Tüm alıştırma soruları

A client with a history of cirrhosis is being monitored $2$ hours after a large-volume paracentesis in which $6$ liters of ascitic fluid were removed. The client's current vital signs are: blood pressure $94/78$ mm Hg, heart rate $116$ bpm, and respiratory rate $24$/min. An arterial blood gas (ABG) analysis reveals a pH of $7.29$, a $PaCO_2$ of $31$ mm Hg, and an $HCO_3^-$ of $15$ mEq/L. The unlicensed assistive personnel (UAP) is preparing to assist the client into a high-Fowler's position to eat a meal. Which action should the nurse take first to reduce the risk of a severe complication?

A palliative care team is managing an older adult client who is completely bedbound due to profound cachexia and intractable bone pain. The client exhibits significant muscle wasting and thin, fragile skin. Which interventions are appropriate to include in the client's non-pharmacologic comfort and skin integrity regimen? Select all that apply.

A registered nurse (RN) is providing care for a client who is receiving intravenous antibiotics for a localized skin infection. Which of the following activities is most appropriate for the RN to delegate to the unlicensed assistive personnel (UAP)?

During the night shift, a client who sustained a moderate traumatic brain injury becomes profoundly disoriented. The client repeatedly attempts to leave the neurological step-down unit, claiming they need to 'go to work.' An unlicensed assistive personnel (UAP) asks the registered nurse (RN) to authorize a vest restraint for safety. Which legal and professional actions must the RN take? (Select all that apply)

An outpatient clinic registered nurse (RN) is assessing a 78-year-old client with a history of severe major depressive disorder. The RN observes bilateral, thumb-sized contusions on the client's inner upper arms. The client's adult child, who serves as the primary caregiver, interrupts to state, 'My parent is just getting clumsy and bumps into door frames.' The client remains silent, then calmly hands the RN a cherished family watch, stating with a sudden, serene expression, 'I finally feel completely at peace; I will not be needing this anymore.' Based on legal and professional responsibilities, which of the following is the priority action for the RN?

A non-English speaking client on the acute medical-surgical unit is scheduled for a percutaneous liver biopsy. The healthcare provider has just finished discussing the procedure with the client via a hospital-approved remote video interpreter. The nurse enters the room to facilitate the signing of the informed consent document. Which of the following actions by the nurse are legally and ethically appropriate? Select all that apply.

An oncology nurse is reviewing the most recent clinical updates for $4$ assigned clients. Based on the principles of prioritization, which client requires the nurse's immediate assessment?

A staffing shortage on an acute medical-surgical unit requires the immediate reassignment of several clients. The interdisciplinary care team available consists of a registered nurse (RN) floated from the maternal-newborn unit, an experienced licensed practical nurse (LPN/VN), and an unlicensed assistive personnel (UAP). Which client care assignment demonstrates the safest and most appropriate application of delegation principles?

A nurse is coordinating care for a client who had a permanent colostomy placed 2 days ago and is preparing for discharge. The client is tearful, refuses to look at the stoma, and states, 'I do not know how I will ever afford all of these pouches and supplies.' Which of the following actions by the nurse reflect appropriate collaboration and delegation? (Select all that apply.)

A 55-year-old client returns to the medical-surgical unit following an esophagogastroduodenoscopy (EGD) with banding of esophageal varices. The client received intravenous midazolam and fentanyl during the procedure and is currently lethargic but arousable. The client's vital signs are: BP 110/70 mmHg, HR 85 bpm, RR 14/min, and SpO2 96% on room air. Which of the following actions is the most appropriate priority for the nurse to reduce the client's risk of physiological complications?

A client is brought to the emergency department experiencing a severe asthma exacerbation. The client is initially restless and tachypneic with an arterial blood gas (ABG) showing a pH of $7.50$, $PaCO_2$ of $28 \text{ mm Hg}$, and $HCO_3^-$ of $24 \text{ mEq/L}$. One hour later, the nurse notes that the client has become lethargic and the respiratory rate has decreased to $10$ breaths per minute. A repeat ABG shows a pH of $7.28$, $PaCO_2$ of $58 \text{ mm Hg}$, and $HCO_3^-$ of $24 \text{ mEq/L}$. Which of the following is the priority nursing action?

The charge nurse is observing a newly licensed nurse provide care for a client who is receiving continuous enteral nutrition through a percutaneous endoscopic gastrostomy (PEG) tube. Which of the following actions by the newly licensed nurse indicate appropriate basic care and comfort measures? Select all that apply.

A nurse is preparing to administer an intravenous piggyback (IVPB) dose of a prescribed antibiotic through a client's continuous primary intravenous infusion of 0.9% sodium chloride. In what order should the nurse perform the following actions? Arrange the steps from first to last.

A client diagnosed with meningococcal meningitis is transferred to the general medical unit. Which infection control measures are appropriate for this client? Select all that apply.

During a psychosocial assessment, a 77-year-old client tearfully states, 'When I look back on my life, I realize I accomplished very little, and now my time has simply run out.' Based on Erikson's theory of psychosocial development, which developmental outcome is this client demonstrating?

A clinic nurse is providing education to new parents about the sequence of expected motor skill progression during early childhood development. Place the following fine motor milestones in the chronological order in which they are typically achieved. Arrange the items from the earliest acquired skill to the latest.

A nurse is assessing a client who is recovering in the intensive care unit following a coronary artery bypass graft (CABG) surgery. Which of the following clinical findings should indicate to the nurse that the client is developing cardiac tamponade? Select all that apply.

A nurse is preparing to enter the room of a client who requires contact and droplet precautions. In what order should the nurse don (put on) the required personal protective equipment (PPE)? Arrange the steps in the correct sequence from first to last.

Review the clinical profiles of the following five clients. Evaluate the infectious agent, phase of illness, and presenting symptoms to select the most appropriate transmission-based precaution category for each client.

Shift responsibilities on a high-acuity cardiopulmonary and renal unit must be distributed by the coordinating RN. The available personnel for task distribution include one LPN/VN and one UAP. Based on the principles of safe delegation and scope of practice, which task assignment is correct?