Tüm alıştırma soruları

3881 soru

Soru 901Soru →

A nurse is caring for a client receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes into the transfusion, the client reports sudden chills, severe lower back pain, and shortness of breath. In what chronological order should the nurse perform the following actions to reduce the risk of further physiological deterioration? Arrange the actions from first to last.

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Cevap

The correct sequence is: Stop the transfusion, replace the IV tubing with normal saline, assess the client, notify the provider and blood bank, and finally return the blood products to the blood bank.
In any severe adverse reaction, the immediate priority is to stop the offending agent. Following cessation, maintaining vascular access with new tubing and normal saline ensures the client can receive emergency treatments without receiving more blood. Only after stabilizing the line should the nurse assess the client fully to gather data for the provider. Notification follows assessment, and administrative tasks (returning the bag for investigation) are completed last.

Adım Adım Çözüm

1
Stop the blood transfusion immediately.
The flow of incompatible blood into the client is halted.
This is the most critical first step to minimize the severity of the acute hemolytic reaction and prevent further physiological deterioration.
2
Replace the IV tubing and infuse 0.9% sodium chloride.
Intravenous access is maintained without administering additional blood.
Flushing the existing tubing would push more blood into the client. New tubing ensures safety while keeping the vein open for emergency medications.
3
Assess the client's vital signs and clinical status.
Current physiological data (blood pressure, oxygenation, heart rate) is obtained.
The nurse needs accurate, up-to-date assessment data to effectively communicate the client's condition to the healthcare provider.
4
Notify the primary healthcare provider and the blood bank.
The medical team is alerted and treatment orders can be obtained.
The provider must prescribe interventions (e.g., oxygen, fluids, diuretics, vasopressors) to manage the systemic reaction.
5
Return the blood bag and tubing to the blood bank.
The blood products are prepared for investigation.
The blood bank must analyze the remaining blood, tubing, and records to determine the exact cause of the adverse reaction.

Anahtar Kavram

Management of acute hemolytic transfusion reactions prioritizes immediately stopping the causative agent, maintaining hemodynamic stability, and communicating findings.
Soru 902Soru →

A nurse is preparing to administer ondansetron 4 mg4 \text{ mg} via intravenous (IV) push to a client experiencing nausea. The medication vial is labeled 2 mg/mL2 \text{ mg/mL}. How many milliliters (mL) should the nurse administer?

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Cevap: 2 mL2 \text{ mL}

Cevap

2 mL2 \text{ mL}
The correct volume is calculated by taking the desired dose (4 mg4 \text{ mg}), dividing it by the available concentration (2 mg2 \text{ mg}), and multiplying by the volume (1 mL1 \text{ mL}). This mathematically evaluates to 2 mL2 \text{ mL}, which is the correct volume to administer the prescribed dose.

Adım Adım Çözüm

1
Identify the prescribed dose (Desired) and the available concentration (Have).
Desired = 4 mg4 \text{ mg}, Have = 2 mg2 \text{ mg} in 1 mL1 \text{ mL}.
These values are needed for the standard dosage calculation formula.
2
Apply the dosage calculation formula: (Desired / Have) ×\times Volume.
(4 mg/2 mg)×1 mL=2 mL(4 \text{ mg} / 2 \text{ mg}) \times 1 \text{ mL} = 2 \text{ mL}.
This determines the exact volume of medication to administer to deliver the prescribed dose safely.

Anahtar Kavram

Intravenous Medication Dosage Calculation
Soru 903Soru →

A nurse is preparing to administer an initial intravenous (IV) loading dose of phenytoin to a client diagnosed with a seizure disorder. The client has an existing continuous IV infusion of 5% dextrose in water (D5W) running at 75 mL/hr. Which action should the nurse take to ensure safe administration of the medication?

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Cevap: Pause the primary infusion and flush the line with 0.9% sodium chloride before and after administering the medication.

Cevap

Pause the primary infusion and flush the line with 0.9% sodium chloride before and after administering the medication.
Phenytoin is strictly incompatible with dextrose solutions such as D5W. When mixed, the medication will rapidly crystallize and precipitate in the IV tubing. To administer the medication safely, the nurse must pause the dextrose infusion and flush the line thoroughly with a compatible solution, specifically 0.9% sodium chloride (normal saline), both before and after the phenytoin is given.

Adım Adım Çözüm

1
Identify the compatibility of the prescribed medication (phenytoin) with the current continuous IV fluid (5% dextrose in water).
Determine that phenytoin is highly incompatible with dextrose-containing solutions and will precipitate if mixed.
Administering incompatible medications together can cause crystallization in the IV line, creating an embolism risk and rendering the medication ineffective.
2
Determine the appropriate intervention to administer the medication safely through the existing IV access.
Decide to pause the dextrose infusion and clear the line.
The line must be completely free of dextrose before the phenytoin is introduced.
3
Select the correct flush solution to use before and after the medication administration.
Select 0.9% sodium chloride (normal saline) to flush the IV tubing.
Normal saline is the only widely accepted compatible IV fluid for phenytoin administration.

Anahtar Kavram

Phenytoin Intravenous Compatibility and Administration Principles
Soru 904Soru →

A nurse is evaluating a client who has been receiving continuous nasogastric (NG) suctioning for 3 days due to a paralytic ileus. The client reports new-onset severe muscle cramping and palpitations. The cardiac monitor displays frequent premature ventricular contractions (PVCs). The client's respiratory rate is 10 breaths/min and shallow. Arterial blood gas (ABG) results are: pH 7.54, PaCO2 49 mm Hg, PaO2 88 mm Hg, and HCO3 35 mEq/L. To reduce the risk of impending physiological decompensation, which action is the nurse's priority?

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Cevap: Initiate a prescribed intravenous potassium chloride protocol.

Cevap

The correct action is to initiate a prescribed intravenous potassium chloride protocol.
The client is experiencing metabolic alkalosis resulting from the loss of gastric acid via prolonged nasogastric suctioning. Gastric secretions are rich in both hydrogen and potassium ions; therefore, significant depletion leads to severe hypokalemia. The client's symptoms of muscle cramping, palpitations, and frequent premature ventricular contractions (PVCs) are classic signs of hypokalemia and represent an immediate, life-threatening risk for lethal ventricular dysrhythmias. The priority action is to stabilize the myocardium by initiating a prescribed potassium chloride replacement protocol. The client's decreased respiratory rate and elevated PaCO2 represent an expected and necessary compensatory mechanism to retain acid and lower the blood pH.

Adım Adım Çözüm

1
Analyze the arterial blood gas (ABG) results and clinical presentation.
The ABG reveals metabolic alkalosis (pH 7.54, HCO3 35 mEq/L) with partial respiratory compensation (PaCO2 49 mm Hg). The clinical signs (muscle cramping, palpitations, PVCs) strongly indicate severe hypokalemia.
Prolonged nasogastric suctioning removes hydrochloric acid and potassium from the stomach, leading to an alkalotic state and severe potassium depletion.
2
Identify the most immediate life-threatening risk to the client.
The frequent premature ventricular contractions (PVCs) indicate a high risk for lethal ventricular dysrhythmias.
Hypokalemia increases myocardial excitability, making the heart vulnerable to fatal arrhythmias like ventricular tachycardia or ventricular fibrillation.
3
Determine the priority nursing action based on the physiological risk.
The nurse must prioritize administering potassium chloride.
Replacing potassium directly addresses the immediate cardiac threat and stabilizes the myocardial cells, which takes precedence over other non-emergent interventions.

Anahtar Kavram

Identifying and managing fluid, electrolyte, and acid-base imbalances associated with therapeutic procedures to prevent life-threatening cardiac complications.
Tahmini Süre:2m 0s
Soru 905Soru →

A nurse is preparing to administer sodium nitroprusside to a client experiencing a hypertensive emergency. The client weighs 78 kg78 \text{ kg}. The prescribed continuous intravenous infusion rate is 4 mcg/kg/min4 \text{ mcg/kg/min}. The pharmacy provides a prepared IV bag containing 50 mg50 \text{ mg} of sodium nitroprusside in 250 mL250 \text{ mL} of 5%5\% dextrose in water (D5W).

Calculate the required infusion pump rate in mL/hr\text{mL/hr}. (Record your answer to the nearest whole number.)

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Cevap: 94

Cevap

94
To determine the correct infusion pump rate, the calculation must account for the client's weight, the desired dose per minute, the time conversion to hours, and the available concentration of the medication. The calculation requires converting the prescribed 4 mcg/kg/min4 \text{ mcg/kg/min} to an hourly rate based on the 78 kg78 \text{ kg} weight, resulting in 18,720 mcg/hr18,720 \text{ mcg/hr}. The available concentration is calculated by converting 50 mg50 \text{ mg} to 50,000 mcg50,000 \text{ mcg} and dividing by 250 mL250 \text{ mL}, which is 200 mcg/mL200 \text{ mcg/mL}. Dividing the hourly dose by the concentration yields the required volume of 93.6 mL/hr93.6 \text{ mL/hr}, which rounds to 94 mL/hr94 \text{ mL/hr}.

Adım Adım Çözüm

1
Calculate the total required dose in micrograms per minute.
4 mcg/kg/min×78 kg=312 mcg/min4 \text{ mcg/kg/min} \times 78 \text{ kg} = 312 \text{ mcg/min}
To determine the specific amount of medication the client needs every minute based on their body weight.
2
Convert the required dose from micrograms per minute to micrograms per hour.
312 mcg/min×60 minutes/hr=18,720 mcg/hr312 \text{ mcg/min} \times 60 \text{ minutes/hr} = 18,720 \text{ mcg/hr}
Infusion pumps are programmed in mL/hr\text{mL/hr}, so the total dose required per hour must be established before finding the fluid volume.
3
Determine the concentration of the provided IV solution in micrograms per milliliter.
50 mg=50,000 mcg50 \text{ mg} = 50,000 \text{ mcg}. Then, 50,000 mcg÷250 mL=200 mcg/mL50,000 \text{ mcg} \div 250 \text{ mL} = 200 \text{ mcg/mL}
To find out exactly how much medication is contained in a single milliliter of the provided IV fluid.
4
Calculate the exact infusion pump rate.
18,720 mcg/hr÷200 mcg/mL=93.6 mL/hr18,720 \text{ mcg/hr} \div 200 \text{ mcg/mL} = 93.6 \text{ mL/hr}
Dividing the hourly dose by the concentration yields the exact volume of fluid that must be delivered per hour.
5
Round the calculated infusion rate as directed in the question.
Round 93.693.6 to the nearest whole number, resulting in 9494.
The question explicitly requires the final answer to be recorded to the nearest whole number.

Anahtar Kavram

Weight-based intravenous medication dosage calculation converting mcg/kg/min to mL/hr.
Soru 906Soru →

A 78-year-old client with advanced Alzheimer's disease, severe kyphosis, and a recent right hemispheric stroke resulting in right homonymous hemianopsia and dysphagia is admitted to a palliative care unit. The client is completely bedbound, non-verbal, and grimaces frequently when turned. When planning the client's basic care and comfort interventions, which of the following actions should the nurse include in the plan of care? (Select all that apply.)

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Cevap: Position the overbed table and initiate communication primarily from the client's left side to accommodate the visual field deficit.; Support the client's head, neck, and upper shoulders with customized pillow placement when lying supine to accommodate the altered spinal curvature.; Perform oral hygiene using a soft suction toothbrush, carefully inspecting the buccal mucosa for pocketed food after every meal.

Cevap

The correct basic care interventions include approaching the client from their unaffected visual field (the left side), supporting their kyphotic spinal curvature with customized pillows, and performing meticulous oral care with buccal inspections to clear pocketed food.
For a client with right homonymous hemianopsia, the right half of the visual field is absent; therefore, the nurse must approach and place objects on the unaffected left side to prevent startling the client. Severe kyphosis alters the spine's natural alignment; forcing the client flat can cause severe discomfort and compromise the airway, requiring the head and neck to be supported with pillows. Dysphagia following a stroke often leads to food pocketing in the cheeks on the affected side, requiring meticulous oral care with a suction toothbrush to prevent the delayed aspiration of residual food.

Adım Adım Çözüm

1
Analyze the neurological deficits (right homonymous hemianopsia and dysphagia) to determine safe interaction and hygiene practices.
The nurse must approach from the left side where vision is intact, and use a suction toothbrush to clear pocketed food, preventing aspiration.
Neurological deficits directly impact how a client interacts with their environment and their ability to swallow safely.
2
Evaluate the musculoskeletal status (severe kyphosis) to guide positioning.
The head and neck must be supported with pillows when supine to maintain the kyphotic curvature.
Forcing a kyphotic spine flat against a bed causes severe musculoskeletal pain and airway compromise due to extreme neck extension.
3
Assess the behavioral indicators of pain in the context of dementia.
Grimacing must be recognized as acute pain requiring intervention, not dismissed as normal aging.
Clients with advanced Alzheimer's cannot verbalize pain; behavioral cues are reliable indicators of distress.
4
Review skin integrity guidelines and delegation rules for high-risk clients.
Donut cushions are contraindicated for pressure relief, and feeding a dysphagic stroke client cannot be delegated to a UAP.
Donut cushions cause tissue ischemia. UAPs lack the clinical judgment to assess swallowing mechanisms and early signs of aspiration.

Anahtar Kavram

Complex Synthesis of Basic Care and Comfort in Geriatric Neurological Clients
Soru 907Soru →

A community health nurse is developing a population health program and mentoring a nursing student on the levels of disease prevention. The nurse asks the student to identify an example of tertiary prevention. Which of the following examples provided by the student indicates a correct understanding?

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Cevap: Teaching a client who recently survived a myocardial infarction how to implement energy conservation techniques during activities of daily living.

Cevap

The intervention that involves teaching energy conservation techniques to a myocardial infarction survivor.
Tertiary prevention involves interventions directed at clients who already have a chronic disease or are recovering from a severe health event. The goal is to minimize disease progression, prevent complications, and maximize the client's functional capacity. Teaching a myocardial infarction survivor how to manage daily activities safely is a classic example of rehabilitative tertiary care.

Adım Adım Çözüm

1
Define tertiary prevention.
Tertiary prevention focuses on individuals who already have a symptomatic disease or disability, aiming to soften the impact, prevent complications, and restore function.
Establishing the correct definition is necessary to evaluate the interventions presented in the options.
2
Evaluate the immunization clinic intervention.
Vaccines prevent disease before it ever occurs, which classifies strictly as primary prevention.
This identifies the correct prevention level for immunizations and eliminates it as an answer.
3
Evaluate the cognitive screening intervention.
Screenings are secondary prevention (early detection). Furthermore, attributing sudden severe confusion to normal aging is a critical clinical error.
This rules out the option based on both an incorrect prevention level and a dangerous clinical misconception.
4
Evaluate the burn prevention workshop intervention.
Prevention education is primary prevention. Also, using abstract reasoning is developmentally inappropriate for three-year-old children.
This rules out the option due to an incorrect prevention level and flawed developmental application.
5
Evaluate the myocardial infarction teaching intervention.
This intervention targets a client with an established disease to optimize their cardiac function and prevent complications from overexertion, which perfectly fits the definition of tertiary prevention.
This confirms the correct answer.

Anahtar Kavram

Levels of Disease Prevention
Tahmini Süre:1m 30s
Soru 908Soru →

A clinic nurse is developing a health promotion and lifestyle modification plan for a 68-year-old client with newly diagnosed prediabetes and mild osteoarthritis. Which of the following nursing interventions and teaching points are appropriate? Select all that apply.

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Cevap: Instruct the client to replace saturated fats with olive oil and increase the daily intake of fresh vegetables.; Recommend low-impact physical activities, such as water aerobics, for 30 minutes on most days of the week.; Teach the client to establish a consistent sleep-wake schedule to improve overall sleep hygiene and metabolic regulation.

Cevap

The appropriate interventions are instructing the client on dietary changes (using olive oil and vegetables), recommending low-impact exercises like water aerobics, and teaching the importance of a consistent sleep-wake schedule.
Effective health promotion for a client with prediabetes and osteoarthritis requires a multifaceted lifestyle approach. Substituting saturated fats with unsaturated fats like olive oil helps manage insulin resistance and cardiovascular risk. Low-impact exercises, such as water aerobics, promote necessary physical activity while minimizing stress on vulnerable osteoarthritic joints. Additionally, a consistent sleep schedule improves sleep hygiene, which is vital for metabolic regulation and overall health.

Adım Adım Çözüm

1
Analyze the client's clinical profile.
The client is an older adult (68 years old) requiring lifestyle management for prediabetes and mild osteoarthritis.
Understanding the client's specific diagnoses ensures that selected lifestyle modifications are safe and physiologically appropriate.
2
Evaluate the evidence-based lifestyle modification options.
Dietary changes (unsaturated fats/vegetables), low-impact joint-friendly exercise, and good sleep hygiene are all correct primary interventions.
These interventions directly target insulin resistance and physical deconditioning while accommodating the client's joint limitations.
3
Identify and eliminate options containing nursing misconceptions or nontherapeutic actions.
Options presenting screening as primary prevention, severe pain as normal aging, and 'why' questions as therapeutic are eliminated.
Nurses must apply correct levels of prevention, distinguish pathology from normal aging, and use therapeutic communication to effectively support lifestyle changes.

Anahtar Kavram

Evidence-Based Lifestyle Modifications and Health Promotion Strategies
Soru 909Soru →

A surgical unit nurse is evaluating the clinical status of four clients who recently underwent major abdominal procedures. Based on the documented assessments, which client finding should the nurse recognize as the earliest physiological indicator of a developing hemorrhagic shock state?

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Cevap: A resting heart rate increasing from 7676 to 9898 beats per minute and a progressively narrowing pulse pressure

Cevap

The earliest indicator is a resting heart rate increasing from 76 to 98 beats per minute and a progressively narrowing pulse pressure.
During the initial (compensated) stage of hemorrhagic shock, the body's physiological adaptation involves activating the sympathetic nervous system to maintain adequate tissue perfusion. This response triggers peripheral vasoconstriction (which elevates diastolic pressure and narrows the pulse pressure) and an increased heart rate to sustain cardiac output long before the systolic blood pressure drops.

Adım Adım Çözüm

1
Analyze the physiological phases of hemorrhagic shock.
Identify that the initial (compensatory) stage involves sympathetic nervous system activation to maintain cardiac output before blood pressure falls.
Understanding the timeline of shock progression is necessary to distinguish early signs from late decompensation.
2
Evaluate the clinical findings in each option against the compensatory shock phase.
Tachycardia and a narrowing pulse pressure match the expected peripheral vasoconstriction of the compensatory phase.
Vasoconstriction raises diastolic blood pressure, narrowing the gap between systolic and diastolic values (pulse pressure) while the heart pumps faster to compensate for volume loss.
3
Rule out alternative distractors reflecting late shock, normal findings, or positional changes.
Severe hypotension is a late sign, the ABG values are entirely normal, and orthostatic changes upon standing are expected positional responses.
Eliminating findings that do not fit the specific criteria of 'earliest systemic shock indicator' confirms the correct choice.

Anahtar Kavram

Early Compensatory Mechanisms in Hypovolemic/Hemorrhagic Shock
Soru 910Soru →

An occupational health nurse is evaluating an employee who appears visibly unwell after returning from a lunch break. The employee confidentially admits to attempting to stop using prescribed hydrocodone without medical assistance, stating, 'My last dose was over 24 hours ago.' Which assessment findings corroborate that this individual is experiencing acute opioid withdrawal? Select all that apply.

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Cevap: Rhinorrhea and excessive tearing; Diffuse muscle aches and visible piloerection; Increased bowel motility and reports of abdominal cramping

Cevap

The correct findings are rhinorrhea and excessive tearing, diffuse muscle aches and visible piloerection, and increased bowel motility with abdominal cramping.
Opioid withdrawal produces a rebound excitability of the sympathetic nervous system because the central nervous system depressant effect of the drug is abruptly removed. Classic manifestations of this hyperactive state include rhinorrhea (runny nose), lacrimation (tearing), diaphoresis, piloerection (goosebumps), muscle aches, mydriasis (pupillary dilation), insomnia, agitation, and gastrointestinal distress such as abdominal cramping and diarrhea.

Adım Adım Çözüm

1
Analyze the client's history and timeline.
The client abruptly stopped taking hydrocodone (an opioid) after prolonged use, with the last dose over 24 hours ago.
Identifies that the client is at the correct time interval to experience acute opioid withdrawal syndrome.
2
Differentiate between the physiological effects of opioid intoxication and withdrawal.
Opioid intoxication causes CNS and parasympathetic depression (lethargy, constricted pupils, constipation), while withdrawal causes sympathetic nervous system rebound (restlessness, dilated pupils, diarrhea, piloerection, rhinorrhea).
Clarifies the underlying physiological mechanism driving the clinical manifestations.
3
Evaluate each option against the expected signs of sympathetic rebound.
Rhinorrhea, tearing, piloerection, muscle aches, and abdominal cramping accurately reflect the hyperactive withdrawal state. Pupillary constriction and lethargy reflect the depressed intoxication state.
Determines which options correctly answer the stem.

Anahtar Kavram

Opioid Withdrawal Syndrome Manifestations
Soru 911Soru →

A nurse is planning care and safety protocols for a client who is receiving internal radiation therapy (brachytherapy) via a sealed vaginal implant for cervical cancer. Which of the following nursing actions are appropriate to ensure the safe handling of the environment and minimize hazardous exposure? Select all that apply.

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Cevap: Assigning the client to a private room with a private bathroom.; Wearing a personal dosimeter film badge whenever providing direct care in the room.; Ensuring a lead-lined container and long-handled forceps are kept in the client's room at all times.

Cevap

The appropriate actions include assigning the client to a private room with a private bathroom, wearing a personal dosimeter film badge when in the room, and ensuring a lead-lined container with long-handled forceps is always kept in the room.
Clients with sealed internal radiation implants pose a direct radiation hazard to others. They must be placed in a private room with a private bathroom to maximize distance and minimize exposure to other patients and staff. A personal dosimeter film badge is required for any staff member entering the room to accurately measure and monitor their cumulative radiation exposure over time. Additionally, a lead-lined container and long-handled forceps must always be present in the room; if the radioactive source accidentally dislodges, the nurse must use the forceps to place the implant into the lead container safely without direct physical contact.

Adım Adım Çözüm

1
Identify the primary hazard associated with the scenario.
The client has a sealed internal radiation implant (brachytherapy), which poses a continuous radiation hazard to anyone in close proximity.
Understanding the nature of the hazard dictates the required environmental and personal safety precautions.
2
Evaluate standard radiation safety principles (time, distance, and shielding).
Safety protocols require limiting time near the source, maximizing distance (private room), and using shielding (lead container) alongside exposure monitoring (dosimeter badge).
These principles minimize hazardous exposure to healthcare workers and the public.
3
Analyze each option against radiation safety guidelines and nursing delegation boundaries.
Options involving a private room, dosimeter usage, and emergency lead containers are correct. Options involving the removal of linens or delegating education to a UAP violate safety and scope of practice rules.
Linens must stay in the room to prevent accidental loss of the implant, and teaching is strictly an RN responsibility.

Anahtar Kavram

Radiation Safety and Brachytherapy Precautions
Soru 912Soru →

Following an admission for severe pneumonia, a client's clinical status begins to deteriorate. Which of the following initial assessment findings should alert the nurse to the early development of septic shock?

Cevabı ve açıklamayı göster

Cevap: Warm, flushed skin with a bounding pulse

Cevap

Warm, flushed skin with a bounding pulse
The early phase of septic shock, known as the 'warm phase,' is characterized by a hyperdynamic cardiovascular response. Systemic inflammatory mediators cause massive vasodilation, resulting in warm, flushed skin, tachycardia, and bounding pulses. This is a unique physiological adaptation distinct from the initial presentations of other shock types.

Adım Adım Çözüm

1
Analyze the client's condition and the specific stage of the complication being asked.
The client has severe pneumonia and is at risk for septic shock. The question specifically asks for 'early' signs.
Different stages of shock present with distinct physiological signs.
2
Recall the pathophysiology of early septic shock.
Early septic shock is unique because endotoxins cause massive systemic vasodilation while the heart initially compensates by pumping harder (hyperdynamic state).
Understanding the mechanism helps differentiate early septic shock from hypovolemic or cardiogenic shock.
3
Correlate the pathophysiological changes with observable clinical findings.
Massive vasodilation with high cardiac output manifests clinically as warm, flushed skin, tachycardia, and a bounding pulse.
This contrasts with the late phase of shock, where the heart begins to fail and the skin becomes cold and clammy.

Anahtar Kavram

Early Septic Shock Presentation
Soru 913Soru →

A nurse is evaluating the most recent arterial blood gas (ABG) results for a client who was admitted with a severe asthma exacerbation. The results are: pH 7.28, PaCO2 56 mm Hg, and HCO3 24 mEq/L. Which of the following acid-base imbalances should the nurse identify?

Cevabı ve açıklamayı göster

Cevap: Uncompensated respiratory acidosis

Cevap

Uncompensated respiratory acidosis
The client's pH is below the normal range (7.35-7.45), indicating acidosis. The PaCO2 is elevated above the normal range (35-45 mm Hg), which points to a respiratory cause. The bicarbonate (HCO3) level is within the normal range (22-26 mEq/L), meaning the kidneys have not yet begun to compensate. Therefore, the results definitively indicate uncompensated respiratory acidosis.

Adım Adım Çözüm

1
Evaluate the pH level to determine if the client is in acidosis or alkalosis.
The pH is 7.28, which is less than the normal range of 7.35 to 7.45, indicating acidosis.
Determining the primary acid-base status is the first step in ABG interpretation.
2
Evaluate the PaCO2 level to determine if the cause is respiratory.
The PaCO2 is 56 mm Hg, which is greater than the normal range of 35 to 45 mm Hg, indicating a respiratory etiology for the acidosis.
Identifying whether the respiratory parameter aligns with the pH abnormality determines if it is a primary respiratory issue.
3
Evaluate the HCO3 level to determine if the body has begun to compensate.
The HCO3 is 24 mEq/L, which is within the normal range of 22 to 26 mEq/L.
A normal metabolic parameter in the presence of an abnormal pH and respiratory parameter indicates that renal compensation has not yet occurred.

Anahtar Kavram

Interpretation of uncompensated arterial blood gas (ABG) values
Soru 914Soru →

A nurse is inserting a nasogastric (NG) tube for enteral nutrition in an alert adult client. Arrange the following procedural steps in the exact chronological sequence to ensure safe insertion and minimize the risk of tracheal intubation.

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Cevap

The correct sequence for nasogastric tube insertion is: measuring the tube length (NEX method), positioning the neck in hyperextension for initial nasal insertion, flexing the neck forward once the oropharynx is reached, advancing the tube during active swallowing, and finally securing the tube and confirming placement via radiograph.
The correct sequence prioritizes anatomical alignment and airway protection. Measurement (NEX method) establishes the depth baseline. Initial neck hyperextension aligns the nasal passage for the tube's entry. Once the tube hits the posterior pharynx (oropharynx), switching to neck flexion (chin-to-chest) is critical as it closes the epiglottis, shielding the trachea. Advancing specifically during swallowing capitalizes on natural esophageal peristalsis. Finally, securing the tube and obtaining an x-ray is the universal standard for verifying safe gastric placement before use.

Adım Adım Çözüm

1
Measure the tube from the tip of the nose to the earlobe, and then to the xiphoid process.
The target insertion depth is established.
Determining the correct length ensures the tube reaches the stomach rather than remaining in the esophagus or coiling.
2
Instruct the client to extend their neck backward as the tube is inserted into the naris.
The tube passes smoothly through the nasal cavity.
Neck hyperextension straightens the nasopharyngeal pathway, reducing resistance and mucosal trauma.
3
Stop advancement at the oropharynx and instruct the client to bring their chin to their chest.
The epiglottis closes over the larynx.
Forward flexion physically blocks the airway (trachea), directing the tube toward the posterior esophagus.
4
Advance the tube steadily while the client swallows small sips of water.
The tube reaches the predetermined measurement mark.
Swallowing peristalsis pulls the tube downward while the elevated larynx further protects the airway.
5
Secure the tube and prepare for an abdominal radiograph.
The procedure is safely concluded pending confirmation.
Radiographic confirmation is the only definitive method to ensure gastric, rather than pulmonary, placement before feeding.

Anahtar Kavram

Safe anatomical insertion of a nasogastric (NG) tube utilizes specific dynamic client head positions—initial hyperextension followed by flexion—to bypass the airway and safely access the gastrointestinal tract.
Tahmini Süre:1m 30s
Soru 915Soru →

A client is admitted to the psychiatric emergency unit with acute methamphetamine intoxication. The client is pacing the hallway, speaking rapidly, and demonstrating paranoid delusions. Which of the following nursing interventions are appropriate for this client? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Provide a low-stimulus environment by dimming the lights and reducing unit noise.; Maintain a respectful, non-confrontational physical distance when communicating.; Assess for profound depression and suicidal ideation as the intoxication resolves.

Cevap

The appropriate interventions include providing a low-stimulus environment, maintaining a non-confrontational distance, and assessing for severe depression as the drug effects wear off.
Methamphetamine is a powerful central nervous system stimulant. Acute intoxication often presents with severe agitation, hyperactivity, and paranoid psychosis. Maintaining a non-confrontational distance prevents violent outbursts triggered by paranoia. Providing a low-stimulus environment reduces sensory overload and agitation. Furthermore, as the stimulant effects wear off, clients experience a withdrawal 'crash' characterized by severe depression, lethargy, and a high risk of suicide, requiring close monitoring.

Adım Adım Çözüm

1
Identify the pharmacological effects of the involved substance.
Methamphetamine is a potent CNS stimulant that causes hyperactivity, hypervigilance, paranoia, and increased vital signs.
Understanding the toxidrome is essential for predicting client behavior and physiological needs.
2
Determine the immediate safety and environmental needs for a client with stimulant-induced psychosis.
The nurse must provide a low-stimulus environment and maintain a safe physical distance.
Decreasing stimuli prevents escalation of agitation, and maintaining distance prevents triggering defensive aggression associated with paranoia.
3
Anticipate the post-intoxication withdrawal phase.
The nurse must plan to assess for severe depression and suicidal ideation.
The depletion of neurotransmitters following severe stimulant use inevitably leads to a 'crash' phase with high psychiatric risk.
4
Eliminate contraindicated interventions.
Applying immediate restraints, arguing with delusions, and monitoring for opioid toxicity signs are ruled out.
These actions violate safety protocols, use non-therapeutic communication, and apply the wrong clinical assessment parameters.

Anahtar Kavram

Nursing management of acute stimulant intoxication focuses on safety, environmental de-escalation, managing paranoia non-confrontationally, and anticipating the high risk of depression and suicide during the withdrawal phase.
Soru 916Soru →

A client is admitted to the telemetry unit immediately after undergoing a cardiac catheterization using the right femoral artery approach. Which actions are essential for the nurse to take to minimize the risk of complications? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Evaluate the right pedal pulse and capillary refill.; Keep the client's right lower extremity completely straight.; Inspect the groin puncture site for any signs of bleeding or swelling.

Cevap

The essential actions are to evaluate the distal pulses and capillary refill, keep the affected leg straight, and inspect the puncture site for bleeding or swelling.
Minimizing complications after a femoral cardiac catheterization requires interventions focused on maintaining hemostasis and ensuring adequate distal tissue perfusion. Evaluating distal pulses and inspecting the puncture site allow for the early detection of arterial occlusion or bleeding. Keeping the affected leg straight prevents the dislodgement of the clot at the femoral artery site.

Adım Adım Çözüm

1
Identify the procedure and the specific access site.
The client had a cardiac catheterization via the right femoral artery.
The access site determines the specific post-procedure positioning and monitoring requirements needed to prevent hemorrhage.
2
Determine the priority assessments and interventions for this specific site.
The client requires frequent site checks, distal neurovascular assessments, and the affected leg must remain straight.
These actions directly monitor for and prevent the most common complications: bleeding, hematoma formation, and arterial occlusion.
3
Evaluate each option against safe post-procedure protocols.
Elevating the head of the bed too high, delegating the initial assessment, and ignoring early signs of shock are identified as unsafe actions.
These incorrect actions violate fundamental principles of proper positioning, safe delegation, and the early recognition of complications.

Anahtar Kavram

Post-Cardiac Catheterization Care and Complication Prevention
Soru 917Soru →

A nurse is preparing to change the bed linens for a 78-year-old client who is receiving continuous enteral nutrition via a nasogastric (NG) tube. The client must be temporarily placed in a flat, supine position to allow the nurse to safely roll them side-to-side. Which of the following actions should the nurse take?

Cevabı ve açıklamayı göster

Cevap: Stop the continuous enteral feeding infusion before lowering the client to a supine position.

Cevap

The nurse must stop the continuous enteral feeding infusion before lowering the client to a supine position.
When a client receiving continuous enteral tube feedings must be placed supine for basic care procedures such as a bed bath or linen change, the priority action is to pause the feeding pump. This is an essential safety measure to prevent the regurgitation of gastric contents and subsequent aspiration into the lungs. The feeding should remain paused until the head of the bed can be safely elevated back to at least 30 to 45 degrees.

Adım Adım Çözüm

1
Identify the client's current therapy and basic care needs.
The client is receiving continuous enteral tube feedings and requires a linen change, which necessitates lying flat.
Understanding the interaction between the medical intervention and the required care procedure highlights potential safety risks.
2
Recognize the safety risk associated with positioning during enteral feedings.
Lying flat while receiving enteral feeding significantly increases the risk of gastric reflux and pulmonary aspiration.
Standard practice dictates maintaining the head of the bed at 30 to 45 degrees during feedings.
3
Determine the necessary nursing intervention to mitigate the risk.
The feeding pump must be paused before lowering the head of the bed.
Pausing the feeding ensures no new volume is introduced into the stomach while the client is flat, protecting the airway during the basic care procedure.

Anahtar Kavram

Aspiration Prevention during Basic Care
Soru 918Soru →

A nurse is caring for a client with a deep vein thrombosis who is receiving a continuous intravenous (IV) infusion of heparin via a single-lumen peripherally inserted central catheter (PICC). The client suddenly reports severe nausea and vomits dark, coffee-ground emesis. The client's most recent activated partial thromboplastin time (aPTT) is 125 seconds125 \text{ seconds}. The healthcare provider prescribes a stat dose of IV pantoprazole 40 mg40 \text{ mg}. Which sequence of actions is the most appropriate for the nurse to perform?

Cevabı ve açıklamayı göster

Cevap: Immediately stop the heparin infusion, aspirate residual medication from the PICC lumen, flush with 10 mL10 \text{ mL} of 0.9% sodium chloride0.9\% \text{ sodium chloride}, and administer the pantoprazole.

Cevap

The nurse must immediately stop the heparin, aspirate the PICC to remove residual drug, flush with normal saline, and then administer the pantoprazole.
The client is presenting with active gastrointestinal bleeding and a critically supratherapeutic aPTT of 125 seconds125 \text{ seconds} (therapeutic is typically 40−75 seconds40-75 \text{ seconds}). The highest priority is to immediately discontinue the heparin infusion to prevent further hemorrhage. Because a PICC lumen contains dead space filled with the heparin solution, the nurse must aspirate the residual medication; flushing without aspirating would inadvertently administer a bolus of the concentrated anticoagulant directly into the client's circulation. Finally, pantoprazole is chemically incompatible with heparin and requires a thoroughly flushed line (0.9% sodium chloride0.9\% \text{ sodium chloride}) before administration to prevent drug precipitation.

Adım Adım Çözüm

1
Analyze the clinical data.
The client has a panic-level aPTT (125 seconds125 \text{ seconds}) and signs of active gastrointestinal bleeding (coffee-ground emesis).
To determine the client's physiological stability and identify the immediate life-threatening risk.
2
Prioritize the primary nursing intervention.
The continuous heparin infusion must be stopped immediately.
To halt the exogenous source of the coagulopathy that is causing the active hemorrhage.
3
Determine the safe parenteral administration technique for the central line.
The PICC lumen must be aspirated before it is flushed.
Central lines contain dead space that holds residual medication. Aspirating prevents inadvertently flushing a bolus of heparin into the systemic circulation of a bleeding client.
4
Evaluate drug-drug compatibility.
Pantoprazole and heparin are chemically incompatible.
To ensure the central line is thoroughly flushed with 0.9% sodium chloride0.9\% \text{ sodium chloride} before and after the pantoprazole is administered, preventing precipitation.

Anahtar Kavram

Management of life-threatening adverse medication reactions and central line compatibility protocols.
Soru 919Soru →

A nurse is caring for a client who is receiving intravenous fluids through a central venous catheter. The client suddenly develops severe dyspnea, chest pain, and a feeling of impending doom. The nurse suspects a central line-associated air embolism. In what order should the nurse take the following actions to reduce the risk of a life-threatening complication? Arrange the steps from first to last.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct order is: 1) Clamp the catheter, 2) place the client in a left lateral Trendelenburg position, 3) administer oxygen, 4) notify the healthcare provider, and 5) remain with the client.
When an air embolism is suspected, the nurse must rapidly intervene using the 'stop, position, oxygenate' approach to reduce the risk of a fatal pulmonary obstruction. The absolute first priority is to stop more air from entering by clamping the line. The second step is to trap the existing air in the right atrium by placing the client in the left lateral Trendelenburg position. Following this, administering 100% oxygen treats hypoxia and helps absorb the air bubble. Finally, the nurse calls for medical assistance and provides continuous monitoring.

Adım Adım Çözüm

1
Clamp the central venous catheter.
The source of air entry is physically blocked.
The most critical initial action during an adverse event is to stop the causative agent or source.
2
Place the client in a left lateral Trendelenburg position.
The client is positioned on their left side with their head lower than their feet.
This specific position traps the air bubble in the apex of the right atrium, preventing it from migrating into the pulmonary artery and causing a right ventricular outflow tract obstruction.
3
Administer high-flow oxygen via a non-rebreather mask.
The client receives 100% oxygen.
High-concentration oxygen relieves hypoxia and creates a diffusion gradient that helps reduce the size of the air embolus by encouraging nitrogen to exit the bubble.
4
Notify the healthcare provider and the rapid response team.
Advanced medical support is summoned.
Once immediate independent life-saving measures are implemented, the provider must be contacted for advanced interventions.
5
Remain with the client and continuously monitor vital signs.
Continuous observation of the client's status is maintained.
The client is critically unstable and requires continuous monitoring for potential cardiopulmonary arrest.

Anahtar Kavram

The emergency management of a suspected central venous catheter air embolism requires stopping further air entry, properly positioning the client to prevent pulmonary obstruction, and providing oxygenation.
Soru 920Soru →

A client with end-stage renal disease misses two dialysis sessions and presents to the emergency department with profound muscle weakness. The initial serum potassium level is 7.6 mEq/L7.6\text{ mEq/L} (7.6 mmol/L7.6\text{ mmol/L}), and the 12-lead electrocardiogram (ECG) reveals absent P waves, a widened QRS complex, and tall, peaked T waves. The healthcare provider prescribes several emergency interventions. Arrange the following nursing actions in the correct priority order from first to last.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct priority sequence is: 1) Administer intravenous calcium gluconate, 2) Administer an intravenous bolus of regular insulin and 50% dextrose, 3) Administer oral sodium polystyrene sulfonate, 4) Draw a follow-up serum potassium level.
The correct priority for treating symptomatic hyperkalemia follows the principle of protecting the heart first, shifting potassium second, and eliminating potassium third. Calcium gluconate acts in 1 to 3 minutes to stabilize the myocardium and prevent lethal arrhythmias. Regular insulin with dextrose shifts potassium into cells over 15 to 30 minutes, providing a temporary reduction in serum levels. Sodium polystyrene sulfonate is then administered to permanently bind and excrete potassium from the gastrointestinal tract. Finally, drawing a follow-up serum potassium level evaluates the effectiveness of these treatments.

Adım Adım Çözüm

1
Identify the life-threatening physiological abnormality.
The client has severe hyperkalemia (7.6 mEq/L7.6\text{ mEq/L}) accompanied by significant ECG changes (widened QRS, peaked T waves).
Recognizing impending cardiac arrest dictates the immediate need for myocardial stabilization over potassium reduction.
2
Select the intervention for immediate myocardial stabilization.
Intravenous calcium gluconate is administered first.
Calcium directly antagonizes the membrane effects of hyperkalemia. Without it, the client is at imminent risk for ventricular fibrillation.
3
Select the intervention for rapid intracellular potassium shifting.
Intravenous regular insulin and 50%50\% dextrose are administered second.
This quickly lowers the serum potassium level temporarily, buying time for permanent elimination therapies to take effect.
4
Select the intervention for total body potassium elimination.
Oral sodium polystyrene sulfonate is administered third.
This permanently removes potassium from the body via the gastrointestinal tract but has a delayed onset of action (hours).
5
Select the evaluation step.
A follow-up serum potassium level is drawn last.
After administering all acute emergency treatments, the nurse must assess the therapeutic response.

Anahtar Kavram

In the setting of severe hyperkalemia with electrocardiographic changes, myocardial stabilization with intravenous calcium is the absolute first priority, preceding any interventions designed to lower the serum potassium level.
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