Tüm alıştırma soruları

A nurse is planning morning hygiene and mobility care for an 80-year-old client who recently had a halo vest external fixator applied for a stable cervical spine fracture. Which of the following actions is the most appropriate for the nurse to include in the plan of care?

A client on a medical-surgical unit has just been informed by the healthcare provider that a lower extremity amputation is required due to severe vascular complications. The client is tachycardic, pacing the room rapidly, crying loudly, and states, "My life is over. I cannot do this." Which of the following nursing interventions are appropriate for managing the client's acute stress? Select all that apply.

A nurse is evaluating a 72-year-old client who sustained an acute anterior myocardial infarction 24 hours ago. The client has become increasingly restless and reports mild confusion. Current assessment findings include cool and pale skin, a heart rate of 118 beats/minute, and a blood pressure of 102/84 mm Hg. The client's urine output for the past hour was 15 mL. Which action should the nurse take first?

A client on a medical-surgical unit requires a cleansing enema for relief of severe constipation. To facilitate the flow of the enema solution into the colon and promote retention, in which position should the nurse place the client?

A nurse in the neonatal intensive care unit (NICU) is caring for a premature infant. The infant's 16-year-old mother is visiting alongside the maternal grandmother. The grandmother frequently interrupts the adolescent mother during feeding attempts, stating, "You are holding him wrong," and insists on taking over the feeding. The adolescent mother responds by becoming silent, looking down, and withdrawing from the bedside. Which of the following nursing actions are appropriate to address this family dynamic? (Select all that apply.)

A nurse is preparing to transfer a client with left-sided hemiplegia and a history of orthostatic hypotension from the bed to a wheelchair. Arrange the following nursing actions in the correct chronological sequence.

The nurse is conducting initial rounds on a medical-surgical unit. Which client positioning observation requires immediate intervention by the nurse to reduce the risk of complications?

A nurse is caring for a client receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes after the transfusion begins, the client reports sudden chills, severe lower back pain, and dyspnea. The client's heart rate is 115 beats/min and blood pressure is 88/52 mm Hg. What is the correct sequence of priority for the nurse's actions? Arrange the following steps in the correct order.

A nurse is preparing to change the soiled bed linens for a client who is receiving continuous enteral nutrition via a nasogastric tube. The client is currently resting comfortably in a semi-Fowler's position. Which action must the nurse take first before lowering the head of the bed to turn the client?

A nurse is assessing a client who has a central venous catheter (CVC) in place. The client suddenly reports acute chest pain and shortness of breath, and the nurse observes a loose connection at the catheter hub. Suspecting a catheter-related air embolism, arrange the following nursing actions in the priority order they should be performed. (Arrange from first action to last action.)

A triage nurse in an emergency department observes a client pacing rapidly in the waiting area, speaking loudly to other visitors about the delay in seeing a physician. Arrange the following nursing actions in the most appropriate sequence to therapeutically communicate and de-escalate the situation. All options must be used.

A nurse is reviewing a new medication order for a pediatric client who weighs $20\text{ kg}$. The healthcare provider has prescribed oral amoxicillin $400\text{ mg}$ every $8\text{ hours}$ for an infection. The pharmacy reference states that the safe pediatric dosage range is $20\text{ to }40\text{ mg/kg/day}$ administered in equally divided doses every $8\text{ hours}$. Based on this information, which of the following is the most appropriate action by the nurse?

Arterial blood gas (ABG) results for a client with a history of chronic obstructive pulmonary disease (COPD) reveal a pH of 7.28, PaCO2 of 68 mm Hg, HCO3- of 25 mEq/L, and PaO2 of 58 mm Hg. The client is restless and using accessory muscles to breathe. Which initial action by the nurse is the most appropriate?

An older adult client with a ten-year history of chronic obstructive pulmonary disease (COPD) is brought to the emergency department. The client's family reports a progressive decline in the client's level of consciousness over the past six hours, describing the client as 'extremely difficult to wake up.' The client's current respiratory rate is $8$ breaths per minute and shallow. Arterial blood gas (ABG) analysis on room air reveals the following: $pH = 7.21$, $PaCO_2 = 84 \text{ mm Hg}$, $PaO_2 = 52 \text{ mm Hg}$, and $HCO_3^- = 36 \text{ mEq/L}$. Based on these clinical findings, what is the highest priority nursing action?

A nurse is providing care in a memory-care residential facility. During the late afternoon, a client with moderate Alzheimer's disease becomes severely agitated, pushes their dinner tray onto the floor, and begins crying while demanding to 'go home immediately to cook for my little children.' Which of the following behavioral interventions should the nurse implement first?

Multiple clients require evaluation on a high-acuity cardiovascular telemetry unit. Which clinical scenario dictates the most urgent need for the nurse's presence and immediate intervention?

A registered nurse (RN) on a neurology unit is planning the sequence of care for four assigned clients. Arrange the clients in the order they should be assessed, from highest priority (first) to lowest priority (last).

A float nurse is covering a busy surgical oncology and endocrine unit. Which clinical presentation among the assigned clients requires the nurse's immediate intervention?

A client admitted with severe fluid volume overload secondary to acute decompensated heart failure is receiving care from a registered nurse (RN) and an unlicensed assistive personnel (UAP). Which task is most appropriate for the RN to delegate to the UAP?

A client is receiving high-dose unsealed radioactive iodine (I-131) therapy for the treatment of thyroid carcinoma. Twenty-four hours after the isotope administration, the client experiences a sudden, large-volume emesis on the floor of their private isolation room. Which of the following is the priority nursing action for managing this hazardous material?