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Tüm alıştırma soruları

3881 soru

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Soru 1021Soru →

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

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Cevap: A client admitted with acute pancreatitis whose latest vital signs demonstrate a blood pressure of 106/88 mm Hg and a heart rate of 118 beats/minute

Cevap

The client with acute pancreatitis demonstrating a blood pressure of 106/88 mm Hg and a heart rate of 118 beats/minute.
The correct answer identifies the client exhibiting a narrowing pulse pressure (106 - 88 = 18 mm Hg) and tachycardia (118 bpm). In the context of acute pancreatitis, massive fluid shifts from the intravascular space into the retroperitoneal cavity (third-spacing) frequently occur. A narrowed pulse pressure paired with a rising heart rate is a classic physiological hallmark of early hypovolemic shock due to decreased stroke volume and compensatory sympathetic nervous system activation. This client requires immediate fluid resuscitation and assessment to prevent cardiovascular collapse.

Adım Adım Çözüm

1
Analyze the vital signs of the client with acute pancreatitis.
The pulse pressure is exceptionally narrow at 18 mm Hg (106 - 88) and the heart rate is tachycardic at 118 bpm.
To identify subtle signs of physiological deterioration, such as compensatory mechanisms for early shock.
2
Evaluate the ABG results for the client with COPD.
The ABG demonstrates compensated chronic respiratory acidosis (pH 7.34, PaCO2 58, HCO3 32).
To differentiate between an acute respiratory failure crisis and an expected, chronic physiological baseline.
3
Review the laboratory values for the client on continuous heparin therapy.
The aPTT of 78 seconds safely falls within the expected therapeutic range.
To determine if the client is at an acute risk for hemorrhage or clotting.
4
Compare the acuity of all four clients using the prioritization framework (acute vs. chronic, unexpected vs. expected).
The client with pancreatitis exhibits unexpected, acute signs of early hypovolemic shock (third-spacing). The other three clients exhibit expected, stable findings for their respective conditions.
To identify the single client experiencing the most immediate life-threatening condition.

Anahtar Kavram

Prioritization requires identifying acute, unexpected systemic deterioration (such as early signs of shock) over chronic, compensated, or expected postoperative findings.
Soru 1022Soru →

A client is prepped and draped in the operating room for a scheduled surgical procedure. The surgeon is preparing to make the initial incision. Which safety action is the highest priority for the circulating nurse to initiate at this exact moment?

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Cevap: Conduct a time-out with the entire surgical team to verify the client, procedure, and operative site

Cevap

Conduct a time-out with the entire surgical team to verify the client, procedure, and operative site
The correct answer identifies the Universal Protocol, a standardized safety measure established by the Joint Commission. A 'time-out' must be conducted in the location where the procedure will be done, just before starting the procedure. It requires the active communication of all surgical team members to verbally verify that they have the correct client, are performing the correct procedure, and are at the correct anatomical site.

Adım Adım Çözüm

1
Identify the specific clinical phase described in the scenario.
The client is in the operating room, and the initial incision is about to be made.
Understanding the timeline of care dictates which safety protocols are immediately applicable.
2
Determine the most critical safety risk at this exact moment.
The highest risk is a surgical error, such as operating on the wrong client, performing the wrong procedure, or cutting the wrong site.
Surgical errors are catastrophic 'never events' that require strict preventative protocols.
3
Select the intervention that directly mitigates this risk.
Initiating a formal surgical time-out.
The Universal Protocol mandates a time-out involving all team members immediately before starting the procedure.

Anahtar Kavram

Universal Protocol and Surgical Time-Out
Soru 1023Soru →

A nurse on a high-acuity intermediate care unit is preparing to perform initial physical assessments following a shift transition. Based on the documented clinical cues, which client presents the most critical threat to life and must be evaluated first?

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Cevap: A client extubated 4545 minutes ago who demonstrates a high-pitched inspiratory sound, restlessness, and supraclavicular retractions.

Cevap

The client who was extubated 4545 minutes ago and exhibits a high-pitched inspiratory sound, restlessness, and supraclavicular retractions.
The client exhibiting a high-pitched inspiratory sound (stridor), restlessness, and retractions is demonstrating signs of an impending, complete airway obstruction. Under the Airway-Breathing-Circulation (ABC) prioritization framework, establishing and maintaining a patent airway is always the absolute highest priority. Laryngeal edema or laryngospasm can quickly progress to complete occlusion, making ventilation impossible and leading to rapid cardiac arrest. This client requires immediate emergency intervention, such as the administration of racemic epinephrine or reintubation, before any other clients are assessed.

Adım Adım Çözüm

1
Analyze each client's clinical presentation to identify the underlying physiological threat.
The C6 injury client has autonomic dysreflexia (Circulation/Neuro). The extubated client has post-extubation stridor (Airway). The heart failure client has acute pulmonary edema (Breathing). The pacemaker client has symptomatic bradycardia (Circulation).
Accurate clinical identification is required before prioritization can occur.
2
Apply the Airway-Breathing-Circulation (ABC) prioritization framework to the identified threats.
The airway obstruction is placed at the top of the hierarchy, followed by the breathing emergency, and finally the circulatory/neurological emergencies.
The ABC framework is the standard for prioritizing acute life-threatening emergencies, dictating that airway patency must be secured before breathing or circulation can be supported.
3
Select the client with the highest priority based on the ABC hierarchy.
The client with post-extubation stridor is selected as the first priority.
Without a patent airway, all other physiological functions will fail rapidly, making it the most critical and immediate threat to life.

Anahtar Kavram

Prioritization using the Airway-Breathing-Circulation (ABC) framework in life-threatening emergencies.
Tahmini Süre:1m 30s
Soru 1024Soru →

A healthcare provider orders intermittent intravenous ceftriaxone for an adult client diagnosed with community-acquired pneumonia. The client's only vascular access is a peripheral catheter currently infusing lactated Ringer's solution at 100 mL/hr. What is the safest action by the nurse regarding the administration of this antibiotic?

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Cevap: Halt the continuous infusion, flush the line with normal saline, infuse the antibiotic, and flush the line again.

Cevap

The safest action is to halt the continuous infusion of lactated Ringer's, flush the line with normal saline, infuse the antibiotic, and then flush the line again before restarting the primary fluid.
Ceftriaxone binds chemically with calcium to form a particulate precipitate that can lead to fatal organ damage, particularly in the lungs or kidneys. Because lactated Ringer's solution contains calcium, the two fluids are highly incompatible. When a client has a single IV access site, the standard and safest nursing practice is to pause the incompatible continuous fluid, completely flush the tubing with a neutral, compatible solution (like 0.9% sodium chloride), infuse the medication, and then flush the line again before restarting the primary fluid.

Adım Adım Çözüm

1
Verify the compatibility of the prescribed antibiotic (ceftriaxone) with the current continuous IV fluid (lactated Ringer's solution).
Identify that ceftriaxone is incompatible with lactated Ringer's.
Lactated Ringer's contains calcium. Ceftriaxone binds with calcium to form a dangerous, solid precipitate that can cause fatal organ damage.
2
Determine the best procedural intervention for administering an incompatible medication through a single IV access site.
Select the Saline-Administer-Saline (SAS) flush method.
The nurse must clear the IV tubing of the incompatible fluid to ensure the two substances never mix in the line.
3
Execute the administration protocol.
Pause the pump, flush thoroughly with 0.9% sodium chloride, infuse the ceftriaxone, flush again with 0.9% sodium chloride, and restart the pump.
This guarantees that the antibiotic reaches the bloodstream safely without interacting with the calcium-containing primary fluid.

Anahtar Kavram

Ceftriaxone is contraindicated for concurrent administration with calcium-containing intravenous solutions due to the risk of precipitate formation. When managing incompatible medications in a single line, the tubing must be thoroughly flushed with a compatible solution before and after administration.
Soru 1025Soru →

A nurse enters the room of a 72-year-old client who is recovering from a total hip arthroplasty and is receiving intravenous morphine via a patient-controlled analgesia (PCA) pump. The nurse observes the client's spouse pressing the PCA dosing button while the client appears deeply asleep. The spouse states, 'I am pressing the button every time the green light comes on so he doesn't wake up in severe pain.' Which action is the priority for the nurse to take to prevent a critical adverse event?

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Cevap: Intervene to stop the spouse from activating the device and immediately evaluate the client's airway and respiratory status.

Cevap

The nurse must immediately stop the spouse from pressing the button and assess the client's airway and respiratory status.
The correct action directly addresses the immediate physical threat. By stopping the spouse, the nurse prevents further medication delivery. By immediately evaluating the client's airway and respiratory status, the nurse applies the ABCs of prioritization to detect life-threatening opioid-induced respiratory depression, which requires immediate clinical intervention.

Adım Adım Çözüm

1
Analyze the clinical scenario to identify the primary safety threat.
The spouse is administering morphine to a deeply sleeping client ('PCA by proxy'), creating an immediate risk for severe opioid toxicity and respiratory arrest.
Recognizing the mechanism of injury (unauthorized opioid dosing) dictates the urgency and type of the required intervention.
2
Apply Maslow's Hierarchy of Needs and the ABCs (Airway, Breathing, Circulation) framework.
Physiological needs and airway/breathing take absolute precedence over psychosocial needs, teaching, or documentation.
A client who is deeply asleep while receiving excess opioids may have a compromised airway or respiratory depression, which is life-threatening.
3
Determine the most appropriate initial nursing action.
The nurse must halt the unsafe act and immediately assess the client's respiratory rate, depth, and oxygen saturation.
Direct clinical assessment by the registered nurse is mandatory to determine if emergency interventions (such as administering naloxone or bag-valve-mask ventilation) are required.

Anahtar Kavram

Patient-Controlled Analgesia (PCA) Safety and Prioritization
Tahmini Süre:1m 15s
Soru 1026Soru →

An adolescent client is admitted to the unit with a low-grade fever, cervical lymphadenopathy, and a diffuse pink maculopapular rash. Laboratory testing confirms an active infection with the rubella virus. Which specific infection control intervention must the nurse implement?

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Cevap: Wear a standard surgical mask when entering the client's room.

Cevap

The nurse must wear a standard surgical mask when entering the client's room.
Rubella (commonly known as German measles) is transmitted through large respiratory droplets from the respiratory secretions of infected individuals. According to standard infection control guidelines, clients with rubella require droplet precautions. The primary intervention for droplet precautions is wearing a standard surgical mask when entering the room or coming within close contact of the client to protect the healthcare worker's mucous membranes.

Adım Adım Çözüm

1
Identify the transmitted pathogen and its route of transmission based on the clinical vignette.
The pathogen is the rubella virus (German measles), which is transmitted primarily through large respiratory droplets.
Knowing the transmission route is essential for selecting the correct isolation precaution.
2
Determine the appropriate tier of transmission-based precautions for respiratory droplets.
Droplet precautions are required.
Droplet precautions are designed to prevent the spread of pathogens via large respiratory particles that travel short distances (usually within 3 to 6 feet).
3
Select the correct personal protective equipment (PPE) and environmental controls for droplet precautions.
A standard surgical mask is required upon entering the room.
Surgical masks block large respiratory droplets from reaching the nurse's mucous membranes.

Anahtar Kavram

Transmission-Based Precautions: Droplet Precautions
Tahmini Süre:1m 0s
Soru 1027Soru →

A hospitalized client with bilateral lower extremity paralysis is receiving continuous wall oxygen therapy. The nurse notices electrical sparks and flames originating from a telemetry monitor plugged into the wall outlet next to the bed. Which actions should the nurse take to ensure environmental safety? (Select all that apply.)

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Cevap: Evacuate the client immediately to a safe area beyond the fire doors.; Activate the facility's fire alarm system using the nearest pull station.; Turn off the oxygen flowmeter located on the wall near the client's bed.

Cevap

The correct actions are to immediately evacuate the client, activate the fire alarm, and turn off the oxygen source.
The standard fire safety protocol in healthcare facilities follows the RACE mnemonic. The immediate priority is rescuing the client from direct danger (Rescue). Activating the fire alarm is the necessary second step to initiate the facility's emergency response (Alarm). Furthermore, because oxygen vigorously supports combustion, shutting off the local oxygen source is a critical and immediate safety measure to prevent the fire from escalating rapidly or causing an explosion.

Adım Adım Çözüm

1
Identify the immediate environmental hazard.
An active electrical fire is occurring in close proximity to an oxygen source and an immobile client.
Recognizing the interplay between fire, oxygen, and client mobility dictates the urgency of the response.
2
Apply the standard fire safety mnemonic (R.A.C.E.).
Rescue (evacuate client), Alarm (activate pull station), Confine (close doors), Extinguish (if safe).
This standardized sequence ensures maximum life safety during a hospital fire.
3
Address the specific hazard of continuous oxygen therapy.
The oxygen flowmeter must be turned off immediately.
Oxygen accelerates combustion; shutting it off prevents the fire from intensifying uncontrollably.

Anahtar Kavram

Healthcare Fire Safety (R.A.C.E. Protocol) and Oxygen Hazards
Soru 1028Soru →

A 28-year-old client is admitted to the psychiatric unit under a 72-hour involuntary legal hold due to active suicidal ideation. During the morning medication administration, the client refuses to take their prescribed oral antihypertensive medication, stating, 'I have the right to refuse any pill you give me.' Which of the following is the legally appropriate nursing action?

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Cevap: Withhold the medication, document the refusal in the medical record, and notify the healthcare provider.

Cevap

The legally correct action is to respect the client's autonomy by withholding the medication, documenting the event, and notifying the prescribing healthcare provider.
Clients who are admitted under an involuntary psychiatric hold retain their fundamental civil and legal rights, including the right to informed consent and the right to refuse routine medical or psychiatric treatments. Unless a court has declared the client legally incompetent and appointed a guardian, or a specific emergency order for forced medication is in place to prevent imminent harm, the nurse must respect the client's autonomy. The appropriate legal and clinical action is to withhold the medication, accurately document the refusal, and notify the provider so the care plan can be adjusted.

Adım Adım Çözüm

1
Evaluate the client's current legal status and rights.
The client is on an involuntary psychiatric hold but has not been deemed legally incompetent regarding medical decisions.
An involuntary hold restricts freedom of movement for safety but does not automatically strip a client of their right to informed consent and refusal.
2
Determine the nature of the refused intervention.
The medication is a routine oral antihypertensive, not an emergency psychiatric intervention required to prevent immediate harm.
Forced medication is legally restricted to strict emergency situations where the client poses an imminent physical threat to self or others.
3
Select the appropriate nursing intervention.
The nurse must withhold the dose, chart the refusal objectively, and inform the provider.
This upholds the client's legal rights, prevents the tort of battery, and ensures the medical team is aware of the missed dose.

Anahtar Kavram

Legal Right to Refuse Treatment During Involuntary Admission
Tahmini Süre:1m 0s
Soru 1029Soru →

While rounding on a post-surgical unit, a nurse observes a client continuously picking at the edges of their abdominal wound dressing. The client appears disoriented to time and place. Which intervention should the nurse implement first to protect the surgical site while maintaining the least restrictive environment?

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Cevap: Provide the client with a folded washcloth or soft stress ball to manipulate with their hands.

Cevap

Provide the client with a folded washcloth or soft stress ball to manipulate with their hands.
Providing a safe object for the client to hold is a proven, evidence-based restraint alternative. It successfully redirects the client's tactile seeking behavior and occupies their hands, thereby protecting the surgical dressing without restricting their fundamental freedom of movement.

Adım Adım Çözüm

1
Identify the client's risk and current behavior.
The client is disoriented and picking at a surgical dressing, creating a risk for wound contamination and dehiscence.
Recognizing the immediate safety threat is the first step in the clinical decision-making process.
2
Determine the goal of care based on safety principles.
The goal is to protect the surgical site using the least restrictive intervention possible.
Nursing standards and legal guidelines dictate that restraints of any kind must be a last resort.
3
Select the most appropriate initial intervention.
Distracting the client by giving them a harmless object to hold occupies their hands and safely redirects their behavior.
This is an independent nursing action that does not restrict the client's freedom of movement, aligning perfectly with the principle of maintaining the least restrictive environment.

Anahtar Kavram

Restraint Alternatives and the Least Restrictive Environment
Soru 1030Soru →

A nurse is coordinating the interdisciplinary care plan for a client with newly diagnosed amyotrophic lateral sclerosis (ALS) who is experiencing progressive dysphagia, generalized weakness, and early signs of respiratory decline. The client is preparing to transition to home hospice care. Which of the following actions by the nurse demonstrate appropriate multidisciplinary collaboration and safe care? Select all that apply.

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Cevap: Coordinating with the speech-language pathologist to evaluate the client's risk for aspiration and recommend safe swallowing techniques.; Requesting a consultation with the medical social worker to assist the family in arranging home hospice care and identifying community resources.; Collaborating with the respiratory therapist to ensure the family is properly trained on the use of the client's prescribed noninvasive ventilation equipment.

Cevap

The appropriate collaborative actions are coordinating with the speech-language pathologist for swallowing evaluation, requesting a medical social worker consultation for hospice arrangements, and collaborating with the respiratory therapist for ventilation equipment training.
Optimal care for a complex condition like ALS requires a multidisciplinary approach. The speech-language pathologist is uniquely qualified to manage dysphagia and aspiration risks. The medical social worker possesses the expertise to navigate community resources, financial concerns, and hospice transitions. The respiratory therapist is essential for managing progressive respiratory failure and ensuring proper use of ventilation equipment.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and care needs.
The client has ALS with dysphagia, respiratory decline, and requires a transition to home hospice.
Identifying specific deficits allows the nurse to determine which allied health disciplines are required.
2
Match the client's needs to the appropriate allied health scopes of practice.
Dysphagia requires a speech-language pathologist, transition planning requires a medical social worker, and respiratory equipment requires a respiratory therapist.
Effective interdisciplinary collaboration relies on utilizing the specialized skills of each team member.
3
Evaluate the remaining options for safe nursing practice and communication.
Delegating initial teaching, delaying critical respiratory escalations, and providing false reassurance violate safe care standards.
The nurse must prioritize ABCs, delegate within the scope of practice, and use therapeutic communication.

Anahtar Kavram

Interdisciplinary collaboration requires the nurse to correctly identify the specialized roles of allied health professionals while maintaining safe delegation, prioritizing critical physiological changes, and utilizing therapeutic communication.
Tahmini Süre:1m 30s
Soru 1031Soru →

A clinic nurse is providing anticipatory guidance to the parents of a 6-month-old infant during a routine well-child visit. Which of the following developmental milestones should the nurse inform the parents are expected at this age? Select all that apply.

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Cevap: Rolls from back to abdomen; Babbles single consonant-vowel syllables; Bears weight on the legs when held in a standing position

Cevap

The expected developmental milestones for a 6-month-old infant include rolling from back to abdomen, babbling single consonant-vowel syllables, and bearing weight on the legs when held in a standing position.
At 6 months of age, normal developmental milestones include gross motor achievements such as rolling from the back to the abdomen and bearing weight on the legs when supported in a standing position. Language development at this age features babbling with single consonant-vowel sounds (e.g., 'ma', 'da', 'ba').

Adım Adım Çözüm

1
Identify the client's age and the domain of the question.
The client is a 6-month-old infant, and the question asks for expected developmental milestones.
Establishing the specific age is critical for evaluating typical growth and development expectations.
2
Recall the expected gross motor, fine motor, and language milestones for a 6-month-old.
Expected milestones include rolling over (both ways), bearing weight on legs, using a palmar grasp, and babbling.
Recalling exact milestones provides a baseline to evaluate the given options.
3
Evaluate each option against the 6-month milestones.
Rolling, babbling, and bearing weight match the 6-month expectations. Pulling to a stand and the pincer grasp are milestones expected at 9-10 months.
Differentiating 6-month milestones from advanced milestones identifies the correct answers.

Anahtar Kavram

Infant Developmental Milestones (6 Months)
Soru 1032Soru →

A surgical unit nurse is preparing to transfer a client who is 48 hours post-operative following a right total hip arthroplasty (posterior approach) from the hospital bed to a bedside chair. The client is receiving a continuous intravenous infusion of normal saline and exhibits mild confusion today. Which action by the nurse is the priority to prevent injury during this procedure?

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Cevap: Positioning the chair on the client's unaffected left side and guiding the client to keep the right leg extended forward while pivoting.

Cevap

Positioning the chair on the client's unaffected left side and guiding the client to keep the right leg extended forward while pivoting.
The correct action directly protects the new hip joint prosthesis by utilizing the client's strong, unaffected side for the pivoting motion. Furthermore, instructing the client to keep the operative leg extended straight forward ensures that the hip joint does not bend beyond a 90-degree angle, which is a critical, universally required precaution to prevent posterior dislocation following this specific surgery.

Adım Adım Çözüm

1
Analyze the client's surgical history and required mobility constraints.
The client has a right posterior hip arthroplasty, requiring strict precautions: no hip flexion greater than 90 degrees, no adduction, and no internal rotation.
Identifying procedural contraindications is the first step in preventing injury.
2
Evaluate the safest biomechanical transfer technique for this specific client.
Transferring toward the unaffected (left) side provides stability, while keeping the operative (right) leg extended prevents the hip joint from flexing dangerously during the pivot.
Proper body mechanics and positioning are essential to prevent prosthetic dislocation.
3
Assess the impact of the client's cognitive status on the transfer plan.
Because the client is mildly confused, the registered nurse must directly supervise and assist with the transfer to ensure compliance with precautions, ruling out delegation.
Client confusion increases the risk of impulsive movements that could lead to falls or joint dislocation.

Anahtar Kavram

Orthopedic Safety Precautions and Safe Patient Transfer
Soru 1033Soru →

A registered nurse is implementing a safety plan for an older adult client who is confused, frequently attempts to get out of bed unassisted, and is receiving a continuous intravenous (IV) infusion. Which actions by the nurse are appropriate to prevent injury and errors? Select all that apply.

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Cevap: Place the client in a room close to the nurses' station to facilitate frequent visual checks.; Camouflage the IV tubing and insertion site by covering the arm with a stockinette.; Keep the client's bed in the lowest position with the bed exit alarm activated.

Cevap

The appropriate actions are placing the client in a room close to the nurses' station, camouflaging the IV tubing with a stockinette, and keeping the bed in the lowest position with the alarm activated.
The appropriate actions prioritize non-restrictive safety measures and fall prevention. Moving the client closer to the nurses' station increases surveillance. Camouflaging the IV line is a recognized restraint alternative that reduces visual stimulation to pull at the line. Keeping the bed low and using an alarm minimizes the injury risk if the client attempts to stand.

Adım Adım Çözüm

1
Identify the primary risks for this specific client.
The client is at high risk for falls (due to confusion and unassisted bed exits) and potential injury from dislodging the IV line.
Recognizing specific hazards dictates which safety interventions are required.
2
Evaluate interventions for fall prevention.
Maintaining the bed in the lowest position with alarms activated and placing the client close to the nurses' station for frequent observation are correct, evidence-based practices.
These measures increase surveillance and minimize the distance to the floor, reducing the likelihood and severity of a fall.
3
Evaluate interventions for IV line protection.
Camouflaging the insertion site is a valid, non-restrictive alternative to prevent line pulling. Immediate restraint application is incorrect.
Safety protocols mandate that restraints are a measure of last resort; non-restrictive alternatives must be attempted and documented first.
4
Evaluate delegation and medication administration practices.
Assessing mental status cannot be delegated to UAP. IV fluid compatibility must be verified with a reference guide, not by visual clarity alone.
Ongoing evaluation requires nursing clinical judgment. Visual clarity does not rule out microscopic precipitation or chemical incompatibility.

Anahtar Kavram

Implementing a comprehensive safety plan for a confused client requires maximizing non-restrictive interventions, ensuring appropriate delegation of tasks, and adhering strictly to medication administration protocols.
Soru 1034Soru →

A nurse working on a general medical-surgical floor is evaluating client needs following the lunch hour. Which client requires the most immediate assessment by the nurse?

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Cevap: A client with a tracheostomy tube who has a sudden onset of restlessness and an oxygen saturation of 85% on room air

Cevap

The client with a tracheostomy tube who has a sudden onset of restlessness and an oxygen saturation of 85% on room air requires the most immediate assessment.
According to the ABC (Airway, Breathing, Circulation) framework, establishing and maintaining oxygenation is always the highest priority. Sudden restlessness in conjunction with an oxygen saturation of 85% indicates severe, acute hypoxia—likely due to a mucus plug or other airway obstruction in the tracheostomy tube—that requires immediate emergency intervention.

Adım Adım Çözüm

1
Identify the clinical status of each client to determine urgency based on the Airway, Breathing, Circulation (ABC) prioritization framework.
The tracheostomy client has an airway/breathing issue, the tibia client has a comfort issue, the gastroenteritis client has a stable/expected symptom, and the diabetic client has a routine need.
Applying the ABC framework helps isolate immediate physiological threats to life.
2
Recognize the clinical significance of restlessness and low oxygen saturation in a client with an artificial airway.
These are classic signs of severe hypoxemia and potential airway obstruction.
Hypoxia can rapidly lead to respiratory arrest and death if not corrected immediately.
3
Compare the severity of the airway issue to the needs of the other three clients.
The airway issue takes absolute priority over expected mild pain, expected loose stool, and a routine scheduled task.
Stable, expected, and routine findings are prioritized lower than acute, unstable, and life-threatening conditions.

Anahtar Kavram

Prioritization Framework: Airway, Breathing, Circulation (ABC)
Soru 1035Soru →

While observing care delivery on a progressive care floor, the nurse educator evaluates a registered nurse (RN) who is distributing tasks to an unlicensed assistive personnel (UAP). Which delegation decision by the RN demonstrates safe and effective practice?

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Cevap: Instructing the UAP to measure and record the hourly urine volume for a client on a continuous diuretic drip.

Cevap

Instructing the UAP to measure and record the hourly urine volume for a client on a continuous diuretic drip is the correct delegation decision.
Measuring and recording urine volume is a routine, non-invasive task that does not require nursing judgment, making it entirely appropriate for a UAP. While the UAP documents the volume, the RN maintains the responsibility of analyzing the trended output to determine if the continuous diuretic drip is clinically effective.

Adım Adım Çözüm

1
Identify the scope of practice for unlicensed assistive personnel (UAP).
UAP scope includes routine, non-invasive tasks such as measuring vital signs on stable clients, recording intake and output, and assisting with basic activities of daily living.
Understanding the boundaries of UAP practice is required to ensure safe delegation.
2
Evaluate each task to ensure it does not violate the core principles of delegation.
Tasks requiring assessment, clinical judgment, teaching, or evaluation (EAT) must be retained by the RN.
Delegating complex or high-risk tasks jeopardizes client safety and violates nursing practice acts.
3
Determine which task involves routine data collection without the need for interpretation.
Recording hourly urine volume is a standard measurement task that does not require independent clinical judgment, making it safe to delegate.
The UAP can safely collect the data, while the RN remains responsible for analyzing the output to evaluate the effectiveness of the diuretic.

Anahtar Kavram

Delegation and Scope of Practice for UAP
Soru 1036Soru →

A nurse is preparing to enter the room of a client who requires both contact and droplet precautions. Arrange the following steps for donning personal protective equipment (PPE) in the correct chronological order, starting with the first action.

Öğeleri doğru sıraya koymak için sürükleyin

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Cevap

The correct sequence is: perform hand hygiene, put on the isolation gown, apply the surgical mask, position the face shield or goggles, and finally put on clean gloves.
According to the Centers for Disease Control and Prevention (CDC), the correct sequence for donning PPE ensures maximum protection and prevents self-contamination during the process. Hand hygiene must always occur first. The gown is donned first among the garments because of its size and the need to tie it at the back. The mask follows to secure respiratory protection. Eyewear is next to protect the eyes, and gloves are always placed last so they can overlap the gown cuffs to seal the wrists.

Adım Adım Çözüm

1
Perform hand hygiene.
Hands are clean and ready to handle uncontaminated equipment.
Prevents the transfer of pathogens to the clean PPE garments.
2
Put on the isolation gown.
The torso and arms are protected.
The gown is donned first as it is the largest garment and requires reaching behind the neck and waist to fasten the ties.
3
Apply the surgical mask.
The nose and mouth are protected.
The mask is secured next to protect the respiratory system from droplet transmission.
4
Position the face shield or goggles.
The eyes are protected.
Eyewear is placed after the mask so it can sit securely, often resting slightly over the mask's upper edge.
5
Put on clean gloves.
The hands are protected and the wrists are sealed.
Gloves are put on last so they can be stretched over the cuffs of the isolation gown, ensuring no exposed skin at the wrists.

Anahtar Kavram

Standard donning sequence for personal protective equipment (PPE)
Soru 1037Soru →

A nurse is planning care for a group of clients receiving pharmacological and parenteral therapies. Which of the following actions demonstrate safe and effective nursing practice? (Select all that apply.)

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Cevap: Flush a central venous access device with 1010 mL of sterile 0.9%0.9\% sodium chloride before and after administering an intravenous push medication.; Dedicate a single lumen of a multi-lumen central venous catheter exclusively for the administration of total parenteral nutrition.; Review the client's most recent serum potassium level prior to initiating a continuous intravenous infusion of potassium chloride.

Cevap

The correct actions represent adherence to evidence-based safety guidelines: flushing a central line with an appropriately sized syringe (1010 mL), dedicating a single catheter lumen strictly for total parenteral nutrition, and verifying baseline electrolyte values before administering potassium chloride.
Safe parenteral therapy relies on proactive risk management. Using a 1010 mL syringe to flush a central line prevents catheter rupture caused by high pressure. Dedicating a single lumen for total parenteral nutrition prevents dangerous drug interactions and minimizes central line-associated bloodstream infections. Finally, verifying serum potassium levels before initiating a potassium chloride infusion is a mandatory safety check to prevent fatal cardiac dysrhythmias.

Adım Adım Çözüm

1
Evaluate the central line flushing technique.
Using a 1010 mL syringe with 0.9%0.9\% sodium chloride is identified as the correct standard.
Smaller syringes create excessive pressure that can rupture central venous catheters.
2
Analyze the vancomycin dosage calculation and infusion rate.
The rate of 500500 mL/hr is identified as dangerously fast for a 22-gram dose.
Vancomycin must be infused over at least 120120 minutes for a 22-gram dose to prevent Red Man Syndrome.
3
Assess the compatibility of ceftriaxone and lactated Ringer's.
This combination is identified as strictly contraindicated.
Ceftriaxone forms fatal precipitates when mixed with calcium, which is present in lactated Ringer's solution.
4
Evaluate the management of total parenteral nutrition (TPN).
Dedicating a specific central line lumen for TPN is recognized as correct.
TPN has a high infection risk and is incompatible with many medications.
5
Prioritize interventions for a client experiencing an allergic reaction.
Assessing the airway before stopping the penicillin infusion is identified as the incorrect sequence.
The absolute first priority is to stop the offending medication to prevent further systemic allergen exposure.
6
Determine the safety prerequisite for potassium administration.
Checking the most recent serum potassium level is identified as a necessary action.
Potassium is a high-alert medication; giving it without knowing current levels risks fatal hyperkalemia.

Anahtar Kavram

Safe administration of parenteral therapies requires strict adherence to infusion rate guidelines, rigorous compatibility checks, prioritization of source control during adverse reactions, and diligent pre-administration laboratory monitoring.
Soru 1038Soru →

A nurse is preparing to obtain a blood specimen for laboratory testing from a client's central venous catheter (CVC). A continuous intravenous infusion is currently running through the lumen. Arrange the following steps in the correct chronological order for safely drawing the blood specimen using the discard method.

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Cevap

The correct sequence is: Pause the continuous infusion, scrub the connector hub, aspirate and discard the initial 5 mL of blood, withdraw the required specimen, flush the catheter with normal saline, and finally resume the continuous infusion.
To maintain patient safety, specimen integrity, and line patency, the nurse must first stop any fluids that could alter the sample. Strict infection control (scrubbing the hub) is applied next. The discard step guarantees the drawn specimen is pure blood and not diluted with the prior infusion. After the clean sample is collected, the line must be flushed to prevent blood from clotting in the catheter before the continuous therapy is safely resumed.

Adım Adım Çözüm

1
Pause the continuous IV infusion.
The flow of fluid and medication into the bloodstream is temporarily stopped.
Prevents mixing of the IV fluid with the blood specimen, which would alter laboratory results.
2
Scrub the hub with antiseptic.
Pathogens are removed from the entry point.
Maintains strict asepsis and prevents the introduction of bacteria into the central circulation.
3
Aspirate and discard 5 mL of blood.
Residual fluid within the catheter space is removed.
Ensures the subsequent sample is undiluted whole blood.
4
Withdraw the diagnostic specimen.
An accurate, uncontaminated blood sample is obtained.
Provides reliable data for clinical decision-making.
5
Flush the catheter with 0.9% sodium chloride.
The catheter lumen is cleared of all blood.
Prevents the blood from clotting inside the lumen and maintains catheter patency.
6
Restart the continuous infusion.
The client's parenteral therapy continues.
Ensures there is no prolonged interruption in the client's prescribed medical treatment.

Anahtar Kavram

Central Venous Catheter (CVC) Blood Specimen Collection
Tahmini Süre:1m 0s
Soru 1039Soru →

A nurse is caring for a client who has been receiving continuous gastric suctioning via a nasogastric (NG) tube for the past 72 hours due to a mechanical bowel obstruction. During the morning assessment, the client reports muscle cramps and a tingling sensation in the fingertips. Based on the client's clinical presentation and current therapy, which of the following arterial blood gas (ABG) results should the nurse anticipate?

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Cevap: pH 7.50, PaCO2 48 mm Hg, HCO3 32 mEq/L

Cevap

The ABG values indicating metabolic alkalosis with partial respiratory compensation (elevated pH, elevated HCO3, and elevated PaCO2).
Prolonged nasogastric suctioning depletes the body of gastric secretions, which are rich in hydrochloric acid, potassium, and sodium. The loss of acid leads to a primary metabolic alkalosis, characterized by an elevated pH (> 7.45) and an elevated bicarbonate (HCO3 > 26 mEq/L). The body attempts to compensate by decreasing the respiratory rate to retain carbon dioxide, leading to an elevated PaCO2 (> 45 mm Hg). Furthermore, metabolic alkalosis decreases ionized calcium levels in the blood, which causes the neuromuscular excitability manifested as muscle cramps and tingling (paresthesia). The correct option presents the exact parameters of metabolic alkalosis with partial respiratory compensation.

Adım Adım Çözüm

1
Identify the primary physiological impact of continuous nasogastric suctioning.
Gastric contents are highly acidic due to hydrochloric acid. Continuous removal leads to a significant loss of hydrogen ions.
Understanding the fluid being lost determines the resulting acid-base imbalance.
2
Determine the expected acid-base imbalance from the loss of stomach acid.
Loss of body acid results in an accumulation of base (bicarbonate), leading to metabolic alkalosis. This is characterized by an elevated pH (> 7.45) and elevated HCO3 (> 26 mEq/L).
Acid loss directly raises blood pH and increases the relative concentration of bicarbonate.
3
Analyze the client's symptoms of muscle cramps and tingling.
Alkalosis causes increased binding of calcium to albumin, reducing ionized calcium levels in the blood. Hypocalcemia causes neuromuscular excitability, explaining the cramps and tingling.
Correlating clinical signs with the anticipated physiological state confirms the metabolic disturbance.
4
Evaluate the ABG options to find the one representing metabolic alkalosis.
The option with pH 7.50 and HCO3 32 mEq/L represents metabolic alkalosis. The elevated PaCO2 of 48 mm Hg shows the lungs are attempting to compensate by retaining acid (CO2).
Selecting the specific laboratory values that match the deduced clinical condition.

Anahtar Kavram

Acid-Base Imbalances: Metabolic Alkalosis from Gastric Loss
Soru 1040Soru →

A client with a complete transection spinal cord injury at the T4 level suddenly reports a severe, pounding headache and blurred vision. Upon evaluation, profuse diaphoresis is noted above the level of the injury alongside a blood pressure reading of 215/115 mm Hg. Arrange the following nursing actions in the priority order they should be performed, from first to last.

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Cevap

The correct sequence is to first elevate the head of the bed, loosen restrictive clothing, assess the bladder, examine the bowel, and finally administer antihypertensive medication.
Autonomic dysreflexia is a medical emergency characterized by uncontrolled hypertension in clients with spinal cord injuries at or above T6. The priority sequence follows a strict 'immediate safety first, then treat the cause' approach: rapidly lowering blood pressure via orthostasis (sitting up) is always the immediate first action. This is followed by systematically identifying and removing the offending noxious stimuli, starting from the most external and common (tight clothing, full bladder) to the next most common (bowel impaction). Pharmacological intervention is the final step if mechanical removal of stimuli fails.

Adım Adım Çözüm

1
Elevate the head of the bed to a high Fowler's position.
Takes advantage of orthostatic hypotension to lower blood pressure.
The client is experiencing a hypertensive emergency due to autonomic dysreflexia. The most immediate mechanical way to lower blood pressure and prevent stroke is to utilize gravity.
2
Loosen any restrictive clothing or tight devices.
Reduces external skin stimulation.
Tight clothing, tight sheets, or restrictive devices act as noxious sensory stimuli below the level of injury, driving the exaggerated sympathetic response.
3
Assess the urinary drainage system for kinks or bladder distention.
Identifies or rules out the primary cause of autonomic dysreflexia.
A distended bladder is the single most common cause of autonomic dysreflexia. Emptying the bladder often abruptly stops the crisis.
4
Examine the rectum for the presence of a fecal impaction.
Identifies or rules out the secondary cause of autonomic dysreflexia.
If the bladder is not the source, the bowel is the next most likely culprit. This must be checked to remove the noxious stimulus.
5
Administer a rapidly acting intravenous antihypertensive medication.
Pharmacologically lowers the blood pressure.
Medications are used only when conservative measures fail to eliminate the noxious stimuli or if the blood pressure remains critically elevated despite removing the trigger.

Anahtar Kavram

Prioritization and Management of Autonomic Dysreflexia
Tahmini Süre:1m 30s
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Tüm alıştırma soruları — NCLEX-RN | Examkin