Tüm alıştırma soruları

A nurse is preparing to administer a scheduled dose of intravenous phenytoin to a client with a seizure disorder. The client has a single peripheral intravenous line with a continuous infusion of 5% dextrose in water (D5W) infusing at 75 mL/hr. Based on the safe administration guidelines for this medication, which action should the nurse take?

A psychiatric-mental health nurse is formulating verbal interventions for several clients with complex clinical presentations. Pair each client's specific behavior or statement with the most therapeutic and clinically appropriate nursing response.

A client admitted with cardiogenic shock requires hemodynamic support. The healthcare provider prescribes a continuous intravenous infusion of dobutamine at $2.7$ mcg/kg/min. The client's most recent weight is $209$ lbs. The pharmacy dispenses a premixed IV bag containing dobutamine $500$ mg in $250$ mL of $5\%$ dextrose in water. Calculate the appropriate infusion pump rate in mL/hr. (Round the final answer to the nearest tenth.)

A home health nurse is evaluating the support system of a client with newly diagnosed end-stage heart failure who was recently discharged to live with their adult child. The client requires assistance with activities of daily living (ADLs) and complex medication management. Which of the following nursing actions are appropriate to promote a safe and effective support system? Select all that apply.

A 45-year-old client in the emergency department is informed that their spouse has died unexpectedly following a severe motor vehicle crash. The client begins pacing rapidly, shouting at the healthcare team, "You are all lying! We just had breakfast together! You let this happen because you didn't work fast enough!" Which of the following nursing interventions are most appropriate to include in the immediate plan of care? Select all that apply.

A 72-year-old client with end-stage heart failure is receiving mechanical ventilation in the intensive care unit. The client's family, acting as the designated healthcare proxy, has decided to transition to comfort measures only and requests a compassionate terminal extubation. Which of the following nursing interventions should the nurse include in the plan of care? Select all that apply.

An agitated client on the psychiatric acute care unit begins pacing rapidly, shouting at staff, and clenching their fists. To ensure safety while adhering to the principle of least restrictive intervention, arrange the following nursing actions in the order they should be implemented, starting with the least restrictive action first.

A clinical educator is observing a nursing student conduct a comprehensive physical assessment on an older adult client. The client has a history of congestive heart failure and reports a recent onset of abdominal bloating. Which actions by the student demonstrate correct physical assessment technique? Select all that apply.

A triage nurse in a community urgent care center is caring for an older adult client who just received a phone call stating that their spouse of 40 years was killed in a motor vehicle collision. The client is pacing the waiting room, breathing rapidly, and repeatedly stating, "I need to go to the grocery store. He will be expecting dinner soon." Which of the following nursing interventions are appropriate at this time? (Select all that apply.)

A nurse is caring for a client with acute decompensated heart failure and atrial fibrillation. The client has a double-lumen central venous catheter (CVC) with the following continuous infusions:

* Lumen 1: Dobutamine at $10 \text{ mcg/kg/min}$
* Lumen 2: Heparin at $1,200 \text{ units/hr}$

The client develops sudden, severe dyspnea and crackles bilaterally. The provider prescribes furosemide $40 \text{ mg}$ IV push STAT. The client does not have peripheral intravenous access. Which action by the nurse is the most appropriate method to administer the furosemide?

During the admission process for an older adult client, a nurse conducts a baseline physical evaluation. Which actions indicate that the nurse is applying appropriate physical examination principles? Select all that apply.

While conducting morning rounds on an inpatient behavioral health unit, the nurse observes a client who was admitted six days ago for severe depression and suicidal ideation. The client, who previously stayed in bed most of the day, is now suddenly energetic, smiling broadly, and handing out their favorite jewelry to other clients in the dayroom. Which action should the nurse take first?

A healthcare provider has just informed a 45-year-old client that their progressive illness is now considered terminal. After the provider exits the room, the client sits motionless in bed, staring blankly at the wall without speaking. Which of the following is the most appropriate initial nursing action?

During a comprehensive physical examination, a nurse evaluates a client's posterior thorax to determine diaphragmatic excursion. Arrange the following procedural steps of this specific percussion technique in the correct chronological sequence to accurately measure diaphragmatic movement. (Place the first step at the top and the final step at the bottom.)

A registered nurse is providing care for multiple clients and preparing to administer prescribed medications. Which of the following actions demonstrate safe pharmacological and parenteral practices? Select all that apply.

A nurse is caring for a client who was admitted to the psychiatric unit following a severe situational crisis and a subsequent suicide attempt. For the first few days, the client was profoundly depressed, tearful, and withdrawn. Today, the client suddenly appears remarkably peaceful, is smiling, and begins giving away prized personal belongings to other clients on the unit. Which action is the nurse's priority?

A pediatric oncology nurse is caring for a 7-year-old child who was recently diagnosed with acute lymphoblastic leukemia. The child's parent is observed meticulously organizing the child's hospital room, creating detailed spreadsheets of daily laboratory values, and reading advanced medical journals about chemotherapy protocols. When the unit social worker attempts to discuss the emotional impact of the diagnosis, the parent abruptly changes the subject, stating, "We just need to focus on the statistical probabilities and the pharmacokinetics of the treatment plan right now." Which defense mechanism is the parent primarily demonstrating, and what is the most appropriate initial nursing action?

A hospice nurse is interacting with the 5-year-old grandchild of a client who recently died. The child states, 'Grandpa is just sleeping because I was too loud playing my games yesterday. I will be very quiet now so he can wake up.' Which response by the nurse is the most therapeutic?

An acute care nurse is reviewing clinical actions performed during the shift for a group of older adult clients. Which action demonstrates the correct application of physical examination principles?

The nurse is caring for a 28-year-old client on a surgical trauma unit, two days following a traumatic below-the-knee amputation.

Objective cues: The client is lying in bed, staring out the window, and has consistently refused to look at the surgical site during dressing changes.
Client statement: "Just leave the discharge instructions on the bedside table. My partner can read them and do the wound care. I don't want to deal with it."

Based on the client's use of avoidance as a coping mechanism, what is the most therapeutic response by the nurse?