Tüm alıştırma soruları

Several self-transported clients arrive simultaneously at the emergency department entrance covered in an unidentified chemical powder following an incident at a local industrial plant. Some clients are coughing uncontrollably, while others report severe skin irritation. Which of the following is the priority action for the triage nurse?

A nurse is caring for an 82-year-old client scheduled for an elective total hip arthroplasty. The client has no baseline cognitive deficits and has an adult child designated as the medical power of attorney (healthcare proxy). The nurse administers a prescribed dose of intravenous midazolam for preoperative anxiety. Thirty minutes later, the surgeon arrives to obtain informed consent. The client is now drowsy, disoriented to place, and unable to recall the proposed surgery. The adult child states, 'My parent is just confused because of their advanced age. I will sign the consent form.' Which action by the nurse is most appropriate?

A charge nurse on a high-acuity medical-surgical unit is evaluating clinical requests from staff nurses. Which client must the charge nurse instruct the staff to evaluate and intervene with first?

A registered nurse (RN) on a medical-surgical unit is planning care for a client who is two days postoperative following an appendectomy. The client's condition is stable. Which of the following tasks is most appropriate for the RN to delegate to an unlicensed assistive personnel (UAP)?

During a routine preoperative assessment for an elective lumbar laminectomy, the nurse prepares to witness the client's signature on the informed consent form. As the nurse hands over the pen, the client hesitates and states, "I know the surgeon talked to me about this earlier today, but I honestly still have no idea what the actual complications could be." Which of the following is the most appropriate nursing action?

During the morning huddle on an acute nephrology and urology unit, a clinical coordinator evaluates the distribution of client assignments among the healthcare team. The available staff includes an advanced clinical RN, a recent graduate RN, a licensed practical/vocational nurse (LPN/VN), and unlicensed assistive personnel (UAP). Which of the following assigned pairings represents the most appropriate scope of practice and safe delegation?

A registered nurse (RN) is prioritizing care and delegating tasks to a licensed practical nurse (LPN/VN) and an unlicensed assistive personnel (UAP) on a medical-surgical unit. Place the following actions in the order of priority the RN should perform them, from highest to lowest priority.

A progressive care unit nurse is responding to a client with a history of Graves' disease who has abruptly developed severe delirium, a temperature of $40.6^\circ\text{C}$ ($105.1^\circ\text{F}$), and a heart rate of 178 beats per minute. Determine the priority sequence in which the nurse should implement the following collaborative interventions.

An 80-year-old client with a history of moderate dementia is brought to the emergency department by a concerned neighbor after being found wandering outdoors in freezing weather without a coat. The client is shivering, disoriented to place and time, and attempts to walk out of the treatment room, stating, "I have to go home right now to feed my dog." Which of the following is the most appropriate legal and professional action by the registered nurse (RN)?

A nurse on a medical-surgical unit is reviewing the electronic health records of six assigned clients following the morning shift report. Which of the following client findings require immediate follow-up by the nurse? Select all that apply.

A 28-year-old client at 35 weeks gestation is transported to the emergency department via ambulance following a severe motor vehicle collision. The client is secured flat to a rigid backboard with a cervical collar in place. She is conscious, visibly anxious, and reporting generalized abdominal tenderness. Current vital signs are blood pressure 92/54 mm Hg, heart rate 122 beats/min, respiratory rate 26 breaths/min, and oxygen saturation 93% on room air. Which action should the nurse perform FIRST?

A nurse is assessing a client who is recovering from a major abdominal surgery. Which vital sign change should the nurse identify as the earliest compensatory indicator of developing hypovolemic shock?

A client is in the preoperative holding area for an elective hernia repair. As the nurse prepares to administer a prescribed preoperative sedative, the client states, 'I have changed my mind. I do not want to go through with this surgery.' Arrange the following nursing actions in the correct chronological sequence from first to last.

A nurse is evaluating the clinical status of multiple clients across different care settings. Which of the following client situations indicate an acute deterioration or safety risk requiring immediate nursing intervention? Select all that apply.

A registered nurse (RN) is preparing to delegate a routine clinical task to an unlicensed assistive personnel (UAP). Arrange the following steps of the delegation process in the correct chronological order.

The registered nurse on a high-acuity neurology step-down unit is planning initial assessments for four assigned clients after receiving the shift handoff report. Which client must the nurse assess first?

An 78-year-old client with a history of mild dementia is 24 hours post-operative following a right total hip arthroplasty (posterior approach). During morning rounds, the client becomes acutely agitated and continuously attempts to pull at their indwelling urinary catheter. Which basic care and comfort intervention should the nurse implement?

An adult client is receiving a continuous intravenous (IV) infusion of Lactated Ringer's solution at $100$ mL/hr through a peripheral catheter. The healthcare provider prescribes a stat dose of ceftriaxone $1$ gram IV piggyback to treat a diagnosed bacterial infection. Which of the following actions should the nurse take to safely administer the medication?

A clinical nurse preceptor is reviewing the care plan drafted by a newly licensed nurse for an 82-year-old client. The client is bedbound with right-sided hemiplegia following an ischemic stroke, receives continuous enteral nutrition via a nasogastric (NG) tube, and has recently developed urinary incontinence. Which of the following planned interventions should the preceptor identify as correct and appropriate for the client's basic care and comfort? Select all that apply.

A nurse is preparing to administer an intravenous piggyback (IVPB) of cefazolin $1 \text{ gram}$ in $50 \text{ mL}$ of $0.9\%$ sodium chloride to a client with a surgical site infection. The medication is prescribed to infuse over $30 \text{ minutes}$. At what rate in $\text{mL/hr}$ should the nurse set the electronic infusion pump? Record your answer as a whole number.