Tüm alıştırma soruları

A client whose expected hospital discharge was just canceled due to a low hemoglobin level turns away from the nurse and begins to cry silently. Arrange the following nursing actions in the most appropriate therapeutic sequence, from first to last.

An interdisciplinary care team is planning the transition to home for a 78-year-old client who recently underwent a total hip arthroplasty. The client lives in a multi-level home with a spouse who has moderate Alzheimer's disease. Their extended family lives internationally. Which of the following interventions should the nurse recommend to ensure a safe support system? (Select all that apply.)

A nurse in a pediatric clinic is assessing a 3-year-old child who has multiple small, circular burn marks on their back. The parent states, "The child accidentally backed into a hot radiator." The nurse recognizes that the physical injuries are highly inconsistent with the parent's explanation and suspects child physical abuse. Which of the following is the nurse's priority action?

An 82-year-old resident in an assisted living facility has exhibited increased restlessness, intermittent grimacing, and meal refusal over the past 24 hours. The resident has a documented history of chronic constipation. When evaluating this resident's abdominal region, which approach by the nurse is most appropriate?

A client whose newborn infant was just pronounced dead in the neonatal intensive care unit is sitting in a rocking chair, staring blankly at the empty isolette. The client is not crying and has not spoken for the last 20 minutes. The nurse enters the room. Which of the following is the most therapeutic nursing action?

A client is resting in the postpartum unit following a vaginal delivery. The newborn was transferred to the neonatal intensive care unit (NICU) two hours ago due to sudden respiratory distress. The client is crying quietly and states, "This is all my fault. If I had taken better care of myself during the pregnancy, my baby would be here with me." Which of the following is the most therapeutic response by the nurse?

A critical care nurse is caring for a client with septic shock who has a multi-lumen central venous catheter. The client is receiving a continuous intravenous infusion of norepinephrine and is now prescribed an intermittent intravenous infusion of vancomycin. Which of the following nursing actions ensure safe pharmacological and parenteral therapy administration? (Select all that apply.)

A critical care nurse is managing a client with severe sepsis. The client is receiving a continuous intravenous infusion of norepinephrine.

Client Data:
- Weight: $220$ lb
- Current mean arterial pressure (MAP): $54$ mm Hg
- Current infusion pump rate: $18$ mL/hr
- Medication concentration: Norepinephrine $8$ mg in $250$ mL $5\%$ Dextrose in Water (D5W)
- Provider titration protocol: "Increase norepinephrine by $0.04$ mcg/kg/min every $5$ minutes until MAP is $\geq 65$ mm Hg."

The nurse determines the need to increase the infusion rate according to the protocol. What should be the newly programmed infusion pump rate in mL/hr?

*Round the final answer to the nearest tenth.*

A nurse is teaching a client experiencing acute stress how to perform diaphragmatic breathing. Arrange the steps of this stress management technique in the correct chronological order.

A critical care nurse is managing a client with a double-lumen central venous catheter. One lumen is actively infusing continuous total parenteral nutrition (TPN). The second lumen is infusing continuous norepinephrine to maintain the client's mean arterial pressure. The provider writes a new order for an intravenous antibiotic, piperacillin-tazobactam, to be administered over 30 minutes. What is the most appropriate action by the nurse?

A nurse is preparing to administer a transfusion of packed red blood cells (PRBCs) to a client with severe anemia. Which of the following intravenous fluids should the nurse use to prime the blood administration tubing?

The nurse is evaluating the coping mechanisms of several clients. Match each clinical scenario or behavioral observation with the correct defense mechanism it best illustrates.

A client admitted to the medical-surgical unit is pacing the hallway and speaking loudly. The client states to the nurse, "Nobody here knows what they are doing! I waited twenty minutes for someone to answer my call light!" Which of the following is the most therapeutic response by the nurse?

An occupational health nurse is called to the office of an employee who was just unexpectedly terminated after 20 years with the company. The employee initially threw a chair and screamed at the manager. When the nurse arrives 15 minutes later, the employee is sitting quietly, neatly organizing their desk, and states with a flat, calm affect, "It's fine. I have a very permanent solution to this problem waiting in my car. Tell my manager he won't have to worry about me ever again." Which of the following is the priority nursing intervention?

An occupational health nurse is responding to an incident where a factory worker witnessed a severe machinery accident involving a colleague. The witness is trembling, hyperventilating, and repeats, "I should have stopped it. This is entirely my fault. I don't deserve to be here." Which of the following interventions by the nurse are appropriate? Select all that apply.

A nurse in a community mental health clinic is assessing clients experiencing varying psychosocial stressors. Match each client's documented statement and objective behavioral cue to the specific defense mechanism being demonstrated.

An oncology nurse has just finished participating in a care conference where a client's transition to palliative care was finalized. The rest of the interdisciplinary team has left, and the client is sitting alone, crying silently. Arrange the following nursing interventions in the most appropriate sequence to support this client.

A client with a history of cardiovascular disease and new-onset abdominal cramping is undergoing a physical examination at an outpatient clinic. Which techniques should the nurse implement during this assessment? Select all that apply.

An 8-year-old child is brought to an urgent care clinic by a stepparent for a painful right arm. The nurse observes faded bruising in various stages of healing on the child's torso, and a radiograph reveals a spiral fracture of the right humerus. The stepparent states, "He is so clumsy, he fell off his skateboard yesterday." The child remains completely silent, avoids eye contact, and shrinks away when the stepparent approaches. The attending physician examines the child, splints the arm, and states to the nurse, "The mechanism of injury does not match the fracture, but we lack concrete proof of abuse. Let's discharge them to outpatient orthopedics and have the clinic social worker follow up next week to avoid making a false accusation." Which of the following is the priority nursing action?

A client on the behavioral health unit is pacing rapidly in the hallway, wringing their hands, and states, "I cannot take this anymore! Everything is falling apart." Which of the following are therapeutic nursing responses? Select all that apply.