Tüm alıştırma soruları

The healthcare provider has just informed a client with end-stage renal disease about the immediate need to begin hemodialysis. After the provider leaves the room, the client angrily yells at the nurse, "I absolutely refuse to do it! Being tied to a machine three days a week isn't living. I would rather just let nature take its course!" Which of the following responses by the nurse is the most therapeutic?

A client with a history of heart failure is receiving a continuous intravenous infusion of 0.9% sodium chloride at 125 mL/hr. During a reassessment, the nurse notes new-onset bibasilar crackles, a respiratory rate of 28 breaths/min, and an oxygen saturation of 88% on room air. The latest arterial blood gas (ABG) results are pH 7.30, $PaCO_2$ 52 mm Hg, $PaO_2$ 55 mm Hg, and $HCO_3^-$ 25 mEq/L. Which action should the nurse take first to reduce the risk of further physiological deterioration?

A nurse is providing care for a postoperative client who is prescribed strict bed rest. To reduce the client's risk of developing deep vein thrombosis (DVT), which interventions should the nurse include in the plan of care? Select all that apply.

A nurse is evaluating a client who underwent a percutaneous liver biopsy two hours ago. The client is currently resting on their right side with a rolled towel under the puncture site. Which of the following assessment findings requires the most immediate notification to the healthcare provider to reduce the risk of a severe physiological complication?

An emergency department nurse is caring for an 8-year-old client who presents with a spiral fracture of the left humerus. The parent states the child fell off a bicycle. During the physical examination, the nurse observes fading, varied-colored bruises on the child's torso. The child is unusually withdrawn and constantly looks at the parent before answering any questions. Which of the following is the priority nursing action?

A nurse is caring for a client receiving parenteral nutrition via a subclavian central venous catheter (CVC). Upon entering the room, the nurse discovers the IV tubing has disconnected from the catheter hub. The client is suddenly grasping their chest, gasping for air, and reporting a feeling of impending doom. Arrange the following nursing actions in the correct order of priority to manage this life-threatening complication.

At the start of the shift on an adult medical-surgical floor, the charge nurse is finalizing patient assignments. The shift's personnel matrix consists of a core staff registered nurse (RN), an RN temporarily floated from the maternal-newborn (postpartum) unit, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP). Which delegation decision by the charge nurse is most appropriate?

Following a right femoral cardiac catheterization, a client is admitted to the progressive care unit. To minimize the risk of a severe physiological complication, which assessment must the nurse prioritize?

A client is restricted to strict bed rest following a prolonged surgical procedure. Which interventions should the nurse implement to promote physical comfort and prevent tissue breakdown? Select all that apply.

During a shift on the behavioral health unit, a client diagnosed with acute mania begins pacing aggressively, clenching their fists, and shouting threats at peers. Place the following nursing interventions in the correct sequence from first action to last action, prioritizing milieu safety and the principle of least restrictive care.

A young adult who underwent an appendectomy two hours ago reports incisional pain rated as 8 on a 0-to-10 pain scale. The medication administration record includes a prescription for intravenous morphine sulfate. The client is currently resting with eyes closed, arouses easily to verbal stimuli, and has a respiratory rate of 10 breaths per minute. Which action should the nurse take?

While working the evening shift at a behavioral health facility, the registered nurse observes an individual in the manic phase of bipolar disorder wandering into the bedrooms of peers, taking their personal items, and singing loudly. Other individuals on the unit are expressing visible anger, and one peer explicitly threatens to physically retaliate against the hyperactive client. Which action should the nurse implement first to restore safety and maintain a therapeutic environment?

Match each client statement or behavioral scenario with the most appropriate therapeutic nursing response.

A client with advanced dementia is admitted to the medical-surgical unit with severe aspiration pneumonia. The client lacks decision-making capacity and is rapidly declining. The adult children are arguing at the bedside regarding whether to insert a percutaneous endoscopic gastrostomy (PEG) tube or transition exclusively to comfort measures. Arrange the following nursing actions in the most appropriate sequence to address this end-of-life conflict.

A client was admitted to the behavioral health unit three days ago after experiencing a severe situational crisis involving an unexpected divorce and the immediate loss of a career. Initially, the client exhibited extreme agitation, cried continuously, and expressed feelings of profound hopelessness. During morning rounds today, the nurse observes the client sitting calmly, smiling, and giving a valued wristwatch to another client. The client states, 'I have finally figured everything out, and I will not be a burden to anyone anymore.' Which of the following is the priority nursing action?

A client with a history of borderline personality disorder is receiving care on an orthopedic unit following surgical repair of a fractured tibia. The client tells the evening nurse, 'You are the only person who actually cares about me; the day nurses are terrible and ignored my pain.' Later, the client begins shouting in the corridor because a requested snack was unavailable. Which behavioral interventions should the evening nurse implement? Select all that apply.

A client diagnosed with borderline personality disorder frequently interrupts unit meetings, monopolizes conversations, and attempts to engage other clients in arguments regarding facility rules. The registered nurse is developing a plan of care to maintain a safe and therapeutic milieu. Which interventions should the nurse include in the plan of care? Select all that apply.

A nurse is preparing to perform oral care for a client who is unconscious. To prevent the complication of aspiration, which position should the nurse place the client in?

A 38-year-old client is being managed in the neuro-intensive care unit 12 hours after sustaining a severe traumatic brain injury. The client is intubated, mechanically ventilated, and has an intracranial pressure (ICP) monitor in place. To reduce the risk of secondary brain injury and physiological decompensation, which of the following assessment findings require the nurse to intervene immediately? Select all that apply.

A pediatric client is admitted to the intensive care unit with a severe traumatic brain injury following a motor vehicle collision. The client's parent is crying at the bedside and states, 'If only I had taken our usual route to school instead of the shortcut, this never would have happened. It is completely my fault.' Which of the following is the most therapeutic response by the nurse?