gas (ABG) results are as follows:

* $\text{pH}: 7.18$
* $\text{PaCO}_2: 84\text{ mm Hg}$
* $\text{HCO}_3^-: 32\text{ mEq/L}$
* $\text{PaO}_2: 70\text{ mm Hg}$

Based on the client's current clinical presentation and laboratory results, which action should the nurse prioritize?

While performing a morning assessment on a client who underwent an open bowel resection 48 hours ago, the client experiences a sudden, forceful cough. The client states, "Something just gave way in my stomach." The nurse inspects the surgical site and observes that the wound edges have separated with intestinal loops visible outside the abdominal cavity. In what sequence should the nurse perform the following actions? (Arrange the steps in the correct order of priority.)

A 65-year-old client is receiving a continuous intravenous infusion of furosemide for severe fluid volume overload. During the shift, the client becomes increasingly lethargic and reports profound muscle cramps. The nurse notes the client's blood pressure has dropped from 134/82 mmHg to 86/52 mmHg over the past two hours. An arterial blood gas (ABG) analysis reveals the following values: pH 7.53, PaCO2 43 mmHg, and HCO3 36 mEq/L. Which action should the nurse prioritize to mitigate the risk of further physiological decline?

A clinical unit is monitoring a client admitted for acute pyelonephritis. During the afternoon assessment, the client becomes increasingly restless and confused. The nurse reviews the most recent diagnostic and assessment data:

Based on these clinical findings, which of the following interventions should be implemented? (Select all that apply)

A pediatric client weighing 33 lb is prescribed ampicillin 100 mg/kg/day intravenously, divided into equal doses administered every 6 hours. The pharmacy dispenses ampicillin with a concentration of 250 mg/mL. How many mL will the nurse administer per dose? Record your answer to the nearest tenth.

Two hours after a diagnostic colonoscopy with multiple polypectomies, a client begins to complain of severe, continuous abdominal pain that radiates to the right shoulder. The nurse observes that the client's abdomen is rigid and board-like upon inspection. Vital signs reveal a blood pressure of 88/54 mm Hg and a heart rate of 122 beats per minute. Which intervention is the most critical to implement first?

A nurse is caring for a client with a T4 spinal cord injury who suddenly reports a severe, pounding headache and blurred vision. The client's blood pressure is 215/115 mm Hg, heart rate is 52 bpm, and they have profound diaphoresis above the level of the injury. In what order should the nurse perform the following interventions? Arrange the actions from highest priority (first) to lowest priority (last).

A nurse is assessing a client who is receiving a continuous intravenous (IV) infusion of norepinephrine for the treatment of septic shock. The nurse observes that the tissue surrounding the peripheral IV insertion site is pale, swollen, and cool to the touch. Which action should the nurse take first?

A charge nurse is conducting safety rounds on a medical-surgical unit and observes the positioning of several clients. Which client positions increase the risk for physiological complications and require immediate intervention by the nurse? (Select all that apply.)

A nurse is evaluating a client four hours after a percutaneous liver biopsy. The client now reports a new onset of dull right shoulder pain. The nurse reviews the client's vital sign trends:

Which of the following actions should the nurse take first?

A nurse is caring for a client who is receiving a continuous intravenous (IV) infusion of heparin for a deep vein thrombosis. The healthcare provider prescribes a scheduled dose of IV vancomycin to treat a concurrent wound infection. The client currently has a single-lumen peripheral IV catheter. When checking a drug reference guide, the nurse notes that heparin and vancomycin are chemically incompatible. Which action is the most appropriate for the nurse to take?

A nurse is monitoring a client who is receiving a unit of packed red blood cells. Fifteen minutes into the infusion, the client reports sudden, severe lower back pain and a feeling of impending doom. The client's heart rate is 124 beats per minute, blood pressure is 86/52 mm Hg, and the nurse observes dark, reddish-brown urine in the Foley catheter tubing. Arrange the following nursing actions in the correct priority sequence from first to last.