Tüm alıştırma soruları

A nurse is preparing a client's body for family viewing following an expected death from end-stage heart failure. The family is waiting in a nearby consultation room. Place the following nursing actions for post-mortem care in the correct chronological order.

The nurse is reviewing the interdisciplinary notes of four adult clients recovering on a severe trauma and burn step-down unit. Match each documented client statement or behavioral cue to the specific defense mechanism being demonstrated.

A nurse is providing psychosocial care to clients across multiple units. Pair each client's presentation or statement with the most therapeutic nursing response.

A nurse is preparing to administer a prescribed dose of intravenous (IV) furosemide via direct IV push into a client's continuous peripheral infusion of 5% dextrose in water (D5W). Which of the following actions indicate safe medication administration? (Select all that apply)

A client is recovering on the surgical unit following a right total hip arthroplasty (posterior approach). The nurse is assisting the client with positioning in bed. Which intervention should the nurse implement to prevent dislocation of the new hip prosthesis?

A client arrives at a community health clinic in a state of acute panic, stating, "My partner just found out I'm trying to leave. They are looking for me and said they will kill me." The client is hyperventilating, pacing rapidly, and unable to focus. Arrange the following nursing actions in the correct priority order from first to last.

An adolescent client is admitted to an inpatient eating disorder unit for the treatment of severe anorexia nervosa. During the client's first supervised lunch, the nurse observes the client cutting a piece of chicken into minuscule pieces, continuously rearranging them on the plate, and hiding small portions under a napkin. After the allotted 30-minute meal period, the client has consumed less than 15% of the food and states, 'I cannot eat another bite, this food is saturated in grease and makes me nauseous.' Which of the following is the most appropriate nursing response?

An occupational health nurse is evaluating an adult client who recently experienced a traumatic workplace injury resulting in a lower limb amputation. The client stares at the floor and states, "My life is completely over. There is no point in trying to do anything anymore." Which of the following responses by the nurse is the most therapeutic?

An older adult client diagnosed with left-sided heart failure is undergoing a cardiovascular examination. The nurse is preparing to assess the client for an S3 ventricular gallop. Which action by the nurse demonstrates the correct physical assessment technique?

A client waiting for a biopsy procedure is wringing their hands, pacing the hallway, and tells the nurse, "I am so stressed and terrified about what they might find today." Which initial nursing action is the priority to help the client manage their acute stress?

A client recovering from a right-hemisphere cerebrovascular accident has left-sided hemiplegia and requires assistance moving from the bed to a bedside wheelchair. The client is alert, able to follow commands, and can bear partial weight on their unaffected leg. Arrange the following procedural steps in the correct chronological order to ensure a safe transfer.

A client in an outpatient clinic waiting area is becoming visibly frustrated due to a prolonged appointment delay. The client begins pacing rapidly, sighing loudly, and complaining to other visitors about the wait. Which action should the nurse take first?

A nurse is providing post-mortem care for a client who recently passed away. The provider has pronounced the death, and no autopsy is required. Arrange the following nursing actions in the appropriate sequential order to prepare the body for family viewing.

A 79-year-old client with a history of stroke and vascular dementia is directly admitted to the medical-surgical unit from home. During the initial admission process, the nurse observes that the client is visibly malnourished, wearing urine-soaked clothing, and has bilateral heel ulcers covered in purulent drainage. The client's adult child, who is the primary caregiver, remarks, 'Taking care of them is just too overwhelming these days.' Which of the following actions should the nurse implement? Select all that apply.

A client who recently received a diagnosis of multiple sclerosis pushes their breakfast tray aside and stares blankly out the window. When the nurse enters the room, the client sighs heavily and states, "What is the point of eating or taking these pills? I am just going to end up a helpless burden to my spouse anyway." Which response by the nurse is the most therapeutic?

A parent of a toddler diagnosed with terminal neuroblastoma is sitting in the family lounge of the pediatric oncology unit. The parent stares out the window and whispers, "I keep buying him clothes for next winter, even though the oncologist told us he won't make it past autumn. I just cannot stop doing it." Which statement by the nurse demonstrates the most therapeutic communication?

A critically ill client with septic shock is being managed in the intensive care unit. The client has a double-lumen central venous catheter. The first lumen is dedicated to total parenteral nutrition (TPN). The second lumen is delivering a norepinephrine infusion to maintain the client's mean arterial pressure. Following a focal seizure, the healthcare provider prescribes an intravenous (IV) loading dose of phenytoin. Which of the following is the most appropriate nursing action?

A nurse is caring for a client admitted to the inpatient psychiatric unit with severe major depressive disorder. For the past two weeks, the client has been highly withdrawn, refusing meals, and speaking only in one-word responses. Today, the nurse observes that the client is suddenly energetic, smiling, and giving away a prized watch to a peer. Which of the following nursing actions are appropriate? Select all that apply.

A registered nurse (RN) in a long-term care facility assesses a nonverbal older adult client with advanced Alzheimer's disease. The RN observes bilateral, patterned fingertip bruising on the inner aspects of the client's upper arms. The unlicensed assistive personnel (UAP) assigned to the client states, "The client gets highly aggressive during perineal care, so I have to grip their arms tightly to finish the task." Which of the following is the priority action for the RN?

A nurse is conducting an interdepartmental transfer handoff for a 45-year-old client with a C5 spinal cord injury who is moving from an acute neurotrauma unit to an inpatient rehabilitation facility. Using the Identify-Situation-Background-Assessment-Recommendation (I-SBAR) communication tool, arrange the nurse's statements to the receiving interdisciplinary team (rehabilitation physician, physical therapist, occupational therapist, and social worker) in the correct sequence.