Tüm alıştırma soruları

A critical care nurse is managing a mechanically ventilated client equipped with a triple-lumen central venous catheter. The three lumens are continuously delivering norepinephrine, total parenteral nutrition (TPN), and a lipid-based propofol emulsion. The client's cardiac monitor suddenly displays atrial fibrillation with a ventricular response of 152 beats per minute, and the provider orders an emergent intravenous bolus of diltiazem. After verifying that diltiazem is incompatible with both the vasopressor and the sedative, which action is the most appropriate for the nurse to take?

An emergency department nurse is caring for a client who recently experienced a devastating house fire. The client is trembling, disorganized, and repeatedly states, "Everything is gone. I should have just stayed in the house." Arrange the following crisis intervention steps in the correct order from first to last.

A nurse is responding to a client on an inpatient psychiatric unit who is pacing the hallway, speaking loudly, and visibly clenching their fists. Arrange the following therapeutic communication and de-escalation interventions in the correct chronological order from first to last.

A nurse is administering a newly prescribed intravenous antibiotic. Ten minutes into the infusion, the client reports severe shortness of breath, a tight feeling in the throat, and dizziness. The client's blood pressure is $82/50$ mm Hg and heart rate is $128$ bpm. Arrange the following nursing interventions in the correct order of priority.

A rapid response code is called in the psychiatric emergency department for a client demonstrating imminent physical violence. The provider verbally orders immediate four-point mechanical restraints. Arrange the following nursing actions in the correct chronological sequence of implementation.

A registered nurse in a pediatric clinic is evaluating a 4-year-old child during a routine visit. The nurse observes symmetric, well-demarcated burn marks on both of the child's calves. The parent states, 'He was running around and accidentally backed into our space heater.' Which of the following is the priority nursing action?

A 65-year-old client admitted with heart failure reports acute, severe nausea. The client's current vital signs include a blood pressure of 118/74 mmHg and a heart rate of 82 bpm. The healthcare provider prescribes 4 mg of ondansetron to be administered via intravenous (IV) push through an existing intermittent peripheral IV catheter (saline lock). Arrange the following steps in the correct chronological order for safely administering this parenteral medication.

A nurse on a surgical rehabilitation unit is caring for a client who is 48 hours post-operative following a right above-the-knee amputation. Which intervention should the nurse implement?

A client is prescribed a scheduled dose of intravenous (IV) phenytoin to manage seizure activity. The client currently has a continuous peripheral IV infusion of 5% dextrose in water (D5W) infusing. Which action must the nurse implement to administer this medication safely?

A nurse is evaluating a client with severe hepatic cirrhosis who recently underwent a therapeutic bedside paracentesis with the removal of 5 liters of ascitic fluid. Twenty minutes after the procedure, the client reports feeling dizzy and nauseous. The nurse observes that the client's heart rate has increased from 78 to 118 beats per minute, and the blood pressure has decreased from 132/82 mm Hg to 94/56 mm Hg. Which of the following actions should the nurse perform first to mitigate the risk of severe hemodynamic collapse?

A nurse receives a client who has just returned to the medical unit following a percutaneous liver biopsy. To minimize the risk of post-procedure bleeding, which of the following positions should the nurse assist the client into?

A nurse in an orthopedic rehabilitation clinic is providing discharge teaching to a client with a fractured left tibia. The client is prescribed strict non-weight-bearing status for the left leg and is learning to use axillary crutches. When evaluating the client's understanding of how to safely descend a flight of stairs, which statement by the client indicates correct technique?

A client, age 82, with advanced emphysema and cor pulmonale is receiving treatment for hospital-acquired pneumonia. The client is currently prescribed continuous supplemental oxygen at 4 L/min via nasal cannula. During an assessment, the nurse finds the client somnolent, difficult to arouse, and taking 9 shallow breaths per minute. The most recent arterial blood gas analysis reveals a pH of 7.24, PaCO2 of 74 mm Hg, PaO2 of 56 mm Hg, and HCO3 of 32 mEq/L. Based on these clinical findings, which immediate intervention should the nurse implement?

A 55-year-old client is 3 days postoperative following an exploratory laparotomy. During a forceful coughing episode, the client reports a sudden "popping" sensation in the abdomen. The nurse inspects the surgical site and observes an abdominal evisceration. Place the following nursing interventions in the correct priority order to minimize the risk of severe physiological complications. (Arrange the steps from first to last.)

A 54-year-old client is admitted to the medical unit with an acute exacerbation of heart failure. The client's current vital signs are blood pressure 158/96 mm Hg, heart rate 108/min, and temperature 37.6°C (99.7°F). The client appears mildly agitated and is frequently picking at the bed linens. During the admission assessment, the client states, "I drink a half-liter of vodka every day, but I haven't had a drink since yesterday morning. Please do not tell my healthcare provider; I do not want them to judge me." Which action is the most appropriate for the nurse to take?

During a night shift on a medical-surgical unit, an 82-year-old client with profound presbycusis and dense bilateral cataracts suddenly becomes highly agitated. The client, who is in a private room with the door closed for contact precautions, points to a dark corner and insists, 'Those men in the shadows are whispering and planning to hurt me!' The client's vital signs are within normal limits, and oxygen saturation is 97% on room air. Based on principles of sensory and perceptual alterations, which nursing action is the most appropriate priority?

A nurse is preparing to administer an intravenous (IV) infusion of amphotericin B deoxycholate to a client diagnosed with a severe systemic fungal infection. Which of the following nursing actions are appropriate when managing this parenteral therapy? Select all that apply.

A nurse is preparing to discontinue a client's peripheral intravenous (IV) catheter. Place the following steps in the correct chronological order from first to last.

A 68-year-old client is admitted to the medical unit with a history of recurrent syncope, dehydration, and the recent initiation of a new antihypertensive medication. The healthcare provider prescribes orthostatic vital sign measurements. To ensure accurate assessment and reduce the risk of a potential fall, arrange the following procedural steps in the correct chronological order.

A nurse is preparing to draw a blood specimen from a client's central venous catheter (CVC). To maintain catheter patency, prevent infection, and ensure accurate laboratory results, arrange the following steps in the correct chronological sequence.