Tüm alıştırma soruları

3881 soru

Tüm türler3,881 Çoktan seçmeli1,926 Çoklu seçim908 Sayısal119 Eşleştirme66 Sıralama862

A middle-aged adult with a history of schizophrenia is brought to a busy, brightly lit emergency department triage area by law enforcement. The client is pacing rapidly near the exit, covering their ears, and visibly trembling. Diaphoresis is noted, and the client is whispering, 'They are telling me the lights will burn my skin if I do not run.' Vital signs reveal a heart rate of 114 bpm and respirations of 26/min. Which action should the triage nurse take first?

Acknowledge the client's distress and calmly guide them to a low-stimulus room away from the main triage area.

Explain that the fluorescent lights are standard hospital equipment and cannot cause thermal burns.

Assign an unlicensed assistive personnel (UAP) to stand near the exit doors to prevent the client from leaving.

Prepare to administer a prescribed as-needed intramuscular antipsychotic medication to rapidly decrease agitation.

Cevabı ve açıklamayı göster

Cevap: Acknowledge the client's distress and calmly guide them to a low-stimulus room away from the main triage area.

Cevap

Acknowledge the client's distress and calmly guide them to a low-stimulus room away from the main triage area.

The correct action directly addresses the environmental factors exacerbating the client's symptoms. The busy, bright ED is causing sensory overload, feeding the hallucination. Moving the client to a low-stimulus environment is the safest, least restrictive first step. Furthermore, acknowledging the client's emotional state (distress/fear) without confirming the delusion is the cornerstone of therapeutic communication for perceptual alterations.

Adım Adım Çözüm

Analyze the client's clinical presentation.

The client is experiencing active command hallucinations and severe anxiety (elevated HR and RR, diaphoresis, pacing) exacerbated by the highly stimulating environment of the triage area.

Identifying the root cause of the agitation (sensory overload combined with psychotic symptoms) dictates the necessary intervention.

Evaluate the safety and prioritization of interventions.

The immediate risk is elopement or escalation due to panic. The environment is contributing to the perceptual alteration.

Nursing priorities for acute sensory and perceptual alterations focus on providing a safe, predictable, and low-stimulus environment.

Select the least restrictive, most therapeutic initial action.

Moving the client to a quiet room reduces environmental triggers, and acknowledging their fear builds rapport without validating the delusion.

Best practice requires utilizing environmental controls and verbal de-escalation before applying chemical restraints or delegating care of an unstable client.

Anahtar Kavram

Management of acute sensory overload and perceptual alterations involves providing a low-stimulus environment, ensuring safety using least restrictive measures, and therapeutically addressing the emotional content of hallucinations without arguing logic.

Soru 1262Soru →

A home health nurse arrives at the residence of a client with paraplegia for a scheduled wound care visit. The client's spouse is pacing erratically and shouts, 'I cannot take care of this anymore!' The nurse notices three circular, crusted lesions resembling cigarette burns on the client's forearms. The client avoids eye contact and appears fearful. The spouse insists on remaining at the bedside. In what order should the nurse perform the following actions? Arrange the actions from first priority to last.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence prioritizes immediate safety and separation, followed by physical assessment, psychosocial interviewing, objective documentation, and finally, mandatory reporting.

In cases of suspected abuse, the nursing process prioritizes interventions based on safety and Maslow's hierarchy of needs. The absolute first step is to establish a safe environment by tactfully separating the client from the suspected perpetrator. Once safety is secured, the nurse addresses physiological needs by assessing the physical injuries. After physical assessment, the nurse addresses psychosocial needs by interviewing the client privately. Following the completion of the assessment, the nurse objectively documents all findings. Finally, using the gathered information, the nurse fulfills their legal obligation by reporting the suspected abuse to the designated authorities.

Adım Adım Çözüm

Ensure immediate client safety by separating them from the suspected abuser.

The spouse is removed from the room, creating a secure environment.

Safety is always the primary concern in suspected abuse situations; an accurate assessment cannot be performed while the abuser is present.

Assess the client's physical condition.

The nurse evaluates the burns and checks for other injuries.

Physical stabilization and identifying acute trauma take precedence over interviewing and documentation.

Interview the client privately about the injuries.

The nurse asks direct, non-judgmental questions to determine the cause of the injuries.

Direct communication in a safe environment is necessary to validate suspicions and assess the client's immediate risk level.

Document all findings objectively.

Physical descriptions, direct quotes, and behavioral observations are recorded.

Factual documentation provides the foundation for the subsequent legal report and future investigations.

Report the suspected abuse to the appropriate authorities.

Adult protective services is notified of the suspected dependent adult abuse.

Nurses are mandated reporters; however, this step follows safety, assessment, and documentation.

Anahtar Kavram

Prioritization of Care in Suspected Abuse

Soru 1263Soru →

A 54-year-old client is being monitored in the recovery unit two hours after an esophagogastroduodenoscopy (EGD) with esophageal dilation. The client suddenly reports severe, sharp pain in the chest and neck area that worsens with swallowing. The nurse notes a heart rate of 122 bpm, a respiratory rate of 26 breaths/min, and a blood pressure of 90/58 mm Hg. Which of the following is the priority nursing action?

Maintain strict NPO status and immediately notify the healthcare provider.

Assist the client into a flat, supine position with the legs elevated.

Auscultate the abdomen starting in the right lower quadrant for bowel sounds.

Administer the prescribed PRN intravenous opioid analgesic for the severe pain.

Cevabı ve açıklamayı göster

Cevap: Maintain strict NPO status and immediately notify the healthcare provider.

Cevap

Maintain strict NPO status and immediately notify the healthcare provider.

The correct action is to maintain strict NPO status and notify the healthcare provider. The client's symptoms—severe chest and neck pain that worsens with swallowing, tachycardia, tachypnea, and hypotension—are classic indicators of an esophageal perforation. This is a life-threatening complication of esophageal dilation. Keeping the client NPO prevents further leakage of oral or gastric contents into the mediastinum, and the provider must be notified immediately to initiate emergency medical or surgical intervention.

Adım Adım Çözüm

Analyze the client's new symptoms and vital signs.

The client is exhibiting tachycardia, tachypnea, hypotension, and severe neck and chest pain that worsens with swallowing.

These are significant deviations from a stable post-procedure baseline and indicate a severe complication.

Correlate the clinical findings with the specific procedure performed.

An EGD with esophageal dilation carries a risk of esophageal perforation. The symptoms strongly suggest this life-threatening complication, leading to early shock.

Recognizing procedural risks allows the nurse to anticipate and quickly identify complications.

Determine the highest priority nursing intervention to mitigate risk.

The client must be kept strictly NPO, and the provider must be notified immediately.

NPO status prevents further leakage of contents into the mediastinum, and the provider is needed for emergency surgical or medical management.

Anahtar Kavram

Recognizing and Mitigating Complications of Endoscopic Procedures (Esophageal Perforation)

Soru 1264Soru →

A nurse is creating a plan of care for a newly admitted client experiencing an acute exacerbation of chronic obstructive pulmonary disease (COPD) accompanied by severe dyspnea, orthopnea, and profound fatigue. Which interventions should the nurse include to address the client's basic care and comfort? Select all that apply.

Geçerli olan tümünü seçin

Position the client leaning forward with their arms resting on a raised overbed table

Provide small, nutrient-dense meals that require minimal effort to chew

Maintain the client in a flat, supine position during the night to promote restorative sleep

Instruct the unlicensed assistive personnel (UAP) to perform the initial evaluation of the client's skin integrity

Apply bilateral soft wrist restraints if the client exhibits sudden agitation to prevent removal of the oxygen cannula

Cevabı ve açıklamayı göster

Cevap: Position the client leaning forward with their arms resting on a raised overbed table; Provide small, nutrient-dense meals that require minimal effort to chew

Cevap

The correct interventions are positioning the client leaning forward over an overbed table and providing small, nutrient-dense meals that require minimal chewing.

Positioning the client leaning forward over an overbed table (orthopneic position) allows the accessory muscles of respiration to function more effectively, facilitating maximum chest expansion and easing dyspnea. Providing small, easily chewed meals prevents the client from expending excessive energy during eating, thereby reducing oxygen demand and minimizing severe fatigue.

Adım Adım Çözüm

Identify the client's primary physiological challenges based on the clinical presentation.

The client is experiencing severe dyspnea, orthopnea, and fatigue secondary to a COPD exacerbation.

Understanding the underlying pathology is necessary to select appropriate comfort and basic care interventions.

Evaluate the proposed positioning and nutritional interventions for safety and efficacy.

Leaning forward on an overbed table maximizes chest expansion, while small, easy-to-chew meals conserve the client's limited energy.

These actions directly address the client's work of breathing and high risk for exhaustion.

Identify contraindicated actions or safety violations among the distractors.

Supine positioning, delegating an initial assessment to a UAP, and applying restraints for hypoxia-induced agitation are incorrect and potentially harmful.

These choices violate physiological safety principles, nursing scope of practice, and standard restraint protocols.

Anahtar Kavram

Basic care, comfort, and positioning for clients with respiratory compromise

Soru 1265Soru →

A nurse is caring for a client with a complete spinal cord injury at the T3 level. The client suddenly reports a severe, pounding headache. The nurse notes profuse diaphoresis on the client's face and neck, cutis anserina (goosebumps), a blood pressure of 220/115 mm Hg, and a heart rate of 52 bpm. Arrange the following nursing interventions in the priority order they should be performed.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

1. Elevate head of bed, 2. Loosen restrictive clothing, 3. Inspect urinary catheter/bladder, 4. Assess for fecal impaction with anesthetic, 5. Administer antihypertensive medication.

Autonomic dysreflexia is a medical emergency characterized by a massive, uncompensated cardiovascular response to stimulation of the sympathetic nervous system. The absolute first priority is to decrease blood pressure immediately using gravity (sitting the client up). Subsequent steps systematically eliminate the most common noxious stimuli from least invasive/most accessible (clothing) to visceral (bladder, then bowel). Medications are a last resort if primary interventions fail.

Adım Adım Çözüm

Elevate the head of the bed to a high Fowler's position.

Induces orthostatic pooling of blood in the lower extremities.

This immediately reduces venous return and lowers blood pressure, mitigating the immediate threat of hypertensive stroke while other interventions are prepared.

Loosen any restrictive clothing or tight items.

Removes external noxious cutaneous stimuli.

Tight clothing, belts, or binders can trigger or exacerbate the sympathetic discharge. This is the fastest trigger to assess and eliminate.

Inspect the indwelling urinary catheter tubing for kinks and palpate the bladder.

Identifies or rules out bladder distention.

A distended bladder is the leading cause of autonomic dysreflexia. Draining the bladder often completely resolves the hypertensive crisis.

Apply a topical anesthetic to the rectum and gently assess for a fecal impaction.

Identifies or rules out bowel impaction safely.

Bowel impaction is the second most common trigger. The topical anesthetic is mandatory to prevent the digital stimulation from causing a further spike in blood pressure.

Administer a prescribed rapid-acting intravenous antihypertensive medication.

Pharmacologically lowers blood pressure.

Medications (e.g., hydralazine, nitrates) are reserved for cases where the trigger cannot be found, cannot be easily removed, or the blood pressure fails to normalize after trigger removal.

Anahtar Kavram

Management of Autonomic Dysreflexia

Soru 1266Soru →

A pediatric client weighing $48.4\text{ lb}$ is prescribed a continuous intravenous (IV) infusion of fentanyl at $2\text{ \mu g/kg/hr}$ for pain management. The pharmacy dispenses an IV bag containing $500\text{ \mu g}$ of fentanyl in $100\text{ mL}$ of $0.9\%$ sodium chloride. At what rate, in $\text{mL/hr}$ , should the nurse set the IV infusion pump? Record your answer using one decimal place.

Cevabı ve açıklamayı göster

Cevap: 8.8

Cevap

8.8

To determine the correct IV infusion rate, the nurse must first convert the client's weight to kilograms (

48.4 \text{ lb} \div 2.2 = 22 \text{ kg}

). Next, calculate the hourly dose by multiplying the weight by the prescribed rate (

22 \text{ kg} \times 2 \text{ \mu g/kg/hr} = 44 \text{ \mu g/hr}

). Finally, divide the required hourly dose by the concentration of the supplied medication (

500 \text{ \mu g} \div 100 \text{ mL} = 5 \text{ \mu g/mL}

) to find the pump rate in mL/hr (

44 \text{ \mu g/hr} \div 5 \text{ \mu g/mL} = 8.8 \text{ mL/hr}

Adım Adım Çözüm

Convert the client's weight from pounds to kilograms.

22 kg

The prescribed medication dose is weight-based in kilograms, so the weight must be converted first.

Calculate the total hourly dose required in micrograms.

44 \mu g/hr

To determine the exact amount of active medication the client needs per hour based on their weight.

Determine the concentration of the dispensed fentanyl solution.

5 \mu g/mL

To find out how many micrograms of fentanyl are contained in each milliliter of the IV fluid.

Calculate the final IV infusion pump rate.

8.8 mL/hr

To determine the precise volume of fluid to administer per hour to safely deliver the required dose.

Anahtar Kavram

Weight-based intravenous continuous infusion calculation

Soru 1267Soru →

A nurse is evaluating a client who has been receiving continuous nasogastric tube suctioning for the past 72 hours due to a mechanical small bowel obstruction. During the morning assessment, the client exhibits shallow respirations, bilateral muscle twitching, and a heart rate of 110 beats per minute. Which of the following arterial blood gas (ABG) results best correlates with this client's current clinical presentation?

pH 7.52,

PaCO_2

48 mm Hg,

HCO_3^-

32 mEq/L

pH 7.28,

PaCO_2

55 mm Hg,

HCO_3^-

26 mEq/L

pH 7.31,

PaCO_2

38 mm Hg,

HCO_3^-

18 mEq/L

pH 7.49,

PaCO_2

28 mm Hg,

HCO_3^-

24 mEq/L

Cevabı ve açıklamayı göster

Cevap: pH 7.52, $PaCO_2$ 48 mm Hg, $HCO_3^-$ 32 mEq/L

Cevap

pH 7.52,

PaCO_2

48 mm Hg,

HCO_3^-

32 mEq/L

Continuous removal of gastric acid via nasogastric suctioning leads to metabolic alkalosis, evidenced by an elevated pH (7.52) and elevated bicarbonate (

HCO_3^-

32 mEq/L). The body attempts to compensate for this alkalosis by hypoventilating (shallow respirations) to retain carbon dioxide, which explains the elevated

PaCO_2

(48 mm Hg). Furthermore, the client's muscle twitching is a classic sign of associated hypocalcemia or hypokalemia, both of which are common complications of metabolic alkalosis.

Adım Adım Çözüm

Identify the primary acid-base disturbance caused by prolonged nasogastric suctioning.

Loss of gastric acid (hydrochloric acid) leads to a primary metabolic alkalosis.

The stomach contains high levels of acid; removing it systematically increases the relative amount of circulating base (bicarbonate) in the blood.

Determine the expected compensatory physiological response to metabolic alkalosis.

The respiratory system compensates by decreasing the rate and depth of respirations (hypoventilation) to retain

CO_2

Retaining carbon dioxide (an acid) helps lower the elevated blood pH back toward the normal physiological range. This explains the client's shallow respirations.

Analyze the ABG options to find the one matching metabolic alkalosis with partial respiratory compensation.

The correct ABG values will show an elevated pH, elevated

HCO_3^-

, and elevated

PaCO_2

A pH of 7.52 (alkalemia) with an

HCO_3^-

of 32 mEq/L confirms the metabolic origin, while a

PaCO_2

of 48 mm Hg confirms respiratory compensation.

Anahtar Kavram

Metabolic Alkalosis and Respiratory Compensation

Tahmini Süre:1m 30s

Soru 1268Soru →

An older adult client is admitted to the medical unit with severe dehydration. The client is currently experiencing generalized muscle weakness, sudden-onset confusion, and frequent urinary incontinence. An intravenous (IV) fluid infusion is in progress. Which nursing intervention is the most appropriate to maintain this client's basic care and comfort?

Instructing the unlicensed assistive personnel (UAP) to evaluate the perineal skin for early signs of breakdown while changing the client's linens.

Reassuring the family members that the client's sudden onset of confusion is an expected physiological consequence of the normal aging process.

Gently cleansing the perineal region with a pH-balanced cleanser and applying a moisture-barrier product following each incontinent episode.

Initiating the use of soft bilateral wrist restraints to prevent the confused client from inadvertently dislodging the continuous IV infusion.

Cevabı ve açıklamayı göster

Cevap: Gently cleansing the perineal region with a pH-balanced cleanser and applying a moisture-barrier product following each incontinent episode.

Cevap

Gently cleansing the perineal region with a pH-balanced cleanser and applying a moisture-barrier product following each incontinent episode.

The application of pH-balanced cleansers and moisture barriers is a direct basic care and comfort measure that protects the skin from the maceration and chemical irritation caused by urinary incontinence. This prevents skin breakdown and promotes the client's overall physiological integrity and comfort.

Adım Adım Çözüm

Analyze the client's clinical presentation, noting the combination of generalized weakness, new-onset confusion, and urinary incontinence.

The client is identified as being at high risk for impaired skin integrity due to excess moisture and an inability to independently reposition or manage personal hygiene.

Identifying physiological risks is the crucial first step in prioritizing basic care interventions.

Evaluate the proposed interventions against principles of basic care, comfort, safety, and scope of practice.

Skin protection emerges as the primary independent nursing intervention for comfort, while the other options violate safety protocols, misunderstand aging pathology, or involve improper delegation.

Appropriate nursing care must adhere to legal and ethical standards, including proper delegation and avoiding unnecessary restraints.

Anahtar Kavram

Skin Integrity and Hygiene Maintenance

Soru 1269Soru →

A nurse is caring for a client with type 1 diabetes mellitus in the emergency department. The client has a blood glucose level of 450 mg/dL, deep and rapid respirations, and a fruity breath odor. Which of the following acid-base imbalances is this client most likely experiencing?

Metabolic acidosis

Metabolic alkalosis

Respiratory acidosis

Respiratory alkalosis

Cevabı ve açıklamayı göster

Cevap: Metabolic acidosis

Cevap

Metabolic acidosis

The client's presentation of severe hyperglycemia, deep and rapid respirations (Kussmaul respirations), and a fruity breath odor are classic and unmistakable indicators of diabetic ketoacidosis (DKA). In DKA, a severe lack of insulin forces the body to break down fats for energy, a process that produces acidic ketone bodies. The subsequent accumulation of these ketones in the bloodstream directly results in metabolic acidosis. The observed Kussmaul respirations serve as a respiratory compensatory mechanism, attempting to decrease overall blood acidity by forcefully exhaling excess carbon dioxide.

Adım Adım Çözüm

Analyze the client's clinical presentation.

The client has severe hyperglycemia (450 mg/dL), deep and rapid breathing known as Kussmaul respirations, and a fruity breath odor.

Identifying these classic clinical signs is necessary to determine the underlying pathophysiological process occurring in the client.

Correlate the assessment findings with a specific disease process.

These findings are the hallmark signs of diabetic ketoacidosis (DKA), a serious acute complication primarily associated with type 1 diabetes mellitus.

Recognizing DKA allows the nurse to anticipate the physiological effects on the body, particularly concerning acid-base balance.

Determine the resulting primary acid-base imbalance.

DKA involves the accelerated breakdown of fats into ketone bodies, which are strongly acidic. Their accumulation in the bloodstream leads to a state of metabolic acidosis.

Understanding the metabolic source of the acid accumulation confirms that the primary imbalance is metabolic, not respiratory, in origin.

Anahtar Kavram

Diabetic Ketoacidosis and Acid-Base Imbalance

Tahmini Süre:45s

Soru 1270Soru →

A client diagnosed with septic shock is admitted to the intensive care unit and remains profoundly hypotensive despite adequate fluid resuscitation. The healthcare provider orders a continuous intravenous infusion of norepinephrine. The client's weight is $198\text{ lb}$ . The order indicates starting the infusion at $0.1\text{ mcg/kg/min}$ . The medication arrives from the pharmacy as a premixed solution containing $8\text{ mg}$ of norepinephrine in $250\text{ mL}$ of 5% dextrose in water ( $\text{D}_5\text{W}$ ). At what rate should the nurse program the infusion pump? Record your answer in $\text{mL/hr}$ rounded to the nearest tenth.

Cevabı ve açıklamayı göster

Cevap: 16.9

Cevap

16.9

The correct pump rate is found by converting the client's weight to kilograms, finding the total hourly dose in micrograms (

540\text{ mcg/hr}

), and dividing that by the concentration of the IV solution (

32\text{ mcg/mL}

), which yields

16.875

, rounded to

16.9\text{ mL/hr}

Adım Adım Çözüm

Convert the client's weight from pounds to kilograms.

198 \div 2.2 = 90\text{ kg}

The prescribed medication dosage is based on the client's weight in kilograms.

Calculate the required medication dose per minute.

90\text{ kg} \times 0.1\text{ mcg/kg/min} = 9\text{ mcg/min}

To determine the total amount of medication the client must receive every minute based on their weight.

Convert the per-minute dose to an hourly dose.

9\text{ mcg/min} \times 60\text{ min/hr} = 540\text{ mcg/hr}

Intravenous infusion pumps are programmed in milliliters per hour, so the dose must be calculated over an hour.

Determine the concentration of the intravenous solution in micrograms per milliliter.

8\text{ mg} \times 1000 = 8000\text{ mcg}

;

8000\text{ mcg} \div 250\text{ mL} = 32\text{ mcg/mL}

To align the units of the prescribed dose (micrograms) with the available concentration.

Calculate the final infusion pump rate in milliliters per hour.

540\text{ mcg/hr} \div 32\text{ mcg/mL} = 16.875\text{ mL/hr}

Dividing the hourly dose by the concentration provides the volume of fluid to be infused per hour.

Round the final answer to the nearest tenth.

16.9\text{ mL/hr}

This is standard clinical practice and matches the specific instruction in the question.

Anahtar Kavram

Weight-based critical care intravenous medication rate calculation

Soru 1271Soru →

An adult client has just arrived at the medical-surgical unit after undergoing a lumbar puncture. To prevent a common post-procedure complication, how should the nurse position this client in bed?

Flat in a supine position

Elevated in a high Fowler's position

Lateral with knees flexed toward the chest

Semi-Fowler's with the lower extremities elevated

Cevabı ve açıklamayı göster

Cevap: Flat in a supine position

Cevap

The client should be positioned flat in a supine position to prevent a spinal headache.

Following a lumbar puncture, the primary goal is to prevent a spinal headache, which occurs when cerebrospinal fluid (CSF) leaks from the puncture site. Keeping the client flat in a supine position for a prescribed period reduces pressure on the spinal column and minimizes this leakage.

Adım Adım Çözüm

Identify the procedure the client just underwent.

The client had a lumbar puncture.

Different procedures require specific post-operative positioning to prevent complications.

Determine the major complication associated with a lumbar puncture.

A post-lumbar puncture headache (spinal headache) caused by cerebrospinal fluid (CSF) leakage.

Anticipating complications guides the appropriate nursing intervention.

Select the position that minimizes this complication.

A flat, supine position.

Lying flat reduces hydrostatic pressure at the puncture site, decreasing CSF leakage and the likelihood of a headache.

Anahtar Kavram

Post-Lumbar Puncture Positioning

Soru 1272Soru →

A school nurse evaluates a 10-year-old student who frequently visits the health office with vague somatic complaints. The nurse observes that the student is wearing unseasonably warm, oversized clothing, flinches when approached, and exhibits poor personal hygiene. During the interaction, the student quietly states, "I am not allowed to eat breakfast anymore because I am bad." Which of the following actions is the most appropriate for the nurse to take?

Notify the designated state child welfare authorities immediately regarding the suspected maltreatment.

Delay reporting the situation until conclusive proof of the abuse can be gathered from the parents.

Reassure the student by promising that the information they shared will be kept strictly confidential.

Instruct the unlicensed clinic assistant to ask the student detailed questions about their home environment.

Cevabı ve açıklamayı göster

Cevap: Notify the designated state child welfare authorities immediately regarding the suspected maltreatment.

Cevap

The nurse must notify the designated state child welfare authorities immediately regarding the suspected maltreatment.

The correct action demonstrates strict adherence to mandatory reporting laws. Healthcare professionals are legally required to report suspected child abuse and neglect to state authorities immediately based solely on reasonable suspicion. The student's physical presentation (flinching, inappropriate clothing to hide injuries, poor hygiene) and explicit statement about food being withheld constitute strong, actionable indicators of maltreatment.

Adım Adım Çözüm

Analyze the student's clinical presentation and statements.

The student exhibits multiple indicators of abuse and neglect, including inappropriate clothing for the weather, flinching, poor hygiene, and food withholding used as punishment.

Identifying behavioral and physical signs of maltreatment is the first step in protecting vulnerable populations.

Determine the nurse's legal and ethical responsibilities in this scenario.

The nurse is a mandated reporter who is legally obligated to report suspected abuse or neglect to child protective services.

State and federal laws require healthcare professionals to act immediately on reasonable suspicion to ensure client safety.

Select the nursing action that directly fulfills this mandatory reporting obligation.

Notifying state authorities is the correct action; delegating the assessment, keeping the abuse a secret, or waiting for proof are all incorrect and unsafe practices.

Immediate reporting prioritizes the child's safety and complies with established legal mandates.

Anahtar Kavram

Mandatory Reporting of Child Abuse and Neglect

Soru 1273Soru →

A nurse is planning basic care for an 84-year-old client with advanced Alzheimer's disease who is receiving continuous enteral feedings via a percutaneous endoscopic gastrostomy (PEG) tube. The client has a stage 2 pressure injury on the left greater trochanter and has become acutely agitated during the shift, repeatedly attempting to pull at the feeding tube. Which of the following interventions represents the MOST appropriate evidence-based practice for this client?

Conceal the feeding tube by securing it beneath a soft abdominal binder, and position the client in a 30-degree lateral tilt with the head of the bed elevated at 30 to 45 degrees.

Apply prescribed bilateral soft wrist restraints to prevent immediate tube dislodgement, and delegate the evaluation of the client's pressure injury healing progress to the unlicensed assistive personnel.

Turn the client to a 90-degree right lateral position to offload the left trochanter completely, and lower the head of the bed to a flat alignment to promote physical relaxation.

Attribute the sudden onset of agitation to the expected progression of advanced Alzheimer's disease, and dim the room lights while playing soft music to calm the client.

Cevabı ve açıklamayı göster

Cevap: Conceal the feeding tube by securing it beneath a soft abdominal binder, and position the client in a 30-degree lateral tilt with the head of the bed elevated at 30 to 45 degrees.

Cevap

Conceal the feeding tube by securing it beneath a soft abdominal binder, and position the client in a 30-degree lateral tilt with the head of the bed elevated at 30 to 45 degrees.

The correct intervention safely synthesizes multiple aspects of basic care and comfort. Securing the PEG tube under a soft abdominal binder is an evidence-based, less restrictive alternative to physical restraints that protects the medical device from an agitated client. Positioning the client in a 30-degree lateral tilt effectively relieves pressure on the sacrum and trochanter without placing excessive weight on the opposite hip. Most importantly, maintaining the head of the bed at an elevation of 30 to 45 degrees is a mandatory safety measure to prevent life-threatening aspiration in any client receiving continuous enteral feedings.

Adım Adım Çözüm

Analyze the client's clinical presentation and identify priority risks.

The client has a continuous enteral feeding (aspiration risk), a trochanteric pressure injury (skin breakdown risk), and acute agitation (risk for device removal).

Identifying physiological and safety priorities determines which nursing interventions are safe and effective.

Evaluate interventions for protecting the medical device.

An abdominal binder safely conceals the tube without restricting limb movement.

Physical restraints are a last resort and should be avoided if less restrictive alternatives are available.

Determine the optimal positioning strategy.

The client must be positioned in a 30-degree lateral tilt with the head of the bed elevated at 30 to 45 degrees.

A 30-degree tilt avoids direct pressure on either trochanter, while head elevation is a critical requirement to prevent aspiration during continuous tube feedings.

Review scope of practice and delegation principles.

Evaluating the healing progress of a pressure injury cannot be delegated.

Assessments and clinical evaluations are strictly within the scope of practice of the Registered Nurse.

Anahtar Kavram

Complex Basic Care and Comfort Synthesis: Positioning, Device Safety, and Delegation

Soru 1274Soru →

A palliative care nurse is caring for an unresponsive client who is in the active phase of dying from metastatic lung cancer. The client exhibits Cheyne-Stokes respirations accompanied by loud, gurgling sounds during expiration. The client's spouse is visibly frantic and demands, "You need to suction his lungs immediately! He is drowning in his own fluids!" The nurse has a PRN prescription for sublingual atropine drops. Which of the following is the most appropriate initial nursing action?

Reposition the client into a side-lying position, administer the prescribed sublingual atropine, and educate the spouse on the etiology of the respiratory sounds.

Prioritize airway clearance by performing immediate deep nasotracheal suctioning to resolve the pooling secretions and alleviate the spouse's distress.

Instruct the unlicensed assistive personnel (UAP) to explain the physiological changes of the dying process to the spouse while the nurse prepares the medication.

Reassure the spouse by holding their hand and stating, "I know exactly how terrifying this sounds, but please try not to worry because he is not in any pain."

Cevabı ve açıklamayı göster

Cevap: Reposition the client into a side-lying position, administer the prescribed sublingual atropine, and educate the spouse on the etiology of the respiratory sounds.

Cevap

The most appropriate action is to reposition the client into a side-lying position, administer the prescribed sublingual atropine, and educate the spouse on the etiology of the respiratory sounds.

In the active phase of dying, the loss of the swallowing reflex leads to an accumulation of secretions in the oropharynx, causing a sound often referred to as the "death rattle." The priority is to implement comfort measures. Repositioning the client to a side-lying or semi-prone position helps secretions drain naturally. Administering an anticholinergic medication, such as sublingual atropine, helps dry up the secretions. Concurrently, educating the distressed family about the physiological cause of the sound is crucial to alleviate their anxiety, as they often mistakenly fear the client is suffocating or drowning.

Adım Adım Çözüm

Assess the clinical scenario and the client's phase of life.

The client is actively dying and experiencing terminal secretions, commonly known as the "death rattle."

Accurate assessment dictates whether interventions should be curative, restorative, or purely palliative.

Determine the safety and efficacy of the requested intervention (suctioning).

Deep suctioning is identified as contraindicated.

Suctioning causes agitation, mucosal trauma, and is generally ineffective for terminal secretions deep in the oropharynx.

Identify the standard palliative interventions for terminal secretions.

Selection of non-pharmacological (repositioning) and pharmacological (anticholinergics like atropine) measures.

These measures promote comfort, facilitate natural drainage, and effectively reduce the pooling of secretions.

Address the psychosocial needs of the family.

Provide direct therapeutic education regarding the physiological cause of the sounds.

Family distress is often rooted in the misconception that the client is choking or suffocating; timely education alleviates this fear.

Anahtar Kavram

Management of Terminal Secretions and Family Education in Palliative Care

Soru 1275Soru →

A client with severe chronic obstructive pulmonary disease is informed by the pulmonologist that their condition has deteriorated and they will require continuous home oxygen therapy. After the physician leaves the room, the client tightly grips the bedrails and states in an elevated voice, 'This is completely unacceptable. There has to be a new medication I haven't tried. I refuse to drag a tank around with me everywhere I go.' Which of the following is the most therapeutic response by the nurse?

You need to understand that without this oxygen, you are putting a significant strain on your heart.

I know this is difficult to hear, but many people live very active lives while using portable oxygen.

It must be overwhelming to learn about this change and how it will impact your daily independence.

Why are you so resistant to using a therapy that will help you breathe much more easily?

Cevabı ve açıklamayı göster

Cevap: It must be overwhelming to learn about this change and how it will impact your daily independence.

Cevap

The most therapeutic response validates the client's emotions and reflects their underlying concerns about losing independence.

The correct answer utilizes the therapeutic techniques of empathy and reflecting feelings. By acknowledging the client's overwhelming emotions and the specific concern about independence, the nurse validates the client's experience without judgment. This encourages further expression of feelings and builds the therapeutic nurse-client relationship.

Adım Adım Çözüm

Analyze the client's statement and nonverbal behavior to identify their primary need.

The client is demonstrating anger, denial, and anxiety about a loss of independence and a major lifestyle change.

Therapeutic communication requires addressing the emotional component of a message before providing education or reassurance.

Evaluate the nursing responses against evidence-based therapeutic communication techniques.

Only the response that acknowledges and reflects the feeling of being overwhelmed and losing independence is therapeutic.

Reflecting feelings and validating concerns helps the client feel heard, which de-escalates emotional distress and builds trust.

Anahtar Kavram

Therapeutic Communication: Validating and Reflecting Feelings

Soru 1276Soru →

A nurse is preparing to administer an intermittent bolus enteral feeding through a client's established gastrostomy tube. Place the following steps in the correct chronological order from first to last.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is: Elevate the head of the bed, aspirate to verify residual volume, administer the feeding formula, and finally flush the tube with water.

Administering an enteral tube feeding safely requires a sequence of actions that prioritize aspiration prevention and tube patency. First, the client must be positioned upright to reduce aspiration risk. Next, the nurse must measure gastric residual volume to ensure the client is adequately digesting previous feedings. Once safety parameters are met, the formula is administered. Finally, the tube is flushed with water to clear the tubing, preventing occlusion and maintaining patency.

Adım Adım Çözüm

Elevate the head of the bed.

The client is placed in a safe, upright position (at least 30 to 45 degrees).

This utilizes gravity to keep formula in the stomach and prevents pulmonary aspiration.

Check gastric residual volume.

The amount of fluid remaining in the stomach is measured.

This confirms gastrointestinal motility and absorption of prior feedings, preventing overdistention.

Administer the feeding formula.

Nutritional intake is delivered to the client.

This meets the client's metabolic and caloric needs as prescribed by the provider.

Flush the gastrostomy tube.

Water clears the tubing of any residual formula.

Flushing prevents bacterial growth and formula coagulation that could occlude the tube.

Anahtar Kavram

Safe administration of enteral tube feedings

Soru 1277Soru →

A nurse is preparing a client with advanced cirrhosis for a therapeutic bedside paracentesis to relieve severe ascites. To minimize the risk of procedural complications and ensure physiological stability, arrange the following nursing actions in the correct chronological sequence.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence prioritizes preventing mechanical organ injury first, establishing accurate post-void baselines second, positioning for procedural safety third, executing intra-procedural hemodynamic monitoring fourth, and providing post-procedural circulatory support last.

The priority sequence for a paracentesis focuses on a deliberate progression of risk reduction: preventing mechanical organ injury (voiding), establishing accurate clinical baselines (weighing post-void), ensuring safe anatomical needle insertion (upright positioning), monitoring for intra-procedural shock (hemodynamic assessments), and preventing post-procedural circulatory collapse (albumin administration).

Adım Adım Çözüm

Instruct the client to completely empty their bladder.

The bladder decompresses and retracts lower into the pelvic cavity.

This is the most critical initial step to eliminate the risk of accidental bladder perforation by the trocar during insertion into the lower abdomen.

Measure baseline vital signs, dry weight, and abdominal girth.

Accurate baseline physiological parameters are established.

Post-void measurements provide true data unskewed by urine volume, which is essential to evaluate the exact amount of fluid removed and detect hidden post-procedure bleeding.

Assist the client into an upright or high-Fowler's position.

Gravity causes the ascitic fluid to pool in the dependent lower abdominal cavity.

This position protects the intestines by allowing them to float upward, providing a safe, unobstructed fluid pocket for trocar insertion.

Monitor blood pressure and heart rate frequently during fluid drainage.

Early detection of hemodynamic instability is achieved.

Rapid removal of large volumes of fluid can cause profound fluid shifts from the intravascular space, leading to acute hypovolemic shock.

Apply a pressure dressing and administer intravenous albumin.

The puncture site is secured, and oncotic pressure is restored.

Albumin acts as a plasma volume expander to prevent post-paracentesis circulatory dysfunction (PPCD) and severe hypotension following large-volume fluid removal.

Anahtar Kavram

Paracentesis Risk Reduction and Sequential Complication Management

Soru 1278Soru →

A nurse is caring for a client who is experiencing an acute asthma exacerbation. The client is tachypneic, has visible intercostal retractions, and an oxygen saturation of 86% on room air. Arrange the following nursing actions in the priority order they should be performed, from first to last.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct priority order is to first position the client to maximize lung expansion, then apply oxygen to correct hypoxia, followed by the fast-acting bronchodilator, and finally the slow-acting corticosteroid.

Based on the ABC (Airway, Breathing, Circulation) prioritization framework, the nurse must first implement the fastest interventions that require the least preparation. Positioning the client upright immediately improves breathing mechanics. Applying oxygen directly addresses the life-threatening hypoxia (SpO2 86%). Once these immediate supportive measures are in place, the nurse administers the rapid-acting bronchodilator to open the airways, followed by the slow-acting corticosteroid to address inflammation.

Adım Adım Çözüm

Identify the primary physiological problem.

The client has an acute airway and breathing compromise as evidenced by retractions and an oxygen saturation of 86%.

Airway and breathing are the absolute highest priorities according to the ABC framework.

Determine the fastest, most immediate intervention.

Place the client in a high-Fowler's position.

This independent nursing action takes seconds, immediately improves lung expansion, and requires no equipment or medication preparation.

Address the critical tissue hypoxia.

Apply supplemental oxygen via a non-rebreather mask.

An oxygen saturation of 86% is life-threatening and requires immediate high-flow oxygen therapy to prevent ischemic damage.

Relieve the acute bronchospasm.

Administer the albuterol nebulizer.

Short-acting bronchodilators act quickly to open the constricted airways and are the priority medication for an acute asthma attack.

Address the underlying airway inflammation.

Establish intravenous access and administer methylprednisolone.

Systemic corticosteroids are essential for resolving the exacerbation but take several hours to peak, so they follow the immediate life-saving ABC steps.

Anahtar Kavram

Airway, Breathing, Circulation (ABC) prioritization framework for acute respiratory compromise.

Soru 1279Soru →

A critical care nurse is managing a client with severe decompensated heart failure. The client has an admission weight of $184.8 \text{ lbs}$ .

The provider's prescription reads:
- Initiate dobutamine continuous IV infusion at $2.5 \text{ mcg/kg/min}$ .
- Titrate upward by $2.5 \text{ mcg/kg/min}$ every $15 \text{ minutes}$ until mean arterial pressure (MAP) $> 65 \text{ mm Hg}$ , up to a maximum dose of $20 \text{ mcg/kg/min}$ .

The pharmacy dispenses a customized dobutamine solution containing $1,000 \text{ mg}$ of dobutamine in $250 \text{ mL}$ of $5\%$ dextrose in water (D5W). A dedicated central venous catheter port is used for the infusion, alongside a separate line of $0.9\%$ sodium chloride running at $20 \text{ mL/hr}$ .

After initiating the infusion, the nurse performs exactly three upward titrations over the next $45 \text{ minutes}$ before the client's MAP stabilizes at $72 \text{ mm Hg}$ .

What is the dobutamine infusion pump rate in $\text{mL/hr}$ at this effective dose? (Record your answer to the nearest tenth.)

Cevabı ve açıklamayı göster

Cevap: 12.6

Cevap

The current dobutamine infusion pump rate is

12.6 \text{ mL/hr}

The client's weight of

184.8 \text{ lbs}

converts to

84 \text{ kg}

. The initial dobutamine dose of

2.5 \text{ mcg/kg/min}

was titrated upward three times by increments of

2.5 \text{ mcg/kg/min}

, bringing the final effective dose to

10 \text{ mcg/kg/min}

. Multiplying this dose by the client's weight (

84 \text{ kg}

) yields a total of

840 \text{ mcg/min}

, which equals

50,400 \text{ mcg/hr}

when multiplied by

60 \text{ minutes}

. Converting this hourly dose to milligrams (

50,400 \div 1,000

) gives

50.4 \text{ mg/hr}

. The pharmacy provided a concentration of

1,000 \text{ mg}

250 \text{ mL}

, meaning the solution has

4 \text{ mg}

of dobutamine per

1 \text{ mL}

. Dividing the required hourly dose (

50.4 \text{ mg/hr}

) by the concentration (

4 \text{ mg/mL}

) yields the correct infusion pump rate of

12.6 \text{ mL/hr}

Adım Adım Çözüm

Convert the client's weight from pounds to kilograms.

84 \text{ kg}

Critical care weight-based medication dosages are always calculated using the client's weight in kilograms (

184.8 \div 2.2 = 84

Determine the final dobutamine dosage after the three upward titrations.

10 \text{ mcg/kg/min}

The protocol started at

2.5 \text{ mcg/kg/min}

and was increased three times by

2.5 \text{ mcg/kg/min}

each time. Total dose =

2.5 + (3 \times 2.5) = 10 \text{ mcg/kg/min}

Calculate the total required dose in micrograms per minute.

840 \text{ mcg/min}

Multiplying the weight-based dose by the client's actual weight in kilograms determines the exact per-minute requirement (

10 \text{ mcg/kg/min} \times 84 \text{ kg} = 840 \text{ mcg/min}

Convert the per-minute dosage to an hourly dosage.

50,400 \text{ mcg/hr}

Intravenous infusion pumps are programmed in mL per hour, requiring the medication dose to be scaled to an hourly rate (

840 \text{ mcg/min} \times 60 \text{ min/hr} = 50,400 \text{ mcg/hr}

Determine the concentration of the dobutamine solution provided by the pharmacy.

4,000 \text{ mcg/mL}

(or

4 \text{ mg/mL}

)

The IV bag contains

1,000 \text{ mg}

250 \text{ mL}

, which simplifies to

4 \text{ mg/mL}

. To match the hourly dose units, convert mg to mcg:

4 \text{ mg/mL} \times 1,000 \text{ mcg/mg} = 4,000 \text{ mcg/mL}

Calculate the final infusion pump rate in mL/hr.

12.6 \text{ mL/hr}

Dividing the total hourly dose by the fluid concentration yields the volume required per hour (

50,400 \text{ mcg/hr} \div 4,000 \text{ mcg/mL} = 12.6 \text{ mL/hr}

Anahtar Kavram

Advanced parenteral medication titration and complex weight-based dose calculation

Alternatif Yöntem

Using dimensional analysis to solve in a single equation:

\frac{10 \text{ mcg}}{\text{kg} \cdot \text{min}} \times \frac{84 \text{ kg}}{1} \times \frac{60 \text{ min}}{1 \text{ hr}} \times \frac{1 \text{ mg}}{1,000 \text{ mcg}} \times \frac{250 \text{ mL}}{1,000 \text{ mg}} = 12.6 \text{ mL/hr}

Tahmini Süre:4m 0s

Soru 1280Soru →

A nurse is preparing to administer an intravenous (IV) loading dose of phenytoin to a 42-year-old client who recently experienced a tonic-clonic seizure. The client's vital signs are stable, but they remain postictal and drowsy. The client has a single peripheral IV catheter currently infusing 5% dextrose in water (D5W) at 75 mL/hr. Which of the following is the most appropriate nursing action?

Pause the D5W infusion, flush the IV line with 0.9% sodium chloride, administer the phenytoin, and flush again with 0.9% sodium chloride.

Administer the phenytoin via a secondary IV piggyback line connected to the primary D5W infusion to ensure adequate dilution.

Calculate the prescribed dosage rate and inject the phenytoin slowly into the lowest Y-port of the continuous D5W infusion.

Withhold the medication and prioritize establishing a second peripheral IV line exclusively for the phenytoin administration.

Cevabı ve açıklamayı göster

Cevap: Pause the D5W infusion, flush the IV line with 0.9% sodium chloride, administer the phenytoin, and flush again with 0.9% sodium chloride.

Cevap

The most appropriate action is to pause the D5W infusion, flush the IV line with 0.9% sodium chloride, administer the phenytoin, and flush again with 0.9% sodium chloride.

Phenytoin is physically incompatible with all dextrose-containing solutions and will rapidly form a precipitate if mixed. To safely administer the medication through a single existing IV line that is infusing dextrose, the nurse must temporarily stop the primary infusion and thoroughly flush the line with a compatible solution (normal saline) both before and after the medication push. This prevents the drug from contacting the dextrose in the tubing.

Adım Adım Çözüm

Identify the primary infusing fluid and verify compatibility with the prescribed medication.

The nurse notes D5W is infusing and recognizes that phenytoin is incompatible with dextrose.

Phenytoin precipitates when mixed with dextrose solutions, which can cause an embolism or occlude the IV line.

Determine the safest method to utilize the existing single IV access.

The nurse plans to use the SAS (Saline-Administer-Saline) method.

Since a second IV line is not present, the existing line can be used safely if the incompatible fluid is cleared from the tubing.

Execute the administration procedure safely.

Pause the D5W, flush with 0.9% sodium chloride, slowly push the phenytoin, flush again with 0.9% sodium chloride, and then resume the D5W.

This sequence ensures the medication never physically mixes with the dextrose within the catheter or tubing.

Anahtar Kavram

Pharmacological and Parenteral Therapies: IV Compatibility and Safe Medication Administration

ÖncekiSayfa 64 / 195Sonraki

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