Tüm alıştırma soruları

A nurse is preparing to administer a prescribed intravenous (IV) push medication through an established peripheral IV saline lock. Arrange the following steps in the correct order of performance from first to last.

The nurse is observing various clients in an outpatient behavioral health clinic. Match each client behavior or statement to the specific defense mechanism it represents.

A nurse is monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs). Fifteen minutes into the infusion, the client reports sudden, severe lower back pain, chills, and shortness of breath. Arrange the following nursing actions in the correct sequential order of priority to minimize the risk of further physiological deterioration.

A nurse on a locked behavioral health unit is caring for an adult client. The client approaches the nurses' station with a raised voice, tightly clenched fists, and demands immediate access to a restricted personal item. When the nurse explains the unit safety policy, the client becomes abruptly escalated, begins aggressively striking the reinforced glass, and shouts threats at the staff. Which of the following initial interventions should the nurse implement? Select all that apply.

An 82-year-old client is admitted to the medical unit presenting with new-onset severe abdominal cramping and sudden, unexplained confusion. When conducting the physical examination, which action should the primary nurse execute?

A client recovering from abdominal surgery has a continuous peripheral intravenous (IV) infusion of 0.45% sodium chloride. The nurse brings a syringe containing a scheduled dose of IV ondansetron to the bedside. Which of the following actions is the most critical for the nurse to perform before administering this medication through the Y-site port?

While working in a hospice unit, a nurse is caring for a client with metastatic bone cancer who is experiencing periods of severe breakthrough pain. The client's adult child approaches the nurse in the hallway, crying, and states, 'I cannot stand seeing my parent suffer like this anymore. The provider said there are only a few days left. Can't you just give an extra-large dose of morphine to make this end faster?' What is the most therapeutic response by the nurse?

A client is brought to the emergency department with severe acute alcohol intoxication. The client is lethargic and suddenly begins to vomit. Arrange the following nursing actions in the correct order of priority from first to last.

A clinic nurse is preparing to perform a well-child physical examination on a 9-month-old infant who is currently sleeping calmly in the caregiver's arms. Arrange the following assessment steps in the most appropriate clinical sequence. All options must be used.

An older adult client is recovering on a telemetry unit two hours after undergoing a left femoral cardiac catheterization. The client expresses mild back pain from prolonged bed rest and demonstrates new-onset confusion. Which of the following actions should the nurse include in the immediate care plan? Select all that apply.

A nurse is caring for a client who is recovering from a right total hip arthroplasty using a posterior approach. Which of the following nursing actions should the nurse implement to reduce the client's risk for hip dislocation? Select all that apply.

A nurse is monitoring a postoperative client for signs of hemorrhage. Which of the following assessment findings is the earliest physiological indicator that the client is developing hypovolemic shock?

A nurse at a disaster relief shelter is caring for an individual whose neighborhood was completely destroyed by a severe tornado three days ago. Since arriving at the shelter, the individual has been intensely agitated and sobbing inconsolably. This morning, the nurse observes that the individual appears suddenly serene, hands a cherished piece of family jewelry to a shelter volunteer, and states, 'I have finally figured out how to solve all my problems permanently.' What is the priority nursing intervention at this time?

A nurse is caring for a client with severe obsessive-compulsive disorder on a behavioral health unit. The client is tearful and states, 'I spent three hours washing my hands this morning. I feel like my mind is completely broken, and I am never going to get better.' Which of the following responses by the nurse demonstrate the appropriate use of therapeutic communication? (Select all that apply.)

A nurse is evaluating a 64-year-old client who is 3 hours post-cardiac catheterization via the right femoral artery. The client reports new-onset, severe lower back pain and requests to have the head of the bed raised to eat a snack. The client's current vital signs are: blood pressure 98/60 mm Hg (baseline 135/82 mm Hg), heart rate 114/min, and respiratory rate 20/min. Which of the following actions should the nurse take first?

A 70-year-old client is recovering in the telemetry unit 3 hours after a percutaneous transluminal coronary angioplasty (PTCA) utilizing the right femoral artery approach. The client suddenly reports severe lower back pain and generalized weakness. The nurse observes that the client's blood pressure is 84/50 mm Hg and heart rate is 118 beats per minute. A stat arterial blood gas (ABG) reveals a pH of 7.30, PaCO2 of 36 mm Hg, and HCO3 of 16 mEq/L. Which action must the nurse take immediately to mitigate the risk of further physiological decompensation?

A community psychiatric nurse is conducting an initial assessment at the home of a client with severe obsessive-compulsive disorder (OCD). The client's spouse reports that the client must arrange all living room furniture in specific geometric patterns before sitting down, a process that takes hours and causes extreme exhaustion. As the nurse and spouse are talking, the client begins moving a heavy armchair to start the ritual. Which nursing action is most appropriate at this early stage of the therapeutic relationship?

A nurse is caring for a client who is receiving a packed red blood cell (PRBC) transfusion. The client suddenly develops severe chills, lower back pain, and dyspnea. Arrange the following nursing actions in the correct order of priority from first to perform to last.

A nurse is caring for a client who exhibits sudden carpopedal spasms, facial twitching, and a prolonged QT interval on the electrocardiogram. The client's serum calcium level is $6.4\text{ mg/dL}$ ($1.6\text{ mmol/L}$). The healthcare provider urgently prescribes '$1\text{ gram}$ Calcium Chloride IV piggyback over $10\text{ minutes}$'. The client's only vascular access is a $22\text{-gauge}$ peripheral intravenous (PIV) catheter located in the dorsum of the right hand. Which of the following is the PRIORITY action by the nurse?

A college student rushes into the university health clinic, visibly trembling and crying hysterically. The student shouts, "I was just abruptly evicted from my apartment and I have absolutely nowhere to go!" The nurse notes the student is hyperventilating with a respiratory rate of 34 breaths per minute. Which of the following is the priority nursing intervention?