Tüm alıştırma soruları

A nurse is caring for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache and blurred vision. The nurse observes profuse facial diaphoresis and records a blood pressure of 215/115 mm Hg. In what order should the nurse perform the following interventions? Arrange from first to last action.

During a surgical procedure under general anesthesia, the intraoperative monitor reveals a sudden, rapid rise in end-tidal carbon dioxide (ETCO2). Simultaneously, the client develops generalized muscle rigidity and unexpected severe sinus tachycardia. Recognizing a malignant hyperthermia crisis, in which order must the nurse execute or assist with the following collaborative interventions? Arrange the actions from highest priority (first) to lowest priority (last).

A hospitalized client is receiving a continuous infusion of a maintenance fluid through a single-lumen peripheral venous catheter. The healthcare provider has prescribed a scheduled intravenous (IV) bolus medication that is physically incompatible with the current infusion. Arrange the following actions in the correct chronological order to safely deliver the medication.

A nurse is preparing to perform an abdominal assessment on a client who is receiving continuous nasogastric (NG) tube suctioning for a bowel obstruction. Which action should the nurse take to ensure an accurate physical assessment?

Following a therapeutic right-sided thoracentesis to relieve a pleural effusion, a client on the medical-surgical unit suddenly exhibits acute agitation, tachypnea, and sharp right-sided chest pain. To mitigate the risk of severe physiological compromise, which actions must the nurse perform immediately? (Select all that apply.)

A nurse is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, pounding headache. The nurse notes profuse diaphoresis on the client's face and neck, and a blood pressure reading of 210/115 mm Hg. Arrange the following nursing actions in the correct priority order from first to last.

A nurse is changing the administration set for a client's central venous catheter. The client suddenly gasps, reports sharp chest pain, and becomes profoundly dyspneic and tachycardic. Suspecting a central line-associated air embolism, arrange the following nursing actions in the correct priority sequence to minimize physiological risk.

A nurse is caring for a client who is receiving a continuous transfusion of packed red blood cells (PRBCs) through a primary peripheral intravenous (IV) catheter. The client's latest laboratory results reveal a critically low serum potassium level of 2.3 mEq/L, and the healthcare provider prescribes a dose of 40 mEq of IV potassium chloride. A second, saline-locked peripheral IV access is available on the client's other arm. Which of the following is the safest nursing action to implement?

A client in the emergency department is experiencing a severe panic attack and is visibly hyperventilating. Which of the following assessment findings and laboratory values indicate the client is developing respiratory alkalosis? Select all that apply.

A mental health clinic nurse evaluates a client who recently experienced a traumatic home eviction. The client paces the examination room, wrings their hands, and states, "I have nowhere to go. I am a complete failure as a provider." Which of the following responses by the nurse demonstrate therapeutic communication? Select all that apply.

A nurse is caring for a client admitted with acute pancreatitis. Which of the following assessment findings should the nurse identify as indicators that the client is developing systemic inflammatory response syndrome (SIRS)? Select all that apply.

While caring for a client with a deep vein thrombosis, the registered nurse prepares to administer a scheduled dose of intravenous levofloxacin. The client has a single peripheral venous catheter currently infusing continuous intravenous heparin. What is the priority action the nurse must perform before proceeding?

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

Upon returning to the inpatient mental health facility from a supervised community outing, a client with a history of substance use disorder walks briskly toward the dormitory area. The registered nurse notices the client keeping their right hand tightly concealed inside their jacket pocket. When approached, the client avoids eye contact, turns away, and says, "Leave me alone, I'm just exhausted." Which action should the nurse take to best maintain the safety of the therapeutic environment?

A nurse is caring for a postpartum client who is tearful in her room. The client states, "I am a terrible mother. I cannot even produce enough milk to feed my own baby." Which of the following responses by the nurse are therapeutic? Select all that apply.

A nurse in a palliative care unit is caring for a terminally ill client who has entered the active phase of dying. The client suddenly becomes highly restless, pulls at the bed linens, and converses with deceased relatives. The client's adult child is visibly distressed and pleads with the nurse, 'Please tell my mother she is in the hospital and her parents are not here.' Which is the priority nursing action?

A 68-year-old client is being monitored in the progressive care unit two hours after undergoing a bedside left-sided thoracentesis for a pleural effusion. The client suddenly becomes restless, diaphoretic, and has a respiratory rate of 34 breaths/min. The nurse observes diminished breath sounds on the left side and asymmetrical chest expansion. An arterial blood gas (ABG) reveals a pH of 7.49, PaCO2 of 29 mm Hg, PaO2 of 56 mm Hg, and HCO3 of 23 mEq/L. Which action should the nurse implement first to reduce the risk of severe physiological decompensation?

A client arrives at the medical-surgical unit after undergoing a flexible bronchoscopy with a transbronchial biopsy under conscious sedation. To reduce the risk of potential physiological complications, which actions should the nurse include in the client's immediate care plan? Select all that apply.

An adult client is receiving scheduled enteral nutrition through a percutaneous endoscopic gastrostomy tube. Which intervention should the nurse implement to decrease the risk of aspiration?

A nurse is caring for a client with post-traumatic stress disorder (PTSD) on an inpatient mental health unit. Following a loud argument between two other clients in the dayroom, the client retreats to a corner, begins hyperventilating, covers their ears, and screams, "Don't touch me! Keep away!" The client is trembling, visually scanning the room, and clenching their fists. Which initial nursing action is the priority?