Tüm alıştırma soruları

An adult client is receiving care in the emergency department for a severe asthma exacerbation. The initial arterial blood gas (ABG) on room air indicated $\text{pH} = 7.48$, $\text{PaCO}_2 = 28 \text{ mm Hg}$, and $\text{HCO}_3^- = 23 \text{ mEq/L}$. Two hours later, the nurse observes that the client has become extremely lethargic and their respiratory effort has noticeably decreased. A follow-up ABG reveals $\text{pH} = 7.29$, $\text{PaCO}_2 = 56 \text{ mm Hg}$, and $\text{HCO}_3^- = 24 \text{ mEq/L}$. Which action is the highest priority for the nurse to take?

An ambulatory care nurse is assessing a caregiver who arrived with a 4-week-old infant for a scheduled immunization visit. The caregiver is trembling, crying profusely, and states, 'I cannot handle this. I have not slept in almost a week, the baby will not stop screaming, and I am a complete failure.' Which of the following initial interventions by the nurse are appropriate? Select all that apply.

A hospice nurse is caring for a client with end-stage liver disease who acutely develops severe terminal delirium, characterized by distressing hallucinations and physical agitation. The client's family is present and extremely frightened by the sudden change in behavior. Arrange the following nursing actions in the correct priority sequence.

A nurse in a pediatric rehabilitation unit is caring for a 15-year-old client who is recovering from a severe traumatic brain injury. The client's separated parents are arguing loudly at the bedside regarding the discharge plan. The mother insists on home care with a private aide, while the father demands placement in a residential facility. Both parents turn to the nurse and ask, "What do you think is the best choice for our child?" The client begins to cry, becomes restless, and the cardiac monitor shows a heart rate increase from 88 to 128 beats/min. Which action is the nurse's priority?

An orthopedic unit nurse is initiating a telephone call to the on-call physician regarding a post-surgical client experiencing sudden respiratory distress. Place the nurse's intended statements in the correct sequence following the SBAR interprofessional communication framework.

During a system-wide electronic charting outage, the unit secretary hands the charge nurse a stack of freshly recorded vital sign and assessment flowsheets from the assistive personnel. Based on the documented data, which client requires the nurse's immediate bedside evaluation?

A client with severe peripheral arterial disease is scheduled for a below-the-knee amputation. Two hours ago, the surgeon explained the procedure to the client using a certified medical interpreter. The nurse now enters the room to witness the informed consent signature. The client's adult child, who speaks fluent English, is at the bedside and states, 'My father just told me he changed his mind. He does not want the surgery and would rather pass away naturally.' Arrange the following nursing actions in the correct priority sequence.

A care team on a medical neurology unit consists of a registered nurse, a licensed practical nurse, and an unlicensed assistive personnel. When distributing the workload for the shift, which task assignment by the registered nurse demonstrates safe and appropriate delegation?

A registered nurse (RN) is caring for an older adult client who is scheduled for an elective surgical procedure. The healthcare provider has completed the discussion regarding the procedure, risks, and benefits. As the RN prepares to have the informed consent document signed, which actions are the legal responsibilities of the RN? Select all that apply.

A registered nurse on a medical-infectious disease unit is reviewing client data following the morning change-of-shift report. Which client requires the nurse's most immediate assessment?

A nurse in an outpatient clinic is evaluating a 78-year-old client brought in by their adult child. During the physical examination, the nurse observes multiple patterned bruises on the client's upper back and bilateral forearms in various stages of healing. The client avoids eye contact and remains silent during the assessment. The adult child answers all questions and states, "They are so unsteady and keep falling, so I sometimes have to tie them to the chair at home to keep them safe." Which of the following are legally appropriate nursing actions? (Select all that apply)

A registered nurse is caring for an alert and oriented client with severe anemia who has been prescribed a packed red blood cell (PRBC) transfusion. The client states, 'I cannot accept this blood because it violates my religious beliefs.' Arrange the following nursing actions in the legally and ethically correct chronological order. All options must be used.

A nurse is assessing an older adult client admitted with dehydration. The nurse notes multiple unexplained bruises in various stages of healing on the client's arms and back. The client's adult child, who is the primary caregiver, repeatedly interrupts the client and refuses to leave the room. Which ethical and legal actions should the nurse take? Select all that apply.

An elderly client who recently stabilized following an acute exacerbation of chronic obstructive pulmonary disease (COPD) is scheduled for transfer to a subacute rehabilitation center. The client's family is actively resisting the transfer, exhibiting hostility toward the unit staff, and refusing to sign the necessary transition documents. Which of the following is the most appropriate action for the primary nurse to take?

A preoperative nurse is preparing a client who only speaks Mandarin for an elective cholecystectomy. The surgeon is present and ready to discuss the procedure to obtain informed consent. In what order should the nurse ensure the following actions are completed to legally and ethically secure informed consent?

The registered nurse (RN) is planning care for a group of clients on an orthopedic trauma unit. The care team includes an experienced licensed practical nurse (LPN/VN) and an unlicensed assistive personnel (UAP). Which of the following tasks is most appropriate for the RN to delegate to the LPN/VN?

A 32-year-old client is scheduled for a laparoscopic cholecystectomy and appears highly anxious. The client asks the nurse, "Is there a chance I could die during this surgery?" Which response by the nurse best demonstrates the ethical principle of veracity while maintaining a therapeutic relationship?

A client with generalized weakness is admitted to a medical unit. The admission screening indicates the client is at high risk for falling. Which standard safety interventions should the nurse implement? Select all that apply.

A nurse in a neurological rehabilitation unit is caring for a client recovering from a severe exacerbation of multiple sclerosis. The client has developed new-onset bilateral intention tremors and profound fatigue. During morning care, the client is unable to grip a toothbrush, repeatedly drops eating utensils, and becomes tearful about the inability to perform prescribed intermittent self-catheterization. Which collaborative action is most appropriate for the nurse to implement?

The parents of a 7-year-old child diagnosed with leukemia are discussing a proposed experimental chemotherapy trial with the pediatric oncologist. The oncologist explains the risks and alternatives, then leaves the room. Before signing the document, the parents tell the registered nurse, "We don't understand half of what the doctor just said, but we'll sign whatever it takes to save our child." Which of the following actions should the registered nurse take in this situation?