Tüm alıştırma soruları

3881 soru

Soru 941Soru →

While caring for a client with a continuous intravenous (IV) infusion of normal saline, the nurse receives a new prescription for an IV push analgesic. Which action is the most critical for the nurse to perform before injecting the medication into the existing IV line?

Cevabı ve açıklamayı göster

Cevap: Verify the compatibility of the analgesic with the continuous normal saline infusion.

Cevap

The most critical action is to verify the compatibility of the analgesic with the continuous normal saline infusion.
Before administering any intravenous medication through an existing continuous IV line, it is a fundamental safety requirement to verify that the medication is compatible with the infusing fluid. Incompatible solutions can form precipitates, inactivate the medication, or cause life-threatening emboli in the client's bloodstream.

Adım Adım Çözüm

1
Identify the route of administration and the existing setup.
The prescribed medication is an IV push intended for an active IV line running normal saline.
Understanding the current IV setup is necessary to identify potential chemical or physical interactions.
2
Determine the safety requirements for administering multiple IV substances simultaneously.
The nurse must ensure that the new medication and the continuous IV fluid will not adversely react with each other.
Mixing incompatible medications in the IV line can lead to precipitation, drug inactivation, or severe adverse client reactions.
3
Select the appropriate priority action.
Verifying compatibility is chosen as the first and most critical step before administration.
This action directly prevents the administration of incompatible substances, ensuring client safety.

Anahtar Kavram

Safe Intravenous (IV) Medication Administration and Compatibility
Tahmini Süre:45s
Soru 942Soru →

A nurse is caring for a client who is in the immediate postoperative period following a total thyroidectomy. Which of the following actions should the nurse take to reduce the risk of complications? (Select all that apply.)

Geçerli olan tümünü seçin

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Cevap: Elevate the head of the bed to a semi-Fowler's position.; Ensure that suction equipment and a tracheostomy tray are immediately available at the bedside.; Support the client's head and neck with pillows to minimize tension on the suture line.

Cevap

The correct actions are elevating the head of the bed to a semi-Fowler's position, ensuring emergency airway equipment is at the bedside, and supporting the head and neck with pillows.
Following a thyroidectomy, it is critical to reduce the risk of airway compromise and bleeding. Elevating the head of the bed to a semi-Fowler's position reduces edema at the surgical site and facilitates breathing. Supporting the head and neck with pillows prevents hyperextension and minimizes tension on the suture line. Ensuring that suction equipment and a tracheostomy tray are readily available at the bedside is an essential safety measure in case of sudden airway obstruction from a hematoma or laryngeal edema.

Adım Adım Çözüm

1
Identify the client's specific postoperative risks.
The client is at high risk for airway obstruction, hemorrhage, and tension on the surgical incision following a thyroidectomy.
Understanding specific complications guides appropriate preventative nursing interventions.
2
Evaluate positioning interventions.
A semi-Fowler's position with head and neck support is indicated to promote drainage and protect the airway, whereas a flat position is contraindicated.
Proper positioning reduces surgical site edema and prevents hyperextension, which protects both the airway and the suture line.
3
Determine appropriate monitoring and safety equipment.
A tracheostomy tray and suction must be at the bedside, and the nurse must accurately monitor for early signs of hemorrhage, such as tachycardia.
Immediate availability of emergency equipment and accurate recognition of early shock signs are crucial for reducing the risk of life-threatening complications.

Anahtar Kavram

Postoperative risk reduction for a thyroidectomy involves maintaining airway patency, utilizing proper positioning to minimize edema and incisional tension, and monitoring for early signs of hemorrhage.
Soru 943Soru →

A healthcare provider prescribes haloperidol 3 mg3 \text{ mg} intramuscularly (IM) for a client experiencing severe agitation. The pharmacy supplies a vial labeled haloperidol 5 mg/mL5 \text{ mg/mL}. How many mL\text{mL} should the nurse administer? (Record the answer using one decimal place.)

Cevabı ve açıklamayı göster

Cevap: 0.6

Cevap

0.6
To determine the correct volume to administer, the nurse must divide the desired dose (3 mg3 \text{ mg}) by the available dose (5 mg5 \text{ mg}), and then multiply by the available volume (1 mL1 \text{ mL}). The calculation is (3÷5)×1=0.6 mL(3 \div 5) \times 1 = 0.6 \text{ mL}.

Adım Adım Çözüm

1
Identify the desired dose.
The desired dose is 3 mg3 \text{ mg}.
This is the specific amount of medication the provider prescribed.
2
Identify the available concentration.
The available concentration is 5 mg5 \text{ mg} per 1 mL1 \text{ mL}.
This is the strength of the medication supplied by the pharmacy.
3
Calculate the volume to administer.
3 mg5 mg×1 mL=0.6 mL\frac{3 \text{ mg}}{5 \text{ mg}} \times 1 \text{ mL} = 0.6 \text{ mL}.
Using dimensional analysis or the standard 'Desired over Have' formula determines the correct administration volume.

Anahtar Kavram

Medication dosage calculation for parenteral administration
Tahmini Süre:1m 0s
Soru 944Soru →

A 65-year-old client is transferred to the telemetry unit immediately following a diagnostic cardiac catheterization accessed via the right femoral artery. The client is awake, reports feeling hungry, and has stable vital signs. The right pedal pulse is palpable. To reduce the risk of severe hemorrhage or hematoma at the puncture site, which positioning directive must the nurse enforce?

Cevabı ve açıklamayı göster

Cevap: Maintain strict bedrest with the right leg kept completely straight and immobile.

Cevap

Maintain strict bedrest with the right leg kept completely straight and immobile.
Following a femoral artery access procedure, maintaining the affected extremity completely straight and keeping the client on strict bedrest is critical. This specific position prevents tension and flexion at the groin, allowing a stable clot to form and preventing life-threatening arterial bleeding or hematoma development at the high-pressure puncture site.

Adım Adım Çözüm

1
Identify the procedure and access site from the clinical vignette.
The client underwent a cardiac catheterization via the right femoral artery.
Understanding the access site is crucial for anticipating specific post-procedure complications.
2
Determine the highest priority risk associated with this specific procedure.
The greatest immediate risk is arterial hemorrhage or hematoma formation at the high-pressure femoral puncture site.
Arterial access sites require meticulous care to ensure a stable clot forms and prevents life-threatening blood loss.
3
Select the nursing intervention that directly mitigates this risk.
Keeping the affected leg straight and maintaining strict bedrest prevents flexion at the groin, protecting the puncture site.
Any bending at the hip increases intra-abdominal pressure and mechanical stress on the artery, which can easily dislodge the clot.

Anahtar Kavram

Post-procedure positioning to prevent arterial bleeding
Soru 945Soru →

A nurse is planning a bed bath and a linen change for a client who is 12 hours post-operative following a craniotomy and is currently being managed for increased intracranial pressure (ICP). Which of the following actions should the nurse implement to ensure client safety and comfort?

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Cevap: Enlist the assistance of another staff member to logroll the client while maintaining the head and neck in a neutral, midline alignment.

Cevap

The nurse should enlist assistance to logroll the client, ensuring the head and neck are kept in a neutral, midline position to promote venous drainage.
The correct action is to logroll the client with assistance, keeping the head and neck in a neutral, midline position. In a client with increased intracranial pressure (ICP) following a craniotomy, preventing neck flexion or rotation is critical. A neutral neck alignment ensures that the jugular veins remain uncompressed, allowing for continuous and optimal venous drainage from the brain. This prevents dangerous elevations in ICP that can occur during turning and hygiene care.

Adım Adım Çözüm

1
Analyze the client's clinical status and risks.
The client is post-craniotomy and at risk for further increases in intracranial pressure (ICP).
Identifying the primary risk dictates the constraints on physical movement and positioning during hygiene care.
2
Evaluate the impact of physical positioning on ICP.
Actions that obstruct jugular venous return (neck flexion/rotation) or increase intrathoracic/intra-abdominal pressure (hip flexion, flat position) must be avoided.
Cerebral blood volume and ICP are directly influenced by the efficiency of venous drainage from the head.
3
Select the hygiene intervention that aligns with neurological safety parameters.
Logrolling with assistance and keeping the head neutral is the only option that safely accommodates the need for hygiene while preventing ICP spikes.
This method prevents twisting of the cervical spine, thereby protecting the jugular veins from compression.

Anahtar Kavram

Basic care and positioning for clients with increased intracranial pressure (ICP)
Soru 946Soru →

A triage nurse at a primary care clinic is reviewing telephone messages from the caregivers of four older adult clients. Which client should the nurse contact first?

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Cevap: An 84-year-old client whose caregiver reports a sudden onset of urinary incontinence and unexplained restlessness that began this morning.

Cevap

The client whose caregiver reports a sudden onset of urinary incontinence and unexplained restlessness that began this morning.
The correct answer identifies an acute, unexpected change in the client's baseline status. Sudden onset of urinary incontinence and cognitive or behavioral changes (such as restlessness) are not normal parts of the aging process. These symptoms frequently represent an atypical presentation of an acute illness in older adults, such as a urinary tract infection (UTI), hypoxia, or adverse medication effects, and require immediate medical evaluation.

Adım Adım Çözüm

1
Analyze the client presentations in the stem.
The nurse must prioritize four older adult clients based on the acuity and stability of their reported findings.
Prioritization requires identifying which client is experiencing an acute, unstable, or potentially life-threatening condition.
2
Evaluate each option to differentiate normal aging from acute pathology.
Senile purpura (dark purple skin patches), decreased basal body temperature, and visual changes (requiring more light) are all expected, chronic physiological adaptations to aging.
Recognizing normal senescence prevents unnecessary interventions for expected age-related changes.
3
Identify the unexpected, acute finding.
Sudden urinary incontinence and new-onset restlessness indicate an acute change in condition.
In older adults, acute infections (like a UTI) or metabolic imbalances often present atypically with sudden confusion, restlessness, or loss of continence rather than classic symptoms like a high fever.

Anahtar Kavram

Normal Physiological Changes of Aging vs. Acute Pathology
Soru 947Soru →

A nurse is preparing to administer a large-volume cleansing enema to an adult client experiencing severe constipation. In what order should the nurse perform the following actions? Arrange the steps from first to last.

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Cevabı ve açıklamayı göster

Cevap

The correct sequence is: assist the client into the left lateral Sims position, lubricate the tubing tip, insert the tubing 3 to 4 inches, elevate the container 12 to 18 inches, and finally open the roller clamp.
Administering a cleansing enema requires a systematic and safe procedural flow. The nurse must first place the client in the left lateral Sims position to align the anatomy with gravity for optimal fluid flow. Next, the tubing tip is lubricated to prevent mucosal trauma. The tube is then gently inserted 3 to 4 inches into the rectum. After secure insertion, the container is elevated 12 to 18 inches to establish safe hydrostatic pressure, preventing rapid infusion and cramping. Finally, the clamp is opened to initiate the slow flow of the solution.

Adım Adım Çözüm

1
Position the client appropriately.
The client is in the left lateral Sims position.
This specific position exposes the anus and uses gravity to help the fluid flow naturally into the descending and sigmoid colon.
2
Prepare the equipment for insertion.
The enema tube tip is lubricated.
Lubrication is necessary immediately prior to insertion to prevent tissue injury and ensure a smooth entry.
3
Insert the tube into the rectum.
The tube is inserted 3 to 4 inches.
This depth passes the internal and external anal sphincters safely. Inserting it further could damage the intestinal wall.
4
Set the appropriate hydrostatic pressure.
The enema bag is elevated 12 to 18 inches above the anus.
Holding the bag too high causes the fluid to infuse too rapidly, which can trigger severe cramping and premature expulsion of the fluid.
5
Begin the infusion.
The roller clamp is opened.
Once all safety measures (position, insertion depth, and pressure head) are established, the fluid can be safely administered.

Anahtar Kavram

Safe administration of a large-volume cleansing enema (Hygiene and Elimination)
Tahmini Süre:1m 30s
Soru 948Soru →

A nurse is assessing the risk profiles of several clients on a medical-surgical unit. Which of the following clients are at greatest risk for developing respiratory acidosis? (Select all that apply.)

Geçerli olan tümünü seçin

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Cevap: A client who received a large dose of intravenous hydromorphone.; A client with a high cervical spinal cord injury affecting diaphragmatic function.

Cevap

The clients at greatest risk for respiratory acidosis are the one who received intravenous hydromorphone and the one with a high cervical spinal cord injury.
Respiratory acidosis develops when there is compromised alveolar ventilation (hypoventilation), leading to the accumulation and retention of carbon dioxide in the blood. Central nervous system depressants like hydromorphone reduce the respiratory drive. High cervical spinal cord injuries impair the neural control of the diaphragm, leading to inadequate lung expansion and poor gas exchange. Both of these mechanisms lead to elevated carbon dioxide levels and respiratory acidosis.

Adım Adım Çözüm

1
Identify the physiological mechanism that causes respiratory acidosis.
Respiratory acidosis is caused by hypoventilation, which leads to the retention and accumulation of carbon dioxide in the bloodstream.
Understanding the underlying etiology is essential to identify which clinical conditions place clients at risk.
2
Evaluate each client's condition to determine if it causes hypoventilation.
Hydromorphone (an opioid) suppresses the respiratory center in the brain, and a high cervical spinal injury impairs the neural control of the diaphragm. Both conditions cause hypoventilation.
Conditions that impair the respiratory drive or mechanics of breathing directly lead to respiratory acidosis.
3
Identify conditions that cause alternative acid-base imbalances to eliminate them as options.
A panic attack causes hyperventilation (respiratory alkalosis), and severe diarrhea causes bicarbonate loss (metabolic acidosis).
Recognizing the causes of other imbalances ensures the correct options are selected.

Anahtar Kavram

Etiology of Respiratory Acidosis
Soru 949Soru →

An acute care facility experiences a sudden hospital-wide cyberattack, resulting in a complete failure of the electronic health record (EHR) system. The incident command center declares a system downtime emergency. Arrange the following response actions in the correct chronological sequence.

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Cevap

The correct chronological sequence is: 1. Conduct a rapid assessment of clients; 2. Retrieve the unit's emergency downtime box; 3. Distribute paper flowsheets and MARs; 4. Initiate the use of manual paper requisition slips; 5. Enter the clinical data back into the EHR after the system is restored.
During an emergency response to a cyberattack or EHR downtime, the nursing process and safety principles dictate a specific operational flow. The nurse must first ensure immediate client safety, as network outages can sometimes affect interconnected medical devices. Second, the nurse secures the means to document care by retrieving the downtime box. Third, the nurse empowers the staff by distributing the forms. Fourth, the nurse coordinates care across the facility using manual requisitions. Finally, the nurse participates in the recovery phase by retroactively entering data once the system is online.

Adım Adım Çözüm

1
Conduct a rapid assessment of clients and life-sustaining equipment.
Immediate client safety and physiological stability are verified.
Direct client safety is universally the highest priority during any facility emergency, including technological infrastructure failures.
2
Retrieve the emergency downtime box.
Essential paper forms and downtime protocols are available for the unit.
Nurses require the appropriate physical tools to transition smoothly from electronic to manual documentation.
3
Distribute paper flowsheets and MARs to the staff.
Clinical staff are equipped to document care immediately.
This step ensures the continuity of legal and clinical documentation on the unit during the outage.
4
Initiate manual requisition processes for ancillary departments.
New orders, laboratory tests, and pharmacy needs can be processed.
Maintaining external communication and workflow with other departments is essential once internal documentation is secure.
5
Retroactively enter data into the EHR once it is restored.
The electronic health record is fully updated and complete.
This completes the emergency response cycle by transitioning back to normal operations and restoring the permanent legal record.

Anahtar Kavram

Electronic Health Record (EHR) Downtime Emergency Response Protocol
Soru 950Soru →

Match each client scenario with the most appropriate transmission-based precaution.

Soldaki öğeye tıklayın, sonra eşleşen sağdaki öğeye tıklayın

Öğeler

Client with severe diarrhea and confirmed Clostridioides difficile
Client with a maculopapular rash and confirmed rubeola (measles)
Client with bacterial meningitis caused by Neisseria meningitidis
Client with a urinary tract infection caused by Vancomycin-resistant enterococci (VRE)

Eşleşmeler

Cevabı ve açıklamayı göster

Cevap

C. difficile matches with soap and water contact precautions; Measles matches with airborne precautions; N. meningitidis matches with droplet precautions; VRE matches with standard contact precautions including alcohol-based hand rub.
Each pathogen requires specific precautions based on its mode of transmission and characteristics: standard contact (VRE), contact with spore-specific hand hygiene (C. difficile), airborne (measles), and droplet (N. meningitidis).

Adım Adım Çözüm

1
Identify the primary mode of transmission for each pathogen.
C. difficile and VRE are spread by contact. Measles is spread by the airborne route. N. meningitidis is spread by droplets.
Understanding the transmission route dictates the baseline isolation category.
2
Determine specific hand hygiene requirements for the contact precaution pathogens.
C. difficile requires soap and water due to its spores. VRE can be managed safely with alcohol-based hand rubs.
Not all contact precautions have the same hand hygiene rules; spore-forming bacteria require mechanical removal via handwashing.
3
Determine specific respiratory protection requirements for the respiratory pathogens.
Measles requires an N95 respirator in a negative-pressure room. N. meningitidis requires a standard surgical mask without negative pressure.
Airborne particles remain suspended and require a fitted respirator, while droplets drop quickly and only require a standard mask.

Anahtar Kavram

Standard and Transmission-Based Precautions
Tahmini Süre:1m 30s
Soru 951Soru →

A client is brought to the emergency department experiencing a severe panic attack. The client is acutely tachypneic with a respiratory rate of 34 breaths/minute and reports numbness and tingling in the fingers. Based on these clinical findings, which acid-base imbalance should the nurse suspect?

Cevabı ve açıklamayı göster

Cevap: Respiratory alkalosis

Cevap

Respiratory alkalosis
The correct answer is respiratory alkalosis. When a client experiences a panic attack and hyperventilates, they exhale excessive amounts of carbon dioxide (CO2). Because CO2 acts as an acid in the body, its rapid removal causes the blood pH to increase, resulting in an alkalotic state of respiratory origin. The reported numbness and tingling in the fingers are classic signs of the neuromuscular irritability that accompanies alkalosis.

Adım Adım Çözüm

1
Identify the primary physiological change occurring in the client.
The client is hyperventilating (respiratory rate of 34 breaths/minute).
Tachypnea during a panic attack directly alters gas exchange in the lungs.
2
Determine the effect of hyperventilation on arterial carbon dioxide (PaCO2) levels.
Excessive carbon dioxide is exhaled, lowering the PaCO2 level in the blood (hypocapnia).
Carbon dioxide acts as an acid in the blood; rapid and deep breathing blows off this CO2, reducing overall acidity.
3
Correlate the decreased PaCO2 with the resulting acid-base imbalance.
A primary deficit in carbon dioxide causes the blood pH to rise, leading to respiratory alkalosis.
Because the imbalance originates from altered breathing patterns, it is classified as a respiratory condition.

Anahtar Kavram

Respiratory Alkalosis secondary to hyperventilation
Tahmini Süre:1m 0s
Soru 952Soru →

A nurse is establishing a plan for basic care and comfort for a client who returned to the surgical unit 4 hours ago following a transsphenoidal hypophysectomy. The client has nasal packing in place and is restricted to breathing through the mouth. Which interventions should the nurse include in the client's care plan? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Administer oral hygiene utilizing a soft foam swab and warm saline rinses.; Apply a continuous layer of water-soluble moisturizer to the client's lips to alleviate dryness.; Maintain the head of the bed elevated at a 30-degree angle.

Cevap

The correct interventions are administering oral hygiene with a soft swab and saline, applying water-soluble moisturizer to the lips, and maintaining the head of the bed elevated at a 30-degree angle.
Following a transsphenoidal hypophysectomy, the client must breathe through the mouth, causing significant dryness. Comfort is maintained by applying water-soluble lip moisturizer and performing oral care with warm saline and soft swabs, as a traditional toothbrush could easily tear the delicate surgical incision located near the upper gum line. Furthermore, maintaining the head of the bed at a 30-degree angle is essential to decrease intracranial pressure, reduce swelling, and prevent cerebrospinal fluid leaks.

Adım Adım Çözüm

1
Analyze the client's surgical procedure and current condition.
The client had a transsphenoidal hypophysectomy, has a delicate suture line in the upper gum or nasal cavity, and is breathing exclusively through the mouth due to nasal packing.
Understanding the surgical approach identifies specific anatomical risks, such as a cerebrospinal fluid leak and suture disruption, alongside immediate comfort needs like a dry mouth.
2
Evaluate the proposed positioning and comfort measures.
Elevating the head of the bed 30 degrees is necessary to decrease intracranial pressure. Flat positioning is harmful. Moisturizing lips and using soft swabs for oral care promote comfort without damaging the surgical site.
Proper positioning and specialized oral hygiene prevent severe complications while addressing basic comfort requirements.
3
Review the delegation and safety interventions.
Assessing for a halo sign is a clinical judgment that the registered nurse must perform. Preemptive restraints are inappropriate and violate the principle of using the least restrictive measures first.
Ensuring safe delegation and the appropriate use of safety devices are core nursing responsibilities.

Anahtar Kavram

Postoperative basic care following transsphenoidal surgery requires meticulous oral hygiene modifications, continuous head elevation, and careful clinical monitoring for complications like cerebrospinal fluid leakage.
Soru 953Soru →

A nurse is preparing to administer an intermittent intravenous (IV) piggyback antibiotic to a client. The client currently has a continuous primary IV infusion of 0.9% sodium chloride running via an electronic infusion pump. In what order should the nurse perform the following actions? Arrange the steps from first to last.

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Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first verify medication compatibility, prepare the secondary tubing by spiking and priming, cleanse the primary line access port, attach the tubing while lowering the primary bag, and finally open the clamp and program the infusion pump.
The safe and effective administration of an intravenous piggyback (IVPB) medication follows a strict sequence prioritizing safety, asepsis, and fluid dynamics. First, the nurse must verify compatibility between the secondary medication and the primary infusion to prevent precipitation. Next, the nurse prepares the equipment by closing the clamp, spiking the bag, and priming the tubing to remove air. Once the equipment is ready, the nurse cleanses the uppermost access port (above the pump) immediately before connection to maintain strict asepsis. The nurse then attaches the secondary tubing and uses an extension hook to lower the primary bag; this utilizes hydrostatic pressure to ensure the secondary medication infuses first. Finally, the nurse opens the clamp and programs the infusion pump to deliver the medication safely.

Adım Adım Çözüm

1
Verify the compatibility of the secondary antibiotic with the primary 0.9% sodium chloride infusion.
Ensures the two fluids will not react adversely when mixed in the primary tubing.
Incompatible medications can form crystals or precipitates, which can occlude the line or cause a fatal embolism in the client.
2
Close the secondary tubing roller clamp, spike the antibiotic bag, and prime the tubing.
The secondary line is filled with medication and all air is expelled.
Preparing the tubing before accessing the patient's line minimizes the time the access port is left open and prevents air from entering the circulatory system.
3
Cleanse the uppermost access port on the primary intravenous tubing with an antimicrobial swab.
The connection site is thoroughly disinfected.
Scrubbing the hub with friction removes microorganisms and prevents catheter-related bloodstream infections. This must be done immediately prior to connection.
4
Attach the secondary tubing to the primary line and use an extension hook to lower the primary fluid bag.
The secondary bag is positioned higher than the primary bag in the IV setup.
Because standard infusion pumps draw fluid from the highest source of hydrostatic pressure, hanging the secondary bag higher ensures the antibiotic infuses first rather than the primary fluid.
5
Open the secondary tubing roller clamp, program the infusion pump, and initiate the secondary infusion.
The antibiotic administration begins at the prescribed rate.
The electronic pump controls the precise delivery rate, and the clamp must be open to allow fluid flow and prevent occlusion alarms.

Anahtar Kavram

Safe administration of intravenous piggyback (IVPB) medications requires verifying compatibility, maintaining strict asepsis, and utilizing hydrostatic pressure to ensure the correct medication infuses.
Tahmini Süre:1m 0s
Soru 954Soru →

An experienced registered nurse (RN) and a licensed practical nurse (LPN/VN) are partnered to provide care on an inpatient oncology floor. The RN is reviewing the morning task list. Which of the following interventions are appropriate for the RN to delegate to the LPN/VN? Select all that apply.

Geçerli olan tümünü seçin

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Cevap: Administering a scheduled intramuscular antiemetic to a client experiencing chemotherapy-induced nausea; Reinforcing prior education about infection prevention measures for a client with severe neutropenia preparing for discharge; Inserting an indwelling urinary catheter for a client experiencing acute urinary retention secondary to a pelvic tumor

Cevap

The RN can safely delegate administering the intramuscular antiemetic, reinforcing prior education about infection prevention, and inserting the indwelling urinary catheter.
The RN safely delegates tasks that have predictable outcomes and do not require independent nursing judgment. The LPN/VN scope of practice legally includes administering standard oral, intramuscular, and subcutaneous medications; performing routine sterile procedures such as urinary catheterization; and reinforcing education that was initially provided and documented by the RN. Therefore, delegating the administration of the antiemetic, the insertion of the Foley catheter, and the reinforcement of infection prevention education is appropriate.

Adım Adım Çözüm

1
Identify the legal and professional scope of practice for a Licensed Practical Nurse (LPN/VN).
The LPN/VN scope includes performing predictable, routine tasks, administering standard medications (excluding high-risk IV push or continuous titrations), performing sterile procedures, and reinforcing established teaching.
Understanding scope of practice limits is the foundation of safe delegation.
2
Determine which tasks require the RN's specific, non-delegable competencies.
The RN cannot delegate the core nursing process elements: Evaluation, Assessment, and primary Teaching (often remembered by the acronym EAT).
These tasks demand advanced, independent nursing judgment and critical thinking.
3
Analyze each proposed task to ensure it does not cross into the RN's exclusive scope.
Initial admission assessments, titrating high-alert continuous IV drips, and evaluating the clinical effectiveness of a newly prescribed treatment are strictly RN responsibilities. The remaining tasks align with LPN/VN competencies.
Applying specific delegation rules to the clinical scenario ensures safe client care and regulatory compliance.

Anahtar Kavram

Delegation to the Licensed Practical Nurse (LPN/VN) requires adherence to scope of practice guidelines; LPN/VNs can manage routine care, standard medication administration, sterile procedures, and teaching reinforcement, but cannot perform initial assessments, evaluate clinical responses, provide primary education, or manage unstable IV therapies.
Soru 955Soru →

A registered nurse (RN) is working with an unlicensed assistive personnel (UAP) on an orthopedic unit. Which of the following tasks should the RN safely delegate to the UAP?

Cevabı ve açıklamayı göster

Cevap: Applying anti-embolism stockings to a client who is two days post-operative

Cevap

Applying anti-embolism stockings to a client who is two days post-operative
Applying anti-embolism stockings to a stable client is a routine, standard procedure with a highly predictable outcome. It does not require nursing assessment, clinical judgment, or teaching, making it perfectly safe and appropriate to delegate to a UAP.

Adım Adım Çözüm

1
Identify the standard scope of practice for an unlicensed assistive personnel (UAP).
UAPs can perform routine, standard tasks that do not require nursing judgment, assessment, or teaching.
Understanding scope of practice boundaries is essential for safe task delegation.
2
Analyze each option against the delegation rules (Do not delegate Evaluation, Assessment, or Teaching).
Initial ambulation requires assessment, evaluating medication requires nursing judgment, and educating requires teaching. Applying stockings is the only routine task.
To determine which specific task is appropriate and safe to assign to the UAP.

Anahtar Kavram

Delegation to Unlicensed Assistive Personnel
Soru 956Soru →

A nurse enters the room of a client receiving internal radiation therapy (brachytherapy) for cervical cancer. The nurse discovers that the intracavitary radioactive applicator has accidentally dislodged and is resting on the client's bed linens. To safely reduce the risk of harmful radiation exposure, arrange the following nursing actions in the correct priority sequence.

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Cevap

The correct sequence is: 1) Clear the room and keep the client still, 2) Don a lead apron, 3) Use long-handled forceps, 4) Place the implant in a lead-lined container, and 5) Notify the radiation safety officer and provider.
The correct sequence prioritizes the ALARA (As Low As Reasonably Achievable) radiation safety principles: Time, Distance, and Shielding. The immediate priority is to use distance to protect unshielded visitors by evacuating them and keeping the client still to prevent the source from falling. Next, the nurse must apply personal shielding (lead apron) before approaching the hazard. To minimize exposure time and maintain distance, the nurse uses long-handled forceps to retrieve the source and immediately secures it in a lead-lined container. Only after the acute physical hazard is contained should the nurse leave the bedside to notify the radiation safety officer and provider.

Adım Adım Çözüm

1
Instruct the client to remain completely still and direct all visitors to exit the room.
Unshielded individuals are removed from the radiation field.
Distance is the most effective immediate protection against radiation exposure. Keeping the client still prevents the source from falling to the floor, which would widen the contamination area.
2
Put on a lead-lined apron to ensure personal shielding.
The nurse's core organs are protected from gamma radiation.
ALARA principles dictate that personnel must utilize appropriate shielding before closely approaching an active radiation source.
3
Grasp the dislodged radioactive implant using long-handled forceps.
The radioactive source is retrieved safely.
Radioactive materials must never be touched directly with hands. Forceps provide necessary distance between the radiation source and the nurse's hands.
4
Place the radioactive implant into the lead-lined containment pig located in the room.
The radiation source is fully shielded and contained.
Placing the source in the designated lead pig immediately terminates the acute radiation exposure hazard in the environment.
5
Notify the radiation safety officer and the healthcare provider of the dislodgement.
Specialized personnel are alerted to the incident.
Once the immediate danger is neutralized, specialists must evaluate the client for potential tissue damage, sweep the room for residual radiation, and adjust the cancer treatment plan.

Anahtar Kavram

ALARA Principles and Internal Radiation Safety Protocols
Tahmini Süre:1m 30s
Soru 957Soru →

A nurse is caring for a client with a history of heart failure who suddenly develops severe dyspnea, extreme anxiety, and a cough producing pink, frothy sputum. The nurse suspects acute pulmonary edema. In what order should the nurse perform the following actions? (Arrange the actions in the correct sequence from first to last)

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is: Position the client in a high-Fowler's position, Administer high-flow oxygen via a face mask, Assess vital signs and auscultate lung sounds, Administer prescribed intravenous furosemide, and finally, Document the clinical findings and response to interventions.
In an acute respiratory crisis such as pulmonary edema, the nurse must prioritize immediate, non-pharmacological life-saving actions. Positioning the client upright is the fastest intervention to improve breathing mechanics and reduce preload. This is immediately followed by oxygen administration to correct hypoxia. Once the airway and breathing are mechanically supported, the nurse must obtain baseline vital signs to ensure the client's blood pressure can tolerate the subsequent administration of intravenous loop diuretics. Finally, after the client is stabilized and interventions are implemented, the nurse documents the entire event.

Adım Adım Çözüm

1
Position the client in a high-Fowler's position.
The diaphragm lowers and venous return decreases.
This immediate, equipment-free action maximizes lung expansion and reduces preload, directly addressing the pathophysiology of pulmonary edema.
2
Administer high-flow oxygen via a face mask.
Alveolar oxygen concentration increases.
The client is experiencing severe gas exchange impairment. Oxygen must be administered immediately after positioning to treat life-threatening hypoxia.
3
Assess vital signs and auscultate lung sounds.
Baseline clinical data is obtained.
Objective data must be gathered before administering medications to ensure the client is hemodynamically stable enough to receive diuretics.
4
Administer prescribed intravenous furosemide.
Diuresis is initiated.
Loop diuretics remove excess fluid and further decrease preload, which is the definitive treatment for acute cardiogenic pulmonary edema, but must follow ABC interventions and baseline assessment.
5
Document the clinical findings and response to interventions.
The medical record is updated.
Documentation is always the final step of the nursing process after completing acute interventions and stabilization.

Anahtar Kavram

Prioritization of acute pulmonary edema management follows the ABCs (Airway, Breathing, Circulation) and the nursing process, moving from immediate physical interventions to pharmacological treatments and concluding with documentation.
Soru 958Soru →

A local hospital has activated its emergency operations plan due to a nearby bridge collapse resulting in mass casualties. The nursing supervisor instructs the medical-surgical unit charge nurse to immediately identify clients for safe discharge to create surge capacity. Which of the following clients should the charge nurse recommend for immediate discharge?

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Cevap: A client with lower extremity cellulitis who has received 48 hours of intravenous antibiotics and is prescribed to transition to oral antibiotics today.

Cevap

The client transitioning to oral antibiotics for cellulitis should be recommended for immediate discharge.
In a mass casualty situation where an emergency operations plan is activated, the charge nurse must identify clients who are physiologically stable and require the least amount of skilled nursing care. The client with cellulitis who is ready to transition to oral medications is hemodynamically stable, requires no further acute interventions, and can safely manage their condition at home, making them the appropriate choice to clear a bed for incoming victims.

Adım Adım Çözüm

1
Analyze the goal of the emergency response plan.
The goal is to safely create surge capacity (free up beds) for incoming mass casualty victims by identifying the most stable clients.
Disaster protocols require prioritizing resources for the most critically injured while ensuring current inpatients are not discharged to an unsafe situation.
2
Evaluate the stability and discharge readiness of each client.
The client with cellulitis is stable and transitioning to home care. The older adult has acute confusion. The chest pain client is undiagnosed. The postoperative client shows early signs of shock.
Accurate clinical assessment determines which client requires ongoing acute care nursing intervention.
3
Select the client with the lowest acuity and risk of decompensation.
The client transitioning to oral antibiotics is chosen.
This client requires no further acute intravenous therapy or continuous monitoring and can safely recover in the community.

Anahtar Kavram

Discharge Prioritization during Mass Casualties
Soru 959Soru →

A charge nurse is evaluating the care of a client who returned to the unit following a large-volume paracentesis for severe ascites. Which of the following assessment findings or nursing actions require IMMEDIATE follow-up to prevent physiological decompensation? (Select all that apply.)

Geçerli olan tümünü seçin

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Cevap: A heart rate of 118 beats per minute with a narrowing pulse pressure; A urine output of 15 mL collected over the first hour post-procedure; A rigid, board-like abdomen with generalized guarding upon palpation

Cevap

The assessment findings requiring immediate follow-up are the heart rate of 118 beats per minute with a narrowing pulse pressure, the urine output of 15 mL over the first hour, and the rigid, board-like abdomen.
Following a large-volume paracentesis, clients are at extremely high risk for Post-Paracentesis Circulatory Dysfunction (PPCD) and hypovolemic shock due to rapid fluid shifts. Tachycardia combined with a narrowing pulse pressure and severe oliguria (15 mL/hr) are early, critical indicators of this life-threatening shock state. Additionally, a rigid, board-like abdomen with guarding is a definitive sign of peritonitis resulting from an accidental bowel perforation. All three of these findings indicate impending physiological decompensation and require immediate medical intervention.

Adım Adım Çözüm

1
Analyze the specific physiological risks associated with a large-volume paracentesis.
The primary risks include profound intravascular fluid shifts leading to hypovolemic shock (Post-Paracentesis Circulatory Dysfunction) and organ damage such as accidental bowel puncture.
Rapid removal of ascitic fluid causes sudden splanchnic vasodilation and a significant decrease in effective arterial blood volume.
2
Evaluate the clinical findings for indicators of systemic shock or hypoperfusion.
A heart rate of 118 bpm coupled with a narrowing pulse pressure, along with an hourly urine output of only 15 mL, are critical indicators of decreased tissue perfusion.
Tachycardia and a narrowed pulse pressure are early compensatory mechanisms to maintain cardiac output; oliguria confirms inadequate renal blood flow.
3
Evaluate the clinical findings for signs of procedural trauma.
A rigid, board-like abdomen with guarding is an acute emergency finding.
This physical presentation is the cardinal sign of peritonitis, strongly suggesting an accidental bowel perforation occurred during the procedure.
4
Assess the remaining routine clinical data and nursing actions for appropriateness.
The ABG values are within expected normal limits, and placing the client in a high-Fowler's position is a therapeutically correct intervention.
Expected or normal findings and correct interventions do not require immediate correction or follow-up by the charge nurse.

Anahtar Kavram

Recognizing the manifestations of Post-Paracentesis Circulatory Dysfunction (PPCD) and procedural complications (peritonitis) to mitigate risk.
Tahmini Süre:1m 30s
Soru 960Soru →

A surgical nurse is developing a daily care regimen for a client who is 48 hours postoperative following a right above-the-knee amputation. To prevent musculoskeletal complications and ensure safe hygiene practices, which intervention is most appropriate to include in the plan?

Cevabı ve açıklamayı göster

Cevap: Assist the client into a prone position for 20 to 30 minutes three to four times daily.

Cevap

Assist the client into a prone position for 20 to 30 minutes three to four times daily.
Following an above-the-knee amputation, the client is at a high risk for developing hip flexion contractures, which can severely impair future mobility and the ability to use a prosthesis. Assisting the client into a prone position for 20 to 30 minutes several times a day promotes full extension of the hip joint and is the standard nursing intervention to prevent these contractures.

Adım Adım Çözüm

1
Analyze the client's surgical procedure and postoperative timeframe.
The client is 48 hours post-above-the-knee amputation (AKA).
Identifying the procedure and timing helps determine the physiological risks, specifically hip flexion contractures which peak as a risk after the initial 24 hours.
2
Evaluate each intervention against the risk of hip flexion contractures.
Elevation on pillows and prolonged sitting both promote hip flexion and are contraindicated.
The hip must be periodically extended to maintain joint mobility for future prosthesis use.
3
Assess the delegation task for scope of practice compliance.
Delegating an incision evaluation to a UAP during a bed bath is inappropriate.
Assessment is strictly an RN responsibility.
4
Identify the action that safely promotes comfort and prevents complications.
Placing the client in a prone position for short intervals is the standard of care.
The prone position naturally extends the hip joint, directly counteracting the flexion contracture risk without compromising safety.

Anahtar Kavram

Postoperative Positioning and Contracture Prevention in Amputation
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Tüm alıştırma soruları — NCLEX-RN | Examkin