Tüm alıştırma soruları

3881 soru

Soru 821Soru →

During the management of a client with diabetic ketoacidosis, a continuous intravenous infusion of regular insulin is running via a dedicated peripheral catheter. A new prescription for an intermittent intravenous antibiotic must be initiated promptly. The drug reference manual indicates that this specific antibiotic is physically incompatible with regular insulin. Which intervention ensures safe parenteral administration?

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Cevap: Initiate a second peripheral venous access site to administer the antibiotic.

Cevap

The correct action is to initiate a second peripheral venous access site to administer the antibiotic independently.
When two intravenous medications are physically incompatible, they absolutely cannot be mixed in the same line due to the risk of precipitate formation, which can cause catheter occlusion or life-threatening emboli. Because the client is receiving a continuous regular insulin infusion for diabetic ketoacidosis, pausing the infusion is clinically contraindicated as it would rapidly worsen the client's ketoacidosis. Therefore, the only safe and effective pharmacological action is to establish a second peripheral intravenous line.

Adım Adım Çözüm

1
Analyze the clinical scenario and the pharmacological properties of the prescribed medications.
The client requires continuous insulin for diabetic ketoacidosis and a prompt antibiotic for infection, but the two medications are physically incompatible in the same line.
Identifying physical incompatibility is the first critical step in preventing medication errors and potentially fatal adverse reactions.
2
Determine the clinical feasibility of interrupting the primary continuous infusion.
Regular insulin given for diabetic ketoacidosis has a very short half-life; pausing it can cause severe rebound hyperglycemia and worsening metabolic acidosis.
Continuous high-alert medications for life-threatening, unstable conditions should not be interrupted to accommodate intermittent therapies.
3
Select the safest administration route that adheres to parenteral therapy guidelines.
A new, independent peripheral intravenous site must be established.
Separate venous access ensures both medications are delivered safely and on schedule without the risk of line precipitation or interruption of critical endocrine therapy.

Anahtar Kavram

Safe Administration of Incompatible Intravenous Medications
Soru 822Soru →

A client is receiving treatment in the emergency department for a severe asthma exacerbation. The client's initial presentation included marked restlessness, a respiratory rate of 34 breaths/min, and an arterial blood gas (ABG) revealing a pH of 7.49 and a PaCO₂ of 27 mm Hg. After two hours of therapy, the nurse observes that the client has become profoundly lethargic and the respiratory rate has decreased to 14 breaths/min. A follow-up ABG shows a pH of 7.28 and a PaCO₂ of 62 mm Hg. Which of the following is the priority nursing action?

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Cevap: Prepare the team and equipment for immediate endotracheal intubation and mechanical ventilation.

Cevap

The priority action is to prepare the team and equipment for immediate endotracheal intubation and mechanical ventilation.
During a severe asthma exacerbation, clients initially hyperventilate, leading to respiratory alkalosis. If the asthma is not resolved, respiratory muscles become exhausted. This fatigue causes the respiratory rate to drop, leading to CO₂ retention (respiratory acidosis) and subsequent altered mental status (lethargy). This physiological collapse indicates impending respiratory failure, making preparation for endotracheal intubation the immediate life-saving priority.

Adım Adım Çözüm

1
Analyze the initial clinical presentation.
The client was initially hyperventilating (RR 34) with respiratory alkalosis (pH 7.49, low PaCO₂).
This is a typical early physiological adaptation to hypoxemia during an asthma attack.
2
Evaluate the clinical changes and the follow-up ABG.
The client is now lethargic with a 'normal' RR (14), but the ABG shows uncompensated respiratory acidosis (pH 7.28, high PaCO₂).
A falling respiratory rate and rising PaCO₂ in a severe asthma exacerbation signal respiratory muscle fatigue and loss of compensatory mechanisms.
3
Determine the priority nursing intervention based on ABCs (Airway, Breathing, Circulation).
The client is experiencing impending respiratory failure.
Immediate mechanical ventilation is required to restore gas exchange and prevent cardiac arrest.

Anahtar Kavram

In severe asthma, a transition from respiratory alkalosis to respiratory acidosis accompanied by lethargy and a normalizing respiratory rate indicates impending respiratory failure requiring immediate intubation.
Soru 823Soru →

A nurse is preparing to draw a diagnostic blood specimen from a client's central venous catheter (CVC) using the syringe method. Arrange the following actions in the correct procedural sequence. All options must be used.

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Cevap

The correct sequence is to disinfect the hub, flush the line to check patency, withdraw a waste sample, draw the actual specimen, and finally flush the line to clear residual blood.
When drawing blood from a central venous catheter, maintaining sterility and ensuring an uncontaminated sample are paramount. Scrubbing the hub is the first step to prevent central line-associated bloodstream infections. Flushing the line confirms patency. The critical step of withdrawing a waste sample ensures that the subsequent diagnostic sample is not diluted by the normal saline flush or residual medications. After obtaining the specimen, a larger volume flush is required to completely clear the lumen of blood, preventing fibrin buildup and occlusion.

Adım Adım Çözüm

1
Scrub the needleless connector of the catheter with an appropriate antiseptic swab.
The entry point is disinfected.
This prevents the introduction of microorganisms into the client's bloodstream and reduces the risk of central line-associated bloodstream infections (CLABSI).
2
Flush the catheter lumen with 10 mL of preservative-free 0.9% sodium chloride.
Catheter patency is confirmed.
Flushing ensures the line is open and clears previously infused fluids that could mix with the blood.
3
Withdraw and discard a 5 mL waste sample of blood from the catheter lumen.
The flush solution is removed from the line.
Discarding the initial blood prevents dilution and contamination of the diagnostic specimen by the saline.
4
Attach a new sterile syringe and withdraw the required volume of blood for the specimen.
The diagnostic sample is obtained.
This sample will accurately reflect the client's physiological laboratory values without interference from flush solutions.
5
Flush the catheter vigorously with 10 to 20 mL of 0.9% sodium chloride using a pulsatile method.
Residual blood is cleared from the line.
A final flush prevents blood from pooling and clotting in the catheter, maintaining its long-term patency.

Anahtar Kavram

Central Venous Catheter Blood Specimen Collection Procedure
Soru 824Soru →

A client is receiving continuous bladder irrigation (CBI) following a transurethral resection of the prostate (TURP). The client suddenly reports severe lower abdominal cramping, and the nurse observes that the outflow drainage has significantly decreased. Arrange the following nursing actions in the correct priority sequence to manage this complication.

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Cevap

The correct sequence is to first assess the tubing for kinks, then stop the irrigation fluid, manually irrigate the catheter to clear clots, administer antispasmodic medication, and finally reassess the client's response.
When managing a client with decreased CBI outflow and severe cramping, the nurse must follow a sequence prioritizing bladder safety. First, a non-invasive assessment of the tubing checks for easily fixable kinks. If the tubing is patent, the inflow must be stopped immediately to prevent further distension. Next, manual irrigation clears the likely cause, which is typically blood clots. Once the obstruction is cleared, pharmacological management of spasms is appropriate, followed by final evaluation of the interventions.

Adım Adım Çözüm

1
Assess the catheter tubing for kinks or compression.
Rules out simple mechanical causes for the outflow obstruction.
Non-invasive assessment is the safest and most immediate first step when equipment appears to malfunction.
2
Stop the continuous bladder irrigation.
Prevents additional fluid from entering the bladder.
Decreased outflow with continued inflow rapidly leads to bladder overdistension and potential rupture.
3
Manually irrigate with sterile normal saline.
Dislodges any blood clots blocking the catheter.
Clots are the most common cause of internal obstruction following a TURP; manual irrigation directly clears the pathway.
4
Administer an antispasmodic medication.
Relieves bladder spasms.
Treats the underlying irritation and cramping once the physical blockage has been resolved.
5
Reassess pain and drainage characteristics.
Confirms the complication has been resolved.
Evaluation is the final step of the nursing process to ensure client safety and treatment efficacy.

Anahtar Kavram

Continuous Bladder Irrigation (CBI) Complication Management
Soru 825Soru →

A client admitted with acute decompensated heart failure requires hemodynamic support. The prescribed treatment plan includes dobutamine to be administered at 7.5 mcg/kg/min7.5 \text{ mcg/kg/min}. The client's current weight is 198 lbs198 \text{ lbs}. The medication is supplied as 500 mg500 \text{ mg} of dobutamine mixed in 250 mL250 \text{ mL} of 5% dextrose in water5\% \text{ dextrose in water} (D5WD_5W). What is the required infusion pump rate in mL/hr\text{mL/hr}? (Round the final answer to the nearest tenth.)

Cevabı ve açıklamayı göster

Cevap: 20.3

Cevap

20.3
To find the correct pump rate in mL/hr\text{mL/hr}, the nurse must determine the total micrograms needed per hour (7.5 mcg×90 kg×60 minutes=40,500 mcg/hr7.5 \text{ mcg} \times 90 \text{ kg} \times 60 \text{ minutes} = 40,500 \text{ mcg/hr}) and divide it by the concentration of the available IV fluid (500,000 mcg÷250 mL=2,000 mcg/mL500,000 \text{ mcg} \div 250 \text{ mL} = 2,000 \text{ mcg/mL}). This calculation yields 20.25 mL/hr20.25 \text{ mL/hr}. Rounding to the nearest tenth provides the final correct rate of 20.3 mL/hr20.3 \text{ mL/hr}.

Adım Adım Çözüm

1
Convert the client's weight from pounds (lbs) to kilograms (kg).
90 kg90 \text{ kg}
Medication dosing is prescribed based on weight in kilograms, so 198÷2.2=90198 \div 2.2 = 90.
2
Calculate the required dose per minute.
675 mcg/min675 \text{ mcg/min}
Multiply the prescribed dose (7.5 mcg/kg/min7.5 \text{ mcg/kg/min}) by the client's weight (90 kg90 \text{ kg}).
3
Convert the per-minute dose to an hourly dose.
40,500 mcg/hr40,500 \text{ mcg/hr}
Infusion pumps are programmed in mL/hr\text{mL/hr}, so the total hourly medication requirement must be determined by multiplying the minute dose by 60 minutes60 \text{ minutes}.
4
Convert the total available medication from milligrams (mg) to micrograms (mcg).
500,000 mcg500,000 \text{ mcg}
Units must match the prescribed dose unit (micrograms) for accurate calculation.
5
Calculate the concentration of the IV solution.
2,000 mcg/mL2,000 \text{ mcg/mL}
Divide the total micrograms (500,000 mcg500,000 \text{ mcg}) by the total volume (250 mL250 \text{ mL}).
6
Determine the required infusion rate.
20.25 mL/hr20.25 \text{ mL/hr}
Divide the hourly dose (40,500 mcg/hr40,500 \text{ mcg/hr}) by the concentration (2,000 mcg/mL2,000 \text{ mcg/mL}).
7
Round the final answer to the nearest tenth.
20.320.3
Adhere to the specific rounding instructions provided in the question.

Anahtar Kavram

Weight-based continuous IV infusion calculation
Soru 826Soru →

A nurse evaluates a client four hours after a subtotal thyroidectomy. Which assessment findings indicate a developing physiological complication that requires immediate intervention? Select all that apply.

Geçerli olan tümünü seçin

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Cevap: A harsh, high-pitched respiratory sound heard during inspiration; Spasmodic contractions of the hand and fingers when a blood pressure cuff is inflated; The client reports a sensation of tightness and increasing pressure at the surgical site

Cevap

The assessment findings requiring immediate intervention are a harsh, high-pitched respiratory sound, spasmodic contractions of the hand with blood pressure cuff inflation, and a reported sensation of increasing tightness at the surgical site.
Following a subtotal thyroidectomy, the most critical risks include airway obstruction (indicated by stridor or a high-pitched respiratory sound), hemorrhage or hematoma formation (indicated by reports of increasing neck pressure or tightness), and inadvertent removal or damage to the parathyroid glands causing acute hypocalcemia (indicated by Trousseau's sign, which is hand spasms when a blood pressure cuff is inflated). All three of these findings represent acute, life-threatening complications that require immediate emergency intervention.

Adım Adım Çözüm

1
Analyze the surgical procedure and its specific anatomical risks.
A subtotal thyroidectomy involves surgery on the neck, placing the airway, laryngeal nerves, and parathyroid glands at high risk for injury.
Identifying procedure-specific risks is essential for distinguishing expected postoperative recovery from life-threatening complications.
2
Evaluate each assessment finding against known postoperative complications.
Stridor indicates airway obstruction, Trousseau's sign indicates acute hypocalcemia, and neck pressure indicates a potential hematoma.
Early recognition of these specific cues allows for immediate, life-saving interventions.
3
Differentiate critical complications from normal postoperative baseline data.
Normal arterial blood gases, stable vital signs, and minimal serosanguineous drainage are expected findings that do not require emergency intervention.
Prioritization requires eliminating expected or stable data to focus on immediate threats to physiological integrity.

Anahtar Kavram

Postoperative complications of thyroid surgery (airway obstruction, hematoma, and hypocalcemia) require immediate recognition and intervention.
Soru 827Soru →

A client admitted with an active upper gastrointestinal bleed is receiving a continuous intravenous (IV) infusion of pantoprazole. The healthcare provider prescribes a scheduled dose of IV ciprofloxacin for a concurrent urinary tract infection. The client has a single peripheral IV catheter. The nurse consults the facility's drug compatibility reference and notes that pantoprazole and ciprofloxacin are physically incompatible. Which action by the nurse is the most appropriate?

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Cevap: Insert a second peripheral intravenous catheter to administer the ciprofloxacin.

Cevap

The most appropriate action is to insert a second peripheral intravenous catheter to administer the ciprofloxacin.
When a client is receiving a continuous critical infusion (such as pantoprazole for an active GI bleed) and requires a secondary medication that is physically incompatible, the nurse must insert a second IV catheter. Pantoprazole continuous infusions are used to maintain a gastric pH above 6.0, which stabilizes platelet aggregates and prevents rebleeding. Pausing this infusion for an hour to administer ciprofloxacin would place the client at high risk for hemorrhage. Mixing the incompatible medications will cause precipitation. Therefore, a new IV line is the only safe solution.

Adım Adım Çözüm

1
Identify the primary clinical problem and the prescribed treatments.
The client has an active GI bleed receiving continuous pantoprazole and needs IV ciprofloxacin for an infection.
Understanding the criticality of the continuous infusion guides intervention priorities.
2
Analyze the compatibility of the prescribed medications.
Pantoprazole and ciprofloxacin are physically incompatible.
Incompatible medications cannot be mixed in the same IV tubing as they can form precipitates, which may cause an embolism or occlude the catheter.
3
Evaluate alternative administration methods.
Pausing the pantoprazole is unsafe because maintaining a high gastric pH is critical to stabilize clots in an active GI bleed. Y-site administration is contraindicated due to incompatibility.
The safety and efficacy of the critical continuous infusion must be maintained.
4
Determine the safest nursing action.
Establishing a second IV access allows both medications to infuse safely and concurrently.
Provides a dedicated line for the incompatible antibiotic while preserving the critical continuous infusion.

Anahtar Kavram

Management of incompatible intravenous medications when continuous critical infusions are prescribed.
Soru 828Soru →

A nurse is preparing to administer a prescribed intravenous (IV) push medication through a client's dedicated peripheral IV line, which currently has a continuous infusion of 5% dextrose in water (D5W) running. Which of the following actions must the nurse take to ensure safe medication administration? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Verify the compatibility of the IV push medication with the continuous D5W infusion prior to administration.; Scrub the needleless connector port closest to the client with an appropriate antiseptic before attaching the medication syringe.; Time the administration of the medication strictly according to the manufacturer's recommended rate using a timekeeping device.

Cevap

The nurse must verify the compatibility of the medication with the D5W infusion, scrub the injection port closest to the client with an antiseptic before use, and strictly time the administration rate.
Safe administration of an IV push medication requires verifying compatibility with the primary continuous fluid to avoid precipitation. It also requires rigorous infection control by scrubbing the hub, and strict adherence to administration rates to avoid speed shock or toxicity.

Adım Adım Çözüm

1
Assess the IV setup and the prescribed medication.
The nurse identifies the primary continuous infusion is D5W and an IV push medication is due.
Understanding the current setup is necessary to plan for safe parenteral administration.
2
Verify compatibility and calculate the exact dosage.
The nurse confirms the medication is compatible with D5W and calculates the precise volume without rounding to the nearest whole number.
Incompatibility can cause harmful precipitates, and inappropriate rounding of IV medications can lead to dangerous dosage errors.
3
Assess the site, prepare the port, and administer the medication.
The nurse independently assesses the IV site for infiltration, scrubs the hub, and pushes the medication over the recommended time.
Site assessment cannot be delegated to a UAP, scrubbing prevents bloodstream infections, and correct timing prevents speed shock.

Anahtar Kavram

Safe Intravenous (IV) Medication Administration Principles
Soru 829Soru →

During a routine assessment on a medical-surgical unit, a nurse evaluates a client who is 15 minutes into a transfusion of packed red blood cells (PRBCs). The client suddenly reports severe flank pain, chills, and an impending sense of doom. Vital signs reveal a temperature of 38.8°C (101.8°F) and a blood pressure of 88/50 mm Hg. The nurse immediately stops the transfusion. Which of the following actions should the nurse take next?

Cevabı ve açıklamayı göster

Cevap: Disconnect the blood tubing directly at the intravenous catheter hub and attach new tubing primed with 0.9% sodium chloride.

Cevap

The correct action is to disconnect the blood tubing directly at the intravenous catheter hub and attach a completely new IV tubing set primed with 0.9% sodium chloride.
When an acute hemolytic transfusion reaction occurs, the immediate priority after stopping the transfusion is to maintain intravenous access and provide hemodynamic support without infusing any more of the reactive blood product. Disconnecting the blood tubing directly at the hub and attaching completely new tubing primed with normal saline ensures that the residual blood in the old tubing is removed and not inadvertently pushed into the client's circulatory system.

Adım Adım Çözüm

1
Recognize the clinical manifestations of an acute hemolytic transfusion reaction.
The client's flank pain, chills, hypotension, and feeling of impending doom indicate a severe incompatibility reaction.
Early recognition dictates the immediate cessation of the transfusion, which the nurse has already completed.
2
Determine the safest method to maintain intravenous access for emergency interventions.
The existing blood tubing must be disconnected directly at the intravenous catheter hub.
Leaving the old tubing connected and flushing it would force the residual reactive blood contained within the line directly into the client's circulatory system, exacerbating the life-threatening reaction.
3
Initiate an infusion of 0.9% sodium chloride.
A new tubing set primed with normal saline is attached to the hub, and the infusion is started.
Normal saline is compatible with blood products, helps maintain venous access for subsequent emergency medications, and provides fluid volume to support the client's dropping blood pressure.

Anahtar Kavram

Management of Acute Hemolytic Transfusion Reactions
Soru 830Soru →

Following a closed reduction and synthetic cast application for a fractured right tibia, a 35-year-old client is admitted to the orthopedic unit. Several hours into the shift, the client complains of a deep, relentless ache in the right calf that remains severe despite receiving a recent dose of intravenous hydromorphone. Assessment reveals a heart rate of 110 beats/min, blood pressure of 142/88 mm Hg, and sluggish capillary refill in the right toes. Which intervention must the nurse execute promptly to prevent a limb-threatening complication?

Cevabı ve açıklamayı göster

Cevap: Maintain the affected extremity at the level of the client's heart and alert the provider.

Cevap

Maintain the affected extremity at the level of the client's heart and alert the provider.
The clinical findings of deep, unrelenting pain that is out of proportion to the injury and unrelieved by opioids, combined with delayed capillary refill, strongly suggest developing compartment syndrome. This is a surgical emergency where elevated pressure within the myofascial compartment compromises circulation. The correct risk-reduction action is to immediately notify the healthcare provider and maintain the extremity at heart level. Elevating the limb above the heart is strictly contraindicated as it further reduces arterial perfusion to the compromised tissues.

Adım Adım Çözüm

1
Analyze the clinical presentation.
The client exhibits unrelenting pain out of proportion to the injury, unrelieved by opioids, along with sluggish capillary refill.
These are classic early indicators of acute compartment syndrome, a physiological emergency.
2
Determine the physiological risk.
Increased pressure within the fascial compartment is compromising local tissue perfusion.
If uncorrected, this increased pressure leads to irreversible ischemia, nerve damage, and tissue necrosis.
3
Select the priority intervention.
The nurse must keep the limb at heart level and notify the surgeon immediately for potential fasciotomy.
Elevating the limb above the heart decreases arterial pressure and exacerbates ischemia, making heart-level positioning critical.

Anahtar Kavram

Compartment Syndrome Assessment and Positioning
Soru 831Soru →

During bedside handoff on a progressive care unit, a client who sustained an anterior myocardial infarction the previous day becomes extremely restless. The assessment reveals pale, diaphoretic skin and a weak radial pulse of 118 beats per minute. The current blood pressure measurement is 84/60 mm Hg, and the client's urine output has been 15 mL over the last hour. Which action is the priority for this client?

Cevabı ve açıklamayı göster

Cevap: Activate the rapid response team and anticipate the administration of inotropic medications.

Cevap

The priority action is to activate the rapid response team and anticipate the administration of inotropic medications.
The correct answer addresses a severe, life-threatening complication. The client is exhibiting classic signs of cardiogenic shock (hypotension, tachycardia, oliguria, altered mental status, and poor peripheral perfusion) resulting from significant left ventricular damage post-anterior myocardial infarction. Activating the rapid response team immediately brings critical care resources to the bedside. Furthermore, inotropes are typically required to improve myocardial contractility and restore adequate tissue perfusion.

Adım Adım Çözüm

1
Analyze the clinical findings presented in the scenario.
The client has a history of an anterior myocardial infarction and now presents with extreme restlessness, pale/diaphoretic skin, tachycardia (118 bpm), hypotension (84/60 mm Hg), and oliguria (15 mL/hr).
Identifying the cluster of symptoms is required to determine the underlying physiological complication.
2
Synthesize the findings to identify the specific complication.
The symptoms indicate impaired tissue perfusion and pump failure, specifically cardiogenic shock, which is a known complication of anterior myocardial infarctions.
Recognizing the transition from stable to decompensated status directs the urgency of the intervention.
3
Determine the highest priority nursing intervention.
The nurse must immediately activate the rapid response team to bring critical care resources to the bedside and prepare for interventions that support cardiac output, such as inotropes.
In a state of acute circulatory collapse, immediate collaborative resuscitation is prioritized over independent diagnostic data gathering or contraindicated interventions.

Anahtar Kavram

Cardiogenic Shock Recognition and Prioritization
Soru 832Soru →

A nurse is caring for a client who is receiving intravenous fluids via a central venous catheter. The nurse notices that the IV tubing has accidentally disconnected from the catheter hub. The client suddenly reports severe shortness of breath and exhibits cyanosis, tachycardia, and a loud, churning murmur over the precordium. Suspecting an air embolism, arrange the following nursing actions in the priority order they should be performed, from first to last.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first clamp the central venous catheter, then place the client in a left lateral Trendelenburg position, followed by administering high-flow oxygen, activating the rapid response team, and finally monitoring and documenting the client's status.
In the event of an air embolism, prioritization follows the principle of stopping the cause, managing the immediate anatomical threat, supporting physiology, and then escalating care. Clamping the line directly stops the air entry. Left lateral Trendelenburg positioning anatomically traps the air, preventing a fatal pulmonary blockage. Oxygen supports the resulting hypoxia and helps dissolve the embolus. Only after these immediate bedside interventions should the nurse step away from direct care to call for the rapid response team, followed by ongoing monitoring.

Adım Adım Çözüm

1
Clamp the central venous catheter.
Stops further air from entering the venous system.
Negative intrathoracic pressure can draw a lethal amount of air into an open central line within seconds, making this the most critical initial action.
2
Place the client in a left lateral Trendelenburg position.
Traps the air in the apex of the right atrium and ventricle.
This specific position (Durant's maneuver) uses gravity to prevent the air bubble from advancing into the pulmonary artery, where it would cause a complete right ventricular outflow tract obstruction.
3
Administer high-flow oxygen via a non-rebreather mask.
Treats hypoxia and reduces the size of the air embolus.
Breathing 100% oxygen increases the diffusion gradient for nitrogen to leave the bubble, accelerating its resorption while providing maximal oxygenation.
4
Activate the rapid response team and notify the healthcare provider.
Summons emergency medical assistance.
The client requires immediate medical evaluation and potential advanced interventions, such as aspiration of the air from the right ventricle.
5
Monitor vital signs and document the event.
Provides ongoing assessment of hemodynamic stability.
Continuous monitoring evaluates the effectiveness of the interventions and ensures a detailed clinical record for the healthcare team.

Anahtar Kavram

Management of a Central Line-Associated Air Embolism
Soru 833Soru →

A client admitted with a deep vein thrombosis is prescribed a continuous intravenous (IV) infusion of heparin. The client weighs 209 lbs209 \text{ lbs}. The prescribed protocol dictates an initial infusion rate of 18 units/kg/hr18 \text{ units/kg/hr}. The pharmacy supplies a premixed IV bag containing 25,000 units25,000 \text{ units} of heparin in 250 mL250 \text{ mL} of 0.45%0.45\% sodium chloride. At what rate in mL/hr should the nurse program the infusion pump? Record your answer to one decimal place.

Cevabı ve açıklamayı göster

Cevap: 17.1

Cevap

17.1
To determine the correct infusion rate, the nurse must first convert the client's weight to kilograms (209 lbs÷2.2=95 kg209 \text{ lbs} \div 2.2 = 95 \text{ kg}). Next, calculate the hourly dose by multiplying the weight by the prescribed rate (95 kg×18 units/kg/hr=1710 units/hr95 \text{ kg} \times 18 \text{ units/kg/hr} = 1710 \text{ units/hr}). Finally, divide the hourly dose by the concentration of the IV bag (25,000 units÷250 mL=100 units/mL25,000 \text{ units} \div 250 \text{ mL} = 100 \text{ units/mL}) to find the rate in mL/hr (1710 units/hr÷100 units/mL=17.1 mL/hr1710 \text{ units/hr} \div 100 \text{ units/mL} = 17.1 \text{ mL/hr}).

Adım Adım Çözüm

1
Convert weight from pounds to kilograms.
95 kg95 \text{ kg}
The heparin dose is prescribed based on the client's weight in kilograms.
2
Calculate the required hourly dose of heparin.
1710 units/hr1710 \text{ units/hr}
Multiply the client's weight in kg by the prescribed dosage rate of 18 units/kg/hr18 \text{ units/kg/hr}.
3
Determine the concentration of the available heparin solution.
100 units/mL100 \text{ units/mL}
Divide the total units in the bag (25,000 units25,000 \text{ units}) by the total volume (250 mL250 \text{ mL}) to find the units per mL.
4
Calculate the volumetric IV pump infusion rate.
17.1 mL/hr17.1 \text{ mL/hr}
Divide the required hourly dose (1710 units/hr1710 \text{ units/hr}) by the solution concentration (100 units/mL100 \text{ units/mL}) to determine the required mL per hour.

Anahtar Kavram

Weight-based intravenous medication dosage calculation and infusion pump programming.
Soru 834Soru →

A client hospitalized with acute heart failure exacerbation and severe pulmonary congestion receives a stat prescription for 80 mg of intravenous furosemide. The pharmacy provides the medication in vials with a concentration of 10 mg/mL. To prevent a known irreversible sensory complication associated with this therapy, which administration technique should be utilized?

Cevabı ve açıklamayı göster

Cevap: Administer the 8 mL dose continuously over a minimum of 4 minutes.

Cevap

The safest technique is to administer the 8 mL dose continuously over a minimum of 4 minutes.
High doses of furosemide administered intravenously carry a significant risk of ototoxicity, which can cause permanent hearing loss. To mitigate this risk, standard pharmacological safety guidelines require the medication to be given at a rate no faster than 20 mg per minute. For an 80 mg dose, this requires a minimum administration time of 4 minutes.

Adım Adım Çözüm

1
Identify the total dose and volume of the prescribed medication.
The dose is 80 mg. At a concentration of 10 mg/mL, the total volume to administer is 8 mL.
Accurate dose and volume calculation is a mandatory first step before determining the administration rate.
2
Determine the maximum safe intravenous administration rate for the medication.
High-dose furosemide should be administered at a maximum rate of 20 mg per minute.
Rapid administration of high-ceiling loop diuretics is directly linked to transient or permanent ototoxicity (hearing loss).
3
Calculate the minimum time required to safely push the medication.
Dividing the 80 mg dose by the maximum rate of 20 mg/minute yields a minimum safe administration time of 4 minutes.
This ensures the medication is delivered slowly enough to prevent acoustic nerve damage while still achieving therapeutic diuresis.

Anahtar Kavram

Intravenous furosemide must be administered slowly (not exceeding 20 mg/min for high doses) to prevent ototoxicity, and principles of safe parenteral therapy dictate verifying compatibility and prioritizing acute interventions.
Soru 835Soru →

A nurse is caring for a client who underwent a partial bowel resection 12 hours ago. The client's baseline vital signs were temperature 37.0°C (98.6°F), heart rate 78 beats/min, respiratory rate 14 breaths/min, and blood pressure 124/76 mm Hg. Which of the following new assessment findings should the nurse identify as the earliest indicator that the client is developing hypovolemic shock?

Cevabı ve açıklamayı göster

Cevap: A heart rate of 116 beats/min and a blood pressure of 110/90 mm Hg

Cevap

The earliest indicator of developing hypovolemic shock is a heart rate of 116 beats/min and a blood pressure of 110/90 mm Hg.
In the early (compensatory) stage of hypovolemic shock, the body's sympathetic nervous system initiates a compensatory response to decreased intravascular volume. This results in an increased heart rate (tachycardia) to maintain cardiac output and peripheral vasoconstriction to maintain systemic vascular resistance. This vasoconstriction disproportionately elevates the diastolic blood pressure, creating a narrowed pulse pressure (typically a difference of less than 30 mm Hg between systolic and diastolic values).

Adım Adım Çözüm

1
Analyze the client's baseline vital signs and current postoperative timeline.
The client is 12 hours post-abdominal surgery with normal baseline hemodynamics, placing them at risk for active internal hemorrhage.
Establishing the baseline and surgical context identifies the primary physiological risks.
2
Differentiate between early (compensatory) and late (progressive) signs of hypovolemic shock.
Early shock presents with tachycardia and a narrowing pulse pressure due to vasoconstriction. Late shock presents with profound hypotension and poor perfusion (mottled skin).
The question specifically asks for the earliest indicator of decompensation.
3
Evaluate the remaining distractors against expected postoperative findings.
Mild respiratory alkalosis and hypoactive bowel sounds are expected physiological responses to surgical pain and abdominal manipulation.
Expected findings do not indicate an acute physiological deterioration requiring emergency intervention.

Anahtar Kavram

Early Physiological Adaptation to Volume Loss (Compensatory Shock)
Soru 836Soru →

A nurse is assessing a client who is 3 days postoperative following an abdominal laparotomy. The client coughs forcefully and suddenly states, "I feel like something just popped open." The nurse inspects the surgical site and observes a loop of bowel protruding through the incision. Arrange the following nursing actions in the correct priority order from first to last.

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Cevap

The correct priority sequence for managing a surgical evisceration is: stay with the client and call for assistance, position the client in a low Fowler's position with bent knees, cover the exposed bowel with sterile moist dressings, assess vital signs, and then notify the surgeon.
Wound evisceration is a physiological emergency requiring swift, sequential action. The nurse must first ensure safety by staying with the client and calling for help. Next, reducing mechanical tension on the abdomen by placing the client in a low Fowler's position with bent knees prevents further organ protrusion. Protecting the exposed tissue with sterile, saline-soaked dressings is the next critical priority to prevent tissue necrosis and infection. Once the site is secured and protected, assessing vital signs is necessary to evaluate for shock. Finally, the provider is notified with all assessment data to arrange for immediate surgical repair.

Adım Adım Çözüm

1
Ensure continuous presence and secure assistance.
Help is summoned without leaving the client unattended.
Evisceration is a critical emergency. Leaving the client risks further injury and severe anxiety. Help is needed to gather supplies and contact the provider.
2
Adjust the client's position to a low Fowler's position with knees flexed.
Abdominal wall tension is minimized.
This specific position relaxes the rectus abdominis muscles, which prevents additional abdominal contents from protruding through the opened incision.
3
Protect the exposed viscera with sterile, saline-moistened dressings.
The bowel is protected from the external environment and drying.
Exposed internal organs can quickly become necrotic if they dry out, and they are highly susceptible to severe infection. Sterile normal saline maintains tissue viability.
4
Obtain vital signs and assess perfusion.
The client's physiological stability is determined.
Evisceration can cause rapid fluid shifts and significant pain, leading to hypovolemic shock. Baseline vital signs are needed before calling the provider.
5
Communicate the critical situation to the surgical team.
Definitive surgical treatment is initiated.
Nursing interventions stabilize the client, but surgical repair in the operating room is the only definitive treatment for an evisceration.

Anahtar Kavram

Management of a postoperative abdominal evisceration requires immediate, sequential actions to reduce abdominal tension, protect the exposed viscera from necrosis and infection, and prepare the client for emergency surgery.
Soru 837Soru →

A nurse is planning care for a client who is receiving continuous total parenteral nutrition (TPN) via a peripherally inserted central catheter (PICC). Which of the following interventions should the nurse include in the client's plan of care? (Select all that apply.)

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Cevap: Monitor capillary blood glucose levels every 4 to 6 hours.; Keep a liter of 10% dextrose in water (D10W) readily available on the unit.; Change the TPN administration set and filter every 24 hours.

Cevap

The appropriate interventions include monitoring blood glucose every 4 to 6 hours, keeping 10% dextrose in water available, and changing the TPN tubing and filter every 24 hours.
Total parenteral nutrition (TPN) safely requires strict metabolic and infection control monitoring. Because of the high dextrose load, blood glucose must be monitored every 4 to 6 hours to detect hyperglycemia. If the TPN bag empties before the next one is available, a 10% dextrose in water (D10W) solution must be infused at the prescribed TPN rate to prevent dangerous rebound hypoglycemia. Furthermore, the nutrient-rich solution is highly susceptible to bacterial growth, requiring the tubing and filter to be replaced every 24 hours.

Adım Adım Çözüm

1
Analyze the metabolic requirements and risks associated with total parenteral nutrition (TPN).
Identify that TPN has a high dextrose concentration, posing risks for hyperglycemia during infusion and hypoglycemia if stopped abruptly.
Understanding the composition of TPN dictates the need for frequent blood glucose checks and having D10W on standby.
2
Evaluate infection control standards for parenteral nutrition.
Determine that the high nutrient content necessitates changing the administration set and filter every 24 hours.
Strict asepsis is required to prevent central line-associated bloodstream infections (CLABSI).
3
Assess intravenous line compatibility and delegation principles.
Recognize that TPN requires a dedicated line and that managing IV pumps is strictly a nursing responsibility.
Co-administering medications risks precipitation or occlusion, and UAPs lack the scope of practice to manage IV infusions.

Anahtar Kavram

Safe administration and monitoring of Total Parenteral Nutrition (TPN)
Soru 838Soru →

A nurse is evaluating the condition of a client admitted to the intensive care unit with severe diabetic ketoacidosis (DKA). The client is lethargic and exhibiting deep, rapid respirations. Based on the client's clinical presentation, which of the following arterial blood gas (ABG) values are consistent with the expected acid-base imbalance and physiological compensation? Select all that apply.

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Cevap: pH 7.28; PaCO2PaCO_2 26 mm Hg; HCO3−HCO_3^- 12 mEq/L

Cevap

The expected ABG values for a client with DKA experiencing respiratory compensation include a decreased pH (such as 7.28), a decreased HCO3−HCO_3^- (such as 12 mEq/L), and a decreased PaCO2PaCO_2 (such as 26 mm Hg).
DKA results in the systemic accumulation of ketones, leading to a primary metabolic acidosis (characterized by a low pH and a low HCO3−HCO_3^-). The body's natural physiological response is to increase the rate and depth of breathing (Kussmaul respirations) to excrete volatile acids in the form of carbon dioxide (CO2CO_2) and normalize the pH. Therefore, the expected ABG results demonstrate a low pH, a low HCO3−HCO_3^-, and a compensatory low PaCO2PaCO_2.

Adım Adım Çözüm

1
Identify the primary acid-base imbalance associated with DKA.
Diabetic ketoacidosis produces excess systemic ketoacids, leading to metabolic acidosis characterized by a low pH and a depleted HCO3−HCO_3^- level.
Understanding the underlying pathophysiology determines the primary laboratory abnormalities.
2
Determine the body's compensatory mechanism for metabolic acidosis.
The respiratory system compensates by increasing the rate and depth of breathing (Kussmaul respirations) to exhale more carbon dioxide, thereby lowering the PaCO2PaCO_2.
Compensation aims to return the blood pH toward a normal physiological range by manipulating the opposite acid-base component.
3
Evaluate the provided ABG values against the expected pathophysiological changes.
A pH of 7.28, HCO3−HCO_3^- of 12 mEq/L, and PaCO2PaCO_2 of 26 mm Hg accurately reflect partially compensated metabolic acidosis.
Matching the clinical findings to the ABG values confirms accurate interpretation of the client's status.

Anahtar Kavram

Partially compensated metabolic acidosis in Diabetic Ketoacidosis (DKA)
Soru 839Soru →

A telemetry nurse is called to the room of a client who suffered a comminuted pelvic fracture seventy-two hours prior. The client is suddenly grasping their chest, expressing a severe feeling of doom, and sweating profusely. Assessment reveals a heart rate of 138138 beats per minute, a respiratory rate of 3434 breaths per minute, and a blood pressure of 98/76 mm Hg98/76 \text{ mm Hg}. Room air pulse oximetry displays an oxygen saturation of 85%85\%. The rapid arterial blood gas (ABG) results are as follows: pH=7.53\text{pH} = 7.53, PaCO2=29 mm Hg\text{PaCO}_2 = 29 \text{ mm Hg}, HCO3−=24 mEq/L\text{HCO}_3^- = 24 \text{ mEq/L}, and PaO2=56 mm Hg\text{PaO}_2 = 56 \text{ mm Hg}. Which of the following conclusions accurately reflects this client's current physiological derangement?

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Cevap: Uncompensated respiratory alkalosis with severe hypoxemia, indicating a probable pulmonary embolism.

Cevap

The client is experiencing uncompensated respiratory alkalosis and severe hypoxemia, which strongly suggests a pulmonary embolism.
The arterial blood gas results demonstrate an elevated pH (alkalosis) driven by a decreased PaCO2 (respiratory origin). The normal bicarbonate level indicates there is no metabolic compensation yet. This state of uncompensated respiratory alkalosis, paired with profound hypoxemia (low PaO2), sudden feeling of doom, and severe tachycardia in a client with a recent pelvic fracture, is the classic clinical presentation of a pulmonary embolism causing dead-space ventilation and resultant hyperventilation.

Adım Adım Çözüm

1
Evaluate the pH value to determine the primary acid-base status.
The pH\text{pH} is 7.537.53.
A pH greater than 7.45 indicates alkalosis.
2
Analyze the respiratory and metabolic components to find the cause.
The PaCO2\text{PaCO}_2 is low at 29 mm Hg29 \text{ mm Hg}, and the HCO3−\text{HCO}_3^- is normal at 24 mEq/L24 \text{ mEq/L}.
A low carbon dioxide level perfectly aligns with an alkaline pH, indicating a primary respiratory alkalosis. The normal bicarbonate level indicates the kidneys have not yet initiated compensation.
3
Analyze oxygenation and vital sign trends to determine the underlying pathology.
The PaO2\text{PaO}_2 is 56 mm Hg56 \text{ mm Hg}, accompanied by a narrowed pulse pressure (22 mm Hg22 \text{ mm Hg}), tachycardia, and tachypnea.
Severe hypoxemia combined with sudden chest pain, tachypnea, and a history of pelvic fracture points directly to a massive pulmonary embolism causing right ventricular strain and hyperventilation.

Anahtar Kavram

Arterial Blood Gas Interpretation and Pulmonary Embolism Recognition
Soru 840Soru →

A nurse in the emergency department receives a client who sustained full-thickness thermal burns to the face, neck, and anterior chest from a house fire. Arrange the following nursing interventions in the priority order they should be performed. All options must be used.

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Cevap

The correct priority order follows the primary and secondary survey framework (Airway, Breathing, Circulation). The nurse must first assess the airway, then administer oxygen, followed by establishing IV access, initiating fluids, and finally estimating the burn extent.
In the emergent phase of burn care, life-saving interventions must follow the ABCs of trauma. Securing a patent airway is the absolute first priority, especially for facial and neck burns that can rapidly swell. This is immediately followed by supporting breathing with 100% oxygen to counteract carbon monoxide and hypoxia. Once oxygenation is supported, the nurse addresses circulation by establishing large-bore IV access and initiating aggressive fluid resuscitation to prevent burn shock. Finally, during the secondary survey, the nurse calculates the total body surface area burned to refine the long-term fluid resuscitation plan.

Adım Adım Çözüm

1
Prioritize Airway (A).
The nurse assesses the client's airway patency and respiratory effort.
Facial and neck burns carry a severe risk of inhalation injury and rapid airway occlusion from progressing edema.
2
Prioritize Breathing (B).
The nurse administers 100% humidified oxygen via a non-rebreather mask.
Clients exposed to house fires are at high risk for carbon monoxide poisoning and hypoxia, requiring immediate high-flow oxygen.
3
Prioritize Circulation (C).
The nurse inserts two large-bore intravenous catheters.
Severe burns cause massive capillary leak and fluid shifts. Vascular access must be secured before hypovolemic shock progresses.
4
Intervene for Circulation.
The nurse initiates fluid resuscitation with prescribed Lactated Ringer's solution.
Isotonic fluid replacement is critical to maintain cardiac output, organ perfusion, and prevent fatal burn shock.
5
Perform the Secondary Survey.
The nurse estimates the total body surface area burned using the Rule of Nines.
Once life-threatening ABC issues are stabilized, the nurse assesses the full extent of the injury to guide ongoing fluid administration calculations.

Anahtar Kavram

Emergent Management of Burn Injuries
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