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Tüm alıştırma soruları

862 soru

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Soru 821Soru →

The nurse is changing the intravenous tubing on a client's central venous catheter. During the procedure, the client suddenly gasps for air, grasps their chest, and becomes cyanotic. Arrange the following nursing actions in the correct priority sequence.

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Cevap

The correct sequence is to first clamp the central venous catheter, then place the client in the left lateral Trendelenburg position, administer 100% oxygen via a non-rebreather mask, notify the rapid response team and healthcare provider, and finally monitor vital signs and respiratory status continuously.
In the event of a suspected air embolism from a central venous catheter, the immediate priority is to stop further air entry by clamping the line. The next critical action is positioning the client in the left lateral Trendelenburg position, which traps the air in the apex of the right ventricle and prevents it from occluding the pulmonary circulation. Once the embolus is isolated, administering 100% oxygen helps treat hypoxia and promotes the resorption of the nitrogen gas bubble. After these immediate life-saving parameters are secured, the nurse must notify the rapid response team and healthcare provider, followed by continuous monitoring of the client's hemodynamic status.

Adım Adım Çözüm

1
Identify the sudden onset of respiratory distress, chest pain, and cyanosis during a central line procedure as a classic presentation of an air embolism.
The nurse recognizes an immediate, life-threatening physiological emergency.
Rapid clinical judgment is required to prioritize actions that stop further harm.
2
Clamp the central venous catheter immediately.
The pathway for air to enter the vascular system is closed.
Stopping the source of air entry is the most critical first step to prevent the embolus from enlarging.
3
Reposition the client to a left lateral Trendelenburg position.
The air bubble rises and becomes trapped in the apex of the right ventricle.
This specific positioning prevents the air from migrating into the pulmonary circulation, which would otherwise cause cardiovascular collapse.
4
Apply high-flow oxygen.
The client receives maximal oxygenation, and nitrogen gradient changes.
Oxygen treats the immediate hypoxia and helps shrink the air embolus by encouraging nitrogen resorption.
5
Call for emergency assistance and initiate continuous monitoring.
Advanced life support providers are alerted, and baseline post-event hemodynamics are established.
While calling for help is essential, it must follow the immediate independent nursing interventions that stabilize the client's physiological state.

Anahtar Kavram

Prioritization of care for a client experiencing an air embolism requires immediate mechanical interventions (clamping and positioning) before pharmacological or supportive measures.
Soru 822Soru →

A nurse is preparing to administer an intermittent bolus enteral feeding via a nasogastric (NG) tube to a client. Arrange the following procedural steps in the correct chronological order from first to last.

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The correct sequence for administering an intermittent bolus enteral feeding is to first elevate the head of the bed, followed by verifying tube placement and checking the gastric residual volume. Next, the nurse flushes the tube with water to confirm patency, administers the feeding formula by gravity, and concludes by flushing the tube again to prevent occlusion.
Safe administration of enteral feedings follows a strict sequential protocol. The client must first be positioned upright (30-45 degrees) to prevent aspiration. Once safely positioned, the nurse must confirm the tube is in the stomach and check residual volume to ensure tolerance. A pre-flush verifies patency. After patency is confirmed, the feeding is administered. Finally, a post-flush clears the tube to maintain future patency.

Adım Adım Çözüm

1
Position the client with the head of the bed elevated at least 30 to 45 degrees.
The client is in a semi-Fowler's or high-Fowler's position.
This utilizes gravity to keep gastric contents in the stomach and significantly reduces the risk of pulmonary aspiration.
2
Verify correct tube placement and assess gastric residual volume (GRV).
Tube location in the stomach is confirmed and feeding tolerance is established.
It is a critical safety measure to ensure the formula will not be delivered into the respiratory tract and to verify the client is digesting previous feedings.
3
Flush the tube with 30 mL of sterile water.
The tube's patency is confirmed.
This clears the tube and prepares it for the thicker feeding formula, ensuring there are no blockages.
4
Administer the enteral feeding formula by gravity.
The prescribed nutritional support is delivered.
Gravity allows the formula to flow at a safe, tolerated rate into the stomach.
5
Flush the tube with another 30 mL of sterile water.
The tube is cleared of any residual formula.
Formula left in the tube can coagulate, leading to blockages and bacterial proliferation.

Anahtar Kavram

Safe Enteral Nutrition Administration
Soru 823Soru →

A nurse is preparing to administer a prescribed intravenous (IV) push medication through a client's peripheral intermittent IV access device (saline lock). Arrange the following steps in the correct order from first to last.

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The correct sequence is: perform hand hygiene, clean the injection port, aspirate and flush with saline to assess patency, administer the medication, and perform the final saline flush at the same rate as the medication administration.
The SAS (Saline-Administer-Saline) method is the standard protocol for administering an IV push medication through an intermittent saline lock. First, standard precautions (hand hygiene and gloves) are implemented. Next, the injection port is disinfected to prevent bloodstream infections. The nurse then checks patency by aspirating for blood and flushing with saline to ensure the line has not infiltrated. After verifying patency, the medication is administered at the prescribed rate. Finally, a second saline flush clears the medication from the tubing; crucially, this flush must be administered at the same rate as the medication to prevent rapidly bolusing the residual drug left in the extension tubing.

Adım Adım Çözüm

1
Perform hand hygiene and don clean gloves.
A barrier is created to prevent the transmission of microorganisms.
Standard precautions must be established before any patient contact or invasive vascular procedure.
2
Clean the injection port with an antimicrobial swab.
The surface of the injection port is disinfected.
Scrubbing the hub prevents the introduction of skin flora and pathogens into the bloodstream during vascular access.
3
Aspirate for blood return and flush the catheter with 0.9% sodium chloride.
The nurse verifies the line is patent and positioned correctly within the vein.
Administering medications into an infiltrated line can cause severe tissue damage, especially if the drug is a vesicant.
4
Administer the prescribed medication at the recommended rate.
The client receives the therapeutic dose of the medication safely.
Pushing medications too quickly can result in drug toxicity, speed shock, or profound adverse cardiovascular reactions.
5
Flush the IV catheter with 0.9% sodium chloride at the same rate as the medication.
The residual medication in the device is delivered to the client, and the catheter is cleared.
Flushing at the same rate prevents the remaining medication in the extension tubing from being pushed into the circulation as a rapid bolus.

Anahtar Kavram

Administration of an IV push medication through a peripheral intermittent lock requires the SAS (Saline-Administer-Saline) sequence to verify patency, deliver the medication safely, and maintain catheter function.
Soru 824Soru →

A nurse is preparing to administer a large-volume cleansing enema to a client who is experiencing severe constipation following abdominal surgery. 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 begins with positioning the client appropriately in the left lateral Sims position to utilize gravity, followed by lubricating the tubing tip. Next, the nurse carefully inserts the tubing directing it toward the umbilicus, then initiates the fluid flow by raising the container to the appropriate height. Finally, the nurse monitors the client's tolerance, clamping the tubing temporarily if cramping occurs.
This chronological sequence adheres to anatomical principles and safety guidelines for enema administration. Placing the client in the left lateral Sims position properly aligns the sigmoid colon. Lubricating the tubing prevents trauma, and directing it toward the umbilicus follows the bowel's natural contour. Raising the container only after safe insertion allows controlled fluid flow, and maintaining vigilance to clamp the tubing upon cramping prevents severe spasms.

Adım Adım Çözüm

1
Assist the client into the left lateral Sims position.
The client's anatomy is optimally aligned for the procedure.
This position takes advantage of gravity, directing fluid into the sigmoid and descending colon.
2
Lubricate the tip of the enema tubing.
The tubing is prepared for atraumatic insertion.
Water-soluble lubricant reduces friction and protects delicate rectal tissues.
3
Insert the tubing 3 to 4 inches into the rectum, aiming toward the umbilicus.
The tubing safely enters the bowel.
Aiming toward the umbilicus respects the natural anatomical curve of the rectum.
4
Raise the enema container and open the clamp.
The enema solution begins to infuse into the colon.
Elevating the bag 12 to 18 inches establishes a safe gravity-driven flow rate.
5
Clamp the tubing if cramping occurs.
The infusion pauses, allowing the client's colon to relax.
Temporary clamping prevents excessive bowel spasms, discomfort, and premature expulsion of the fluid.

Anahtar Kavram

Safe administration of a large-volume enema requires appropriate anatomical positioning, atraumatic insertion, and flow control to promote bowel evacuation while minimizing client discomfort.
Soru 825Soru →

A nurse is caring for a client who is receiving an infusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion is initiated, the client develops sudden chills, lower back pain, and a heart rate of 118 beats/min. Place the following nursing interventions in the correct order to reduce the risk of further physiological deterioration. (Arrange the steps from first action to last action)

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The correct sequence is to first stop the transfusion, replace the tubing to infuse normal saline, assess the client, notify the provider and blood bank, and finally return the blood product and equipment.
When an acute hemolytic transfusion reaction is suspected (indicated by lower back pain, chills, and tachycardia), the overriding priority to reduce risk is to stop the offending agent. Immediately stopping the transfusion limits the amount of incompatible blood received. The nurse must then maintain IV access for emergency drugs, but must do so by disconnecting the blood tubing at the hub and attaching new tubing primed with normal saline to avoid pushing residual blood into the client. Assessing the client's vital signs and respiratory status follows to determine the extent of physiological decompensation. The healthcare provider and blood bank are then notified so orders can be received and the facility's reaction protocol can be initiated. Finally, the blood bag and tubing are sent to the blood bank for crossmatch re-testing.

Adım Adım Çözüm

1
Stop the transfusion
Halts the infusion of the incompatible blood product.
Reduces the total volume of reactive blood cells entering the circulation, mitigating the severity of the reaction.
2
Replace tubing and infuse normal saline
Maintains intravenous access without infusing residual blood.
Ensures a patent line for emergency medications while preventing the incompatible blood in the original tubing from entering the client.
3
Assess the client
Establishes current physiological status.
Provides critical clinical data to report to the provider and determines the immediate need for airway support or hemodynamic interventions.
4
Notify provider and blood bank
Mobilizes the medical team and initiates laboratory investigation.
Allows for the prescription of emergency medications and alerts the lab to a potential systemic typing error.
5
Return equipment to blood bank
Provides materials for analysis.
Enables the laboratory to determine the exact cause of the reaction (e.g., clerical error, unexpected antibody) by re-testing the original product.

Anahtar Kavram

Management of acute hemolytic transfusion reactions
Soru 826Soru →

A client is admitted to the intensive care unit with severe diabetic ketoacidosis (DKA). The initial blood glucose level is 680 mg/dL, and the client exhibits Kussmaul respirations. The nurse prepares to implement the standard DKA treatment protocol. Arrange the following nursing actions in the correct chronological sequence from first to last.

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The correct sequence is: 1) Establish IV access and infuse normal saline, 2) Verify serum potassium, 3) Initiate IV regular insulin, 4) Add 5% dextrose to fluids.
The standard protocol for diabetic ketoacidosis (DKA) prioritizes life-threatening deficits in a specific order: volume, electrolytes, and then glucose/acidosis correction. Fluid resuscitation is the absolute first priority to reverse hypovolemia. Next, potassium must be checked because insulin therapy will push potassium intracellularly, risking fatal hypokalemia. Only after verifying potassium can insulin be safely administered. Finally, dextrose is added when glucose reaches 250 mg/dL to prevent hypoglycemia and cerebral edema.

Adım Adım Çözüm

1
Address hypovolemia
Infuse 0.9% sodium chloride bolus
Osmotic diuresis in DKA causes severe fluid depletion; restoring intravascular volume and perfusion is the absolute first step.
2
Evaluate electrolyte status
Verify serum potassium level
Insulin therapy lowers serum potassium by shifting it intracellularly. Administering insulin to a hypokalemic client can cause fatal arrhythmias, so potassium must be checked first.
3
Correct hyperglycemia and acidosis
Initiate continuous IV regular insulin
Once perfusion is stabilizing and potassium is safe, continuous insulin is required to stop lipolysis, halt ketone production, and normalize blood glucose.
4
Prevent complications of rapid glucose drop
Add 5% dextrose to IV fluids
When blood glucose drops to 250 mg/dL, dextrose is added to prevent sudden hypoglycemia and shifts in osmolality that can cause cerebral edema.

Anahtar Kavram

The primary management sequence for Diabetic Ketoacidosis (DKA) prioritizes volume expansion first, followed by electrolyte evaluation, insulin administration, and finally glucose stabilization to prevent cerebral edema.
Soru 827Soru →

A nurse in the emergency department is caring for a client admitted with a severe asthma exacerbation. The client exhibits audible wheezing, intercostal retractions, and an oxygen saturation of 88% on room air. Arrange the following nursing actions in the correct order of priority from first to last.

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The correct sequence is to first position the client upright, apply supplemental oxygen, administer nebulized albuterol, establish IV access, and finally administer intravenous methylprednisolone.
The correct sequence adheres to the ABC prioritization framework and the principle of least invasive to most invasive interventions. Positioning immediately addresses airway mechanics (Airway). Oxygen administration directly treats life-threatening hypoxia (Breathing). Nebulized albuterol resolves the acute bronchospasm causing the distress (Breathing). IV access secures a route for circulation-level interventions (Circulation), allowing the administration of systemic corticosteroids, which take hours to act and are therefore the lowest immediate priority.

Adım Adım Çözüm

1
Elevate the head of the bed to a high Fowler's position.
The diaphragm drops and lung expansion is physically maximized.
This is the fastest, least invasive action to immediately support airway mechanics without requiring any equipment.
2
Administer supplemental oxygen.
Life-threatening hypoxemia is corrected.
An oxygen saturation of 88% indicates severe hypoxia that takes precedence over pharmacological interventions according to the ABCs.
3
Administer nebulized short-acting bronchodilators.
Bronchospasm is rapidly reversed.
Airway smooth muscle relaxation is required immediately after securing oxygenation to allow gas exchange at the alveolar level.
4
Establish peripheral IV access.
A route for systemic medications is secured.
IV access is necessary for further systemic treatment but is an invasive procedure that should not delay immediate airway and breathing support.
5
Administer IV corticosteroids.
Systemic inflammation is targeted.
Steroids have a delayed onset of action (hours) and are therefore prioritized last among these acute, emergent interventions.

Anahtar Kavram

In acute respiratory distress, nursing prioritization follows the ABC (Airway, Breathing, Circulation) framework, initiating the fastest and most direct non-pharmacological interventions before progressing to pharmacological and systemic treatments.
Soru 828Soru →

An adult client with suspected cirrhosis is scheduled for a bedside percutaneous liver biopsy. To minimize the risk of procedural and post-procedural complications, arrange the following nursing actions in the correct chronological sequence. (Place the first action at the top and the final action at the bottom.)

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The correct sequence begins with reviewing coagulation labs, followed by supine positioning with the right arm elevated, instructing the client to exhale and hold their breath during insertion, applying immediate pressure to the site, and finally placing the client in a right lateral position.
The correct sequence prioritizes pre-procedural safety by first verifying coagulation status. Next, the client is positioned to maximize access while minimizing anatomical risk. Instructing the client to exhale and hold their breath protects the diaphragm and lungs. Finally, applying immediate manual pressure followed by a right lateral position provides necessary continuous compression to prevent the most common severe complication: hemorrhage.

Adım Adım Çözüm

1
Review the client's most recent prothrombin time (PT), INR, and platelet count.
Coagulation status is verified.
Identifies bleeding risk before the procedure begins, which is the highest priority safety check.
2
Position the client supine with their right arm resting behind their head.
The lower right rib cage is expanded.
Provides optimal and safe access to the biopsy site.
3
Instruct the client to exhale completely and hold their breath during needle insertion.
The diaphragm is elevated and held stationary.
Prevents accidental puncture of the lung or pleura during needle advancement.
4
Apply direct, firm pressure to the biopsy insertion site.
Hemostasis is initiated.
Controls immediate bleeding as soon as the needle is withdrawn.
5
Assist the client into a right lateral decubitus position.
The client's body weight compresses the puncture site.
Provides continuous external pressure to the liver to prevent post-procedural internal hemorrhage.

Anahtar Kavram

Reduction of Risk Potential during Percutaneous Liver Biopsy
Soru 829Soru →

While performing a routine surgical incision check on a postoperative laparotomy client, the client experiences a forceful coughing episode and reports a sudden tearing sensation. Upon inspection, the nurse observes complete separation of the surgical wound layers with visible protrusion of intestinal loops. Arrange the following emergency nursing actions in the correct priority sequence to mitigate the risk of severe physiological decompensation.

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The correct sequence is to first call for assistance, then position the client to reduce abdominal tension, cover the exposed organs with sterile moist dressings, assess vital signs for impending shock, and finally prepare the client for emergency surgery.
In any acute surgical emergency involving structural failure (evisceration), the nurse must adhere to a strict order of operations: secure help without abandoning the client, mitigate the immediate physical mechanism of injury (relieve abdominal tension), protect the vulnerable tissue from irreversible damage (moist sterile dressings), evaluate systemic impact (vital signs), and facilitate definitive medical treatment (surgery prep).

Adım Adım Çözüm

1
Call for immediate assistance and delegate a colleague to notify the surgeon.
Additional nursing staff is secured without abandoning the critically vulnerable client.
The primary nurse must remain with the client to monitor the airway and prevent the client from touching the wound. A delegated colleague can rapidly retrieve sterile saline and dressings.
2
Place the client in a low Fowler's position with the knees flexed.
Intra-abdominal pressure is mechanically decreased.
Elevating the head of the bed slightly (15-20 degrees) and bending the knees relaxes the rectus abdominis muscles, which stops the mechanical force pushing the intestines out of the abdominal cavity.
3
Cover the protruding organs with sterile, saline-moistened dressings.
Exposed viscera are protected from the external environment.
Applying sterile, saline-soaked dressings prevents the delicate intestinal mucosa from drying out—which can cause irreversible tissue necrosis—and provides a critical barrier against infection.
4
Assess vital signs continuously to monitor for hypovolemic shock.
Baseline hemodynamic status is established during the crisis.
Evisceration can precipitate massive third-spacing of fluids and hemorrhagic or hypovolemic shock. Once the physical integrity of the bowel is protected, continuous cardiovascular monitoring dictates fluid resuscitation needs.
5
Prepare the client for emergency surgical repair.
The client is readied for definitive operative intervention.
Evisceration cannot be managed conservatively. Verifying informed consent, ensuring large-bore IV access, and preparing the chart for the operating room are the final risk reduction steps before transfer.

Anahtar Kavram

Management of a surgical evisceration requires immediate intervention to prevent bowel ischemia and shock, prioritizing tension reduction and tissue protection while never leaving the client unattended.
Soru 830Soru →

A nurse is caring for a client who is receiving an intravenous transfusion of packed red blood cells (PRBCs). Fifteen minutes after the infusion begins, the client becomes restless and reports sudden chills and severe lower back pain. In what order should the nurse perform the following interventions? Arrange the actions from first to last.

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Cevap

The correct sequence of actions is: stop the transfusion immediately, maintain the IV line with normal saline using completely new tubing, assess the client's vital signs, notify the healthcare provider and blood bank, and finally return the blood bag and tubing to the blood bank.
Acute hemolytic transfusion reactions present rapidly with chills, lower back pain, tachycardia, and hypotension. According to prioritization principles, the absolute priority is to stop the infusion to prevent further exposure to the incompatible antigen. Next, the nurse must ensure a patent IV line using a completely new tubing setup with normal saline to avoid flushing any residual blood into the client. Once the source of harm is stopped and vascular access is secured, the nurse performs a focused assessment to gather vital data. This assessment data is then communicated to the healthcare provider and the blood bank. Finally, the remaining blood product and all associated tubing are sent to the laboratory for required crossmatch and contamination testing.

Adım Adım Çözüm

1
Stop the transfusion immediately.
Further infusion of the reactive blood product is halted.
This is the most critical first step to minimize the volume of incompatible blood entering the client's circulation, halting the antigen-antibody reaction.
2
Maintain the intravenous line with normal saline using new tubing.
Intravenous access is safely preserved without administering more blood.
Vascular access is crucial for administering emergency medications or fluids. New tubing prevents the remaining blood in the old line from being flushed into the client.
3
Assess the client's vital signs and respiratory status.
Baseline data for the adverse reaction is established.
The nurse needs current physiological data to accurately report the client's hemodynamic and respiratory stability to the healthcare provider.
4
Notify the healthcare provider and the blood bank.
The medical team is informed and emergency interventions can be ordered.
The provider will direct the pharmacological management of the reaction, and the blood bank will document the event and prepare for investigation.
5
Return the blood bag and attached administration set to the blood bank.
The exact cause of the reaction can be formally investigated.
Laboratory analysis of the remaining blood and tubing is required to identify if there was a clerical error, incompatibility, or bacterial contamination.

Anahtar Kavram

Management of a suspected acute hemolytic transfusion reaction
Soru 831Soru →

A nurse is preparing to draw a blood specimen for laboratory analysis from a client's multi-lumen central venous catheter. Continuous intravenous fluids are currently infusing through the other lumens. Arrange the following actions in the correct chronological sequence to safely obtain the blood sample.

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Cevap

The correct sequence is to first pause all other infusions, then scrub the hub, flush to check patency, draw and discard the initial waste blood, draw the required lab specimen, and finally flush the line vigorously with normal saline.
Safely drawing blood from a central venous catheter requires a strict sequence to prevent infection, preserve catheter patency, and ensure accurate laboratory results. Pausing other infusions prevents sample contamination. Scrubbing the hub maintains asepsis. The initial flush verifies patency. Drawing a discard volume is critical to clear the catheter's dead space of flush solutions. After the pure specimen is collected, a large-volume pulsatile flush is required to clear all red blood cells and prevent catheter thrombosis.

Adım Adım Çözüm

1
Pause all continuous intravenous infusions on the other lumens.
Stops the flow of fluids that could mix with the blood return.
Ensures the laboratory specimen is not contaminated or diluted by infusing medications or fluids.
2
Scrub the needleless connector hub with an antimicrobial swab.
Disinfects the access point.
Reduces the risk of Central Line-Associated Bloodstream Infections (CLABSI).
3
Attach a syringe and flush with 0.9% sodium chloride.
Clears the immediate hub and verifies the catheter is not occluded.
Confirms line patency and ensures blood can be safely and easily aspirated.
4
Aspirate and discard 5 to 10 mL of blood.
Removes the fluid resting in the dead space of the catheter.
Prevents the laboratory specimen from being diluted with flush solution or residual medication.
5
Withdraw the required volume of blood for the specimen.
Collects an accurate, undiluted blood sample.
Fulfills the diagnostic laboratory order.
6
Flush the lumen vigorously with 10 to 20 mL of 0.9% sodium chloride.
Clears all residual red blood cells from the internal walls of the catheter.
Prevents the catheter from clotting off and maintains long-term patency.

Anahtar Kavram

Central Venous Catheter (CVC) Blood Sampling Protocol
Soru 832Soru →

A nurse enters a client's room and discovers that the intravenous tubing has disconnected from the client's central venous catheter. The client is suddenly experiencing severe dyspnea, tachycardia, and a feeling of impending doom. Suspecting an air embolism, arrange the following nursing actions in the correct priority order to minimize further physiological risk.

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Cevap

The correct priority sequence is: Clamp the catheter, position the client in the left lateral Trendelenburg position, administer 100% oxygen, activate the rapid response team, and continuously monitor vital signs.
The priority sequence in an air embolism emergency focuses on immediately stopping further air entry, preventing the embolus from traveling to the pulmonary circulation, treating hypoxemia, and securing advanced medical support. Clamping the catheter addresses the direct cause. The left lateral Trendelenburg position uses gravity to trap the air in the right ventricle. High-flow oxygen is then applied to treat tissue hypoxia and shrink the nitrogen bubble, followed by obtaining emergency assistance and continuous monitoring.

Adım Adım Çözüm

1
Clamp the central venous catheter.
The source of air entry into the circulatory system is immediately stopped.
Preventing further air entry is the absolute first priority to minimize the size of the embolus.
2
Place the client in the left lateral Trendelenburg position.
The air bubble rises and becomes trapped in the apex of the right ventricle.
This positioning prevents the air embolus from being pumped into the pulmonary artery, where it could cause a fatal pulmonary embolism.
3
Administer 100% oxygen via a non-rebreather mask.
The client receives maximal oxygenation.
High-flow oxygen treats severe hypoxemia and establishes a diffusion gradient that helps resorb nitrogen gas from the air embolus.
4
Activate the rapid response team and notify the healthcare provider.
Emergency medical personnel are dispatched to the client's room.
Once immediate stabilizing measures are in place, advanced medical interventions must be prepared.
5
Continuously monitor the client's vital signs and oxygen saturation.
The client's hemodynamic and respiratory status is closely tracked.
Ongoing assessment is necessary to detect deterioration and guide further resuscitation efforts until the rapid response team arrives.

Anahtar Kavram

Emergency management of a central venous catheter-associated air embolism prioritizes immediately stopping air entry, utilizing therapeutic positioning (left lateral Trendelenburg) to trap the air, and maximizing oxygenation.
Soru 833Soru →

A client with a complete T4 spinal cord injury reports a sudden, severe, throbbing headache and blurred vision. The nurse observes profuse diaphoresis above the level of the injury and obtains a blood pressure reading of 218/114 mm Hg. Arrange the following nursing interventions in the priority order of execution.

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The correct priority sequence for managing autonomic dysreflexia is to first sit the client upright, then loosen restrictive clothing, identify and correct the most common trigger (bladder), check for the second most common trigger (bowel), and finally administer antihypertensive medication if non-pharmacological measures fail.
Autonomic dysreflexia is a medical emergency characterized by an uninhibited sympathetic response to a noxious stimulus below the level of the spinal cord injury (typically at or above T6). The immediate priority is to lower the blood pressure to prevent a hemorrhagic stroke, which is achieved first by elevating the head of the bed (taking advantage of orthostatic hypotension). The next step is to remove any immediate cutaneous triggers by loosening tight clothing. The nurse must then systematically identify and remove the underlying noxious stimulus. Because bladder distention is the most common cause, assessing the urinary catheter or bladder is the next priority. If the bladder is not the cause, the bowel is assessed for impaction (using anesthetic to prevent further stimulation). Finally, if conservative measures fail to resolve the hypertensive crisis, short-acting antihypertensive medications are administered.

Adım Adım Çözüm

1
Place the client in a high-Fowler's position.
The client's head is elevated, promoting orthostatic reduction in blood pressure.
This is the most critical initial action to immediately lower blood pressure and prevent cerebral hemorrhage.
2
Loosen any restrictive clothing or tight devices.
Potential sensory triggers on the skin are removed.
Tactile stimuli from tight clothing can exacerbate the excessive sympathetic response.
3
Assess the indwelling urinary catheter tubing for kinks or obstruction.
The most common source of noxious stimuli is evaluated.
A distended bladder is the leading cause of autonomic dysreflexia, and resolving it often terminates the crisis.
4
Examine the rectum for fecal impaction after applying a topical anesthetic ointment.
The second most common source of noxious stimuli is evaluated.
If the bladder is empty, bowel impaction must be ruled out. Anesthetic is required to avoid worsening the sympathetic response during digital stimulation.
5
Administer the prescribed short-acting antihypertensive medication.
Blood pressure is pharmacologically lowered.
Medications are indicated if the noxious stimulus cannot be found or removed, or if the blood pressure remains dangerously high despite interventions.

Anahtar Kavram

Management of autonomic dysreflexia requires immediate positional changes to lower blood pressure, followed by rapid identification and removal of noxious stimuli, beginning with the bladder, then the bowel, prior to pharmacological intervention.
Soru 834Soru →

A nurse is preparing to perform open-system tracheostomy tube suctioning for an adult client who is experiencing audible coarse crackles and a sudden decrease in oxygen saturation. To minimize the risk of mucosal trauma and hypoxemia, arrange the following procedural steps in the correct chronological sequence. All options must be used.

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Cevap

The correct sequence ensures patient safety by prioritizing equipment preparation, pre-oxygenation, atraumatic insertion, proper positioning at the carina, safe suctioning limits, and physiological recovery.
Performing tracheostomy suctioning requires strict adherence to a specific chronological sequence to minimize the risks of hypoxemia, atelectasis, mucosal trauma, and infection. Validating a safe suction pressure (100-120 mm Hg) is the critical first step to ensure the equipment will not cause harm. Hyperoxygenation must immediately precede insertion to provide an oxygen reservoir for the client. The catheter is then inserted without suction to protect the mucosa, advanced until resistance is felt (indicating contact with the carina), and immediately withdrawn slightly (1-2 cm) to prevent mucosal invagination into the catheter tip. Suction is applied only during withdrawal, accompanied by a twisting motion, and strictly limited to 10-15 seconds to prevent profound hypoxemia. Finally, the client must be allowed to recover while being monitored before any subsequent passes are attempted.

Adım Adım Çözüm

1
Prepare and verify equipment parameters.
Wall suction is confirmed at a safe setting of 100 to 120 mm Hg for an adult.
Prevents tissue avulsion from excessive pressure and ensures functional clearance capacity.
2
Pre-oxygenate the client.
Client receives 100% oxygen prior to the procedure.
Compensates for the inevitable oxygen depletion that occurs when both air and secretions are suctioned from the airway.
3
Insert the catheter passively.
The sterile catheter is advanced down the tracheostomy tube without active suction.
Reduces friction and prevents adherence to the tracheal wall, avoiding mucosal stripping.
4
Position the catheter tip safely.
After meeting resistance at the carina, the catheter is pulled back 1 to 2 cm.
The carina is highly sensitive; direct suctioning on it causes severe trauma and can stimulate dangerous vagal bradycardia.
5
Apply active suction and remove.
Continuous suction is applied while twisting the catheter outward for 10 to 15 seconds max.
Twisting clears lateral secretions, while the strict time limit prevents profound atelectasis and hypoxia.
6
Evaluate and rest.
Vital signs and breath sounds are checked.
Determines the effectiveness of the intervention and allows the client to re-establish normal oxygenation.

Anahtar Kavram

Airway Management: Tracheostomy Suctioning Protocol
Tahmini Süre:1m 30s
Soru 835Soru →

An adult client requires a large-volume cleansing enema for the treatment of severe constipation. The nurse has gathered all necessary supplies and warmed the solution. In what order must the nurse execute the following procedural steps to safely administer the enema? (Arrange the steps in the correct chronological sequence.)

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Cevap

The correct sequence is: position the client in the left lateral Sims position, lubricate the rectal tube, insert the tube into the rectum, elevate the container to the proper height, and finally release the clamp.
Administering an enema requires a logical sequence prioritizing anatomical alignment, client safety, and comfort. Proper positioning (left lateral Sims) must occur first. The tube is then lubricated to prevent tissue injury before being gently inserted into the rectum. Once the tube is correctly placed, the container is elevated to the appropriate height to establish safe hydrostatic pressure. Only after these preparatory and positioning steps are complete should the nurse release the clamp to begin fluid instillation.

Adım Adım Çözüm

1
Determine the optimal client position.
Assist the client into the left lateral Sims position.
This uses gravity to aid fluid flow into the descending and sigmoid colon.
2
Prepare the tubing for insertion.
Lubricate the distal tip of the tube.
This minimizes mucosal irritation and prevents trauma.
3
Insert the tube.
Advance the tube 3 to 4 inches toward the umbilicus.
This ensures passage past the sphincters while respecting the bowel's natural contour.
4
Establish the correct fluid pressure.
Elevate the enema bag 12 to 18 inches above the anus.
Proper elevation prevents rapid instillation that could cause excessive cramping or damage.
5
Initiate fluid flow.
Release the tubing clamp.
This allows gravity to instill the solution slowly into the colon.

Anahtar Kavram

Cleansing Enema Administration Sequence
Soru 836Soru →

A nurse is caring for a client who is receiving continuous enteral nutrition via a nasogastric tube. Upon entering the room, the nurse observes the client coughing forcefully, expectorating formula, and displaying circumoral cyanosis. Arrange the following nursing actions in the priority order they should be performed. (Place the first action at the top and the last action at the bottom.)

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Cevap

The correct sequence is: Stop the feeding, position and suction the airway, administer oxygen, assess vital signs and lung sounds, and then notify the healthcare provider.
In any medical emergency, the nurse must first remove the immediate source of harm and then systematically follow the ABC (Airway, Breathing, Circulation) framework. Stopping the feeding halts the aspiration source. Positioning the client laterally and suctioning clears the airway. Administering oxygen supports breathing and treats cyanosis. Only after these life-saving, stabilizing interventions are performed should the nurse conduct a full diagnostic assessment and notify the provider for further orders.

Adım Adım Çözüm

1
Identify and remove the immediate threat to the client.
The continuous enteral feeding infusion is stopped.
Stopping the pump immediately halts the ongoing source of the aspiration.
2
Secure the client's airway.
The client is placed in a lateral position and the oropharynx is suctioned.
This removes formula from the airway and prevents further downward aspiration, satisfying the 'Airway' priority.
3
Support breathing and oxygenation.
Supplemental oxygen is administered.
Circumoral cyanosis indicates hypoxia; providing oxygen addresses the 'Breathing' priority after the airway is clear.
4
Assess physiological status.
Vital signs and lung sounds are obtained.
A comprehensive assessment is required to evaluate the client's response to interventions and determine the extent of pulmonary compromise.
5
Communicate clinical findings.
The primary healthcare provider is notified.
Medical intervention, such as diagnostic imaging or antibiotic therapy, will be needed following a significant aspiration event.

Anahtar Kavram

Prioritization of nursing interventions during an acute aspiration event following the ABC (Airway, Breathing, Circulation) framework.
Soru 837Soru →

A nurse is caring for a client receiving intravenous fluids via a central venous catheter. The nurse enters the room and observes that the IV tubing has disconnected from the catheter hub. The client is suddenly exhibiting severe dyspnea, tachycardia, and expresses a feeling of impending doom. Arrange the following nursing actions in the correct order of priority.

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Cevap

The correct sequence is to first clamp the catheter, then place the client in the left lateral Trendelenburg position, followed by administering high-flow oxygen, notifying the healthcare team, and finally obtaining vital signs.
In the event of a suspected air embolism from a central venous catheter, the nurse must act immediately to stop the air entry by clamping the line. The next physiological priority is to prevent the air bubble from traveling to the pulmonary circulation by placing the client in the left lateral Trendelenburg position. Once the air is trapped and further entry is prevented, oxygenation is supported with 100% oxygen to treat hypoxemia and shrink the nitrogen bubble. Only after these immediate life-saving actions are complete should the nurse call for advanced help and gather assessment data like vital signs.

Adım Adım Çözüm

1
Clamp the central venous catheter immediately.
Prevents further air from entering the circulatory system.
When an air embolism is suspected due to a disconnected central line, eliminating the source of air entry is the highest priority.
2
Position the client in the left lateral Trendelenburg position.
Displaces the air embolus to the right ventricular apex.
This positioning prevents the air from migrating into the pulmonary arterial circulation, which would cause an obstruction.
3
Administer 100% high-flow oxygen via a non-rebreather mask.
Treats hypoxemia and accelerates nitrogen absorption.
High concentrations of oxygen reduce the size of the air bubble by creating a diffusion gradient that pulls nitrogen out of the embolus.
4
Activate the Rapid Response Team and notify the healthcare provider.
Escalates care and brings advanced support to the bedside.
The client has experienced a life-threatening complication requiring advanced medical interventions and potential transfer to the intensive care unit.
5
Obtain a complete set of vital signs and initiate continuous cardiac monitoring.
Provides objective data on the client's hemodynamic status.
Assessment follows life-saving interventions to evaluate the client's response and detect complications like arrhythmias or shock.

Anahtar Kavram

Management of a Central Venous Catheter Air Embolism
Soru 838Soru →

A client with a right tibial fracture is non-weight-bearing on the affected extremity. The nurse is instructing the client on how to safely ascend a flight of stairs using axillary crutches. Arrange the following actions in the correct sequence from first to last.

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Cevap

The correct sequence for ascending stairs with crutches is to first place body weight on the crutches, step up with the unaffected leg, shift weight to the unaffected leg, and finally bring the crutches and the affected leg up to the stair tread.
When ascending stairs with crutches, the standard safety principle is 'up with the good.' The client must first stabilize their body by supporting their weight on the crutches. Next, they advance the unaffected (strong) leg up to the stair tread. Once the strong leg is firmly placed, they transfer their body weight onto it. Finally, they use the strength of the unaffected leg to lift their body, bringing both the crutches and the affected (injured) leg up to the same stair tread. This specific sequence maintains center of gravity, ensures stability, and protects the non-weight-bearing extremity from bearing an unsafe load.

Adım Adım Çözüm

1
Place weight on crutches.
The unaffected leg is free to move without compromising balance.
Ensures complete stability and a solid base of support before attempting to step up against gravity.
2
Advance the unaffected leg onto the stair.
The strong leg is positioned on the higher level.
The strong leg is required to lift the body's entire weight. This follows the 'up with the good' principle.
3
Transfer body weight to the unaffected leg.
The arms and crutches are relieved of the body's weight.
Prepares the client to lift the assistive devices and safely elevate the injured extremity.
4
Bring the crutches and affected leg up to the stair.
The entire body and assistive devices rest on the same stair tread.
Completes the upward movement while maintaining strict non-weight-bearing status on the affected leg.

Anahtar Kavram

Assistive Devices: Crutch Walking on Stairs
Soru 839Soru →

A nurse is preparing to administer an intravenous (IV) push medication through the lowest injection port of a primary IV line. The client has a single-lumen central venous catheter with a continuous infusion of a medication that is physically incompatible with the prescribed IV push drug. Arrange the following steps in the correct chronological order to safely administer this medication.

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Cevap

The correct sequence is to first stop the pump, clamp the primary tubing, flush to clear the incompatible drug, administer the IV push medication slowly, flush again at the same slow rate to clear the line, and finally unclamp and restart the pump.
Safe administration of an IV push medication through a line with an incompatible continuous infusion requires complete isolation and clearing of the catheter. The pump must be stopped and the tubing clamped to prevent retrograde flow and mixing. The line is flushed before administration to clear the incompatible fluid, and flushed after administration at the same slow rate to prevent a rapid bolus of the medication residing in the catheter's dead space.

Adım Adım Çözüm

1
Stop the continuous intravenous infusion pump.
The flow of the incompatible medication is halted without triggering pressure alarms.
Stopping the pump prevents active flow against the upcoming clamp and stops the delivery of the incompatible fluid.
2
Clamp or pinch the primary IV tubing above the injection port closest to the client.
The injection port is isolated from the rest of the primary tubing.
This prevents retrograde flow of the IV push medication up into the primary line, preventing mixture and precipitation.
3
Scrub the injection port hub, aspirate for a blood return, and flush the line with 10 mL of 0.9% sodium chloride.
The catheter lumen is completely cleared of the continuous infusion medication.
A complete flush is required to ensure no incompatible medication remains in the catheter lumen before the IV push drug is introduced.
4
Administer the prescribed IV push medication over the recommended duration.
The medication is safely delivered into the cleared line.
Administering over the recommended time prevents adverse reactions and toxicity.
5
Flush the line with 10 mL of 0.9% sodium chloride at the same rate the medication was administered.
The remaining medication in the catheter is delivered to the patient at a safe, controlled rate.
Central venous catheters have significant dead space. A rapid flush would push this residual medication into the bloodstream as a dangerous bolus.
6
Unclamp the primary IV tubing and restart the continuous intravenous infusion.
The patient's baseline continuous therapy is resumed.
Because the line is now fully cleared of the IV push drug, the incompatible continuous infusion can safely restart without risk of precipitation.

Anahtar Kavram

When administering an IV push medication through a central line with an incompatible continuous infusion, the line must be clamped and thoroughly flushed before and after administration. Crucially, the post-flush must be delivered at the same slow rate as the medication to avoid bolusing the residual drug held in the catheter's dead space.
Soru 840Soru →

A client is 3 days post-operative following an abdominal laparotomy. While coughing forcefully, the client reports a 'giving way' sensation in the abdomen. The nurse inspects the surgical site and observes that the incision has separated with a loop of bowel protruding. Arrange the following nursing actions in the correct priority sequence to mitigate further physiological risk.

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Cevap

The correct sequence is: remain with the client and call for help, position the client in low Fowler's with knees flexed, cover the bowel with sterile saline-soaked dressings, assess vital signs, and prepare for emergency surgery.
The correct sequence prioritizes immediate client safety, anatomical tension reduction, tissue preservation, and hemodynamic monitoring. The nurse must first secure the situation by staying with the client and calling for help. Next, placing the client in a low Fowler's position with knees flexed reduces intra-abdominal pressure, preventing further organ protrusion. Once help brings supplies, the nurse covers the bowel with sterile saline-soaked dressings to prevent tissue necrosis and infection. After securing the physical defect, the nurse assesses vital signs to monitor for shock, and finally prepares the client for the definitive surgical intervention.

Adım Adım Çözüm

1
Secure the environment and client safety.
The nurse remains with the client and calls for immediate assistance.
Leaving the client could result in severe injury; help is needed to obtain sterile supplies and contact the surgeon.
2
Reduce abdominal tension.
The client is placed in a low Fowler's position with knees flexed.
This specific anatomical position relaxes the abdominal muscles and prevents further evisceration.
3
Protect the exposed viscera.
The protruding organs are covered with sterile, saline-moistened dressings.
Bowel tissue can quickly become necrotic if allowed to dry; sterile saline maintains moisture and reduces infection risk.
4
Evaluate hemodynamic status.
Vital signs are assessed.
Evisceration can lead to rapid fluid shift and hypovolemic shock; close monitoring of perfusion is necessary.
5
Facilitate definitive treatment.
The client is prepared for emergency surgery.
Surgical intervention is the only definitive resolution for an abdominal evisceration.

Anahtar Kavram

Evisceration emergency management and risk reduction
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