Tüm alıştırma soruları

A nurse is planning care for a client who has just returned to the medical-surgical unit following a lumbar puncture. Which of the following positions should the nurse maintain for this client immediately after the procedure?

A client arrives at the medical unit after undergoing a diagnostic lumbar puncture. Which positioning instruction is the most appropriate for the nurse to provide?

A client is admitted to the observation unit with atypical chest pain. Following a negative cardiac workup, the client remains visibly tense, exhibits rapid and shallow breathing, and tells the nurse, "I just cannot catch my breath when I think about all the debt I owe." What is the priority nursing action for this client?

An adult client with a history of alcohol use disorder and major depressive disorder is admitted to a medical unit for the treatment of severe pneumonia. On the third day of hospitalization, the client, who previously exhibited profound sadness and psychomotor retardation, suddenly appears peaceful and states, "I finally figured out how to solve all my problems. I will not be a burden to my family anymore." The nurse also notes that the client is diaphoretic and has visible bilateral hand tremors. Which of the following nursing actions are appropriate to include in the immediate plan of care? Select all that apply.

A pediatric unit nurse is organizing care for a 6-year-old client who is one day postoperative following a tonsillectomy. The client's condition has remained stable throughout the night. Which specific task is most appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)?

A client is receiving a continuous intravenous (IV) infusion of unfractionated heparin. The nurse must administer a scheduled dose of an IV push medication that is chemically incompatible with heparin. The client has a single peripheral IV access line. Arrange the following actions in the correct sequence to safely administer the medication.

A nurse is instructing a client on the proper procedure for a 24-hour urine collection for creatinine clearance. In what chronological order should the nurse instruct the client to perform the following steps? Arrange the steps in the correct sequence.

A 55-year-old female client visits an ambulatory care clinic for an annual well-woman examination. The nurse is coordinating the client's health promotion and preventive care plan. Arrange the following nursing actions in the most appropriate chronological sequence.

A 74-year-old client is admitted to the progressive care unit with a large acute pulmonary embolism and is receiving a continuous intravenous (IV) heparin infusion. The nurse is creating a plan of care to monitor for and reduce the risk of potential physiological complications. Which of the following actions should the nurse include in the plan of care? Select all that apply.

An adult client admitted with a fractured femur received a dose of intravenous morphine 20 minutes ago. The orthopedic surgeon arrives, explains the necessity of an urgent open reduction and internal fixation (ORIF) to the client, and asks the registered nurse to witness the surgical consent signature. Which of the following actions by the nurse are appropriate? Select all that apply.

While organizing the morning workflow on a general medical unit, the nurse considers which tasks can be safely assigned to the unlicensed assistive personnel (UAP). Which task is appropriate for the nurse to delegate to the UAP?

A home health registered nurse (RN) is evaluating the self-care capacity of a 68-year-old client with early-stage Alzheimer's disease and poorly controlled type 2 diabetes mellitus. The client lives with their adult child, who works outside the home during the day. The nurse is developing a management plan to promote the client's maximum independence while ensuring clinical safety. Which action represents the most appropriate integration of self-care principles for this client?

A client in the pre-operative holding area is informed that a scheduled tissue biopsy has been postponed due to an unexpected laboratory issue. The client begins pacing rapidly, clenching their fists, and loudly states, 'I cannot handle this! The waiting is agonizing!' Which responses by the nurse utilize appropriate stress management and de-escalation techniques? Select all that apply.

A registered nurse on a high-acuity cardiac step-down unit is evaluating assessment data for a group of assigned clients. Which of the following client presentations require immediate intervention by the nurse? Select all that apply.

A nurse on an acute mental health unit responds to a sudden commotion in the common area. A client experiencing substance-induced psychosis is hurling chairs at the reinforced windows and shouting, "The gas is coming through the vents!" Verbal de-escalation attempts have completely failed, and the client is now attempting to lift a heavy wooden table. Which actions should the nurse implement? Select all that apply.

A nurse is preparing to administer an intravenous loading dose of phenytoin to an adult client who was recently admitted for status epilepticus. The client is currently stable but requires the medication to prevent recurrent seizure activity. The client has a continuous peripheral intravenous (IV) infusion of $5\% \text{ dextrose in water}$ ($D_5W$) running at $75\text{ mL/hr}$. Which of the following nursing actions is essential for the safe administration of this medication?

An oriented and competent client with progressive amyotrophic lateral sclerosis (ALS) is receiving palliative care and continuous non-invasive positive pressure ventilation. The client tells the nurse, "I am exhausted from fighting this. I want to take off this mask and let nature take its course." The client's adult children are at the bedside, visibly distraught, and state, "He is just having a bad day and is depressed. You cannot take it off, he will not survive the night!" There are no advance directives on file. Which action should the nurse take first?

A nurse is preparing to administer a prescribed intravenous (IV) infusion of potassium chloride to a client who has a serum potassium level of 2.9 mEq/L and is experiencing premature ventricular contractions (PVCs). Which actions are safe and appropriate for the nurse to implement? Select all that apply.

A nurse is monitoring a client receiving a transfusion of packed red blood cells. Fifteen minutes after the infusion begins, the client suddenly develops severe lower back pain, chills, and dyspnea. Suspecting an acute hemolytic transfusion reaction, arrange the following nursing actions in the correct priority sequence from first to last.

A client in the cardiac intensive care unit requires a continuous intravenous infusion of dobutamine at $10\text{ \mu g/kg/min}$ for severe ventricular dysfunction. The client currently has only one functioning peripheral venous access site. After assessing new-onset bilateral crackles and an oxygen saturation of $88\%$, the healthcare provider prescribes an immediate $80\text{ mg}$ intravenous bolus of furosemide. Which of the following actions is the safest and most appropriate method to administer the prescribed diuretic?