Tüm alıştırma soruları

A client recovering from a massive anterior wall myocardial infarction is being monitored with a pulmonary artery catheter. Over the last hour, the client has become increasingly lethargic. The nurse evaluates the following hemodynamic and laboratory parameters:

- Heart rate: $118$ beats/min
- Mean arterial pressure (MAP): $54$ mm Hg
- Central venous pressure (CVP): $16$ mm Hg (Normal: $2$-$8$ mm Hg)
- Pulmonary artery wedge pressure (PAWP): $24$ mm Hg (Normal: $6$-$12$ mm Hg)
- Cardiac index (CI): $1.7$ L/min/m $^2$ (Normal: $2.5$-$4.0$ L/min/m $^2$)
- Systemic vascular resistance (SVR): $2150 \text{ dynes/sec/cm}^{-5}$ (Normal: $800$-$1200 \text{ dynes/sec/cm}^{-5}$)

Arterial blood gas (ABG) results on a $40\%$ Venturi mask reveal: pH $7.24$, PaCO $_2$ $58$ mm Hg, HCO $_3^-$ $25$ mEq/L, and PaO $_2$ $58$ mm Hg.

Based on this physiological presentation, which intervention most accurately addresses the primary pathophysiological failure?

A nurse is formulating a care plan for a client admitted with severe, watery diarrhea who is awaiting stool culture results for suspected Clostridioides difficile (C. diff). The client also has an active methicillin-resistant Staphylococcus aureus (MRSA) infection in a sacral pressure injury. Which of the following infection control interventions are appropriate to include in the plan of care? Select all that apply.

An emergency department triage nurse evaluates an ambulatory individual presenting with a progressive three-week history of severe cough, night sweats, and hemoptysis. To ensure proper standard and transmission-based precautions, arrange the following nursing actions in the correct chronological sequence from first to last.

While conducting bedside rounds, a nurse observes that a client's internal radiation implant (brachytherapy) has become dislodged and is resting on the mattress. Which of the following is the most appropriate initial action by the nurse?

A client in the intensive care unit is intubated and requires bilateral soft wrist restraints to prevent the dislodgment of the endotracheal tube. The healthcare provider has written the initial prescription. Which of the following nursing actions are appropriate? Select all that apply.

A community health nurse is conducting an educational session for a group of older adult clients regarding expected physiological changes associated with the aging process. Which of the following statements by the clients indicate an accurate understanding of normal aging transitions? Select all that apply.

A nursing house supervisor is allocating inpatient beds for several direct admissions from the emergency department. The hospital currently has only one unoccupied negative-pressure isolation room. Which of the following clients must be prioritized for placement in this room?

An ambulatory care nurse is speaking with a client who was just informed they have early-stage Alzheimer's disease. The client laughs and says, "The doctor doesn't know what he's talking about. I just have a little trouble remembering names sometimes, like anyone my age." Which of the following is the most therapeutic response by the nurse?

During an intake assessment at a community behavioral health clinic, a client seeking treatment for alcohol dependence states, "I do not understand why everyone is making such a big deal. I can stop drinking whenever I choose." Which response by the nurse is most appropriate?

A 28-year-old client is visiting her mother, who has terminal ovarian cancer and has just been transitioned to comfort care. The daughter begins to cry and says to the nurse, "I do not know how I am going to survive without her." Which response by the nurse is the most therapeutic?

During a group therapy session in the main lounge, a client with acute mania abruptly stands up, overturns a table, and begins aggressively threatening the facilitator with a clenched fist. Place the following psychiatric emergency interventions in the correct chronological sequence, prioritizing immediate safety and adhering to the least restrictive environment doctrine. (Arrange from first action to last action.)

A 45-year-old client on the oncology unit has just been informed that their chemotherapy was ineffective and the tumor has metastasized. The client stares out the window and quietly states, "I did everything the doctors told me to do. I changed my diet, I took the treatments, and it didn't even matter." Which of the following is the most therapeutic response by the nurse?

A home health nurse is evaluating a client recently diagnosed with a chronic, progressive neurological disorder. The client states, "The clinic mixed up my laboratory reports. There is absolutely nothing wrong with me, and I am not taking any of those new medications." Which actions by the nurse are appropriate at this time? Select all that apply.

The nurse is preparing to transfer a client with right-sided hemiparesis from the bed to a wheelchair. To promote a safe transfer, where should the nurse position the wheelchair?

A nurse is creating a plan of care for an older adult client who is on strict bed rest and is at high risk for skin breakdown. Which of the following actions are appropriate to promote basic care and comfort? Select all that apply.

A client who experienced a recent episode of syncope is being evaluated in the clinic. The nurse is preparing to perform a focused assessment of the client's neck vessels. Arrange the following assessment actions in the safest and most appropriate sequence.

A nurse is caring for a client who is preparing for discharge to a skilled nursing facility following a complex cerebrovascular accident. The client pushes their food tray away, begins crying softly, and says to the nurse, "I am just a useless burden to everyone. My children are sending me away because they are tired of dealing with me." Which of the following statements by the nurse demonstrate appropriate therapeutic communication? (Select all that apply.)

A nurse is caring for a 58-year-old client who returned to the unit two hours ago following a percutaneous liver biopsy. The client reports mild right upper quadrant pain. The current vital signs are: blood pressure 98/60 mm Hg, heart rate 112 beats/min, and respiratory rate 20 breaths/min. Which action should the nurse take immediately to minimize the client's physiological risk?

A nurse is caring for a client admitted with end-stage heart failure who was just informed by the healthcare provider that they are no longer a candidate for a heart transplant. After the provider leaves the room, the client stares blankly at the wall and says in a flat tone, "Well, I guess that is it then. All this fighting for nothing." Which of the following is the most therapeutic response by the nurse?

A nurse is caring for a client on a medical-surgical unit who suddenly begins pacing rapidly, clenching their fists, and glaring at staff members. The client is visibly agitated and their behavior is escalating. Arrange the following nursing interventions in the order they should be implemented, prioritizing from the least restrictive approach to the most restrictive.