Tüm alıştırma soruları

A nurse on an obstetrical unit has just received change-of-shift report for four assigned clients. Which client should the nurse assess first?

A chemical processing plant experiences a massive chlorine gas leak, and dozens of affected community members begin arriving at the emergency department via private vehicles. The hospital activates its Emergency Operations Plan (EOP) for a mass casualty hazardous materials incident. Which initial actions should the nursing staff take? Select all that apply.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a right subclavian central venous catheter (CVC). Upon entering the room, the nurse discovers that the intravenous tubing has inadvertently disconnected from the CVC hub, leaving the catheter open to the air. The client is suddenly gasping for breath, grasping their chest, and exhibits a blood pressure of $76/40\text{ mmHg}$ with a heart rate of $138\text{ bpm}$. To immediately mitigate the risk of a fatal physiological complication, which action should the nurse perform first?

A client arrives on the medical unit immediately after undergoing a diagnostic lumbar puncture. To decrease the risk of a cerebrospinal fluid leak and subsequent post-procedure headache, which position is most appropriate for the nurse to implement?

A nurse is organizing the daily care plan for clients on a combined vascular and orthopedic unit. The healthcare team includes an experienced unlicensed assistive personnel (UAP). Which client care task is most appropriate for the nurse to delegate to the UAP?

A nurse in an ambulatory care clinic is coordinating care and managing health information. Which of the following actions indicate appropriate adherence to confidentiality and information security standards? (Select all that apply.)

A client with a persistent cough, night sweats, and hemoptysis is admitted to the medical-surgical unit with suspected active pulmonary tuberculosis. Which of the following infection control interventions must the nurse implement? (Select all that apply.)

A nurse is assuming care of a client who has just been transferred from the intensive care unit (ICU) to a general medical-surgical unit. The client is receiving continuous intravenous (IV) fluids and has a documented history of methicillin-resistant *Staphylococcus aureus* (MRSA). Which of the following actions must the nurse implement to prevent errors and ensure client safety during this care transition? Select all that apply.

A registered nurse is documenting in the electronic health record (EHR) when a pop-up message appears on the screen stating that the computer has been locked and demanding a ransom payment to restore access. Arrange the nurse's subsequent actions in the correct sequence of priority.

A community health nurse is deployed to a field triage station following a structural collapse at a local stadium. The nurse assesses a victim who is unable to walk, has a respiratory rate of 36 breaths/min, and has a strong radial pulse. Based on the START (Simple Triage and Rapid Treatment) method, which triage category should the nurse assign to this victim?

Pair the following nursing interventions with the specific ethical principle that primarily underlies the behavior.

A charge nurse on a step-down unit is observing staff practices regarding the management of protected health information (PHI). Which of the following actions by the healthcare team demonstrate adherence to regulatory privacy and security standards? Select all that apply.

A pediatric orthopedic clinic nurse evaluates a 14-year-old client who was prescribed a thoracolumbosacral orthosis (TLSO) brace for idiopathic scoliosis one month ago. The caregiver reports that the client removes the brace before entering the school building and refuses to wear it around classmates. The client tearfully states, 'Everyone is constantly staring at me and judging how weird I look.' Based on principles of adolescent cognitive and psychosocial development, which nursing intervention is the priority?

A nurse is performing triage at the scene of a train derailment using the START (Simple Triage and Rapid Treatment) method. A victim is lying on the ground and reports being unable to walk due to severe leg pain. Assessment reveals a respiratory rate of 20 breaths per minute, a strong radial pulse, and the ability to follow the command to squeeze the nurse's hand. Which of the following triage tags should the nurse assign to this victim?

A nurse is walking through a high-traffic unit hallway and observes a visitor looking closely at an unattended computer on wheels (COW). The screen is unlocked and displays an active electronic health record (EHR) belonging to a client. Arrange the following actions the nurse should take in the correct sequence, from first to last.

A client voluntarily admitted to an inpatient psychiatric unit tells the nurse during a private conversation, "When I am discharged tomorrow, I am going to shoot my former boss. I have a weapon in my car, but you cannot tell anyone because what I say in here is confidential." Which of the following actions are ethically and legally appropriate for the nurse to take? (Select all that apply.)

A client admitted with measles (rubeola) is experiencing acute confusion and repeatedly attempts to climb out of bed. The client requires airborne precautions. Which action should the nurse take to ensure the client's safety while maintaining proper infection control?

A nursing supervisor is conducting infection control rounds on a medical-surgical unit. Which of the following observed staff actions indicate appropriate adherence to transmission-based precautions? (Select all that apply.)

A clinical nursing educator is conducting a workshop on the Health Insurance Portability and Accountability Act (HIPAA) and legal mandates regarding protected health information (PHI). Which of the following statements by a participating nurse indicate a correct understanding of confidentiality protocols and permitted disclosures? Select all that apply.

A registered nurse (RN) is preparing to delegate the task of obtaining routine morning vital signs for a group of stable clients to an unlicensed assistive personnel (UAP). Arrange the steps of the delegation process in the correct chronological order from first to last.