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3881 soru

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Soru 1401Soru →

An older adult client is brought to the emergency department after awaking with severe orthopnea and a frothy, pink-tinged cough. The client appears extremely agitated and has a respiratory rate of 34 breaths/minute. Arterial blood gas (ABG) values on room air are pH 7.26, PaCO2 62 mm Hg, PaO2 52 mm Hg, and HCO3 24 mEq/L. Which of the following actions should the nurse implement? (Select all that apply.)

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Cevap: Position the client upright with the legs dangling over the edge of the bed.; Prepare the client for immediate noninvasive positive pressure ventilation (NIPPV).; Administer prescribed intravenous loop diuretics.

Cevap

The correct actions include positioning the client upright with legs dangling, preparing for noninvasive positive pressure ventilation, and administering intravenous loop diuretics.
The client's presentation of a frothy, pink-tinged cough and extreme orthopnea indicates acute pulmonary edema, a life-threatening complication of heart failure. The ABG results demonstrate uncompensated respiratory acidosis with severe hypoxemia. Priority nursing actions focus on reducing venous return (preload) by positioning the client upright with legs dangling, reducing fluid volume with loop diuretics, and improving gas exchange using noninvasive positive pressure ventilation to force fluid out of the alveoli and clear retained carbon dioxide.

Adım Adım Çözüm

1
Analyze the clinical presentation (orthopnea, frothy pink-tinged cough, agitation, tachypnea).
The findings strongly indicate acute pulmonary edema, a life-threatening complication of heart failure characterized by fluid in the alveoli.
Identifying the underlying pathophysiology is required to select interventions that reduce fluid volume rather than increase it.
2
Interpret the arterial blood gas (ABG) values: pH 7.26 (acidotic), PaCO2 62 mm Hg (elevated/acidotic), PaO2 52 mm Hg (hypoxemic), HCO3 24 mEq/L (normal).
The ABG indicates uncompensated respiratory acidosis with severe hypoxemia.
Understanding the acid-base imbalance guides respiratory interventions and prevents inappropriate administration of metabolic buffers.
3
Select interventions that safely address both the fluid overload and the acute respiratory failure.
Appropriate actions include dependent positioning to reduce preload, NIPPV to improve gas exchange and clear CO2, and loop diuretics to remove excess fluid. Inappropriate actions include administering fluids, giving bicarbonate, or improperly delegating assessments.
Nursing care must rapidly reverse the physiological decompensation while adhering to the RN scope of practice.

Anahtar Kavram

Management of Acute Pulmonary Edema and Respiratory Acidosis
Soru 1402Soru →

A registered nurse (RN) is conducting an initial home health evaluation for an 80-year-old client who recently suffered a stroke. The client's adult child, who is the designated healthcare power of attorney (POA), is present. The RN observes that the client is unkempt, has a stage 3 sacral pressure injury, and flinches noticeably when the adult child approaches. The adult child states, "I keep the bedroom door locked from the outside at night so they don't wander off, and you need to show my aide how to assess that bedsore." Which of the following actions by the RN are legally required and appropriate? (Select all that apply.)

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Cevap: Initiate a report to the designated state adult protective services agency regarding the suspected neglect and abuse.; Request that the adult child step into another room so the nurse can interview the client privately about their living situation.; Inform the adult child that assessing and staging the pressure injury falls strictly within the licensed nurse's scope of practice.

Cevap

The correct actions include reporting the suspected abuse to protective services, interviewing the client privately, and clarifying that wound assessment cannot be delegated.
The registered nurse is legally mandated to report any reasonable suspicion of elder abuse or neglect directly to protective services, and doing so requires separating the client from the potential abuser to conduct a safe, private interview. Additionally, the nurse must operate within legal scope of practice guidelines, which dictate that clinical assessments—such as staging a pressure injury—cannot be delegated to unlicensed personnel.

Adım Adım Çözüm

1
Analyze the scenario for legal violations and safety risks.
Identified signs of elder abuse/neglect, illegal use of restraint (locked door), and an inappropriate delegation request.
The RN must address multiple concurrent legal responsibilities during the assessment.
2
Determine the required response to the suspected abuse and neglect.
The RN must interview the client privately and report the suspicion to adult protective services.
Mandatory reporting laws require immediate action based on suspicion, without waiting for definitive proof.
3
Evaluate the locked door safety measure.
Recognize that locking a client in a room is false imprisonment and an illegal restraint.
Nurses must advocate for the least restrictive legal alternatives for client safety.
4
Assess the delegation request regarding the pressure injury.
The RN must refuse the delegation.
Clinical assessment and evaluation of wounds fall exclusively within the RN scope of practice.

Anahtar Kavram

Legal Responsibilities: Mandatory Reporting, Proper Delegation, and Restraint Laws
Soru 1403Soru →

A 17-year-old legally married client presents to the emergency department with a ruptured ectopic pregnancy. The client received intravenous fentanyl 15 minutes ago for severe abdominal pain and is currently lethargic but oriented. The operating provider determines that emergency laparoscopic surgery is required immediately. The client's parents and 18-year-old spouse are present in the waiting room. Which of the following nursing actions regarding informed consent are appropriate in this situation? Select all that apply.

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Cevap: Withhold having the client sign the surgical consent form due to the recent opioid administration.; Identify the client's 18-year-old spouse as the legally authorized surrogate decision-maker.; Witness the spouse's signature on the consent form after the operating provider completes the disclosure discussion.

Cevap

The correct actions are to withhold the client's signature due to recent opioid administration, identify the spouse as the legal surrogate, and witness the spouse's signature after the provider's explanation.
The correct actions reflect the integration of several legal concepts: the client is chemically impaired from recent IV fentanyl and cannot sign; her marriage makes her an emancipated minor, meaning her spouse (not her parents) is the legal surrogate; and the nurse's role is strictly to witness the signature after the provider explains the procedure.

Adım Adım Çözüm

1
Assess the client's legal competency to sign the consent form.
The client received IV fentanyl 15 minutes ago and is lethargic, rendering her legally incompetent to sign the document.
Central nervous system depressants impair judgment, making the client temporarily unable to provide legally binding voluntary consent.
2
Determine the appropriate legal surrogate decision-maker.
The 18-year-old spouse is identified as the legally authorized surrogate.
Although the client is 17, her married status makes her an emancipated minor. Therefore, her parents lose guardianship, and her spouse becomes the legal next-of-kin.
3
Determine the appropriate scope of practice for the registered nurse regarding the consent process.
The nurse will witness the surrogate's signature after the operating provider explains the procedure.
The provider must explain the risks and benefits; the nurse only witnesses the signature and ensures the surrogate understands.
4
Evaluate if implied emergency consent applies.
Implied consent is not appropriate in this exact moment.
Implied emergency consent is reserved for situations where a surrogate is unavailable. The spouse is present in the waiting room and can provide immediate consent.

Anahtar Kavram

Informed Consent: Emancipated Minors, Impaired Competency, and Nurse Scope of Practice
Tahmini Süre:2m 0s
Soru 1404Soru →

A client with chronic heart failure requires assistance with morning care while the registered nurse is administering medications to another client. Which specific task can the nurse safely delegate to the unlicensed assistive personnel (UAP)?

Cevabı ve açıklamayı göster

Cevap: Recording the client's total oral fluid intake for the morning.

Cevap

Recording the client's total oral fluid intake for the morning.
Recording oral fluid intake is a routine, standardized task that does not require nursing judgment, making it safe and appropriate to delegate to an unlicensed assistive personnel (UAP).

Adım Adım Çözüm

1
Identify the role and scope of practice of the unlicensed assistive personnel (UAP).
UAPs can perform routine, standard, and unchanging tasks that do not require nursing judgment.
Understanding the limits of an unlicensed role is essential for safe delegation.
2
Evaluate each option against the established guidelines for delegation (avoiding tasks that require assessment, clinical judgment, or teaching).
Assessing edema, making clinical decisions about PRN medications, and teaching diet rationale all require nursing judgment.
The registered nurse retains responsibility for the nursing process, which cannot be transferred to a UAP.
3
Select the task that falls safely within the UAP's capabilities.
Recording oral fluid intake is the only appropriate task among the choices.
It involves collecting basic data without the need for clinical interpretation.

Anahtar Kavram

Delegation to Unlicensed Assistive Personnel (UAP)
Soru 1405Soru →

An emergency department nurse receives an older adult client with advanced dementia who presents with profound dehydration, severe malnutrition, and multiple stage 3 pressure injuries. Shortly after arrival, the client's adult child—the primary caregiver—becomes highly agitated, yells at the clinical staff, and aggressively attempts to pull the client off the stretcher to leave the facility. Arrange the following nursing actions in the priority order they should be implemented. (Place the most immediate priority action first and the lowest priority action last.)

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Cevap

The correct priority sequence is to first secure the environment from the active threat, second stabilize the client's physiological needs, third perform a detailed physical assessment, fourth document the objective findings, and finally fulfill the mandatory reporting requirement.
In complex abuse or neglect scenarios with an active threat, the nurse must synthesize Maslow's Hierarchy of Needs and emergency prioritization frameworks. The absolute first priority is scene safety; if a perpetrator is actively aggressive, security must separate them to protect the client and staff. Only when the environment is safe can the nurse address the airway, breathing, and circulation (ABC) needs, such as profound dehydration. Once stabilized, a full secondary assessment is conducted to quantify the extent of the neglect. These findings and direct quotes are then objectively documented to create a legal record. Finally, after the client is safe and assessed, the nurse fulfills their legal duty to notify Adult Protective Services.

Adım Adım Çözüm

1
Ensure immediate physical safety by involving security to manage the aggressive caregiver.
The client is separated from the suspected abuser, preventing immediate harm or elopement.
Environmental safety takes absolute precedence when there is an active threat of violence or interference with critical medical care.
2
Address acute medical instability by assessing vital signs and starting IV fluids.
The client's severe dehydration is treated, preventing cardiovascular collapse.
Physiological stability (ABCs) is the highest clinical priority once the scene is safe.
3
Perform a complete physical examination of the pressure injuries.
The extent of the physical neglect is thoroughly evaluated and measured.
A secondary survey is required to identify all injuries once immediate life-threatening conditions are managed.
4
Record the assessment data and caregiver's statements objectively.
A factual, legal medical record is created using direct quotes and physical descriptions.
Accurate documentation must reflect the initial presentation and is required to support the subsequent abuse report.
5
Report the suspected elder neglect to the appropriate state agency.
Adult Protective Services is alerted to initiate an official investigation.
Nurses are mandated reporters, but legal notifications should not delay emergency physiological or safety interventions.

Anahtar Kavram

Prioritization in Abuse and Neglect Scenarios
Tahmini Süre:2m 30s
Soru 1406Soru →

A registered nurse receives the morning handoff report for four clients on a general medical unit. In which order should the nurse assess these clients? Arrange the clients from highest priority (first) to lowest priority (last).

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Cevap

The correct order of assessment is: 1) the client with stridor (airway threat), 2) the client with symptomatic hypoglycemia (metabolic emergency), 3) the client with acute pain (non-life-threatening urgent), and 4) the client waiting for discharge (stable).
Prioritization in nursing requires addressing life-threatening issues first. Using the ABC framework, the client with stridor (Airway) takes absolute precedence. Following the ABCs, the client with symptomatic hypoglycemia faces a severe, rapid-onset metabolic crisis that requires immediate intervention. Next, applying Maslow's hierarchy of needs, the client experiencing acute pain has an urgent physiological need that supersedes the final stable client, who only requires routine discharge teaching.

Adım Adım Çözüm

1
Identify the client with the most immediate, life-threatening condition.
The client with stridor has an airway emergency.
The ABC (Airway, Breathing, Circulation) prioritization framework dictates that airway compromise must be treated first to prevent complete respiratory failure.
2
Identify the client with the next most critical physiological need.
The client with type 1 diabetes is experiencing symptomatic hypoglycemia.
Hypoglycemia is a severe circulation/metabolic issue that can quickly lead to seizures or coma if untreated, making it the second highest priority.
3
Evaluate the remaining clients for urgent but non-life-threatening physiological needs.
The client with the fractured femur requires acute pain management.
According to Maslow's hierarchy of needs, acute physiological pain requires attention before psychosocial, stable, or educational needs.
4
Determine the lowest priority client.
The client waiting for discharge instructions is completely stable.
Stable clients requiring routine teaching or discharge procedures are always prioritized last on a medical unit.

Anahtar Kavram

Prioritization of client care using the ABCs and Maslow's Hierarchy of Needs
Tahmini Süre:1m 30s
Soru 1407Soru →

A client who underwent a right knee arthroplasty 2 days ago is preparing to participate in a physical therapy session. The client is hemodynamically stable and alert. Which task should the registered nurse (RN) delegate to the unlicensed assistive personnel (UAP)?

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Cevap: Assisting the client with putting on non-slip footwear

Cevap

Assisting the client with putting on non-slip footwear
The correct answer involves assisting the client with non-slip footwear because this is a standard, unchanging routine activity that promotes basic safety. It does not require nursing judgment, assessment, or teaching.

Adım Adım Çözüm

1
Identify the scope of practice for unlicensed assistive personnel (UAP).
UAPs are permitted to perform standard, routine tasks on stable clients, such as assisting with activities of daily living (ADLs) and basic safety measures.
Delegation must strictly adhere to legal and facility guidelines to ensure client safety.
2
Analyze the options using the 'EAT' (Evaluate, Assess, Teach) mnemonic.
Three of the options involve evaluating pain, teaching about mobility, and assessing the incision.
The RN cannot legally delegate evaluation, assessment, or teaching to unlicensed personnel.
3
Select the option that represents a permissible UAP task.
Putting on non-slip footwear is selected.
It is a standard safety intervention requiring no clinical judgment or advanced knowledge.

Anahtar Kavram

Delegation of routine, non-clinical tasks to UAP
Tahmini Süre:45s
Soru 1408Soru →

During a busy mid-morning shift, multiple client needs arise simultaneously on a general surgical floor. The healthcare team consists of a registered nurse (RN) and an unlicensed assistive personnel (UAP). Which of the following interventions is most appropriate for the RN to delegate to the UAP?

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Cevap: Emptying a closed-suction wound drainage device and documenting the output volume for a client who is three days post-operative.

Cevap

The correct answer is emptying a closed-suction wound drainage device and documenting the output volume for a client who is three days post-operative.
Delegating the task of emptying a closed-suction wound drainage device and documenting the output is appropriate because it is a routine, standard procedure with a predictable outcome. The client is three days post-operative and clinically stable, so this intervention does not require independent nursing judgment, initial assessment, or teaching.

Adım Adım Çözüm

1
Analyze the scope of practice for an unlicensed assistive personnel (UAP).
The UAP can perform standard, unchanging procedures on clients who are clinically stable.
Delegation decisions must ensure the task does not require independent nursing judgment.
2
Evaluate each task to determine if it requires nursing assessment, clinical judgment, or teaching.
Feeding a client with a weakened gag reflex requires swallowing assessment. Demonstrating a technique is a form of teaching. Obtaining initial vital signs on a tachycardic patient requires assessment of an unstable client.
The RN cannot delegate tasks involving the core nursing process (Evaluate, Assess, Teach).
3
Select the task that fits within the UAP's authorized scope of practice.
Emptying a surgical drain and recording the output volume is a routine task with predictable outcomes.
This task adheres to the Five Rights of Delegation and is safe for the UAP to perform.

Anahtar Kavram

Delegation and Scope of Practice
Soru 1409Soru →

A registered nurse is working with an unlicensed assistive personnel (UAP) on a medical-surgical unit. The nurse is planning care for a stable client recovering from bacterial pneumonia. Which of the following tasks can the nurse safely delegate to the UAP? Select all that apply.

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Cevap: Emptying the urinary catheter drainage bag and documenting the output volume; Transferring the client from the hospital bed to a bedside chair for lunch

Cevap

The tasks that can be safely delegated include emptying the urinary catheter drainage bag and transferring the client from the bed to a bedside chair.
The UAP scope of practice includes assisting stable clients with basic activities of daily living (ADLs), hygiene, mobility (such as transfers), and collecting routine data (such as measuring urine output). Both transferring the client and documenting catheter output fit these criteria and do not require clinical judgment.

Adım Adım Çözüm

1
Review the scope of practice for an unlicensed assistive personnel (UAP).
Identify that UAPs can perform standard, routine, and uncomplex tasks for stable clients.
Understanding scope of practice prevents unsafe delegation.
2
Evaluate the clinical scenario using the 'EAT' mnemonic (Evaluate, Assess, Teach).
Identify that the registered nurse must retain tasks involving evaluation, assessment, and teaching.
This mnemonic highlights the core clinical judgment responsibilities that cannot be delegated.
3
Analyze each provided task against delegation rules.
Select the tasks involving basic care, mobility, and routine documentation, while rejecting those involving respiratory assessment, treatment evaluation, and initial education.
Applying the rules to each option determines the correct selections.

Anahtar Kavram

Delegating to Unlicensed Assistive Personnel
Soru 1410Soru →

A nurse on an oncology unit has just received shift report for four assigned clients. In which order should the nurse assess these clients? Arrange the clients from highest priority (first to be assessed) to lowest priority (last to be assessed).

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Cevap

Assess the transfusion reaction first, followed by the neutropenic fever, then the PCA pump refill, and finally the client with consent questions.
Prioritization requires addressing immediate threats to life first (ABCs), followed by systemic physiological threats, localized physiological needs, and finally psychosocial or routine needs. The transfusion reaction is an immediate circulatory threat. The neutropenic fever is a high-risk systemic threat. The empty PCA pump is a localized physiological need. The questions regarding consent represent a routine psychosocial need.

Adım Adım Çözüm

1
Identify active, life-threatening physiological emergencies (ABCs).
The client with lower back pain and chills during a blood transfusion is experiencing an acute hemolytic reaction.
This is an immediate airway and circulatory threat requiring the immediate cessation of the blood product.
2
Identify high-risk, time-sensitive conditions.
The neutropenic client with a new fever is placed second.
Neutropenic fever is a medical emergency that can rapidly deteriorate into sepsis, requiring rapid intervention just after stabilizing the actively reacting client.
3
Prioritize acute physiological needs without an immediate threat to life.
The client needing a PCA refill is placed third.
Pain is a high priority for comfort and physiological stability but does not supersede circulatory collapse or sepsis.
4
Address routine, stable, or psychosocial needs.
The client with questions about informed consent is placed fourth.
This is a non-urgent administrative and educational need that can wait until all unstable clients are safely managed.

Anahtar Kavram

Prioritization of Care using Maslow's Hierarchy and ABCs (Airway, Breathing, Circulation)
Soru 1411Soru →

The nursing team on a specialized gastroenterology unit consists of a registered nurse (RN) and an unlicensed assistive personnel (UAP). The RN is reviewing the current needs of four assigned clients to determine appropriate task delegation. Which of the following interventions is safe and most appropriate to assign to the UAP?

Cevabı ve açıklamayı göster

Cevap: Measuring and recording the total volume of oral fluid intake and urine output for a client with acute gastroenteritis.

Cevap

Measuring and recording the total volume of oral fluid intake and urine output for a client with acute gastroenteritis.
Measuring and recording intake and output is a routine, standard procedure that does not require specialized nursing judgment or assessment. This task safely falls within the expected scope of practice for an unlicensed assistive personnel (UAP) when caring for a stable client.

Adım Adım Çözüm

1
Analyze the scope of practice for an unlicensed assistive personnel (UAP).
UAPs are permitted to perform routine, standard, and unchanging tasks such as measuring vital signs on stable clients, assisting with personal hygiene, and recording intake and output.
Understanding the defined scope of practice is essential for safe and legal delegation.
2
Evaluate each option against the EAT framework (Evaluate, Assess, Teach).
Pain assessment involves evaluation; diet instruction involves teaching; caring for a client with active lower gastrointestinal bleeding requires immediate RN assessment.
The RN retains accountability for the nursing process and cannot delegate evaluation, assessment, or teaching.
3
Select the task that involves a stable client and fits within the UAP's established scope.
Recording intake and output for a client with gastroenteritis is a routine data collection task that does not require independent nursing judgment.
This task adheres to the Five Rights of Delegation and ensures client safety.

Anahtar Kavram

Delegating tasks to Unlicensed Assistive Personnel (UAP) according to NCSBN guidelines.
Tahmini Süre:1m 0s
Soru 1412Soru →

A nurse is finalizing the plan of care for a client who is scheduled to undergo a bedside percutaneous liver biopsy. Identify the actions the nurse must implement to minimize the client's risk for procedure-related complications. (Select all that apply.)

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Cevap: Verify that the client's most recent prothrombin time and platelet count are within acceptable parameters.; Instruct the client to exhale and hold their breath when the biopsy needle is inserted.; Maintain the client on strict bed rest for the prescribed duration following the biopsy.

Cevap

The correct interventions are verifying coagulation parameters, instructing the client on the exhalation and breath-holding technique, and enforcing post-procedure bed rest.
The correct actions involve reducing bleeding and puncture risks. Verifying coagulation studies ensures the client's blood can clot normally. Having the client hold their breath after exhaling elevates the diaphragm, protecting the lungs. Maintaining bed rest ensures the newly formed clot at the puncture site is not disrupted.

Adım Adım Çözüm

1
Analyze the physiological risks associated with a percutaneous liver biopsy.
The primary risks are hemorrhage (due to the liver's high vascularity) and pneumothorax (due to the liver's proximity to the diaphragm and lungs).
Understanding the potential complications dictates which preventive actions are necessary.
2
Evaluate the pre-procedure and intra-procedure options for safety.
Checking coagulation labs (PT, platelets) mitigates bleeding risk. Having the client hold their breath after exhaling elevates the diaphragm, mitigating pneumothorax risk.
These actions directly address and reduce the most common severe complications.
3
Evaluate the post-procedure options for safety and recovery.
Bed rest stabilizes the clot. Conversely, deep palpation can destroy the clot, and left-sided positioning fails to apply necessary pressure to the liver.
Post-procedure care must focus on maintaining hemostasis at the puncture site.

Anahtar Kavram

Reduction of Risk Potential: Liver Biopsy Complications
Tahmini Süre:1m 0s
Soru 1413Soru →

A nurse is caring for a 45-year-old client who was recently diagnosed with advanced pancreatic cancer. During the morning assessment, the client states, "I spent the entire night reading medical journals. The statistics for this cancer are poor, but I have drafted a spreadsheet of experimental trials, their p-values, and statistical significance. I need you to arrange a meeting with the research director today so we can review the pharmacological variables." The client exhibits no visible emotion while discussing the diagnosis. Which of the following defense mechanisms is the client primarily demonstrating, and what is the priority nursing action?

Cevabı ve açıklamayı göster

Cevap: Intellectualization; acknowledge the client's effort in gathering information while gently exploring the emotional impact of the diagnosis.

Cevap

The client is demonstrating intellectualization, and the nurse should acknowledge the client's information-gathering efforts while gently exploring the emotional impact of the diagnosis.
The correct answer accurately identifies the client's behavior as intellectualization, a defense mechanism where a person uses excessive reasoning, logic, and abstract thinking to avoid experiencing uncomfortable or distressing emotions. Facing a terminal diagnosis, the client protects their ego by focusing on 'p-values' and 'pharmacological variables' rather than grief or fear. The corresponding nursing action is highly therapeutic: it validates the client's current coping strategy (researching) without challenging it, while simultaneously opening the door for emotional expression at a pace the client can handle.

Adım Adım Çözüm

1
Analyze the client's statement and behavioral cues to identify the active defense mechanism.
The client focuses entirely on complex clinical data (p-values, experimental trials) and displays no emotion regarding a terminal diagnosis, which fits the definition of intellectualization.
Accurately identifying the coping mechanism is the essential first step in formulating a safe and therapeutic nursing response.
2
Evaluate the proposed nursing actions for therapeutic value and psychological safety.
Gently exploring the client's emotions while acknowledging their research efforts maintains the therapeutic relationship without abruptly destroying the client's protective coping mechanism.
Stripping a defense mechanism too quickly by forcing confrontation can precipitate a psychological crisis, while completely ignoring the emotional aspect prevents healthy adaptation to the illness.

Anahtar Kavram

Defense Mechanisms: Recognizing Intellectualization and Applying Therapeutic Communication
Soru 1414Soru →

A registered nurse is planning initial assessments for a group of assigned clients. Arrange the following clients in the correct order for assessment, from highest priority (most urgent) to lowest priority (least urgent).

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Cevap

The correct sequence for assessment is: 1) the client with sudden shortness of breath and chest pain, 2) the client reporting dizziness when standing, 3) the client with a blood glucose of 145 mg/dL, and 4) the client asking about breakfast.
Prioritization is guided by the Airway, Breathing, Circulation (ABC) framework and the acuity of the clients' conditions. The client experiencing sudden shortness of breath and chest pain with a history of deep vein thrombosis is exhibiting signs of a pulmonary embolism, an immediate threat to breathing and circulation. This client is the highest priority. The client with dizziness when standing has a circulatory issue (orthostatic hypotension) and is a high fall risk, making them the second priority. The client with a fasting glucose of 145 mg/dL is medically stable and requires only routine assessment, placing them third. The client asking a question about a future procedure has an informational need, which is the lowest priority and should be addressed last.

Adım Adım Çözüm

1
Identify the client with the most critical, life-threatening physiological instability.
The client with a deep vein thrombosis is experiencing sudden shortness of breath and chest pain, indicating a potential pulmonary embolism.
According to the ABC (Airway, Breathing, Circulation) framework, airway and breathing compromises must be addressed first to preserve life.
2
Identify the client with the next most urgent physiological need.
The client with gastroenteritis is experiencing dizziness upon standing, indicating orthostatic hypotension.
Circulation issues and fall risks take precedence over routine assessments, placing this client second in priority.
3
Differentiate between routine physiological needs and non-urgent informational needs.
The client with diabetes has a stable, mildly elevated blood glucose reading of 145 mg/dL, representing a routine physiological assessment.
Stable physiological assessments are prioritized over general inquiries.
4
Assign the lowest priority to tasks that do not involve physiological stability.
The client asking about breakfast prior to an ultrasound is placed last.
Answering questions about routine procedures is an important nursing function but does not impact physiological stability, so it can be safely delayed.

Anahtar Kavram

Prioritizing Client Care Using the ABC Framework
Soru 1415Soru →

A 24-year-old client is admitted to the inpatient behavioral health unit with severe anorexia nervosa.

Objective cues:
- BMI is 14.2
- Vital signs: heart rate 52 bpm
- Recent laboratory results indicate hypokalemia (K+ 2.9 mEq/L)

During mealtime, the client abruptly pushes the food tray away, crosses their arms tightly, and shouts at the nurse, "You are constantly trying to control every aspect of my life! You are exactly like my mother, always forcing your rules on me. You don't care about my health; you just want to make me fat!"

Based on the client's presentation, which of the following nursing actions represents the most appropriate response to the client's coping mechanisms?

Cevabı ve açıklamayı göster

Cevap: Recognize the use of projection and displacement, maintain a non-defensive posture, and clearly reinforce the therapeutic boundaries and expectations for the meal.

Cevap

The correct action is to recognize the use of projection and displacement, maintain a non-defensive posture, and clearly reinforce the therapeutic boundaries and expectations for the meal.
The correct answer accurately identifies the client's maladaptive defense mechanisms (projection of control issues and displacement of anger from the mother). During an acute state of anxiety and psychiatric distress, the most therapeutic nursing action is to avoid becoming defensive, maintain a calm and neutral demeanor, and set clear, consistent limits regarding the unit's behavioral and nutritional expectations. This provides a safe, structured environment without escalating the client's anxiety.

Adım Adım Çözüm

1
Analyze the client's verbal statements to identify the specific defense mechanisms being used.
The statement 'You are constantly trying to control every aspect of my life!' demonstrates projection (attributing their own internal conflict over control onto the nurse). The statement 'You are exactly like my mother' demonstrates displacement (redirecting unresolved emotions about the mother onto the nurse).
Accurately identifying the underlying coping mechanisms is the first step in formulating a targeted, therapeutic response.
2
Evaluate the client's physical and psychological stability based on the provided objective cues.
The client is medically unstable (BMI 14.2, bradycardia, severe hypokalemia) and experiencing acute psychological distress, making them a high-priority client.
The client's physiological instability dictates that nutritional intake is a critical medical priority, while their psychological state indicates that deep, insight-oriented therapy would currently be ineffective and potentially harmful.
3
Select the nursing intervention that safely addresses the behavior while maintaining therapeutic communication and boundaries.
The most therapeutic action is to remain non-defensive, avoid arguing with the client's projected feelings, and firmly but calmly set limits by reinforcing the expectations for the meal.
Confronting defenses or asking 'why' blocks communication. Delegating an unstable client is unsafe.

Anahtar Kavram

Therapeutic Response to Maladaptive Coping Mechanisms
Soru 1416Soru →

Following the evening shift handoff on a cardiovascular step-down unit, the nurse prepares to evaluate four assigned clients. Arrange the clients in the order they should be assessed, from highest priority to lowest priority.

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Cevap

The correct priority sequence is: 1) the client with unrelieved chest pain, 2) the client with heart failure and oliguria, 3) the client requiring a time-sensitive aPTT draw, and 4) the client waiting for discharge teaching.
Prioritization in nursing care is guided by the ABCs (Airway, Breathing, Circulation) and Maslow's Hierarchy of Needs. Unstable clients with acute, life-threatening conditions must be assessed first, followed by clients with urgent changes in condition, then those with time-sensitive needs, and finally stable clients requiring routine care or education.

Adım Adım Çözüm

1
Identify life-threatening or ABC (Airway, Breathing, Circulation) emergencies.
The client with chest pain unrelieved by nitroglycerin is experiencing active ischemia.
Active myocardial ischemia poses an immediate threat to the client's life and requires rapid assessment and intervention.
2
Identify acute physiological instability or systemic deterioration.
The client with heart failure producing only 30 mL of urine over two hours is exhibiting signs of decreased cardiac output.
Oliguria in a client receiving diuretics is a critical sign of hypoperfusion, requiring prompt evaluation, though it does not take precedence over an active myocardial infarction.
3
Evaluate remaining clients for time-sensitive tasks.
The client requiring a scheduled aPTT draw for a heparin drip is identified as the third priority.
The client is stable, but a timely blood draw is essential for safely adjusting the continuous medication infusion.
4
Identify stable clients requiring routine care or education.
The client awaiting discharge teaching represents the lowest priority.
The client is physiologically stable and waiting to go home; educational activities can be safely delayed.

Anahtar Kavram

Prioritization of Care based on Acuity and Stability
Soru 1417Soru →

A charge nurse is coordinating care on a busy renal and metabolic disorders unit. The nursing team includes a registered nurse (RN) and an unlicensed assistive personnel (UAP). Which task is most appropriate for the RN to delegate to the UAP?

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Cevap: Measuring the morning capillary blood glucose level for a stable client with type 2 diabetes

Cevap

Measuring the morning capillary blood glucose level for a stable client with type 2 diabetes
Measuring capillary blood glucose on a stable client is a routine, standardized procedure with predictable outcomes that falls securely within the established scope of practice for a trained UAP. It does not require independent nursing judgment.

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1
Identify the legal and professional scope of practice for unlicensed assistive personnel (UAP).
UAPs are permitted to perform routine, standardized tasks with predictable outcomes on stable clients.
Delegation must adhere to the 'Five Rights of Delegation', ensuring the right task is assigned to the right person based on their competency and role.
2
Analyze each option to determine if it requires the nursing process (assessment, diagnosis, planning, implementation of teaching, or evaluation).
Evaluating pain medication, explaining fluid guidelines, and assessing an AV fistula all involve the nursing process and clinical judgment.
The RN is legally accountable for the nursing process and cannot delegate tasks requiring specialized nursing knowledge to unlicensed personnel.
3
Select the task that does not require independent nursing judgment.
Measuring a capillary blood glucose level for a stable client is identified as the correct task to delegate.
This is a standard procedure with a predictable outcome that a trained UAP can safely perform.

Anahtar Kavram

Delegation and Scope of Practice based on the Nursing Process
Soru 1418Soru →

A 45-year-old client is recovering on the surgical unit following a traumatic bilateral lower extremity amputation. While the nurse is performing wound care, the client exhibits a flat affect and states, "The biomechanical principles of the human gait can be perfectly replicated using carbon fiber and microprocessors. The absence of organic tissue is structurally irrelevant to my future functionality." Which action by the nurse represents the most appropriate management of the client's coping mechanism?

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Cevap: State, "You clearly understand the technology well. What is it like for you to think about utilizing these prosthetics?"

Cevap

The correct action is to state, "You clearly understand the technology well. What is it like for you to think about utilizing these prosthetics?"
The client is demonstrating intellectualization and isolation of affect, using technical facts to distance themselves from the emotional trauma of the amputations. The most therapeutic nursing action is to acknowledge the client's cognitive statements while gently inviting them to explore the associated feelings. This approach supports the client without abruptly stripping away their necessary psychological defense mechanism, bridging the gap between logic and emotional reality.

Adım Adım Çözüm

1
Analyze the client's behavior and statement.
The client is using complex terminology and focusing entirely on facts with a flat affect, indicating the defense mechanisms of intellectualization and isolation of affect.
Identifying the specific coping mechanism is required to determine the appropriate therapeutic intervention.
2
Evaluate the clinical safety and purpose of the defense mechanism.
The defense is temporarily protecting the client's ego from the overwhelming trauma of bilateral amputation and is not immediately physically harmful.
Defense mechanisms should only be challenged directly if they pose an immediate threat to physical safety or essential medical treatment.
3
Select the most therapeutic communication strategy.
The nurse validates the client's cognitive focus while gently probing the isolated emotional state.
This bridges the gap between the intellect and the emotion without abruptly stripping away the client's protective psychological barrier.

Anahtar Kavram

Therapeutic Management of Intellectualization
Soru 1419Soru →

The registered nurse is planning care for a client with chronic heart failure who is stable and scheduled for discharge in the morning. Which tasks are appropriate to delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Geçerli olan tümünü seçin

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Cevap: Obtaining the client's daily morning weight using a standing scale; Recording the amount of oral fluid the client consumes during breakfast; Ambulating the client to the bathroom

Cevap

The correct tasks to delegate are obtaining the morning weight, recording oral fluid intake, and ambulating the client to the bathroom.
Unlicensed assistive personnel (UAP) can safely perform routine, standardized tasks for stable clients that do not require clinical judgment. Obtaining daily weights, measuring intake and output, and assisting with ambulation are predictable tasks with minimal potential for harm, making them perfectly appropriate for delegation.

Adım Adım Çözüm

1
Evaluate the client's stability and needs.
The client is stable and preparing for discharge, making routine care delegation safe.
Delegation is only appropriate for clients who are clinically stable and have predictable outcomes.
2
Analyze each task against the scope of practice for unlicensed assistive personnel.
Tasks involving assessment (edema), teaching/evaluation (diet selection), and medication administration must be excluded.
The RN cannot delegate tasks requiring nursing judgment, assessment, teaching, or evaluation (often remembered by the acronym EAT).
3
Select the routine, standard tasks that require no clinical judgment.
Weighing the client, documenting intake, and assisting with ambulation are selected.
These are standard, unchanging procedures that fall firmly within the UAP's scope of practice.

Anahtar Kavram

Delegation to Unlicensed Assistive Personnel (UAP)
Soru 1420Soru →

A nurse has just administered an intramuscular injection to a client and needs to dispose of the used syringe and needle. Which of the following is the correct action for handling this potentially infectious material?

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Cevap: Drop the intact syringe and needle immediately into a designated, puncture-resistant sharps container.

Cevap

Drop the intact syringe and needle immediately into a designated, puncture-resistant sharps container.
According to standard precautions and occupational safety guidelines, used needles and syringes must be discarded immediately and intact into a designated, rigid, puncture-resistant sharps container. This action prevents needle-stick injuries and ensures the safe handling of infectious materials.

Adım Adım Çözüm

1
Identify the type of hazardous material requiring disposal.
The material is a used syringe with an attached needle, classified as an infectious sharp.
Accurate classification of the material dictates the specific OSHA and CDC disposal guidelines to follow.
2
Apply standard precautions for the disposal of sharps.
The correct action is to dispose of the item immediately and intact into a rigid sharps container.
Immediate disposal without manipulation (like recapping or bending) minimizes the risk of accidental needle-stick injuries and transmission of bloodborne pathogens.

Anahtar Kavram

Safe Disposal of Infectious Sharps
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