Tüm alıştırma soruları

3881 soru

Soru 841Soru →

A laboratory technician urgently reports that a client's serum potassium level is 2.6 mEq/L2.6 \text{ mEq/L}. The healthcare provider immediately prescribes an intravenous (IV) infusion of 40 mEq40 \text{ mEq} of potassium chloride in 100 mL100 \text{ mL} of 0.9% sodium chloride to be infused over 30 minutes. Which of the following is the priority nursing action before administering this medication?

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Cevap: Withhold the medication and immediately contact the healthcare provider to clarify the unsafe infusion rate.

Cevap

The nurse's priority action is to withhold the medication and immediately contact the healthcare provider to clarify the unsafe infusion rate.
The prescribed administration rate of 40 mEq of potassium chloride over 30 minutes (equivalent to 80 mEq/hr) is dangerously high and can cause fatal cardiac arrhythmias. The maximum safe infusion rate for intravenous potassium chloride is generally 10 mEq/hr for a peripheral line and up to 20 mEq/hr for a central line with continuous cardiac monitoring. The nurse's priority is to identify this life-threatening safety violation and contact the prescribing provider to clarify the order.

Adım Adım Çözüm

1
Analyze the prescribed dosage and rate of the intravenous potassium chloride.
The prescription calls for 40 mEq40 \text{ mEq} to be infused over 30 minutes, which equates to an hourly rate of 80 mEq/hr80 \text{ mEq/hr}.
Verifying the prescription against clinical safety parameters is the first critical step in medication administration.
2
Compare the calculated rate against maximum safe administration guidelines.
The prescribed rate of 80 mEq/hr80 \text{ mEq/hr} vastly exceeds the absolute maximum safe limit of 1010 to 20 mEq/hr20 \text{ mEq/hr}.
Infusing potassium chloride too rapidly can induce severe hyperkalemia and lethal cardiac dysrhythmias, such as ventricular fibrillation.
3
Determine the priority nursing intervention based on the safety analysis.
The nurse must withhold the medication and contact the healthcare provider immediately to correct the prescription.
Nurses are legally and ethically responsible for ensuring medication safety and must actively question and halt orders that are demonstrably harmful.

Anahtar Kavram

Safe administration of high-alert intravenous medications (Potassium Chloride)
Tahmini Süre:1m 30s
Soru 842Soru →

A nurse is preparing to initiate a continuous intravenous (IV) infusion of dopamine for a client who weighs 85 kg85 \text{ kg}. The healthcare provider prescribes dopamine to infuse at 5 mcg/kg/min5 \text{ mcg/kg/min}. The available premixed IV solution contains 400 mg400 \text{ mg} of dopamine in 250 mL250 \text{ mL} of 5%5\% dextrose in water. How many mL/hr\text{mL/hr} should the nurse program the infusion pump to deliver? (Record the answer to the nearest whole number).

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Cevap: 16

Cevap

16
To safely administer a continuous weight-based IV infusion, the nurse must convert the prescribed dose (mcg/kg/min) into the pump setting format (mL/hr). This involves multiplying the client's weight by the dose to find the mcg/min, multiplying by 60 to find the mcg/hr, converting micrograms to milligrams to match the supplied medication, and dividing by the concentration of the IV bag. The exact calculation yields 15.9375 mL/hr15.9375 \text{ mL/hr}, which correctly rounds to 16 mL/hr16 \text{ mL/hr}.

Adım Adım Çözüm

1
Calculate the required dose in micrograms per minute.
85 kg×5 mcg/kg/min=425 mcg/min85 \text{ kg} \times 5 \text{ mcg/kg/min} = 425 \text{ mcg/min}
Dosing is weight-based, so the total body weight must be multiplied by the prescribed rate.
2
Convert the per-minute dose to an hourly dose.
425 mcg/min×60 min/hr=25,500 mcg/hr425 \text{ mcg/min} \times 60 \text{ min/hr} = 25,500 \text{ mcg/hr}
IV pumps are programmed in mL per hour, requiring the medication dose to be aligned with the hourly timeframe.
3
Convert the hourly dose from micrograms to milligrams.
25,500 mcg÷1000 mcg/mg=25.5 mg/hr25,500 \text{ mcg} \div 1000 \text{ mcg/mg} = 25.5 \text{ mg/hr}
The available medication concentration is provided in milligrams, so units must match before determining volume.
4
Determine the concentration of the available dopamine solution.
400 mg÷250 mL=1.6 mg/mL400 \text{ mg} \div 250 \text{ mL} = 1.6 \text{ mg/mL}
This establishes how many milligrams of dopamine are in each single milliliter of the IV fluid.
5
Calculate the infusion pump rate in mL/hr.
25.5 mg/hr÷1.6 mg/mL=15.9375 mL/hr25.5 \text{ mg/hr} \div 1.6 \text{ mg/mL} = 15.9375 \text{ mL/hr}
Dividing the required hourly dose by the concentration yields the total fluid volume needed per hour.
6
Round the final answer to the nearest whole number.
1616
The question explicitly requires recording the answer to the nearest whole number.

Anahtar Kavram

Weight-based intravenous continuous infusion rate calculation
Soru 843Soru →

A client with a closed head injury is being continuously monitored in the neuro-intensive care unit. The nurse suspects the client's intracranial pressure (ICP) is rising to a critical level, initiating the physiological adaptation known as Cushing's triad. Which of the following vital sign trends support this clinical deterioration? (Select all that apply)

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Cevap: A widening pulse pressure, with blood pressure changing from 124/78 mm Hg to 178/70 mm Hg; A gradual decrease in heart rate from 86 beats/min to 44 beats/min; An irregular respiratory pattern alternating between deep breathing and periods of apnea

Cevap

The vital sign trends that indicate Cushing's triad are a widening pulse pressure (severe systolic hypertension), a decreasing heart rate (bradycardia), and an irregular respiratory pattern.
Cushing's triad is a life-threatening physiological reflex indicating impending brain herniation. It is characterized by severe systolic hypertension causing a widening pulse pressure, profound bradycardia due to baroreceptor stimulation, and irregular respirations resulting from direct brainstem compression. The correct options directly describe these three classic adaptations.

Adım Adım Çözüm

1
Analyze the clinical scenario and the client's current risk factors.
The client has sustained a closed head injury, placing them at severe risk for increased intracranial pressure (ICP) and impaired cerebral perfusion.
Understanding the primary pathology guides the anticipation of specific physiological adaptations and decompensation patterns.
2
Identify the distinct physiological parameters that define Cushing's triad.
Cushing's triad consists of three specific signs: severe hypertension with a widened pulse pressure, bradycardia, and irregular respirations.
Cushing's response is a central nervous system reflex where the body intensely elevates systemic blood pressure to overcome high ICP, which secondarily triggers a parasympathetic slowing of the heart rate, while brainstem compression disrupts normal breathing.
3
Evaluate each answer choice against the components of Cushing's triad.
The choices describing widening pulse pressure, bradycardia, and apnea match the triad perfectly. The choices describing narrowing pulse pressure and tachycardia reflect hypovolemic shock patterns.
Accurate differentiation between neurological decompensation and systemic shock prevents fatal misinterpretations of vital sign trends.

Anahtar Kavram

Cushing's Triad and Impaired Neurological Adaptation
Soru 844Soru →

A client on the cardiac step-down unit suddenly develops severe dyspnea, audible wheezing, and expectorates pink, frothy sputum. The vital signs monitor shows an oxygen saturation of 84% on room air and a heart rate of 122 beats/min. Arrange the following nursing interventions in the most appropriate sequential order from first to last.

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Cevap

First, position the client upright with legs dangling. Second, provide supplementary oxygen. Third, administer the intravenous loop diuretic. Finally, place an indwelling urinary catheter.
The correct sequence relies on the ABCs and prioritization principles for acute physiological decompensation. In acute pulmonary edema, positional changes (high-Fowler's with legs dangling) represent the fastest, most effective non-pharmacological method to reduce preload and improve lung expansion. This is immediately followed by oxygen therapy to directly address the 84% oxygen saturation. Once basic airway and breathing mechanics are supported, pharmacological reduction of the fluid volume is initiated. Lastly, placing a catheter allows the nurse to monitor the therapeutic response to the diuretic.

Adım Adım Çözüm

1
Elevate the head of the bed to high-Fowler's and dangle the client's legs.
Decreases venous return to the right atrium and drops pulmonary venous pressure.
Positional changes are the fastest interventions to relieve respiratory distress in acute heart failure.
2
Apply high-flow oxygen via a non-rebreather mask.
Increases alveolar oxygen concentration.
The client is experiencing severe hypoxemia (84%) due to fluid in the alveoli, requiring immediate respiratory support.
3
Administer an intravenous loop diuretic.
Initiates rapid diuresis and provides mild venodilation.
Treats the underlying physiological fluid overload driving the acute pulmonary edema.
4
Insert an indwelling urinary catheter.
Allows for strict, continuous monitoring of urine output.
Required to safely evaluate the therapeutic effectiveness of the loop diuretic and monitor hemodynamic status.

Anahtar Kavram

Prioritization in Acute Pulmonary Edema
Soru 845Soru →

A nurse is caring for an older adult client who is receiving intravenous antibiotics for complicated pyelonephritis. During the mid-shift assessment, the client is restless and mildly confused. The nurse obtains the following vital signs:

ParameterCurrent ValueAdmission Baseline
Temperature37.2°C (99.0°F)37.0°C (98.6°F)
Heart Rate114 beats/min82 beats/min
Respiratory Rate24 breaths/min16 breaths/min
Blood Pressure104/84 mm Hg132/78 mm Hg

Which of the following actions is the priority for the nurse to implement?

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Cevap: Notify the healthcare provider immediately and prepare to administer an isotonic intravenous fluid bolus.

Cevap

The priority action is to notify the healthcare provider immediately and prepare to administer an isotonic intravenous fluid bolus.
The client is exhibiting classic signs of early, compensatory septic shock resulting from their systemic infection. These signs include a dramatically narrowing pulse pressure (the difference between systolic and diastolic pressure is only 20 mm Hg), tachycardia, tachypnea, and new-onset altered mental status (restlessness and confusion). Immediate medical intervention, typically beginning with rapid isotonic fluid resuscitation, is required to prevent progression to uncompensated shock.

Adım Adım Çözüm

1
Analyze the client's current vital signs compared to the admission baseline.
The client has developed significant tachycardia (114 beats/min), tachypnea (24 breaths/min), and a markedly narrowed pulse pressure (decreased from a baseline of 54 mm Hg down to 20 mm Hg).
Identifying subtle hemodynamic changes is critical for the early detection of life-threatening complications.
2
Correlate the physical assessment findings with the vital signs and underlying diagnosis.
The new-onset restlessness and confusion, combined with the concerning vital sign trends in a client with a severe systemic infection (pyelonephritis), strongly indicate inadequate cerebral and systemic tissue perfusion.
Altered mental status is frequently the earliest sign of hypoxia or decreased perfusion, particularly in the older adult population.
3
Determine the clinical priority based on the assessment data.
The client is in the early (compensatory) stage of septic shock and requires immediate medical intervention.
Prompt isotonic fluid resuscitation is necessary to restore intravascular volume, improve cardiac output, and prevent the progression to irreversible multi-organ failure.

Anahtar Kavram

Early Recognition and Management of Compensatory Septic Shock
Tahmini Süre:1m 30s
Soru 846Soru →

A client is admitted to the emergency department with an acute severe asthma exacerbation. Upon admission, the client is extremely restless, tachypneic with a respiratory rate of 34 breaths/min, and exhibiting loud, bilateral expiratory wheezes. The baseline arterial blood gas (ABG) on room air is obtained. Two hours later, after continuous bronchodilator therapy, the client becomes lethargic. The respiratory rate decreases to 14 breaths/min, and breath sounds are significantly diminished with minimal audible wheezing. A repeat ABG is drawn while the client is on a non-rebreather mask. The results are as follows:

ValueAdmission (Room Air)2 Hours Later (Non-rebreather)
pH7.507.28
PaCO228 mm Hg58 mm Hg
PaO268 mm Hg62 mm Hg
HCO3-23 mEq/L24 mEq/L

Based on these findings, which action should the nurse take first?

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Cevap: Prepare the client for immediate endotracheal intubation.

Cevap

Prepare the client for immediate endotracheal intubation.
In an acute asthma exacerbation, clients initially hyperventilate, leading to respiratory alkalosis. If the client begins to fatigue from the extreme work of breathing, ventilation decreases, causing carbon dioxide retention (respiratory acidosis). The combination of respiratory acidosis, lethargy, and diminished breath sounds (a 'silent chest') is a critical medical emergency indicating impending respiratory failure. The immediate priority is to secure the airway and initiate mechanical ventilation.

Adım Adım Çözüm

1
Analyze the baseline assessment and initial ABG.
The client was hyperventilating, causing uncompensated respiratory alkalosis (pH 7.50, PaCO2 28 mm Hg).
To establish the client's initial baseline and understand the early compensatory mechanism in an asthma attack.
2
Analyze the repeat assessment and second ABG.
The client has developed uncompensated respiratory acidosis (pH 7.28, PaCO2 58 mm Hg) and is displaying lethargy with diminished breath sounds.
To identify any clinical deterioration or significant changes in the client's respiratory status.
3
Correlate clinical findings with asthma pathophysiology.
The shift from alkalosis to acidosis, combined with lethargy and a 'silent chest' (diminished wheezing), indicates severe respiratory muscle fatigue and inability to ventilate.
To determine the true severity and meaning behind the sudden decrease in wheezing and rising CO2.
4
Determine the highest priority nursing action.
The nurse must prepare for immediate endotracheal intubation.
Impending respiratory failure requires immediate advanced airway management to prevent cardiac and respiratory arrest.

Anahtar Kavram

Identifying impending respiratory failure in an acute asthma exacerbation by recognizing the shift from respiratory alkalosis to respiratory acidosis and the clinical sign of a 'silent chest.'
Soru 847Soru →

A nurse is preparing to perform a routine scheduled dressing change for a client's central venous catheter (CVC). In what order should the nurse perform the following actions? Arrange the steps in the correct chronological sequence.

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Cevap

The correct sequence is: place mask on client -> remove old dressing -> don sterile gloves -> scrub with chlorhexidine -> allow to air dry -> apply new sterile dressing.
A central venous catheter dressing change is a sterile procedure that requires strict adherence to infection control principles. Protecting the site from respiratory droplets is the first priority. The old dressing is then carefully removed with clean gloves to avoid dislodgement. To maintain asepsis, the nurse must change to sterile gloves before cleansing the site. Chlorhexidine requires a back-and-forth friction scrub and must dry completely to be effective. Finally, the site is covered with a new sterile transparent dressing to maintain a protective barrier.

Adım Adım Çözüm

1
Place a surgical mask on the client and turn their head.
The client's respiratory droplets are directed away from the site.
Prevents contamination of the CVC site with airborne flora when the old dressing is removed.
2
Remove the existing transparent dressing.
The insertion site is exposed.
The old dressing must be removed using clean gloves, pulling toward the site to prevent dislodgement.
3
Remove clean gloves, perform hand hygiene, and don sterile gloves.
The nurse's hands are prepared for a sterile procedure.
Maintaining strict asepsis is critical before touching the exposed insertion site or using sterile cleansing supplies.
4
Scrub the insertion site with chlorhexidine.
The skin around the insertion site is disinfected.
Friction and the antiseptic properties of chlorhexidine reduce microbial count on the skin.
5
Allow the cleansed area to air dry.
The chlorhexidine achieves maximum efficacy.
Chemical disinfectants require adequate contact and drying time to destroy pathogens.
6
Apply a new sterile transparent dressing.
The CVC site is securely covered.
Provides a barrier against microorganisms while allowing nurses to monitor for infection.

Anahtar Kavram

Central Venous Catheter (CVC) Sterile Dressing Change Procedure
Tahmini Süre:1m 30s
Soru 848Soru →

The nurse is reviewing the status of four clients on a medical-surgical step-down unit. Which client requires the most immediate assessment by the nurse?

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Cevap: A client who underwent a percutaneous liver biopsy 4 hours ago and is now restless, with a heart rate of 108 bpm and a blood pressure of 106/82 mm Hg.

Cevap

The client who underwent a percutaneous liver biopsy 4 hours ago and is now restless, with a heart rate of 108 bpm and a blood pressure of 106/82 mm Hg.
The correct answer identifies a client exhibiting early, subtle signs of hypovolemic shock due to internal bleeding, a critical complication following a highly vascular procedure like a percutaneous liver biopsy. Restlessness is often the earliest sign of hypoxia and decreased cerebral perfusion. Furthermore, a narrowing pulse pressure (106 - 82 = 24 mm Hg) occurs in early shock as the sympathetic nervous system initiates peripheral vasoconstriction, which raises the diastolic pressure to compensate for decreased cardiac output. This client requires immediate assessment and intervention to prevent profound shock.

Adım Adım Çözüm

1
Analyze the clinical presentation of the client who had a liver biopsy.
The client is restless with a heart rate of 108 bpm and a pulse pressure of 24 mm Hg (106 - 82 = 24).
A highly vascular procedure like a liver biopsy carries a significant risk of bleeding. Restlessness, tachycardia, and a narrowing pulse pressure are classic early signs of hypovolemic shock.
2
Evaluate the arterial blood gas results for the client with emphysema.
The pH is normal (7.36), PaCO2 is elevated (56 mm Hg), and HCO3 is elevated (30 mEq/L).
This indicates fully compensated respiratory acidosis, which is an expected chronic baseline for severe emphysema and does not represent an acute decompensation.
3
Assess the stability of the client with viral gastroenteritis.
The client has slightly low blood pressure, dry mucous membranes, and an elevated heart rate.
While requiring intravenous or oral fluid replacement, these are signs of mild dehydration and do not indicate immediate life-threatening cardiovascular collapse.
4
Evaluate the status of the client receiving heparin therapy.
The partial thromboplastin time (PTT) is 75 seconds, and the client has mild calf pain.
A PTT of 75 seconds is within the therapeutic goal for heparin (1.5 to 2.5 times the control), and mild calf pain is expected with a deep vein thrombosis.
5
Prioritize the clients based on acuity and risk of imminent harm.
The client who underwent the liver biopsy is prioritized as the most critical.
Active internal bleeding leads to rapid decompensation and requires immediate life-saving interventions, making it the highest priority.

Anahtar Kavram

Prioritization and Early Recognition of Hypovolemic Shock
Soru 849Soru →

A nurse is preparing to administer intermittent intravenous (IV) vancomycin to a client who has a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which of the following actions should the nurse include in the medication administration process? (Select all that apply)

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Cevap: Verify the client's most recent serum creatinine and blood urea nitrogen (BUN) levels.; Program the electronic infusion pump to deliver the medication over a minimum of 60 minutes.; Confirm that a serum trough level was drawn just prior to initiating the dose.

Cevap

The correct actions are verifying renal function labs (BUN and creatinine), infusing the medication over at least 60 minutes, and confirming that a serum trough level was drawn prior to the dose.
Vancomycin is a high-alert antibiotic that requires strict nursing protocols to prevent harm. Because it is nephrotoxic, baseline and ongoing monitoring of BUN and creatinine is essential. The drug has a narrow therapeutic window, meaning trough levels must be evaluated just prior to administration to prevent toxicity. Finally, to prevent a histamine-mediated infusion reaction known as Red Man Syndrome, vancomycin must always be administered via an electronic infusion pump over a minimum of 60 minutes.

Adım Adım Çözüm

1
Evaluate the medication being administered (IV vancomycin) and identify its major risks and monitoring requirements.
Recognize that vancomycin is a potent antibiotic with known nephrotoxic and ototoxic effects, and a risk for infusion reactions.
Understanding the drug profile determines the necessary nursing assessments and administration speed.
2
Analyze each option against safe parenteral administration principles and vancomycin-specific protocols.
Identify that monitoring renal labs, checking trough levels, and infusing slowly over 60+ minutes are standard safety protocols.
These steps prevent nephrotoxicity and Red Man Syndrome.
3
Identify contraindicated actions related to IV compatibility and delegation.
Determine that Y-siting with TPN violates compatibility rules, and delegating an IV assessment violates scope of practice.
TPN requires a dedicated line, and clinical assessments cannot be delegated to UAPs.

Anahtar Kavram

Safe administration of high-alert parenteral antibiotics (Vancomycin) including monitoring, rate control, and IV compatibility.
Soru 850Soru →

During a shift assessment, the nurse receives a new prescription for 300 mg of phenytoin via intravenous (IV) push for a client with seizure activity. The client has a single peripheral IV access site currently infusing a continuous solution of 5% dextrose in 0.45% sodium chloride at 100 mL/hr. Which method of administration demonstrates the safest practice by the nurse?

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Cevap: Pausing the continuous IV fluid, flushing the access with 0.9% sodium chloride, administering the medication slowly over at least 6 minutes, and flushing again with 0.9% sodium chloride.

Cevap

The safest practice is to pause the incompatible dextrose infusion, flush the line thoroughly with normal saline (0.9% sodium chloride), administer the phenytoin over at least 6 minutes, and flush again with normal saline before restarting the continuous fluid.
Phenytoin is highly incompatible with all dextrose-containing solutions and will precipitate (crystallize) in the IV tubing if mixed. Therefore, the continuous dextrose infusion must be paused, and the line must be flushed with a compatible solution (0.9% sodium chloride) both before and after administration. Additionally, phenytoin carries a high risk for cardiovascular collapse if pushed too quickly; its administration rate must never exceed 50 mg per minute. A 300 mg dose requires a minimum administration time of 6 minutes to ensure patient safety.

Adım Adım Çözüm

1
Evaluate the compatibility of the prescribed medication with the currently infusing IV fluids.
Identify that phenytoin is incompatible with the infusing 5% dextrose in 0.45% sodium chloride.
Mixing phenytoin with dextrose causes immediate crystallization and precipitation, which can occlude the IV line or cause an embolus.
2
Determine the necessary actions to prevent precipitation in a single-access IV line.
Determine that the continuous infusion must be paused, and the line must be flushed with a compatible solution (0.9% sodium chloride) before and after medication administration.
Flushing with normal saline clears the dextrose from the line, creating a safe environment for the phenytoin.
3
Calculate the safe administration rate for the prescribed dose.
Calculate that a 300 mg dose must be administered over a minimum of 6 minutes.
Phenytoin carries a black box warning for cardiovascular risk and must not be administered faster than 50 mg/min (300 mg / 50 mg/min = 6 minutes).

Anahtar Kavram

Phenytoin IV administration safety principles: managing dextrose incompatibility and adhering to strict maximum infusion rates.
Soru 851Soru →

A nurse is caring for a client who is 6 hours postoperative following a coronary artery bypass graft (CABG). The nurse notes that the client's mediastinal chest tube drainage has abruptly stopped over the past hour. Which of the following assessment findings indicate the client is developing cardiac tamponade? Select all that apply.

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Cevap: Jugular venous distention with clear lung auscultation; Muffled and distant heart sounds upon auscultation; A decrease in systolic blood pressure of 15 mm Hg during inspiration

Cevap

The correct findings indicating cardiac tamponade are jugular venous distention with clear lungs, muffled and distant heart sounds, and a decrease in systolic blood pressure of 15 mm Hg during inspiration (pulsus paradoxus).
Cardiac tamponade is a life-threatening complication characterized by the accumulation of fluid in the pericardial sac, which compresses the heart and prevents adequate ventricular filling. This obstructive shock state classically presents with Beck's triad: jugular venous distention (due to right-sided filling resistance), muffled heart sounds (due to fluid muffling the acoustics), and hypotension with a narrowing pulse pressure. Additionally, pulsus paradoxus—a drop in systolic blood pressure greater than 10 mm Hg upon inspiration—is a hallmark assessment finding.

Adım Adım Çözüm

1
Analyze the clinical scenario and the specific risk factors involved.
The client is post-CABG with an abrupt cessation of chest tube drainage, which strongly suggests blood is pooling in the mediastinum or pericardial space, leading to cardiac tamponade.
Identifying the complication allows the nurse to anticipate the expected physiological manifestations of obstructive shock.
2
Recall the classic clinical manifestations of cardiac tamponade.
The hallmark signs are Beck's triad (hypotension, jugular venous distention, muffled heart sounds) and pulsus paradoxus.
These findings reflect the pathophysiology of fluid compressing the heart, reducing diastolic filling, and severely decreasing stroke volume.
3
Evaluate each option against the physiological changes of tamponade.
Select the options representing Beck's triad and pulsus paradoxus, while eliminating options that represent incorrect hemodynamic shifts (such as widened pulse pressure or bradycardia).
Accurate interpretation of vital signs and physical assessments is critical to distinguishing tamponade from other post-operative complications.

Anahtar Kavram

Clinical manifestations of cardiac tamponade and obstructive shock
Soru 852Soru →

A nurse is evaluating a client who is being managed for septic shock. The client presents with cool, pale extremities, a respiratory rate of 28 breaths/minute, and a serum lactate level of 6.2 mmol/L. Based on this clinical presentation, which arterial blood gas (ABG) result should the nurse anticipate?

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Cevap: pH 7.28, PaCO2PaCO_2 30 mm Hg, HCO3−HCO_3^- 14 mEq/L

Cevap

The anticipated arterial blood gas result is pH 7.28, PaCO2PaCO_2 30 mm Hg, and HCO3−HCO_3^- 14 mEq/L, representing metabolic acidosis with partial respiratory compensation.
The correct ABG result demonstrates a low pH and low bicarbonate, indicative of metabolic acidosis, along with a low PaCO2PaCO_2, reflecting partial respiratory compensation. This aligns exactly with a client in septic shock who is producing excess lactic acid (indicated by the high lactate level) and hyperventilating (28 breaths/minute) to compensate.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client has signs of poor tissue perfusion (cool, pale extremities) and an elevated serum lactate of 6.2 mmol/L.
Elevated lactate in the setting of shock indicates anaerobic metabolism and the development of lactic acidosis, a form of metabolic acidosis.
2
Determine the primary acid-base imbalance.
Metabolic acidosis, characterized by a low pH (< 7.35) and a low HCO3−HCO_3^- (< 22 mEq/L).
The accumulation of lactic acid consumes bicarbonate, leading to a direct drop in blood pH.
3
Evaluate the respiratory compensatory mechanism.
The client is tachypneic (28 breaths/minute), which blows off carbon dioxide, leading to a low PaCO2PaCO_2 (< 35 mm Hg).
The respiratory system attempts to compensate for metabolic acidosis by increasing the rate and depth of breathing to eliminate CO2CO_2, an acidic gas.

Anahtar Kavram

Acid-Base Imbalances in Shock States
Soru 853Soru →

A critical care team is managing a client with a severe hypertensive emergency, presenting with a blood pressure of 210/120 mm Hg210/120 \text{ mm Hg}. Because sodium nitroprusside can cause profound hypotension, it must be administered via a controlled infusion pump. The primary healthcare provider orders a continuous intravenous infusion starting at 4 mcg/kg/min4 \text{ mcg/kg/min}. The medication arrives from the pharmacy as a solution containing 100 mg100 \text{ mg} of sodium nitroprusside diluted in 100 mL100 \text{ mL} of normal saline. The client weighs 87 kg87 \text{ kg}.

Calculate the infusion pump rate in mL/hr\text{mL/hr}. Round the final answer to the nearest tenth.

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Cevap: 20.9

Cevap

The infusion pump should be programmed to 20.9 mL/hr20.9 \text{ mL/hr}.
To determine the correct IV pump rate, first calculate the total micrograms required per minute by multiplying the dose by the client's weight (4×87=348 mcg/min4 \times 87 = 348 \text{ mcg/min}). Next, convert this to an hourly rate (348×60=20,880 mcg/hr348 \times 60 = 20,880 \text{ mcg/hr}). Then, find the concentration of the IV solution in micrograms by converting 100 mg100 \text{ mg} to 100,000 mcg100,000 \text{ mcg}, which yields 1000 mcg/mL1000 \text{ mcg/mL}. Finally, divide the required hourly dose by the concentration (20,880÷1000=20.8820,880 \div 1000 = 20.88) and round to the nearest tenth to get 20.9 mL/hr20.9 \text{ mL/hr}.

Adım Adım Çözüm

1
Calculate the total mcg required per minute.
4 mcg/kg/min×87 kg=348 mcg/min4 \text{ mcg/kg/min} \times 87 \text{ kg} = 348 \text{ mcg/min}
The prescription is weight-based, so the ordered dose must be multiplied by the client's weight in kilograms.
2
Convert the per-minute dose to an hourly dose.
348 mcg/min×60 min/hr=20,880 mcg/hr348 \text{ mcg/min} \times 60 \text{ min/hr} = 20,880 \text{ mcg/hr}
Infusion pumps are programmed in mL per hour, requiring a time conversion from minutes to hours.
3
Determine the concentration of the medication in mcg/mL.
100 mg=100,000 mcg100 \text{ mg} = 100,000 \text{ mcg}. Concentration = 100,000 mcg÷100 mL=1000 mcg/mL100,000 \text{ mcg} \div 100 \text{ mL} = 1000 \text{ mcg/mL}.
The unit of measurement for the dose (mcg) must match the unit used for the solution concentration to accurately calculate volume.
4
Calculate the final infusion rate.
20,880 mcg/hr÷1000 mcg/mL=20.88 mL/hr20,880 \text{ mcg/hr} \div 1000 \text{ mcg/mL} = 20.88 \text{ mL/hr}. Rounded to the nearest tenth: 20.9 mL/hr20.9 \text{ mL/hr}.
Dividing the hourly dose by the concentration yields the fluid volume to be infused per hour.

Anahtar Kavram

Weight-based critical care medication continuous infusion rate calculations (mcg/kg/min to mL/hr)
Soru 854Soru →

A client admitted with severe sepsis is receiving a continuous intravenous (IV) infusion of norepinephrine through a peripheral IV catheter. The client's current blood pressure is 88/54 mm Hg88/54 \text{ mm Hg} and heart rate is 112 beats/min112 \text{ beats/min}. The healthcare provider prescribes a scheduled dose of IV pantoprazole. After consulting a drug reference, the nurse determines that norepinephrine and pantoprazole are incompatible. Which action should the nurse take?

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Cevap: Establish a second peripheral IV access site and administer the pantoprazole through the new line.

Cevap

The correct action is to establish a second peripheral IV access site and administer the pantoprazole through the new line.
When a client requires a life-sustaining continuous infusion such as a vasopressor, it cannot be safely paused. Because the newly prescribed medication is incompatible with the continuous infusion, the only safe and effective nursing action is to establish a second IV access site. This ensures the client continues to receive hemodynamic support while safely receiving the prescribed pantoprazole.

Adım Adım Çözüm

1
Identify the primary clinical problem and constraints.
The client is hypotensive and dependent on a continuous norepinephrine infusion. The prescribed pantoprazole is incompatible with norepinephrine.
Understanding drug incompatibilities and the client's hemodynamic dependence on vasopressors is essential for safe medication administration.
2
Evaluate the risk of pausing the continuous infusion.
Stopping norepinephrine, even briefly, can lead to a precipitous drop in blood pressure and profound shock.
Life-sustaining infusions must remain continuous to support circulation.
3
Determine the safest method to administer the incompatible medication.
A new, separate IV line must be inserted.
This prevents mixing incompatible drugs and allows the vasopressor to run uninterrupted.

Anahtar Kavram

Management of Incompatible IV Medications and Life-Sustaining Infusions
Soru 855Soru →

A bedside nurse is establishing the care plan for a newly admitted adult client who has a suspected Neisseria meningitidis infection. The client experiences severe photophobia and nuchal rigidity. Which of the following infection isolation interventions must be included in the client's care plan? Select all that apply.

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Cevap: Don a standard surgical mask when providing direct care within 3 feet of the client.; Place a standard surgical mask on the client during essential transport to other hospital departments.; Discontinue transmission-based precautions after the client receives 24 hours of appropriate intravenous antibiotics.

Cevap

The nurse should don a surgical mask when providing direct care, place a surgical mask on the client during essential transport, and maintain the precautions until 24 hours of effective antibiotics have been administered.
Neisseria meningitidis is spread via large respiratory droplets. Appropriate droplet precaution interventions include the nurse wearing a surgical mask during close contact, ensuring the client wears a mask during any required transport to contain secretions, and maintaining these precautions until the client has received 24 hours of effective antimicrobial therapy.

Adım Adım Çözüm

1
Identify the primary mode of transmission for Neisseria meningitidis.
Neisseria meningitidis is transmitted through large respiratory droplets.
Determining the pathogen's transmission route dictates the specific isolation category required.
2
Determine the required personal protective equipment (PPE) for droplet precautions.
A standard surgical mask is required when working within 3 feet of the client.
Large respiratory droplets do not remain suspended in the air and typically travel only short distances, making masks sufficient.
3
Evaluate transport and duration requirements for droplet precautions.
The client must wear a mask during transport, and isolation can end after 24 hours of effective antibiotic therapy.
Masking the client contains the source of infection, and 24 hours of targeted antibiotics eliminates communicability for this specific pathogen.
4
Differentiate droplet precautions from airborne and contact precautions to eliminate incorrect interventions.
Negative-pressure rooms and routine gown/glove use upon entry are excluded from the care plan.
Negative pressure is required for airborne pathogens, and routine gowning/gloving upon entry is required for contact pathogens.

Anahtar Kavram

Neisseria meningitidis requires droplet precautions, which mandate surgical masks for staff, masking the client during transport, and continuing isolation until 24 hours of targeted antibiotic therapy are completed.
Soru 856Soru →

A client admitted to the neurology step-down unit with a traumatic brain injury is agitated and repeatedly attempting to dislodge their external ventricular drain. After alternative interventions have failed, the healthcare provider prescribes bilateral soft wrist restraints. Which of the following nursing actions are appropriate to ensure client safety? Select all that apply.

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Cevap: Remove the restraints one at a time every 2 hours to perform range-of-motion exercises.; Fasten the restraint straps to the movable portion of the bed frame.; Ensure that two fingers can be easily inserted between the restraint and the client's wrist.

Cevap

The appropriate actions are to remove the restraints one at a time every 2 hours, fasten the straps to the movable portion of the bed frame, and ensure two fingers can fit under the restraint.
For a client in non-violent medical restraints, the nurse must ensure proper circulation and skin integrity by removing the restraints (one at a time) at least every 2 hours to perform range-of-motion exercises. Fastening the straps to the movable portion of the bed frame prevents injury if the bed's position is adjusted. Ensuring that two fingers can slide between the restraint and the client's wrist guarantees that the device is secure without compromising neurovascular status.

Adım Adım Çözüm

1
Identify the type of restraint and the legal and safety requirements for its use.
The client requires non-violent medical restraints to prevent the removal of a life-sustaining medical device (external ventricular drain).
Understanding the indication determines the frequency of monitoring and the specific safety protocols that must be followed.
2
Evaluate each nursing action against evidence-based safety standards for physical restraints.
Proper application (two-finger fit), correct attachment points (movable bed frame), and routine release (every 2 hours) are required standards. PRN orders, square knots, and delegating assessments to UAP are unsafe and prohibited.
Adhering strictly to restraint standards prevents patient injury, maintains adequate circulation, and ensures legal compliance.

Anahtar Kavram

Safe application, monitoring, and legal documentation of physical restraints.
Soru 857Soru →

A nurse is developing a plan of care for a client who is a devout Jehovah's Witness and is experiencing active gastrointestinal bleeding with a hemoglobin level of 6.2 g/dL (62 g/L). The client has signed an advance directive explicitly refusing blood products. Which of the following nursing interventions are appropriate for this client? Select all that apply.

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Cevap: Administer intravenous volume expanders such as lactated Ringer's solution or 0.9% sodium chloride.; Administer prescribed subcutaneous epoetin alfa and intravenous iron preparations.; Explore the client's personal willingness to accept minor blood fractions such as albumin or immunoglobulins.

Cevap

The appropriate interventions include administering intravenous volume expanders (like lactated Ringer's), administering epoetin alfa with iron, and exploring the client's willingness to accept minor blood fractions such as albumin.
Jehovah's Witnesses refuse whole blood and its four primary components: red blood cells, white blood cells, platelets, and plasma. Therefore, PRBCs and FFP are strictly prohibited. However, non-blood volume expanders (such as lactated Ringer's or 0.9% sodium chloride) and medications that stimulate red blood cell production (such as epoetin alfa and iron) are acceptable and crucial for managing severe anemia. Additionally, the acceptance of minor blood fractions (such as albumin, cryoprecipitate, or immunoglobulins) is considered a matter of personal conscience, making it essential for the nurse to explore the client's individual willingness to accept them.

Adım Adım Çözüm

1
Identify the client's religious affiliation and associated medical restrictions.
The client is a Jehovah's Witness and strictly prohibits the transfusion of whole blood and its major components.
Understanding religious doctrine is essential for providing culturally competent care and respecting patient autonomy.
2
Determine which therapies are universally acceptable within the faith.
Non-blood volume expanders and hematopoietic agents (such as epoetin alfa and iron) are fully acceptable.
These interventions help manage hypovolemia and stimulate red blood cell production without violating religious tenets.
3
Identify treatments that require individual consultation based on personal conscience.
Minor blood fractions, such as albumin or immunoglobulins, may be accepted by some individuals within the faith and refused by others.
Clarifying the client's personal stance on fractions ensures care aligns precisely with their specific beliefs.
4
Evaluate the incorrect interventions against ethical, legal, and safety standards.
Administering FFP, transfusing PRBCs during unconsciousness, and delegating treatment discussions to a UAP are recognized as violations.
A competent adult's advance directive remains valid even if incapacitated, plasma is a prohibited major component, and UAPs cannot perform medical teaching or complex assessments.

Anahtar Kavram

Culturally competent care and ethical principles for clients of the Jehovah's Witness faith who refuse blood transfusions.
Soru 858Soru →

The nursing team has just concluded the morning shift handover. Upon reviewing the client profiles, which of the following clinical presentations necessitate an immediate priority assessment? Select all that apply.

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Cevap: A client 2 hours post-total thyroidectomy who reports new-onset numbness and tingling around the lips.; A client admitted 12 hours ago with a fractured femur who suddenly develops confusion and an oxygen saturation of 88% on room air.

Cevap

The clients requiring immediate priority assessment are the one reporting numbness around the lips post-thyroidectomy and the one with a femur fracture developing confusion and hypoxia.
The correct selections involve clients experiencing acute, life-threatening complications related to airway and breathing. The post-thyroidectomy client is showing signs of hypocalcemia (circumoral paresthesia), which places them at immediate risk for laryngospasm and airway loss. The client with a femur fracture is exhibiting classic signs of fat embolism syndrome (sudden hypoxia and confusion), which is a critical respiratory emergency.

Adım Adım Çözüm

1
Analyze each client's presentation to determine if the findings represent an acute, life-threatening complication or an expected, chronic condition.
Two clients exhibit unexpected, acute airway and breathing complications.
The prioritization framework requires nurses to attend to acute airway, breathing, and circulation (ABC) issues before expected or chronic findings.
2
Evaluate the post-thyroidectomy client.
Numbness and tingling around the lips (circumoral paresthesia) is an early sign of hypocalcemia, which can rapidly progress to laryngospasm and airway obstruction.
The parathyroid glands can be accidentally removed or damaged during a thyroidectomy, causing an acute drop in serum calcium levels.
3
Evaluate the client with a fractured femur.
Sudden confusion and hypoxia are hallmark signs of fat embolism syndrome, a respiratory emergency.
Fat emboli from long bone fractures can travel to the pulmonary circulation, causing acute hypoxemia and neurologic changes.
4
Evaluate the remaining clients.
The COPD client, the post-laparoscopic client, and the concussion client all exhibit expected, stable findings for their respective conditions.
Clients with expected or chronic manifestations are lower priority compared to those with unexpected, unstable physiological changes.

Anahtar Kavram

When establishing priorities, the nurse must rapidly identify acute, unexpected findings that threaten airway, breathing, or circulation (ABCs) over chronic, expected, or stable manifestations.
Soru 859Soru →

A nurse is assessing a 24-year-old client who is 6 hours postoperative following an emergency splenectomy for blunt abdominal trauma. Which of the following assessment findings represent critical priority cues that the nurse must immediately report to the healthcare provider? (Select all that apply)

Geçerli olan tümünü seçin

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Cevap: A blood pressure of 108/88 mmHg, changed from a preoperative baseline of 124/76 mmHg; A steady increase in heart rate from 86 to 118 beats per minute over the last two hours; A total urine output of 40 mL collected in the indwelling catheter over the past 2 hours

Cevap

The critical findings that must be reported are the narrowed pulse pressure (108/88 mmHg), the steadily increasing heart rate (86 to 118 bpm), and the low urine output (40 mL over 2 hours).
The client is at high risk for internal hemorrhage and hypovolemic shock following a splenectomy for blunt trauma. Early physiological indicators of compensatory shock include a narrowing pulse pressure (the difference between systolic and diastolic pressure), unexplained progressive tachycardia, and oliguria (urine output less than 30 mL/hr). These findings indicate decreased systemic perfusion and require immediate intervention to prevent irreversible shock.

Adım Adım Çözüm

1
Identify the client's clinical context and time frame.
The client is 6 hours postoperative following a major abdominal surgery (splenectomy) for trauma, placing them at high risk for acute internal hemorrhage and hypovolemic shock.
Establishing the clinical context helps differentiate between expected postoperative recovery findings and signs of life-threatening complications.
2
Evaluate the vital sign trends for signs of hemodynamic instability.
The blood pressure shows a narrowing pulse pressure (dropping from a difference of 48 mmHg to 20 mmHg) and the heart rate is steadily increasing. Both are early compensatory mechanisms for decreased stroke volume.
Recognizing early shock is critical before profound hypotension (decompensation) occurs.
3
Assess organ perfusion indicators, such as urine output.
The urine output is 20 mL/hr (40 mL over 2 hours), which is critically below the minimum adult threshold of 30 mL/hr.
Oliguria indicates that the body is shunting blood away from the kidneys to preserve vital organs, confirming poor systemic perfusion.
4
Differentiate expected postoperative findings from priority cues.
Mild fever, minimal serosanguineous drainage, and hypoactive bowel sounds are all expected 6 hours after abdominal surgery and do not require immediate notification.
Prioritization requires the nurse to filter out expected benign findings to focus entirely on immediate life threats.

Anahtar Kavram

Early recognition of hypovolemic shock involves identifying compensatory mechanisms such as tachycardia, narrowing pulse pressure, and decreased urine output, rather than waiting for profound hypotension.
Soru 860Soru →

Midway through the day shift on an active gastroenterology unit, a registered nurse (RN) is coordinating client care tasks with a licensed practical nurse (LPN/VN) and an unlicensed assistive personnel (UAP). Which of the following task assignments are appropriate for the RN to make? Select all that apply.

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Cevap: Instructing the UAP to record the color and total volume of drainage from a client's nasogastric tube canister.; Assigning the LPN/VN to administer a scheduled subcutaneous injection of enoxaparin to a client awaiting discharge.; Asking the LPN/VN to reinforce low-residue dietary guidelines with a client who received their primary nutritional education from the RN yesterday.

Cevap

The correct task assignments include having the UAP record nasogastric tube drainage, assigning the LPN/VN to administer a scheduled subcutaneous enoxaparin injection, and asking the LPN/VN to reinforce previously taught dietary guidelines.
The appropriate delegations follow the core principles of the National Council of State Boards of Nursing (NCSBN). The RN may delegate standard, predictable procedures to competent team members. Reinforcing education that was already initiated by the RN falls safely within the scope of practice for an LPN/VN. Similarly, administering subcutaneous injections, such as enoxaparin, is a standard task for an LPN/VN caring for a stable client. Unlicensed assistive personnel (UAP) can safely perform routine data collection and standard procedures on stable clients, which includes measuring and documenting the volume and color of drainage from a nasogastric tube. None of these correct tasks involve initial assessment, primary teaching, or clinical evaluation.

Adım Adım Çözüm

1
Analyze the client acuity and the nature of each task proposed in the assignments.
Identified tasks involving data collection, medication administration, teaching, assessment, and evaluation.
Delegation requires matching the complexity of the task with the competency and legal scope of practice of the healthcare team member.
2
Apply the core principles of delegation, recalling that the RN cannot delegate clinical judgment, evaluation, or primary teaching.
Tasks requiring clinical assessment, triage decision-making, and outcome evaluation are flagged as inappropriate for delegation.
These tasks represent core RN responsibilities that ensure client safety and cannot be legally transferred.
3
Match the remaining routine tasks to the documented scope of practice for the LPN/VN and UAP.
Routine medication administration, reinforcement of existing teaching, and basic output measurement are confirmed as appropriate delegations.
Standard, predictable procedures on stable clients are safely within the scope of practice for LPN/VNs and UAPs.

Anahtar Kavram

Delegation Principles and Scope of Practice
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