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Soru 761Soru →

A nurse is caring for a client who has just arrived at the emergency department with diabetic ketoacidosis (DKA). The client is lethargic, displays deep, rapid respirations, and has a blood glucose level of 650650 mg/dL (36.136.1 mmol/L). Arrange the following collaborative and nursing actions in the correct priority sequence.

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The correct priority order is to first establish intravenous access, followed immediately by fluid resuscitation with isotonic saline. Next, the nurse must verify the serum potassium level before initiating a continuous intravenous infusion of regular insulin. Finally, the nurse adds dextrose to the intravenous fluids when the blood glucose drops to 250250 mg/dL (13.913.9 mmol/L).
The correct sequence for managing diabetic ketoacidosis (DKA) prioritizes reversing hypovolemia and preventing shock, followed by safely correcting metabolic abnormalities. Establishing intravenous access and administering isotonic fluids is the most critical first step to restore tissue perfusion. Next, it is essential to check potassium levels, because insulin therapy drives potassium into the cells. Administering insulin without knowing the potassium level risks lethal hypokalemia. Once potassium is confirmed safe, an insulin infusion is started to stop ketogenesis. Finally, adding dextrose when blood glucose reaches 250250 mg/dL (13.913.9 mmol/L) prevents life-threatening hypoglycemia and cerebral edema.

Adım Adım Çözüm

1
Establish intravenous access.
Provides a reliable route for emergency fluids and medications.
Vascular access is the prerequisite for treating severe dehydration and administering intravenous insulin.
2
Infuse 0.9%0.9\% sodium chloride rapidly.
Restores intravascular volume and organ perfusion.
Severe dehydration and hypovolemia are immediately life-threatening in DKA and must be addressed before correcting the metabolic abnormalities.
3
Verify the serum potassium level.
Ensures potassium is at a safe level to receive insulin.
Insulin shifts potassium from the extracellular space to the intracellular space, which can cause severe cardiac dysrhythmias if baseline potassium is already low.
4
Start a continuous regular insulin infusion.
Decreases blood glucose levels and stops ketone production.
Insulin directly treats the underlying metabolic acidosis and severe hyperglycemia of DKA.
5
Add dextrose to intravenous fluids when glucose reaches 250250 mg/dL (13.913.9 mmol/L).
Prevents hypoglycemia and fluid shifts.
Rapid drops in blood glucose can lead to fluid shifting into the brain, causing cerebral edema.

Anahtar Kavram

The primary management of diabetic ketoacidosis focuses on fluid volume replacement first, followed by careful monitoring of potassium levels before initiating insulin therapy.
Soru 762Soru →

A client receiving a packed red blood cell (PRBC) transfusion reports acute lower back pain and sudden shortness of breath. The nurse notes a rapid heart rate and a drop in blood pressure. Arrange the following immediate nursing actions in the correct chronological sequence to manage this severe physiological complication.

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The sequence requires stopping the source of harm, maintaining access safely, assessing the client, communicating with the provider, and finally securing the equipment for analysis.
In any acute physiological crisis, the fundamental principle of risk reduction is to immediately remove the offending agent. Therefore, stopping the transfusion is step one. Step two involves maintaining an open intravenous line with uncontaminated tubing and normal saline, which is vital for managing impending shock. Step three requires a rapid assessment to gather objective data. Step four is communicating this data to the healthcare provider to receive emergency prescriptions. The final step involves the administrative protocol of sending the equipment to the laboratory for diagnostic analysis.

Adım Adım Çözüm

1
Stop the blood transfusion.
The flow of the potentially incompatible blood product into the client's circulatory system is halted.
Continuing the infusion, even for a few seconds, introduces more antigens causing the acute hemolytic reaction, exacerbating the complication.
2
Infuse normal saline through new intravenous tubing.
Intravenous access is maintained without introducing residual blood.
Using the existing tubing would flush remaining incompatible blood into the client. A new line ensures safe delivery of emergency fluids to support blood pressure and renal perfusion.
3
Obtain vital signs and assess cardiopulmonary status.
Objective data regarding the severity of the shock or respiratory distress is gathered.
The nurse needs a baseline assessment of the reaction's severity to effectively report the client's condition to the healthcare provider.
4
Notify the healthcare provider and the blood bank.
The medical team is alerted and further emergency orders are obtained.
The provider will prescribe medications (such as antihistamines, corticosteroids, or vasopressors) based on the nurse's assessment.
5
Send the blood bag and tubing to the blood bank.
The product is transported for laboratory investigation.
Cross-matching and bacterial cultures on the remaining blood determine the specific type of reaction, guiding long-term management.

Anahtar Kavram

Management of Acute Transfusion Reactions
Soru 763Soru →

A nurse is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, pounding headache, and the nurse notes profuse diaphoresis and a blood pressure of 210/110 mm Hg. Arrange the following nursing interventions in the correct order of priority.

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The correct sequence of actions is to first elevate the head of the bed, then loosen restrictive clothing, followed by assessing for the underlying internal trigger (bladder or bowel), and finally administering antihypertensive medications if the symptoms do not resolve.
In autonomic dysreflexia, the immediate threat to life is severe hypertension, which can cause a stroke. Elevating the head of the bed uses gravity to induce orthostatic hypotension. Next, removing immediate surface triggers like tight clothing prevents further stimulation. Then, the nurse must assess for and resolve the most common internal triggers, such as bladder or bowel distention. Only if these interventions fail should antihypertensive medications be administered.

Adım Adım Çözüm

1
Elevate the head of the bed to a high Fowler's position.
Induces orthostatic hypotension.
This is the most rapid and non-invasive way to immediately decrease the client's critically high blood pressure and reduce the risk of a cerebrovascular accident.
2
Loosen any restrictive clothing or devices.
Removes surface sensory triggers.
Tight clothing or devices can act as a noxious stimulus below the level of injury, perpetuating the abnormal sympathetic surge.
3
Assess the bladder and bowel for distention or impaction.
Identifies the primary cause of the episode.
A distended bladder or impacted bowel is the most frequent trigger for autonomic dysreflexia. Resolving this stimulus is required to stop the sympathetic response.
4
Administer a prescribed rapidly acting antihypertensive medication.
Pharmacologically lowers blood pressure.
Medications are indicated if conservative measures, such as positioning and removing triggers, fail to resolve the hypertensive crisis.

Anahtar Kavram

Autonomic dysreflexia is a medical emergency characterized by sudden, severe hypertension. Priority management involves immediate positioning to lower blood pressure, followed by identifying and eliminating the triggering noxious stimulus.
Soru 764Soru →

An emergency department nurse is deployed to the site of a partial factory collapse to conduct field triage. According to the START (Simple Triage and Rapid Treatment) algorithm, arrange the following assessment actions in the correct chronological order.

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The correct sequence for the START algorithm is: 1) Instruct ambulatory victims to move, 2) Assess respirations, 3) Evaluate perfusion, and 4) Check mental status.
The START (Simple Triage and Rapid Treatment) algorithm follows a strict systematic sequence to maximize efficiency during a mass casualty event. The assessment flow uses the mnemonic RPM (Respirations, Perfusion, Mental Status) after initially clearing the walking wounded. Therefore, the correct chronological order is: directing ambulatory clients away (Minor/Green), assessing breathing and airway (Respirations), checking pulses or capillary refill (Perfusion), and evaluating command-following ability (Mental Status).

Adım Adım Çözüm

1
Identify the initial step of the START disaster triage algorithm.
Instructing ambulatory victims to move to a safe zone.
This quickly isolates the 'minor' or green-tagged clients, allowing responders to focus on non-ambulatory victims.
2
Determine the first physiological parameter assessed on non-ambulatory victims.
Assess the respiratory rate and airway.
Airway and breathing are the most critical priorities. If a victim is not breathing, the airway is opened; if still not breathing, they are expectant (black). If breathing is over 30 per minute, they are immediate (red).
3
Identify the next physiological parameter if respirations are adequate (less than 30 breaths per minute).
Evaluate capillary refill or palpate the radial pulse.
Perfusion is the next priority. An absent radial pulse or capillary refill greater than 2 seconds indicates immediate (red) intervention is needed.
4
Determine the final assessment step if both respirations and perfusion are adequate.
Check the ability to obey simple commands.
Mental status determines if the victim is categorized as immediate (red) due to an inability to follow commands, or delayed (yellow) if they can follow commands.

Anahtar Kavram

Disaster Triage Assessment Sequence (START Method)
Soru 765Soru →

A young adult client is admitted to the intensive care unit with profound lethargy, deep and rapid respirations, and a capillary blood glucose of 680 mg/dL (37.7 mmol/L). The healthcare provider diagnoses severe diabetic ketoacidosis (DKA). Arrange the following nursing interventions in the correct physiological priority order for managing this acute crisis. (Place the most immediate priority action at the top and the final transition action at the bottom).

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The correct sequence is: 1) Infuse 0.9% sodium chloride rapidly, 2) Verify the serum potassium level, 3) Initiate a continuous IV regular insulin infusion, 4) Add 5% dextrose when glucose falls to 250 mg/dL, and 5) Administer subcutaneous insulin before stopping the IV infusion.
The physiological management of DKA follows a strict sequential protocol based on life-threatening priorities. The immediate threat is hypovolemic shock from profound osmotic diuresis, necessitating rapid isotonic fluid resuscitation to restore perfusion. Once volume is restoring, the nurse must ensure the serum potassium is safe (>3.3 mEq/L) because insulin therapy will aggressively drive extracellular potassium into the cells. After potassium is verified, a continuous regular insulin infusion is started to reverse ketogenesis and correct the metabolic acidosis. As the blood glucose approaches 250 mg/dL (13.9 mmol/L), dextrose is introduced into the IV fluids to prevent sudden hypoglycemia and protect against cerebral edema from rapid osmolality shifts. Finally, when the acidosis is resolved and the IV insulin is ready to be discontinued, a subcutaneous basal dose must be administered with a 1 to 2 hour overlap to prevent rebound diabetic ketoacidosis.

Adım Adım Çözüm

1
Address the most immediate threat to circulation.
Isotonic fluid resuscitation is initiated.
Profound dehydration from osmotic diuresis compromises tissue perfusion. Intravascular volume must be restored before medications can effectively circulate.
2
Ensure physiological safety prior to pharmacological intervention.
Serum potassium is evaluated.
Insulin therapy causes an intracellular shift of potassium. If the client is hypokalemic, insulin can cause lethal cardiac arrhythmias.
3
Revert the underlying pathophysiological metabolic crisis.
Continuous intravenous regular insulin is started.
Insulin is required to suppress fat breakdown and ketogenesis, which directly reverses the severe metabolic acidosis.
4
Anticipate and prevent iatrogenic complications as treatment progresses.
Dextrose is added to the IV fluids when blood glucose reaches 250 mg/dL (13.9 mmol/L).
A rapid drop in serum osmolality can cause fluid shifts into the brain, resulting in cerebral edema. Dextrose stabilizes the glucose decline.
5
Safely transition the client from acute emergency management to maintenance therapy.
Subcutaneous insulin is given before the IV infusion is stopped.
Intravenous insulin has a very short half-life. An overlap with subcutaneous insulin is necessary to prevent immediate recurrence of ketogenesis.

Anahtar Kavram

The physiological management of Diabetic Ketoacidosis (DKA) requires a strict priority sequence: volume resuscitation, electrolyte safety verification, insulin administration, complication prevention, and safe transition.
Soru 766Soru →

A nurse is preparing to perform a routine sterile dressing change for a client's peripherally inserted central catheter (PICC). To minimize the risk of central line-associated bloodstream infection (CLABSI) and prevent catheter dislodgement, place the following nursing actions in the correct sequential order.

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The correct sequence prioritizes respiratory source control, followed by safe removal of the contaminated dressing, hand hygiene, sterile antisepsis, mandatory air drying, and final sterile occlusion.
The correct sequence systematically eliminates risks by moving from general environmental control (masking) to safe removal (clean technique), transitioning via hand hygiene to absolute asepsis (sterile gloves, friction scrub, air drying), and culminating in environmental sealing (occlusive dressing).

Adım Adım Çözüm

1
Apply a surgical mask to the client and instruct them to turn their head away.
Establishes immediate respiratory droplet source control.
Airborne or droplet pathogens from the client's respiratory tract are a primary source of CLABSI. This must be prevented before exposing the vulnerable insertion site.
2
Don clean gloves and remove the existing dressing by pulling toward the insertion site.
The old dressing is safely detached without disturbing the catheter.
The old dressing is heavily contaminated with skin flora, requiring only clean gloves. Pulling toward the site prevents creating tension that could dislodge the catheter.
3
Discard the old dressing and clean gloves, then perform hand hygiene.
Removes contaminated materials and sanitizes the nurse's hands.
Hand hygiene acts as the critical bridge between the clean removal phase and the sterile application phase, ensuring no pathogens are transferred to the sterile supplies.
4
Don sterile gloves and scrub the site with a chlorhexidine applicator.
The insertion site undergoes chemical and mechanical antisepsis.
Sterile gloves maintain the integrity of the procedure. Chlorhexidine with back-and-forth friction physically disrupts bacterial biofilms in the epidermal layers.
5
Allow the chlorhexidine to air dry completely.
The antiseptic achieves its full bactericidal properties.
Chlorhexidine requires time to chemically destroy bacterial cell walls. Prematurely applying the dressing traps moisture (reducing efficacy), and fanning introduces airborne microbes.
6
Apply a new sterile transparent occlusive dressing.
The catheter site is securely sealed from the environment.
The transparent dressing provides a continuous, sterile barrier against microbial entry while allowing ongoing visual assessment for signs of infection.

Anahtar Kavram

Central line dressing changes mandate a strict sequential transition from clean technique (removing the contaminated dressing) to sterile technique (cleansing and applying the new dressing) to prevent CLABSI, while utilizing mechanical friction and proper drying times for antiseptics.
Soru 767Soru →

A nurse is caring for a client with a T4 spinal cord injury who suddenly develops a severe, throbbing headache, profuse diaphoresis above the level of the injury, and a blood pressure of 220/115 mm Hg. Arrange the following nursing interventions in the priority order of execution.

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The correct sequence of actions for autonomic dysreflexia is: 1. Place the client in a high Fowler's position, 2. Examine the urinary catheter system for kinks or obstruction, 3. Assess the rectum for the presence of fecal impaction, and 4. Administer a prescribed rapid-acting antihypertensive medication.
The utmost priority in autonomic dysreflexia is to immediately lower blood pressure to prevent severe complications, such as a hemorrhagic stroke. Elevating the head of the bed accomplishes this rapidly through orthostatic changes. The subsequent steps focus on locating and eliminating the noxious stimulus triggering the sympathetic response, checking the most common causes first: the bladder, then the bowel. If these nursing measures fail to resolve the crisis, rapid-acting antihypertensives are administered.

Adım Adım Çözüm

1
Recognize the clinical presentation of autonomic dysreflexia.
The client is identified as experiencing a life-threatening hypertensive emergency due to an exaggerated sympathetic response.
The combination of a T4 spinal cord injury, extreme hypertension, diaphoresis, and a severe headache strongly indicates autonomic dysreflexia.
2
Determine the most immediate physical intervention to mitigate stroke risk.
Identify that elevating the head of the bed (high Fowler's) takes precedence over all other actions.
This position leverages gravity to pool blood in the lower extremities, thereby reducing venous return and acutely lowering blood pressure.
3
Identify the logical sequence for assessing and removing potential noxious stimuli.
Prioritize checking the bladder first, followed by the bowel.
Bladder issues (such as a kinked catheter) are the most frequent cause and the quickest to resolve, making it the next logical step before assessing the bowel.
4
Determine when pharmacological intervention is indicated.
Place medication administration as the final step in the sequence.
Antihypertensives are utilized if the underlying cause cannot be found or if blood pressure remains dangerously high after attempting to remove the stimulus.

Anahtar Kavram

Prioritization of interventions for autonomic dysreflexia in clients with spinal cord injuries.
Soru 768Soru →

A nurse enters a client's room and observes that the client's chest tube has accidentally been pulled completely out of the pleural space. The client is awake and alert. To reduce the risk of a life-threatening complication, arrange the following nursing actions in the correct chronological order of priority.

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The correct chronological sequence is to first instruct the client to exhale forcefully and bear down, immediately cover the site with an occlusive dressing, tape the dressing on exactly three sides, auscultate breath sounds and monitor oxygenation, and finally notify the healthcare provider.
The immediate priority when a chest tube is dislodged is to prevent atmospheric air from entering the pleural space, which causes lung collapse. Having the client bear down (Valsalva maneuver) increases intrathoracic pressure, actively pushing air out and preventing air from rushing in. The nurse must then quickly cover the site with a sterile, occlusive dressing. Taping the dressing on exactly three sides is a critical risk-reduction measure; it creates a one-way flutter valve that allows trapped air to escape during exhalation but prevents air entry during inhalation, mitigating the risk of a tension pneumothorax. Once the wound is safely sealed and the immediate physiological threat is neutralized, the nurse must assess the client's respiratory status to determine the severity of the incident. Finally, the nurse notifies the healthcare provider to prepare for chest tube reinsertion, as this is the definitive medical treatment required.

Adım Adım Çözüm

1
Instruct the client to forcefully exhale and bear down (Valsalva maneuver).
Intrathoracic pressure immediately increases.
Prevents atmospheric air from rushing into the pleural space during the brief moment the wound is exposed, reducing pneumothorax severity.
2
Cover the insertion site with a sterile, occlusive petroleum gauze dressing.
The open chest wound is physically sealed.
Re-establishes a barrier to prevent continuous air entry into the pleural space with each inspiration.
3
Secure the dressing to the chest wall with tape on exactly three sides.
A one-way flutter valve is successfully created over the wound.
Allows any trapped intrapleural air to escape during exhalation while preventing air entry during inhalation, significantly reducing the risk of a tension pneumothorax.
4
Auscultate bilateral breath sounds and monitor oxygen saturation.
The physiological impact of the dislodgement is evaluated.
Confirms the effectiveness of the immediate interventions and identifies if the client is experiencing severe respiratory compromise.
5
Notify the healthcare provider to prepare for chest tube reinsertion.
Definitive medical management is initiated.
The client requires invasive medical treatment (reinsertion of the chest tube) which is outside the independent scope of nursing practice.

Anahtar Kavram

Prioritization in airway and breathing emergencies requires neutralizing immediate physical threats before performing thorough assessments or notifying providers.
Soru 769Soru →

A nurse is preparing to administer a scheduled intermittent bolus feeding via a percutaneous endoscopic gastrostomy (PEG) tube for an older adult client recovering from a stroke. Arrange the following nursing actions in the correct sequence of performance. (Place the first action at the top and the last action at the bottom.)

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The correct sequence is: 1) Elevate the head of the bed, 2) Aspirate and measure residual volume, 3) Flush with 30 mL of water, 4) Administer the feeding formula, 5) Flush with a final 30 mL of water and clamp.
The safe administration of an enteral tube feeding follows a logical sequence to protect the airway, assess tolerance, and maintain equipment. The nurse must first elevate the head of the bed to 30 to 45 degrees to utilize gravity in preventing aspiration. Next, the nurse aspirates and measures the gastric residual volume to ensure the previous feeding has been digested, returning the aspirate to maintain electrolyte balance. The tube is then flushed with 30 mL of water to verify patency. Afterward, the formula is administered by gravity to avoid overwhelming the stomach, which can cause cramping or dumping syndrome. Finally, the tube is flushed with another 30 mL of water to clear the lumen of formula, preventing occlusions, and the tube is clamped.

Adım Adım Çözüm

1
Elevate the head of the bed.
The client is in a semi-Fowler's position.
Gravity helps prevent reflux and pulmonary aspiration during the procedure.
2
Aspirate and measure gastric residual.
Gastric emptying and feeding tolerance are assessed.
High residual volumes may indicate delayed emptying, which increases aspiration risk if more feeding is added.
3
Flush the tube with water.
Tube patency is confirmed.
Ensures the tube is clear and functioning properly before the thicker formula is administered.
4
Administer the formula by gravity.
The client receives the prescribed nutrition.
Gravity flow reduces gastrointestinal distress and cramping compared to a rapid bolus push.
5
Flush and clamp the tube.
The tube is cleared of formula and secured.
Prevents the formula from drying and clogging the tube, while clamping prevents air entry or leakage.

Anahtar Kavram

Safe administration of enteral tube feedings
Soru 770Soru →

A nurse is preparing to discontinue a non-tunneled central venous catheter (CVC) from a client's internal jugular vein. To minimize the risk of procedural complications, in what order should the nurse perform the following actions? Arrange the steps in the correct chronological sequence.

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The correct sequence is to position the client supine, instruct them to perform the Valsalva maneuver, withdraw the catheter, apply immediate firm pressure, secure an occlusive dressing, and finally inspect the catheter tip.
The correct sequence prioritizes the reduction of risk potential, specifically preventing an air embolism and hemorrhage. The client must first be positioned supine to increase central venous pressure. Instructing the client to perform the Valsalva maneuver creates positive intrathoracic pressure just before the catheter is withdrawn. Once the catheter is out, immediate pressure ensures hemostasis and prevents air entry. This is followed by securing an air-occlusive dressing for continuous protection. Finally, inspecting the catheter tip ensures no fragments were left behind in the client.

Adım Adım Çözüm

1
Position the client supine
Increases central venous pressure
Minimizes the initial risk of air entering the vein by raising internal pressure above atmospheric levels.
2
Instruct to perform Valsalva maneuver
Increases intrathoracic pressure
Creates a positive pressure gradient to actively prevent an air embolism during the actual removal of the catheter.
3
Withdraw the catheter smoothly
Catheter is removed from the vein
Must be done exactly while the client holds their breath and bears down to prevent air entry.
4
Apply immediate firm pressure
Site is manually compressed
Promotes hemostasis and immediately stops any potential air entry while the vein closes.
5
Apply an air-occlusive dressing
Insertion site is completely sealed
Provides a continuous barrier against atmospheric air entering the healing tissue tract.
6
Inspect the catheter tip
Catheter integrity is verified
Ensures no fragments remain in the vascular system, preventing a life-threatening catheter embolus.

Anahtar Kavram

Prevention of air embolism and catheter embolus during central line discontinuation.
Tahmini Süre:1m 30s
Soru 771Soru →

A client who underwent a subtotal thyroidectomy 12 hours ago experiences a sudden onset of severe agitation. The nurse assesses a heart rate of 172 bpm172\text{ bpm}, a respiratory rate of 32 breaths/min32\text{ breaths/min}, and a temperature of 105.1∘F105.1^\circ\text{F} (40.6∘C40.6^\circ\text{C}). The healthcare provider diagnoses a thyrotoxic crisis (thyroid storm). Arrange the following prescribed nursing interventions in the priority order they should be implemented.

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The priority sequence is: 1) Establish a patent airway and administer high-flow oxygen, 2) Administer intravenous propranolol, 3) Administer propylthiouracil (PTU), 4) Administer an iodine preparation, and 5) Apply a hypothermia blanket and administer acetaminophen.
The management of a thyrotoxic crisis follows a specific physiological progression based on the ABCs and the mechanism of thyroid hormone production. Oxygenation is prioritized first due to massive systemic metabolic demand. Next, extreme sympathetic overactivity must be halted with a beta-blocker to prevent immediate heart failure. Pharmacological management of the thyroid itself follows a strict sequence: an antithyroid agent (PTU) must be given first to block new hormone synthesis, followed by iodine to prevent the release of stored hormones. If iodine is given before PTU, it acts as a substrate for new hormone production. Finally, hyperthermia is managed with cooling measures and acetaminophen (salicylates are avoided as they displace thyroid hormone from binding proteins, increasing free hormone levels).

Adım Adım Çözüm

1
Prioritize airway patency and administer oxygen.
Meets the massive cellular oxygen demand caused by hypermetabolism.
Airway and breathing (ABCs) must be secured first to prevent hypoxic tissue injury.
2
Administer a beta-blocker (propranolol).
Decreases heart rate and sympathetic overstimulation.
Extreme tachycardia (172 bpm172\text{ bpm}) can rapidly lead to heart failure and cardiovascular collapse if not immediately antagonized.
3
Administer an antithyroid medication (PTU).
Halts the synthesis of new thyroid hormones.
The source of the physiological crisis must be addressed by stopping the production of the hormone.
4
Administer an iodine solution (Lugol's solution).
Prevents the release of stored thyroid hormones into the bloodstream.
This must strictly follow PTU administration so the iodine is not utilized to manufacture more hormone.
5
Implement cooling measures and administer acetaminophen.
Reduces the core body temperature of 105.1∘F105.1^\circ\text{F}.
Symptomatic management of hyperthermia is necessary but secondary to stabilizing the cardiopulmonary system and the endocrine cascade.

Anahtar Kavram

Priority physiological interventions for thyrotoxic crisis (thyroid storm)
Soru 772Soru →

A nurse enters the room of a client with a history of asthma. The client is using accessory muscles to breathe, has audible wheezing, and an oxygen saturation of 88% on room air. In which order should the nurse perform the following actions? Arrange the actions in order of priority from first to last.

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Cevap

The priority sequence is to first maximize lung expansion via positioning, then treat the hypoxemia with oxygen, followed by administering a bronchodilator to relieve the spasm, and finally reassessing the client's response.
The correct sequence prioritizes airway and breathing according to emergency care principles. Elevating the head of the bed is the fastest physical action to improve lung expansion. This is immediately followed by supplemental oxygen to correct the severe hypoxemia. Once the patient is oxygenated, the nurse administers the bronchodilator to treat the underlying bronchospasm. Finally, the nurse reassesses the client to evaluate the effectiveness of these interventions.

Adım Adım Çözüm

1
Place the client in a high-Fowler's position.
Immediate improvement in diaphragmatic excursion.
This is the fastest, least invasive independent action to reduce the work of breathing.
2
Apply supplemental oxygen as prescribed.
Correction of the severe hypoxemia.
Oxygen addresses the immediate life-threatening issue of impaired gas exchange.
3
Administer the prescribed short-acting inhaled bronchodilator.
Relaxation of bronchial smooth muscle.
This treats the underlying pathophysiology of the acute asthma exacerbation.
4
Reassess the client's respiratory rate and oxygen saturation.
Determination of treatment efficacy.
Evaluation is necessary to see if the interventions worked or if further escalation is needed.

Anahtar Kavram

Prioritization of Care in Acute Respiratory Distress
Soru 773Soru →

A nurse is assessing a client on postoperative day 3 following an abdominal laparotomy. The client experiences a sudden, forceful episode of coughing, and the nurse observes loops of intestine protruding through the surgical incision. Arrange the following nursing actions in the correct sequence of priority.

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The correct priority sequence is: 1) Call for immediate assistance while remaining at the bedside, 2) Position the client in low Fowler's with knees flexed, 3) Cover the wound with sterile saline-soaked dressings, 4) Assess vital signs, and 5) Prepare the client for surgery.
Wound evisceration is a surgical emergency requiring immediate and prioritized action. The nurse must first ensure safety by calling for help while staying with the client. Second, positioning the client in low Fowler's with flexed knees reduces abdominal tension. Third, the exposed bowel must be immediately protected from drying and necrosis with sterile, saline-soaked dressings. Fourth, vital signs are assessed to monitor for the onset of hypovolemic shock. Finally, the nurse prepares the client for definitive surgical repair.

Adım Adım Çözüm

1
Recognize the medical emergency (wound evisceration) and secure help.
Additional staff are mobilized without leaving the client unattended.
Evisceration is a life-threatening emergency requiring rapid intervention and surgical repair. The primary nurse must stay to protect the organs while others contact the surgeon.
2
Minimize further damage by positioning the client.
The client is placed in low Fowler's position with knees bent.
This position relaxes the abdominal muscles, reducing intra-abdominal pressure and preventing more bowel from protruding.
3
Protect the exposed tissues.
The bowel is covered with sterile, saline-moistened dressings.
Exposed viscera will quickly dry and become necrotic. A sterile, moist environment is critical for tissue preservation until surgery.
4
Evaluate hemodynamic stability.
Vital signs are obtained to check for tachycardia, hypotension, and tachypnea.
Evisceration can cause severe fluid shifts and hypovolemic shock. Baseline vitals are needed to guide fluid resuscitation.
5
Facilitate definitive treatment.
The client is prepped for the operating room.
The only definitive treatment for an evisceration is surgical repair.

Anahtar Kavram

Management of Postoperative Wound Evisceration
Soru 774Soru →

A nurse is preparing to transfer a client who has left-sided hemiparesis from the hospital bed to a wheelchair. In what order should the nurse perform the following actions to ensure a safe transfer? Arrange the steps in the correct chronological sequence.

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The correct sequence begins with positioning the wheelchair on the client's strong side, followed by locking the brakes on both the bed and wheelchair. Next, the nurse assists the client to sit on the edge of the bed and applies a transfer belt. The nurse then braces the client's weak knee and foot, and finally instructs the client to push up with their strong arm to stand and pivot into the chair.
Safe mobility practices dictate a specific sequence to protect both the client and the nurse. The environment must be prepared first by placing the wheelchair on the client's unaffected side, which capitalizes on their functional strength. Locking the brakes immediately after positioning ensures the equipment will not slide. The client is then brought to a dangling position to establish balance, and a transfer belt is applied for a secure grip. Before the client attempts to bear weight, the nurse must brace the hemiparetic (weak) leg to prevent it from collapsing. Finally, the client is instructed to use their strong arm to push off the bed, utilizing their intact motor function to complete the pivot.

Adım Adım Çözüm

1
Position the wheelchair on the right side.
The transfer destination is established on the client's functional side.
Transferring toward the strong side enables the client to bear weight safely and use their unaffected limbs for stability.
2
Lock all wheels.
The bed and wheelchair are immobilized.
Securing the equipment prevents unintended movement that could cause a fall during the transfer.
3
Assist to a sitting position and apply a transfer belt.
The client is upright, and the nurse has a secure grip point.
Dangling allows the client to equilibrate (preventing orthostatic hypotension), and the belt provides a safe handling method.
4
Brace the left knee and foot.
The client's weak leg is physically supported.
Hemiparesis increases the risk of the affected leg buckling; bracing it provides the necessary stability for standing.
5
Instruct the client to push up, stand, and pivot.
The client safely moves from the bed to the wheelchair.
Utilizing the client's upper body strength on the unaffected side promotes independence and minimizes the physical strain on the nurse.

Anahtar Kavram

Safe Client Transfer Principles for Hemiparesis
Soru 775Soru →

A nurse is caring for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache and blurred vision. The nurse observes profuse diaphoresis above the level of the injury, a blood pressure of 210/115 mmHg, and a heart rate of 48 beats/min. Arrange the following nursing actions in the correct priority sequence. (Place the most immediate priority action at the top.)

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The correct sequence of actions for a client experiencing autonomic dysreflexia is: elevate the head of the bed, loosen restrictive clothing, assess for the trigger (bladder/bowel), administer antihypertensive medications if needed, and notify the healthcare provider.
Autonomic dysreflexia is a medical emergency characterized by severe hypertension and bradycardia due to an exaggerated sympathetic response, usually triggered by a lower body stimulus in clients with spinal cord injuries at or above T6. The absolute first priority is to place the client in a sitting or high Fowler's position to utilize orthostatic hypotension to lower the blood pressure. Next, immediate external triggers (like tight clothing) are removed. The nurse then assesses for the most common internal triggers, such as bladder distention or a kinked catheter. If these conservative measures do not resolve the hypertensive crisis, antihypertensive medications are administered. Finally, the provider is notified.

Adım Adım Çözüm

1
Identify the clinical presentation as autonomic dysreflexia.
The combination of severe hypertension, bradycardia, headache, and diaphoresis in a client with a T4 spinal cord injury indicates a life-threatening sympathetic response.
Accurate and immediate recognition dictates the emergency management protocol.
2
Determine the most immediate action to mitigate the severe hypertension.
Elevating the head of the bed to a high Fowler's position uses gravity to induce orthostatic pooling, immediately lowering the blood pressure.
Preventing a cerebrovascular accident is the highest priority and positioning is the fastest intervention.
3
Sequence the subsequent interventions to remove the trigger and provide further treatment.
After positioning, the nurse must loosen restrictive clothing, then assess for the most common internal trigger (bladder issues). If unresolved, medications are given, followed by provider notification.
Trigger removal is the definitive treatment; medications are secondary if trigger removal fails or takes time.

Anahtar Kavram

Management of autonomic dysreflexia requires immediate intervention to lower blood pressure, primarily through positioning, followed by rapid identification and removal of the triggering stimulus.
Soru 776Soru →

An adult client is prescribed a 250 mL intermittent enteral feeding formula via an established nasogastric tube. To minimize the risk of procedural complications, arrange the following nursing actions in the correct chronological sequence.

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The correct sequence is: position the head of the bed, verify tube placement, check gastric residual volume, flush the tube, and finally initiate the feeding.
Safe administration of enteral feedings requires a prioritized approach to minimize the risk of aspiration and misplacement complications. Elevating the head of the bed (at least 30 degrees) is the initial priority to physically protect the airway via gravity. Next, the nurse must verify the tube is in the stomach to ensure fluids will not be instilled into the lungs. Third, measuring the gastric residual volume evaluates the client's tolerance and prevents gastric overdistension. Fourth, flushing the tube maintains patency and clears the line. Finally, once all safety criteria are met, the feeding can be safely administered.

Adım Adım Çözüm

1
Evaluate aspiration risk and adjust client positioning.
The head of the bed is elevated to at least 30 degrees.
This purely physical maneuver protects the airway utilizing gravity, making it the first required action before introducing any fluids or manipulating the tube.
2
Confirm anatomical location of the tube.
Gastric contents are aspirated and assessed.
Before using the tube, it is imperative to rule out pulmonary migration to prevent potentially fatal administration of fluids into the lungs.
3
Assess gastrointestinal function and tolerance.
Gastric residual volume is measured.
A high residual volume indicates delayed gastric emptying, which significantly increases aspiration risk if more volume is added.
4
Ensure tube patency.
The tube is flushed with water.
Flushing clears the line, preventing clogging and ensuring the formula has a clear pathway to the stomach.
5
Deliver nutrition.
The enteral formula is administered.
The intervention is safely completed once all risk-reduction parameters are met.

Anahtar Kavram

Reduction of risk potential during enteral feeding relies on a strict sequence of airway protection, placement verification, tolerance assessment, and maintaining tube patency.
Soru 777Soru →

A registered nurse is preparing to collect a routine laboratory blood specimen from a client's multi-lumen central venous catheter (CVC). Arrange the steps for this procedure in the correct chronological order from first to last.

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The correct sequence is: pause active infusions, flush the line to verify patency, discard a waste sample of blood, collect the required specimen, and perform a final thorough flush.
Obtaining blood from a central venous catheter requires a strict sequence to ensure accurate laboratory results and maintain line patency. Infusions must be stopped first to prevent sample contamination. The line is then flushed to confirm patency. A waste sample must be discarded to clear the line's dead space of flush solution. After the true sample is collected, a vigorous final flush is mandatory to clear all blood from the lumen and prevent catheter clotting.

Adım Adım Çözüm

1
Pause continuous IV infusions.
Prevents medication or fluids from mixing with the blood sample.
Drawing blood while fluids are actively infusing will yield falsely elevated or altered laboratory results corresponding to the infused substances.
2
Clean the hub and flush with normal saline.
Ensures catheter patency.
Confirming the line is open and functioning prevents complications during the blood draw process and maintains sterility.
3
Draw and discard a waste blood sample.
Removes the saline flush and any residual medication from the catheter.
The 'dead space' in the catheter contains fluid that would dilute or alter the laboratory specimen if not discarded first.
4
Collect the blood specimen.
Obtains pure, undiluted blood for testing.
This sample accurately reflects the client's true systemic blood values.
5
Perform a final flush with 10 to 20 mL of normal saline.
Clears all blood from the catheter lumen.
Blood left sitting in the catheter can quickly clot, leading to partial or complete occlusion of the central line.

Anahtar Kavram

Central Venous Catheter Blood Specimen Collection
Soru 778Soru →

A nurse is preparing to administer an intermittent bolus enteral feeding to a client via a nasogastric (NG) tube. The client is currently resting in a supine position. Arrange the following nursing actions in the correct sequence from first to last.

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Cevap

The correct sequence is: Elevate the head of the bed, verify tube placement, check the gastric residual volume, flush the tube with water, and finally administer the feeding formula.
The safe administration of an enteral feeding requires a logical progression that prioritizes airway protection. Elevating the head of the bed is the critical first step to prevent aspiration. Once positioned safely, the nurse must verify the tube is in the stomach, not the airway. After placement is confirmed, checking the gastric residual volume ensures the client is digesting previous feedings and can tolerate more volume. The tube is then flushed to confirm patency and clear any acidic stomach contents from the line before the actual feeding formula is finally administered.

Adım Adım Çözüm

1
Elevate the head of the client's bed to at least 30 to 45 degrees.
The client is placed in a safe semi-Fowler's position.
Before manipulating the tube or instilling anything, the client must be properly positioned to prevent aspiration of stomach contents into the lungs.
2
Verify the correct placement of the nasogastric tube.
The tube is confirmed to be in the stomach.
The nurse must ensure the tube has not migrated to the lungs or esophagus before proceeding with aspiration or feeding.
3
Aspirate the stomach contents to measure the gastric residual volume.
The amount of undigested formula from previous feedings is quantified.
Checking the residual volume determines if the client's gastrointestinal tract is tolerating the feedings and helps prevent overdistension.
4
Flush the nasogastric tube with 30 mL of water.
The tube is cleared and confirmed to be patent.
Flushing clears the tubing, verifies there are no clogs, and prepares the line for the formula.
5
Administer the prescribed volume of the enteral feeding formula.
The client receives the required nutrition.
The formula is administered only after safety, placement, tolerance, and patency have been established.

Anahtar Kavram

Safe administration of enteral tube feedings
Soru 779Soru →

A nurse is preparing to remove a non-tunneled central venous catheter (CVC) from a client's right subclavian vein. Arrange the following nursing actions in the correct sequential order to safely remove the catheter and reduce the risk of an air embolism. (Place the first action at the top and the final action at the bottom.)

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The correct sequence for removing a central venous catheter to minimize risk is: position the client supine, instruct the client to perform the Valsalva maneuver, withdraw the catheter during the maneuver, apply immediate firm pressure, and finally secure the site with an occlusive dressing while verifying catheter intactness.
Removing a central venous catheter carries a high risk of air embolism and bleeding. The safest physiological approach is to maximize central venous pressure before and during the procedure. This is achieved by placing the client flat (supine) and having them perform the Valsalva maneuver. The catheter is removed while the client bears down to prevent air from entering the tract. Immediately after removal, firm pressure is applied to achieve hemostasis, followed by the application of an airtight occlusive dressing to protect the site while the tract heals. Finally, inspecting the catheter tip ensures no fragments have broken off into the client's circulation.

Adım Adım Çözüm

1
Position the client flat (supine).
Increases intrathoracic and central venous pressure.
Prevents a negative pressure gradient that could draw air into the open vein.
2
Instruct the Valsalva maneuver (deep breath, hold, and bear down).
Further maximizes positive intrathoracic pressure.
Ensures the pressure inside the vein is higher than atmospheric pressure.
3
Withdraw the catheter.
The foreign body is removed from the subclavian vein.
Must be timed precisely with the Valsalva maneuver for maximum safety.
4
Apply immediate direct pressure with sterile gauze.
The insertion tract is manually sealed.
Promotes hemostasis and blocks any air entry immediately following catheter exit.
5
Apply an occlusive dressing and inspect the tip.
The site is permanently sealed and the device is verified intact.
Provides an airtight barrier for the healing tract and rules out catheter embolus.

Anahtar Kavram

Prevention of Air Embolism during Central Venous Catheter Removal
Soru 780Soru →

A nurse is preparing to administer an intravenous (IV) push dose of furosemide to a client who is receiving a continuous IV infusion of amiodarone. The client has only one patent peripheral IV line. Amiodarone and furosemide are physically incompatible. Arrange the following steps for safely administering the IV push medication in the correct sequential order.

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The correct sequence is to stop the infusion pump, clamp the primary tubing, flush with normal saline, administer the furosemide, flush again with normal saline at the same slow rate as the medication, and finally unclamp and restart the pump.
When administering an IV push medication through a single patent line with an incompatible continuous infusion, the nurse must meticulously prevent the two medications from mixing to avoid precipitation. The process involves stopping the current infusion and clamping the tubing to isolate the lower port. A normal saline flush creates a liquid buffer, clearing the primary medication from the distal tubing. The secondary medication is then pushed at the correct rate. The second saline flush must be administered at the exact same rate as the medication to ensure the drug remaining in the dead space of the IV catheter is not accidentally bolused. Once the line is clear, the tubing is unclamped and the primary infusion is restarted.

Adım Adım Çözüm

1
Stop the amiodarone infusion pump.
The flow of the incompatible medication is halted.
This is the first essential step to prevent the two incompatible medications from coming into contact with each other.
2
Clamp the primary IV tubing above the lowest injection port.
The pathway back up the primary IV tubing is blocked.
Clamping ensures that subsequent flushes and the IV push medication travel directly into the patient's vein rather than backing up into the primary line.
3
Scrub the injection port and flush the line with 10 mL of 0.9% sodium chloride.
The lower segment of the IV tubing and the catheter hub are cleared of amiodarone.
Normal saline acts as a safe, compatible buffer between the two incompatible medications.
4
Administer the IV push furosemide over 1 to 2 minutes.
The diuretic is safely delivered into the cleared IV line.
Administering the medication over the recommended duration prevents adverse effects such as ototoxicity.
5
Flush the line with 10 mL of 0.9% sodium chloride at the same rate as the medication administration.
The medication remaining in the catheter hub is fully delivered to the patient.
Flushing at the same slow rate prevents a sudden bolus (speed shock) of the residual furosemide.
6
Unclamp the primary tubing and restart the continuous amiodarone infusion.
The continuous antiarrhythmic infusion is resumed.
With the line completely cleared of the incompatible furosemide, it is safe to restart the amiodarone.

Anahtar Kavram

Safe administration of an IV push medication into a continuous infusion of a physically incompatible medication requires stopping the infusion, clamping the line, and utilizing normal saline flushes to create a buffer, taking care to administer the post-medication flush at the same rate as the IV push drug.
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