Tüm alıştırma soruları

3881 soru

Soru 1501Soru →

The primary care provider has prescribed bilateral soft wrist restraints for a client who is severely disoriented and continuously interfering with a newly inserted chest tube. After gathering the necessary supplies, arrange the nurse's subsequent actions in the correct chronological sequence, from first to last.

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Cevap

The correct sequence is: Explain the rationale, wrap the restraint with padding against the skin, insert two fingers to verify fit, fasten the straps to the movable bed frame, and document the intervention.
The correct sequence prioritizes client communication and ethical care first, followed by the safe physical application of the device to the wrist. After the wrist cuff is secured and the fit is verified to prevent circulatory impairment, the limb is safely anchored to a movable part of the bed using an emergency release knot. Finally, comprehensive legal documentation is completed to reflect the procedure.

Adım Adım Çözüm

1
Explain the rationale for the safety device to the client and any present family members.
The client and family are informed about the intervention.
Ethical practice requires clear communication and education before implementing restrictive measures, even if the client's comprehension is impaired.
2
Wrap the restraint device around the client's wrist with the padded portion against the skin.
The restraint cuff is placed correctly on the extremity.
Applying the padded side flush against the skin minimizes shearing forces and reduces the risk of skin breakdown.
3
Insert two fingers between the applied restraint and the client's wrist to verify proper fit.
The tightness of the restraint cuff is validated.
This physical check ensures the restraint is tight enough to prevent escape but loose enough to maintain adequate arterial blood flow and venous return.
4
Fasten the restraint straps to the movable portion of the bed frame using a quick-release knot.
The client's arm is safely secured to the bed.
Tying the straps to the movable frame ensures the restraint won't tighten if the bed's head or foot is adjusted. A quick-release knot allows for immediate removal during emergencies.
5
Document the prior alternative interventions attempted and the exact time of restraint application.
The clinical record reflects adherence to safety protocols and legal requirements.
Thorough documentation demonstrates that restraints were used as a last resort and establishes the timeline for required monitoring intervals.

Anahtar Kavram

Safe application and monitoring of physical restraints requires a standardized, sequential approach to protect the client's rights, maintain skin integrity, prevent neurovascular compromise, and ensure emergency accessibility.
Soru 1502Soru →

A nurse is providing education to a pregnant client at 16 weeks gestation who has a history of intravenous heroin use. The client is currently stable on prescribed buprenorphine maintenance therapy. The client expresses intense anxiety, stating, 'I want to stop taking the buprenorphine completely because I read online that it will cause my baby to have severe withdrawals after birth.' Which of the following is the most appropriate response by the nurse?

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Cevap: Continuing your prescribed medication is the safest option, as it prevents maternal relapse and fetal distress, which pose a much greater risk than treatable newborn withdrawal.

Cevap

The most appropriate response is the one that advises continuing the prescribed medication, emphasizing that preventing maternal relapse and fetal distress is a higher priority than avoiding newborn withdrawal.
The correct answer accurately reflects the standard of care and harm reduction principles for pregnant clients exhibiting high-risk behaviors related to opioid use disorder. Medication-assisted treatment (MAT) with buprenorphine or methadone is strongly recommended throughout pregnancy. The severe risks associated with stopping the medication—specifically maternal relapse, fatal overdose, and withdrawal-induced intrauterine fetal demise—far outweigh the risk of Neonatal Abstinence Syndrome (NAS). NAS is an expected, transient, and medically treatable condition in the newborn, whereas relapse can be fatal.

Adım Adım Çözüm

1
Analyze the client's statement and identify the underlying concern.
The client is experiencing severe anxiety about Neonatal Abstinence Syndrome (NAS) and is considering abruptly stopping her buprenorphine, which is a critical harm reduction medication.
Identifying the client's knowledge deficit and emotional state is required to provide accurate, therapeutic education.
2
Evaluate the physiological risks associated with the client's proposed plan of action.
Abrupt cessation or even gradual tapering of opioid agonist therapy during pregnancy significantly increases the risk of maternal relapse, overdose, and acute fetal distress or demise.
Understanding maternal-fetal physiology guides the prioritization of harm reduction over a completely drug-free state.
3
Select the response that promotes the highest level of safety while addressing the client's concern therapeutically.
The response that advocates for continuing the medication while accurately acknowledging that newborn withdrawal is a treatable condition is the most appropriate.
This applies evidence-based harm reduction principles and prioritizes life-threatening risks over treatable neonatal complications.

Anahtar Kavram

Harm reduction principles and prioritization of medication-assisted treatment (MAT) for opioid use disorder during pregnancy.
Soru 1503Soru →

A gerontological nurse conducts a comprehensive assessment of an 84-year-old client who recently moved into an independent living facility. The family expresses concern regarding several recent changes in the client's behavior and physical status over the past two months. Which of the following findings should the nurse identify as expected age-related transitions rather than pathological processes requiring immediate intervention? Select all that apply.

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Cevap: The client frequently engages in prolonged periods of solitary reminiscence regarding their previous career and past relationships.; The client requires a nightlight in the bedroom due to an increased latency in pupillary adaptation to darkness.; The client demonstrates symmetrically diminished Achilles tendon reflexes bilaterally during a routine neurological examination.

Cevap

The expected age-related findings include solitary reminiscence, requiring a nightlight due to delayed pupillary adaptation, and demonstrating symmetrically diminished Achilles tendon reflexes.
The correct findings represent expected adaptations of advanced age. Solitary reminiscence (life review) is a healthy process necessary for achieving Erikson's stage of Ego Integrity. Decreased pupillary adaptation to darkness (senile miosis) and symmetrically diminished deep tendon reflexes (particularly the Achilles reflex) are expected, non-pathological neurological and sensory changes in the older adult.

Adım Adım Çözüm

1
Analyze the client's developmental and physiological stage.
The client is an 84-year-old in late adulthood. The primary psychosocial crisis is Erikson's Ego Integrity versus Despair.
Establishing a baseline for what constitutes normal aging versus pathology is required to filter the assessment findings.
2
Evaluate the psychosocial assessment findings.
Reminiscence is a healthy part of Ego Integrity. Conversely, isolating oneself and expressing that life was meaningless indicates Despair, a maladaptive outcome.
Differentiating between successful life review and clinical depression/despair prevents missing critical mental health decline in the elderly.
3
Evaluate the physiological assessment findings.
Delayed pupillary adaptation and symmetrically diminished Achilles reflexes are normal systemic signs of aging. Confabulation (inventing memories), early morning awakening, and rapid weight loss are signs of pathology (dementia and major depression/illness).
Nurses must recognize subtle pathological signs that are often incorrectly attributed to 'just getting older'.
4
Select only the findings representing normal transitions.
The correct findings are reminiscence, delayed pupillary adaptation, and diminished Achilles reflexes.
These findings do not require clinical intervention and demonstrate expected aging.

Anahtar Kavram

Differentiating normal physiological senescence and healthy psychosocial development (Ego Integrity) from pathological changes (dementia, depression, despair) in the older adult.
Soru 1504Soru →

A nurse is caring for a client with a gastrostomy tube who is prescribed a scheduled dose of oral methotrexate, a hazardous antineoplastic medication. The medication is currently available in the unit's automated dispensing cabinet as solid oral tablets. Which action by the nurse demonstrates the safest handling of this hazardous material?

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Cevap: Contact the pharmacy to request the medication be compounded and dispensed as an oral liquid suspension.

Cevap

Contact the pharmacy to request the medication be compounded and dispensed as an oral liquid suspension.
Methotrexate is classified as a hazardous drug. According to NIOSH and OSHA safe handling guidelines, hazardous solid medications should never be crushed, broken, or opened on a general patient care unit. Doing so creates toxic dust that aerosolizes, risking inhalation by healthcare workers and contaminating surfaces. If a client requires a liquid formulation for a feeding tube, the nurse must contact the pharmacy to have the medication safely compounded into an oral suspension inside a ventilated biological safety cabinet.

Adım Adım Çözüm

1
Identify the medication classification and safety requirements.
Methotrexate is recognized as a hazardous antineoplastic drug.
Special handling precautions are legally and ethically required by guidelines (e.g., NIOSH, OSHA) to prevent occupational exposure to hazardous drugs.
2
Assess the required route of administration against the available medication form.
The client has a gastrostomy tube, meaning the available solid tablets must be converted to a liquid form for administration.
Solid tablets cannot be administered intact through an enteral feeding tube; they must be dissolved or crushed.
3
Determine the safest method for altering the hazardous medication form.
The nurse determines that crushing hazardous drugs on the unit is inherently unsafe and contacts pharmacy.
Crushing hazardous drugs creates toxic aerosols and contaminates the environment. Pharmacy must compound liquids in a biological safety cabinet with negative pressure.

Anahtar Kavram

Safe Handling and Preparation of Hazardous Drugs (Antineoplastics)
Soru 1505Soru →

The registered nurse is caring for a client who is on strict contact precautions for a Clostridioides difficile infection and is receiving a continuous intravenous infusion of a hazardous antineoplastic agent. Upon entering the room, the nurse observes that the intravenous tubing has disconnected at the hub, the antineoplastic medication is actively dripping onto the floor, and the client has just had a large episode of liquid stool incontinence. Which of the following actions should the nurse take? Select all that apply.

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Cevap: Clamp the disconnected intravenous tubing immediately to halt the flow of the hazardous medication; Don a specialized chemotherapy gown, double chemotherapy gloves, and a face shield prior to cleaning the spill; Contain the liquid medication spill on the floor by carefully placing absorbent pads from a chemotherapy spill kit over it

Cevap

The correct actions are to clamp the intravenous tubing immediately, don specialized chemotherapy personal protective equipment (gown, double gloves, face shield), and contain the spill using absorbent pads from a chemotherapy spill kit.
The management of a combined infectious and hazardous material incident requires immediate prioritization of source control and appropriate protection. The nurse must first stop the active chemotherapy spill by clamping the tubing. Subsequently, the nurse must don appropriate specialized personal protective equipment (chemotherapy gown, double gloves, and face shield) and use a chemotherapy spill kit to contain the spill with absorbent pads. These actions minimize occupational exposure and environmental contamination.

Adım Adım Çözüm

1
Identify the immediate hazards in the environment.
The nurse recognizes an active antineoplastic medication spill and a concurrent biohazard from Clostridioides difficile stool.
Rapid situational awareness determines the necessary safety priorities.
2
Stop the source of the hazardous spill.
The nurse immediately clamps the disconnected intravenous tubing.
Halting the flow of the hazardous medication prevents further environmental contamination and reduces exposure risk.
3
Don appropriate specialized personal protective equipment (PPE).
The nurse applies a chemotherapy gown, double chemotherapy gloves, and a face shield.
Standard contact precautions are insufficient for an antineoplastic spill; specialized PPE is legally and ethically required to protect the nurse from hazardous drug exposure.
4
Contain the spilled hazardous medication.
The nurse places absorbent pads from a chemotherapy spill kit over the liquid on the floor.
Containment prevents the hazardous drug from spreading or aerosolizing before full decontamination can be completed.
5
Perform appropriate hand hygiene after managing the situation.
The nurse washes hands with soap and water after removing PPE.
Alcohol-based hand rubs are ineffective against Clostridioides difficile spores, which must be physically washed away.

Anahtar Kavram

Management of combined hazardous drug spills and infectious biohazards
Soru 1506Soru →

The healthcare provider has prescribed an intermittent intravenous (IV) infusion of potassium chloride for a client experiencing severe hypokalemia. Which of the following safety measures must the registered nurse implement? Select all that apply.

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Cevap: Verify that the client has a urine output of at least 30 mL/hr before initiating the infusion.; Administer the solution using an electronic volumetric infusion pump.; Assess the intravenous insertion site for patency and signs of infiltration prior to beginning the infusion.

Cevap

The correct safety measures are verifying that the client has adequate urine output, administering the solution using an electronic infusion pump, and assessing the IV site for patency before the infusion begins.
Intravenous potassium chloride requires strict adherence to safety protocols. The nurse must verify adequate renal function (urine output of at least 30 mL/hr) because potassium is excreted by the kidneys; poor renal function can lead to life-threatening hyperkalemia. It must always be administered using an electronic volumetric infusion pump to guarantee a precise rate and prevent rapid infusion. Furthermore, because potassium can cause severe tissue damage if it leaks into surrounding tissues, assessing the IV site for patency and infiltration before administration is mandatory.

Adım Adım Çözüm

1
Identify the primary risks associated with the prescribed medication.
Intravenous potassium chloride is a high-alert medication that can cause fatal cardiac arrhythmias if administered too quickly, and tissue necrosis if it extravasates.
Understanding the specific dangers of the medication guides the necessary safety interventions.
2
Evaluate each option against established parenteral therapy safety standards.
Using a pump, checking for IV patency, and ensuring renal clearance are all required safety standards.
These actions directly mitigate the known risks of hyperkalemia, rapid infusion, and tissue damage.

Anahtar Kavram

Safe Administration of Intravenous Potassium Chloride
Soru 1507Soru →

A 42-year-old female client at average risk for breast cancer visits a community wellness center for a routine health evaluation. She states she has never had a mammogram and asks the nurse when she should begin this screening. Based on current consensus guidelines, which of the following is the most appropriate instruction by the nurse?

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Cevap: Recommend scheduling a screening mammogram now and advise returning for the exam every two years.

Cevap

The nurse should recommend scheduling a screening mammogram now and advise returning for the exam every two years.
The correct response reflects the most current evidence-based guidelines, which recommend that women at average risk for breast cancer begin biennial (every two years) screening mammography at age 40. Because the client is 42 years old, she should initiate screening immediately and continue on a two-year schedule.

Adım Adım Çözüm

1
Assess the client's age and risk factors for breast cancer.
The client is 42 years old and at average risk.
Screening guidelines are stratified based on age and personal or family risk factors.
2
Recall the current national evidence-based guidelines for breast cancer screening.
Guidelines recommend biennial screening mammography starting at age 40 for women at average risk.
Applying the most current guidelines ensures safe and effective secondary prevention.
3
Determine the appropriate intervention for this specific client.
Since the client is 42 and has never had a mammogram, she is due for her initial screening and should be screened every two years thereafter.
This aligns the client's care with established health maintenance protocols.

Anahtar Kavram

Secondary Prevention and Evidence-Based Screening Guidelines
Tahmini Süre:1m 0s
Soru 1508Soru →

A clinic nurse is providing discharge instructions to an adult client who has a history of intravenous (IV) substance use and is not currently seeking rehabilitation. Which harm-reduction strategies should the nurse emphasize to promote the client's safety? (Select all that apply.)

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Cevap: Obtain and use a new, sterile syringe for every injection.; Wipe the planned injection site with an alcohol pad before inserting the needle.; Ensure a peer is present and has access to a naloxone kit when injecting.

Cevap

The correct strategies include using a new, sterile syringe for every injection, wiping the injection site with an alcohol pad beforehand, and ensuring a peer is present with access to a naloxone kit.
Harm reduction strategies for intravenous substance use focus on minimizing the risk of infection, vein damage, and fatal overdose. Using a new, sterile needle and syringe for every injection prevents the transmission of bloodborne pathogens. Cleaning the injection site with alcohol reduces the introduction of skin flora into the bloodstream, preventing abscesses and endocarditis. Finally, having a naloxone kit available and avoiding solitary drug use ensures that a life-saving intervention can be administered promptly in the event of an overdose.

Adım Adım Çözüm

1
Identify the client's high-risk behavior and the purpose of the education.
The client actively uses intravenous substances and needs harm-reduction strategies.
Understanding the behavior allows the nurse to provide relevant, non-judgmental education focused on safety.
2
Determine the fundamental goals of harm reduction for this specific population.
The main goals include preventing fatal overdoses, reducing the transmission of bloodborne pathogens, and preventing localized skin or systemic infections.
Harm reduction acknowledges the ongoing behavior and focuses on minimizing its severe negative health impacts.
3
Evaluate each instructional option against established harm-reduction principles.
Strategies promoting sterile equipment, site hygiene, and overdose preparedness are correct. Strategies suggesting any form of sharing or improper cleaning are incorrect.
Evidence-based practice dictates that needles must never be shared or reused, and overdose reversals require immediate intervention by another person.

Anahtar Kavram

Harm reduction strategies for intravenous substance use
Soru 1509Soru →

A client in the intensive care unit is receiving mechanical ventilation. The client suddenly exhibits severe agitation and aggressively attempts to remove the endotracheal tube. After verbal de-escalation fails and the client's oxygen saturation begins to drop rapidly, the nurse determines that emergency physical restraints are required. Arrange the following nursing actions in the correct sequence of execution from first to last.

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Cevap

The correct sequence prioritizes immediate physiological safety (airway protection), followed by verifying the safety of the intervention, obtaining legal medical authorization, addressing psychosocial needs, and finally completing the legal documentation.
The sequence follows the nursing process and emergency prioritization frameworks (Maslow's Hierarchy and ABCs). Airway protection (applying restraints to prevent extubation) is the absolute first priority. Assessing the intervention for safety (two-finger fit) immediately follows. With the client safe, the nurse fulfills legal requirements (notifying the provider), then addresses psychosocial integrity (educating the family), and concludes with administrative duties (documentation).

Adım Adım Çözüm

1
Apply bilateral soft wrist restraints to immediately secure the client's airway.
The client is prevented from extubating themselves, stabilizing their respiratory status.
In a life-threatening emergency, the nurse has the authority and obligation to apply restraints immediately without waiting for an order to prevent fatal harm.
2
Verify proper restraint application by ensuring two fingers can slide between the device and the wrist.
Peripheral circulation and nerve integrity are maintained.
Securing the device must immediately be followed by an assessment of fit to ensure the intervention itself does not cause localized injury.
3
Contact the primary healthcare provider to obtain an emergency, time-limited restraint prescription.
The emergency intervention is legally authorized and medical oversight is established.
Facility protocols and regulatory standards mandate that a provider must be notified and an order obtained shortly after an emergency application (typically within 1 hour).
4
Explain the rationale and temporary necessity of the safety intervention to the family members at the bedside.
Family anxiety is reduced and they understand the therapeutic need for the restraint.
Psychosocial support is prioritized once the client is medically and physically stabilized.
5
Document the specific precipitating behaviors and the failed alternative measures in the medical record.
A legal and clinical record of the emergency is established.
Charting is always the final step in an emergency sequence, executed only after the client is safe and acute interventions are complete.

Anahtar Kavram

Emergency Restraint Application and Prioritization
Soru 1510Soru →

A client on Contact Precautions for a severe *Clostridioides difficile* infection has been discharged. The nurse is responsible for cleaning and disinfecting the reusable medical equipment (e.g., intravenous pump, telemetry monitor) left in the room before returning it to the central supply department. Arrange the following actions in the correct chronological sequence to ensure safe and effective infection control.

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Cevap

The correct sequence is to first don appropriate PPE, clean away visible organic soil with a detergent, apply a sporicidal bleach solution, allow the equipment to air dry for the required contact time, and finally doff the PPE and wash hands with soap and water.
The correct sequence integrates the principles of Contact Precautions with the specific environmental requirements for eradicating *C. difficile* spores. The nurse must first don PPE to prevent self-contamination. Next, the equipment must be cleaned with a detergent, because organic soil can deactivate bleach. Once clean, a sporicidal sodium hypochlorite solution is applied and must be allowed to air dry completely to ensure the necessary contact time for spore destruction. Finally, after doffing PPE, the nurse must wash hands with soap and water, as alcohol-based sanitizers cannot neutralize the resilient coating of *C. difficile* spores.

Adım Adım Çözüm

1
Protect against occupational exposure.
The nurse performs hand hygiene and dons an isolation gown and gloves.
Contact Precautions are mandatory when handling any items from the room of a client with *C. difficile* to prevent transmission of spores to the nurse's skin or clothing.
2
Remove physical barriers to disinfection.
The nurse wipes the equipment with a neutral detergent to remove organic soil.
Organic matter, such as stool, physically shields pathogens and can deactivate the active ingredients in disinfectants like sodium hypochlorite.
3
Apply the appropriate sporicidal agent.
The nurse applies an EPA-registered sodium hypochlorite (bleach) solution.
Standard alcohol-based and quaternary ammonium disinfectants do not kill *C. difficile* spores; a bleach-based solution is required for terminal disinfection.
4
Ensure adequate contact time.
The nurse allows the equipment to air dry undisturbed.
Disinfectants must remain wet on the surface for a manufacturer-specified duration to guarantee sporicidal efficacy; wiping it dry prematurely aborts this process.
5
Remove PPE safely and perform targeted hand hygiene.
The nurse doffs the gown and gloves and washes hands with soap and water.
Hand sanitizer is ineffective against spores. Friction with soap and running water is necessary to physically dislodge and rinse away any spores that may have reached the hands.

Anahtar Kavram

Terminal cleaning for *Clostridioides difficile* requires strict adherence to Contact Precautions, a two-step clean-then-disinfect process using a sporicidal agent (bleach), uninterrupted contact time, and mechanical hand washing with soap and water.
Soru 1511Soru →

A nurse in an intensive care unit is caring for a client who is intubated and mechanically ventilated. The client is experiencing acute agitation and repeatedly grasps at the endotracheal tube. After determining that verbal de-escalation and therapeutic touch are insufficient to maintain airway safety, the nurse obtains a prescription for bilateral soft wrist restraints. Which action should the nurse take to ensure proper safety and compliance with restraint protocols?

Cevabı ve açıklamayı göster

Cevap: Fasten the restraint ties to the movable portion of the bed frame using a quick-release knot.

Cevap

Fasten the restraint ties to the movable portion of the bed frame using a quick-release knot.
To ensure client safety, restraint straps must always be secured to the movable portion of the bed frame. This prevents the restraint from tightening, pulling, or causing injury when the head or foot of the bed is raised or lowered. Additionally, a quick-release knot (slip knot) is mandatory so that healthcare providers can remove the restraints immediately in the event of an emergency, such as a code blue or fire.

Adım Adım Çözüm

1
Identify the regulatory and safety requirements for applying physical restraints in a critical care setting.
Physical restraints must be safe, easily removable in an emergency, and strictly monitored to prevent neurovascular and skin complications.
Improper application can lead to severe injury, circulation impairment, or inability to perform life-saving interventions.
2
Evaluate the proposed nursing actions against evidence-based safety standards.
Tying restraints to a movable bed frame with a quick-release knot aligns with safety standards, while PRN orders, infrequent removal, and improper delegation violate core protocols.
To select the single correct action that demonstrates safe and effective care.

Anahtar Kavram

Safe Restraint Application and Monitoring Protocols
Soru 1512Soru →

A registered nurse is caring for an 82-year-old client who suddenly reports severe cramping abdominal pain and exhibits new-onset abdominal distension. The nurse prepares to perform a focused physical assessment of the client's abdomen. Which of the following actions demonstrates the correct assessment technique?

Cevabı ve açıklamayı göster

Cevap: Inspecting the abdomen for contour and symmetry, followed immediately by auscultating all four quadrants using the diaphragm of the stethoscope

Cevap

Inspecting the abdomen for contour and symmetry, followed immediately by auscultating all four quadrants using the diaphragm of the stethoscope.
The correct sequence for abdominal assessment is inspection, followed immediately by auscultation, then percussion, and finally palpation. Auscultating before percussing or palpating is critical because manual manipulation of the abdomen can stimulate intestinal activity, resulting in artificially altered bowel sounds. Furthermore, the diaphragm of the stethoscope is the correct instrument choice for auscultating the high-pitched sounds of the gastrointestinal tract.

Adım Adım Çözüm

1
Analyze the clinical scenario and the body system involved.
The client requires a focused abdominal assessment due to new-onset severe pain and distension.
Identifying the system guides the specific assessment sequence required.
2
Determine the correct physical assessment sequence for the abdomen.
The sequence must be inspection, auscultation, percussion, and palpation.
Unlike other body systems, the abdomen must be auscultated before percussion and palpation to prevent artificial stimulation of bowel sounds.
3
Identify the appropriate equipment technique for auscultating bowel sounds.
The diaphragm of the stethoscope should be used.
The diaphragm is designed to detect high-pitched sounds, which include normal bowel sounds.

Anahtar Kavram

Abdominal Physical Assessment Sequence and Delegation
Tahmini Süre:1m 15s
Soru 1513Soru →

A nurse is preparing to administer a prescribed intravenous (IV) push medication through a client's existing continuous IV fluid infusion. Which action should the nurse take first to ensure client safety?

Cevabı ve açıklamayı göster

Cevap: Verify the compatibility of the medication with the primary IV fluid.

Cevap

Verify the compatibility of the medication with the primary IV fluid.
Before administering any IV medication into an existing line, the nurse must verify that the medication is compatible with the running continuous IV fluid. If the substances are incompatible, they can form precipitates or crystalize in the tubing, which can act as emboli and cause severe harm to the client. If they are incompatible, the nurse must stop the fluid and flush the line thoroughly with normal saline before and after drug administration.

Adım Adım Çözüm

1
Identify the clinical scenario
The nurse needs to administer an IV push medication into an existing continuous IV line.
Understanding the route and concurrent therapies determines the safety steps required.
2
Determine the highest risk associated with this specific procedure
Mixing two different intravenous substances carries a high risk of chemical or physical incompatibility.
Incompatibility can lead to crystal formation in the tubing, emboli in the client, or neutralization of the drug's therapeutic effect.
3
Select the priority intervention based on the identified risk
The nurse must verify compatibility in a drug reference guide or with the pharmacy before proceeding.
Preventing the administration of incompatible fluids is the most critical step to ensure physiological integrity.

Anahtar Kavram

Intravenous Medication Compatibility and Safety
Tahmini Süre:45s
Soru 1514Soru →

A nurse is performing a comprehensive physical assessment on an 80-year-old client admitted with abdominal distention and new-onset confusion. Which action by the nurse demonstrates correct assessment principles?

Cevabı ve açıklamayı göster

Cevap: Auscultating the abdomen in all four quadrants prior to performing percussion or palpation.

Cevap

The nurse should auscultate the abdomen in all four quadrants prior to performing percussion or palpation.
The correct sequence for an abdominal assessment is inspection, auscultation, percussion, and palpation. Auscultation is performed directly after inspection because manipulating the abdomen can increase bowel motility and alter the true baseline bowel sounds, which could result in a false clinical picture.

Adım Adım Çözüm

1
Evaluate the requirement for the correct physical assessment sequence.
Identify that the standard assessment sequence (Inspection, Palpation, Percussion, Auscultation) must be altered for the abdomen.
Manipulating the abdomen through palpation or percussion before auscultation can stimulate intestinal activity and artificially alter baseline bowel sounds.
2
Analyze the delegation action.
Determine that assessing a new symptom like sudden confusion requires nursing judgment.
The RN is strictly responsible for all primary assessments and cannot delegate tasks requiring clinical evaluation to a UAP.
3
Analyze the interpretation of the client's neurological symptom.
Recognize that acute confusion in an elderly client is a sign of pathology, not normal aging.
Age-related changes include mild cognitive slowing, but an acute change in mental status (delirium) requires immediate investigation for underlying medical causes.

Anahtar Kavram

The correct sequence for abdominal assessment and appropriate recognition of acute pathology in the older adult.
Soru 1515Soru →

A nurse is reviewing the medication administration record for a client admitted with a severe lower respiratory tract infection. The client is scheduled to receive a newly prescribed dose of intravenous (IV) ceftriaxone. During the pre-administration assessment, the nurse notes that the client has a documented allergy to amoxicillin, with the reaction listed as anaphylactic shock. Which of the following actions is the priority for the nurse?

Cevabı ve açıklamayı göster

Cevap: Withhold the scheduled ceftriaxone dose and immediately notify the prescribing healthcare provider.

Cevap

The nurse must withhold the scheduled ceftriaxone dose and immediately notify the prescribing healthcare provider.
Ceftriaxone is a third-generation cephalosporin. Because cephalosporins and penicillins (like amoxicillin) share a structural component known as a beta-lactam ring, there is a recognized risk of cross-reactivity. For a client who has experienced an anaphylactic reaction to penicillin, cephalosporins are generally contraindicated. The safest and most appropriate action is to withhold the dose and contact the healthcare provider for an alternative prescription.

Adım Adım Çözüm

1
Assess the client's allergy history and the newly prescribed medication.
The client has a severe allergy (anaphylaxis) to amoxicillin, which is a penicillin. The prescribed medication is ceftriaxone, which is a cephalosporin.
Identifying potential allergens is a critical first step in safe medication administration.
2
Recognize the pharmacological relationship between the two drug classes.
Penicillins and cephalosporins both contain a beta-lactam ring, leading to a risk of allergic cross-sensitivity.
Understanding drug classifications helps the nurse predict potential adverse reactions.
3
Determine the safest priority nursing intervention based on the assessment.
The medication must be withheld and the provider notified to request a safe alternative antibiotic.
Administering a cephalosporin to a client with a history of penicillin-induced anaphylaxis is contraindicated due to the high risk of a fatal reaction.

Anahtar Kavram

Cross-sensitivity between penicillins and cephalosporins
Soru 1516Soru →

A nurse is caring for a client who is actively experiencing status epilepticus. The healthcare provider prescribes phenytoin IV push. The client has an existing continuous peripheral IV infusion of 5% dextrose in water (D5W) infusing at 100 mL/hr. Which action should the nurse take?

Cevabı ve açıklamayı göster

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

Cevap

Stop the D5W infusion, flush the line with 0.9% sodium chloride, administer the phenytoin, and flush again with 0.9% sodium chloride.
Phenytoin is physically incompatible with solutions containing dextrose (such as D5W) and will precipitate if they come into contact. To safely administer the medication through the same IV line, the nurse must temporarily stop the continuous D5W infusion and flush the line with a compatible solution, specifically 0.9% sodium chloride (normal saline), both before and after the phenytoin is given.

Adım Adım Çözüm

1
Identify the primary IV fluid.
The client is receiving 5% dextrose in water (D5W).
Knowing the primary fluid is necessary to verify medication compatibility.
2
Verify the compatibility of the prescribed IV medication with the primary fluid.
Phenytoin is physically incompatible with dextrose solutions and will form a solid precipitate if mixed.
Administering incompatible medications can cause crystallization, leading to loss of IV access or a life-threatening embolism.
3
Determine the correct administration technique for the incompatible medication.
The continuous infusion must be paused, and the line must be flushed with a compatible solution (0.9% sodium chloride) before and after the phenytoin is administered.
Flushing clears the line of the incompatible fluid, ensuring safe delivery of the medication.

Anahtar Kavram

Phenytoin is physically incompatible with dextrose solutions and must be administered using 0.9% sodium chloride to prevent precipitation.
Soru 1517Soru →

A nurse is caring for a client whose spouse died unexpectedly 3 days ago. The client is pacing the room, crying, and states, 'I do not know how I am going to survive without him. Everything is ruined, and it is my fault for not making him go to the hospital sooner.' Which of the following is the most therapeutic response by the nurse?

Cevabı ve açıklamayı göster

Cevap: You are feeling completely overwhelmed and carrying a heavy burden of blame right now.

Cevap

The response that reflects and validates the client's feelings of being overwhelmed and carrying a burden of blame.
The correct response utilizes the therapeutic techniques of reflection and empathy. By restating the client's feelings of being overwhelmed and taking on blame, the nurse validates the client's emotional experience. This supportive approach does not judge the client or attempt to prematurely 'fix' an unfixable situation, thereby encouraging the client to continue expressing their feelings safely.

Adım Adım Çözüm

1
Analyze the client's behavior and statement.
The client is in the acute stage of grief, expressing profound helplessness, anxiety (manifested by pacing), and unwarranted guilt over the unexpected loss.
Identifying the client's current emotional state is necessary to select an appropriate therapeutic communication technique.
2
Evaluate the nursing responses based on therapeutic communication principles.
The correct response uses reflection and empathy to validate the client's feelings. The other responses use non-therapeutic blocks such as false reassurance, asking 'why' questions, and relying on clichés.
Therapeutic communication should focus on the client's feelings and encourage emotional expression without judging, minimizing, or prematurely attempting to 'fix' the grief.

Anahtar Kavram

Therapeutic Communication in Acute Grief
Soru 1518Soru →

A nurse is preparing to discharge an older adult client who recently had a stroke. The client's spouse, who will be the primary caregiver, states, 'I am terrified. I do not know how I will be able to provide care 24 hours a day by myself.' Which response by the nurse best identifies and utilizes an appropriate support system?

Cevabı ve açıklamayı göster

Cevap: Let's consult with the social worker to explore home health services and respite care options.

Cevap

Consulting with the social worker to explore home health services and respite care options.
The spouse is expressing high risk for caregiver role strain and a lack of support. Providing interdisciplinary referrals to a social worker for home health and respite care directly addresses the need for a practical support system, helping to prevent caregiver burnout and ensuring safe continuous care for the client.

Adım Adım Çözüm

1
Identify the primary concern expressed by the client's spouse.
The spouse is expressing fear and overwhelming burden regarding providing 24-hour care alone.
Understanding the core issue is necessary to determine the appropriate nursing intervention.
2
Recognize the need for an external support system.
The situation requires professional resources and community assistance, not just emotional encouragement or task training.
Providing 24-hour care alone leads to high risk for caregiver role strain and unsafe client conditions.
3
Select the intervention that connects the caregiver to appropriate resources.
Collaborating with a social worker for home health and respite care is the correct action.
Social workers specialize in coordinating community support systems, discharge planning, and respite care services.

Anahtar Kavram

Caregiver Support Systems and Interdisciplinary Referrals
Tahmini Süre:45s
Soru 1519Soru →

A nurse is caring for a client in septic shock who is receiving a continuous intravenous (IV) infusion of norepinephrine through a dedicated single-lumen peripherally inserted central catheter (PICC). The client's current blood pressure is 86/48 mmHg. The healthcare provider prescribes pantoprazole 40 mg IV push daily. Which action should the nurse take first?

Cevabı ve açıklamayı göster

Cevap: Establish a new peripheral intravenous access for the pantoprazole administration.

Cevap

Establish a new peripheral intravenous access for the pantoprazole administration.
Norepinephrine is a critical, life-sustaining vasoactive medication with a very short half-life. Pausing the infusion even briefly can result in a precipitous and potentially fatal drop in blood pressure. Furthermore, administering an IV push medication through a line actively infusing a vasopressor can 'flush' a rapid bolus of the vasopressor into the client, causing a severe hypertensive crisis. Therefore, the only safe priority action is to establish a completely separate IV access for the pantoprazole.

Adım Adım Çözüm

1
Analyze the client's current hemodynamic status and current continuous infusions.
The client is in septic shock with a dangerously low blood pressure (86/48 mmHg) dependent on a continuous norepinephrine infusion.
Norepinephrine has a very short half-life and must be infused continuously without interruption to maintain perfusion.
2
Evaluate the prescribed medication and route.
Pantoprazole 40 mg is prescribed via IV push, which typically requires administration over at least 2 minutes.
Safe medication administration requires knowing the correct rate and ensuring the route will not compromise other treatments.
3
Assess the compatibility and safety of using the existing IV line.
The existing line is a single-lumen PICC dedicated to a vasopressor. Pushing a medication into this line or pausing the pump is contraindicated.
Pushing medication into a vasopressor line can flush a large bolus of the vasopressor into the client (causing hypertensive crisis), and pausing the pump will cause a precipitous drop in blood pressure.
4
Determine the safest alternative intervention.
The nurse must start a separate peripheral IV line to administer the pantoprazole safely.
Establishing a second IV access allows the routine medication to be given without interrupting or altering the delivery of the life-sustaining vasopressor.

Anahtar Kavram

Safe administration of IV push medications with concurrent vasoactive infusions
Soru 1520Soru →

During the evening shift, a client admitted for osteomyelitis returns from an unescorted pass off the unit. The nurse immediately notes that the client is exhibiting severe psychomotor agitation, profound diaphoresis, and pupillary dilation. The client is rapidly pacing the hallway and shouting about hidden cameras. Current vital signs include a heart rate of 128 beats per minute and a blood pressure of 188/110 mm Hg. Based on these manifestations of suspected acute stimulant intoxication, which nursing actions should be prioritized? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Establish continuous electrocardiographic (ECG) monitoring.; Administer a prescribed short-acting benzodiazepine for severe agitation.; Maintain a calm, low-stimulus environment by dimming the lights and speaking softly.

Cevap

The nurse should establish continuous electrocardiographic (ECG) monitoring, administer a prescribed short-acting benzodiazepine, and maintain a calm, low-stimulus environment.
The correct responses directly address the severe physiological and psychological threats of acute stimulant intoxication. Because stimulants cause massive sympathetic activation, continuous ECG monitoring is crucial to detect arrhythmias or ischemia. Benzodiazepines are the drug of choice to reduce central nervous system irritability, thereby preventing seizures, lowering heart rate, and reducing blood pressure. Concurrently, modifying the environment by reducing stimuli is a fundamental non-pharmacological strategy to de-escalate paranoia and severe agitation.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client displays severe psychomotor agitation, paranoia, extreme hypertension (188/110 mm Hg), tachycardia (128 bpm), diaphoresis, and mydriasis.
Recognizing this cluster of symptoms is necessary to identify acute severe stimulant (e.g., cocaine, methamphetamine) intoxication.
2
Determine the highest priority physiological and psychological risks associated with the suspected condition.
The primary risks are cardiac ischemia, fatal arrhythmias, seizures, and violent behavior secondary to paranoia.
Nursing care must prioritize immediate life-saving interventions (ABCs) and environmental safety over routine unit protocols.
3
Select the appropriate nursing interventions that mitigate these identified risks.
ECG monitoring addresses the cardiac risk; benzodiazepines suppress the hyperactive central nervous system to prevent seizures and lower blood pressure; and a low-stimulus environment manages the paranoia and agitation.
These actions represent the evidence-based standard of care for sympathomimetic toxidromes.
4
Eliminate contraindicated actions.
Do not delegate assessments of an unstable client, do not apply physical restraints before attempting less restrictive measures, and avoid non-therapeutic communication blocks.
These incorrect actions compromise client safety, violate legal/ethical guidelines, and worsen the clinical presentation.

Anahtar Kavram

Prioritization in Acute Stimulant Intoxication
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Tüm alıştırma soruları — NCLEX-RN | Examkin