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Tüm alıştırma soruları

3881 soru

Tüm türler3,881Çoktan seçmeli1,926Çoklu seçim908Sayısal119Eşleştirme66Sıralama862
Soru 1961Soru →

An 82-year-old client on the orthopedic unit is scheduled for a total hip arthroplasty later today. While holding the un-signed surgical consent form, the client states, 'The surgeon spoke with me yesterday, but my memory is failing me. I cannot remember if there were other options besides having this surgery.' Which action should the nurse take to ensure the criteria for informed consent are met?

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Cevap: Contact the surgeon to clarify the alternatives to the procedure before the client signs the document.

Cevap

Contact the surgeon to clarify the alternatives to the procedure before the client signs the document.
For informed consent to be legally valid, the client must fully comprehend the procedure, including its risks, benefits, and alternatives. It is strictly the responsibility of the primary healthcare provider (such as the surgeon) to explain these elements. If a client demonstrates a knowledge deficit—such as forgetting the surgical alternatives—the nurse must act as a client advocate by pausing the consent process and notifying the provider to return and clarify the information.

Adım Adım Çözüm

1
Assess the client's current understanding of the planned procedure, its risks, benefits, and alternatives.
The client explicitly states an inability to remember the alternatives to the surgery.
Valid informed consent requires the client to have a clear understanding of the procedure, including alternative treatments, at the time of signing.
2
Identify the boundaries of the nurse's scope of practice regarding informed consent.
The nurse determines that explaining surgical alternatives is the responsibility of the healthcare provider, not the nurse.
The nurse acts as a witness and an advocate but cannot legally provide the primary explanation of medical risks, benefits, or alternatives.
3
Implement the appropriate advocacy intervention based on the assessment.
The nurse halts the signing process and notifies the surgeon.
The provider must return to ensure the client is fully informed before the client can legally grant consent.

Anahtar Kavram

The nurse's role in informed consent is to act as an advocate by witnessing the signature, ensuring the client is competent and acting voluntarily, and notifying the primary provider if the client demonstrates a knowledge deficit regarding risks, benefits, or alternatives.
Soru 1962Soru →

A young adult client recovering from a traumatic brain injury is disoriented and repeatedly attempts to remove a continuous intravenous infusion line. Which legally required action must the registered nurse perform before considering the application of physical restraints?

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Cevap: Implement and document the use of less restrictive safety measures.

Cevap

The nurse must implement and document the use of less restrictive safety measures before considering physical restraints.
By law, physical restraints are considered a safety measure of absolute last resort. Healthcare regulations mandate that the registered nurse must first implement and thoroughly document the failure of less restrictive alternatives (such as providing a sitter, hiding the IV site, reorienting the client, or using bed alarms) before applying any form of physical restraint.

Adım Adım Çözüm

1
Identify the client's safety risk.
The disoriented client is at risk of interrupting necessary medical therapy by pulling at the IV line.
Disorientation from a traumatic brain injury affects the client's judgment and safety awareness.
2
Recall legal and ethical guidelines for restraint use.
Restraints require a specific provider order, cannot be prescribed as PRN, and are only legally permissible after other methods fail.
Federal laws and healthcare regulations protect client rights against unlawful imprisonment and unnecessary physical restriction.
3
Select the priority nursing action prior to restraint use.
The nurse must try alternative, non-restrictive safety measures first.
Less restrictive alternatives (like reorientation, hiding the IV site, or a bed alarm) are legally mandated to be attempted and documented prior to any restraint application.

Anahtar Kavram

Legal requirements and alternatives for physical restraint application.
Tahmini Süre:45s
Soru 1963Soru →

While rounding on a postpartum unit, a nurse is notified of several client needs. Which client condition requires the nurse's immediate clinical evaluation?

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Cevap: A client who delivered vaginally 3 hours ago and has a resting heart rate of 118 bpm with a perineal pad that saturated in 20 minutes

Cevap

The client who delivered 3 hours ago with a resting heart rate of 118 bpm and a rapidly saturating perineal pad requires immediate clinical evaluation.
This client is experiencing signs of postpartum hemorrhage, which is a life-threatening circulatory emergency. A resting heart rate of 118 bpm (tachycardia) is an early physiological indicator of hypovolemic shock, and saturating a perineal pad in less than an hour requires immediate intervention to stabilize the client's circulation. According to the ABC (Airway, Breathing, Circulation) framework, this physiological instability is the absolute highest priority.

Adım Adım Çözüm

1
Analyze each client's condition to identify expected versus unexpected findings.
The crying client, the client with incisional pain, and the client with uterine cramping all exhibit expected postpartum findings. The client with a rapid heart rate and heavy bleeding exhibits unexpected, acute findings.
Recognizing normal physiological adaptation helps isolate clients experiencing acute complications.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework.
The client with tachycardia (118 bpm) and rapid pad saturation is showing signs of compromised circulation due to severe bleeding.
The ABC framework dictates that circulatory compromise is a life-threatening emergency that must take precedence over pain, routine physiological changes, and psychosocial needs.

Anahtar Kavram

Prioritizing acute circulatory compromise over expected postpartum findings using the ABC framework.
Soru 1964Soru →

Effective delegation requires a systematic approach to ensure safe client care. According to the national guidelines established by the NCSBN, arrange the foundational steps of the nursing delegation process in the correct chronological order from first to last.

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Cevap

The correct chronological sequence of the delegation process is: conduct an initial client assessment, confirm personnel competency, provide explicit communication, supervise the care delivery, and evaluate the client's response.
The delegation process follows a strict chronological sequence established by national guidelines to ensure safety and accountability. It begins with assessing the client's stability (Right Circumstance), followed by verifying the staff member's competency (Right Person). Only then can the nurse communicate instructions (Right Direction). During the task, the nurse must provide oversight (Right Supervision), and afterward, they must review the results and provide feedback (Evaluation).

Adım Adım Çözüm

1
Identify the foundational first step of delegation.
Conduct an initial assessment of the client's clinical stability.
A nurse cannot safely delegate care without first evaluating the client to ensure their condition is stable enough for the task to be performed by assistive personnel.
2
Determine the next action related to the personnel.
Confirm the assistive personnel possesses the required competency.
Before assigning the task, the nurse must verify that the individual is legally permitted and practically capable of safely performing it.
3
Identify the step that immediately precedes the task execution.
Provide explicit communication regarding task expectations.
Clear, direct instructions must be given so the personnel knows exactly what is expected, how to do it, and what parameters to report back to the nurse.
4
Determine the nurse's responsibility during the ongoing task.
Supervise the care delivery and remain available for guidance.
The delegating nurse retains ultimate accountability and must actively monitor the ongoing care to ensure it is being done safely.
5
Identify the concluding step of the process.
Evaluate the client's response and offer performance feedback.
The process closes with an evaluation of the clinical outcomes to ensure client safety, followed by providing feedback to support staff development.

Anahtar Kavram

The foundational steps of the nursing delegation process.
Soru 1965Soru →

A triage nurse in the emergency department receives four clients at the same time. Using the ABC (Airway, Breathing, Circulation) and Maslow's hierarchy of needs frameworks, arrange the clients in the order they should be assessed, from highest priority (first) to lowest priority (last).

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Cevap

The correct order of assessment is: 1) the client with airway swelling, 2) the client with spurting bleeding, 3) the client with severe abdominal pain, and 4) the client waiting for discharge instructions.
The correct sequence strictly follows the ABC framework and triage principles. The airway emergency (stridor/swelling) is the most critical and must be seen first. The circulatory emergency (spurting bleeding) follows immediately. The urgent physiological need (severe acute pain) is third, and the stable client requiring routine care (discharge teaching) is safely seen last.

Adım Adım Çözüm

1
Identify the client with an immediate airway or breathing threat.
The client with sudden airway swelling and stridor is identified as having a compromised airway.
According to the ABC framework, airway is always the highest priority because lack of oxygen leads to rapid clinical deterioration and death.
2
Identify any clients with critical circulatory or perfusion issues.
The client with active, spurting bleeding has a severe circulatory threat.
Circulation is the 'C' in the ABC framework and is prioritized immediately after airway and breathing are secured to prevent hypovolemic shock.
3
Assess the remaining clients for acute, urgent physiological needs.
The client with sudden, severe 8/10 abdominal pain is prioritized next.
Acute pain is an urgent physiological need that indicates a potential underlying issue requiring prompt medical attention, taking precedence over stable clients.
4
Identify clients who are stable or require routine care.
The client waiting for discharge instructions for a resolved migraine is placed last.
Stable clients who only need routine teaching or administrative tasks can safely wait without risk of clinical deterioration.

Anahtar Kavram

Prioritization using the ABC (Airway, Breathing, Circulation) framework and Maslow's hierarchy of needs.
Soru 1966Soru →

An unlicensed assistive personnel (UAP) assists a 78-year-old client with a bed bath and notifies the registered nurse (RN) about multiple fading bruises on the client's torso. Upon further assessment by the RN, the client tearfully states, 'My daughter gets so frustrated with me and sometimes she hits me.' Which action is the legal priority for the registered nurse?

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Cevap: Notify the state adult protective services agency regarding the suspected abuse.

Cevap

The registered nurse must immediately notify adult protective services or the appropriate state authority about the suspected elder abuse.
Registered nurses are legally mandated reporters of suspected abuse for vulnerable populations, including older adults. When a client presents with physical signs of injury and verbally discloses abuse, the nurse has a strict legal obligation to report these findings to the designated state authority (such as Adult Protective Services) immediately. The nurse does not need absolute proof to make a report, only a reasonable suspicion.

Adım Adım Çözüm

1
Assess the client's physical condition and statements following the UAP's report.
Identified physical evidence (fading bruises) and received a direct verbal disclosure of physical abuse by a family member.
To gather baseline clinical data regarding the client's safety and well-being.
2
Identify the legal obligations associated with the clinical findings.
Recognized the situation as suspected elder abuse.
Registered nurses are legally designated as mandatory reporters for suspected child, elder, and vulnerable adult abuse.
3
Take the legally mandated action.
Reported the suspected abuse to the appropriate protective services agency.
Failing to report suspected abuse is a violation of state law and professional nursing standards.

Anahtar Kavram

Mandatory Reporting of Elder Abuse
Soru 1967Soru →

After receiving handoff communication at the beginning of the day shift, a registered nurse is planning care for four assigned clients. Which client should the nurse assess first?

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Cevap: A client with an exacerbation of asthma who has new-onset audible wheezing and an oxygen saturation of 88% on room air

Cevap

The client with an exacerbation of asthma who has new-onset audible wheezing and an oxygen saturation of 88% on room air.
The correct answer identifies a client with a new, acute respiratory compromise. Applying the ABC (Airway, Breathing, Circulation) prioritization framework, a client with an airway/breathing issue (wheezing and hypoxia) takes immediate precedence over clients with chronic, stable conditions or routine care needs.

Adım Adım Çözüm

1
Analyze each client's condition based on the Airway, Breathing, Circulation (ABCs) framework and the concept of acute versus chronic.
The asthma client has an acute airway/breathing issue. The other clients have chronic or stable routine care needs.
The ABC framework dictates that airway and breathing issues are the highest priority because they pose the most immediate threat to life.

Anahtar Kavram

Establishing Priorities using the ABC (Airway, Breathing, Circulation) framework
Soru 1968Soru →

A client on a medical-surgical unit is scheduled for a thoracentesis. The healthcare provider has discussed the procedure with the client, and the consent form is now ready to be signed. Which action correctly describes the registered nurse's primary role in the informed consent process?

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Cevap: Witnessing the client's signature and verifying that the consent is given voluntarily

Cevap

The nurse's role is witnessing the client's signature and verifying that the consent is given voluntarily.
The correct answer accurately reflects the registered nurse's legal and ethical role in informed consent. The nurse acts as a witness to the client's signature, confirms that the client is competent to make the decision, and ensures that the client is signing voluntarily without coercion.

Adım Adım Çözüm

1
Identify the core elements of the informed consent process.
The process requires disclosure of information by the provider, comprehension by the client, and voluntary consent.
Understanding the components of consent clarifies which team member is responsible for each part.
2
Differentiate between the healthcare provider's role and the registered nurse's role.
The provider must explain the procedure, risks, benefits, and alternatives. The nurse acts as an advocate and witness.
Nurses must practice within their legal scope of practice and avoid assuming provider responsibilities.
3
Select the action that aligns with the registered nurse's legal scope of practice.
Witnessing the signature and ensuring voluntariness is the correct nursing action.
This action fulfills the nurse's duty as a client advocate and legal witness.

Anahtar Kavram

Informed Consent
Soru 1969Soru →

A pediatric nurse is assessing a 4-year-old child brought to the emergency department with a spiral fracture of the humerus. The caregivers state the child tripped and fell off a small tricycle. The nurse notes that the mechanism of injury is inconsistent with a simple fall and suspects non-accidental trauma. Which of the following is the priority legal action the nurse should take?

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Cevap: Notify the designated state child protective agency about the suspected abuse.

Cevap

Notify the designated state child protective agency about the suspected abuse.
Nurses are legally mandated reporters of suspected child abuse. When a child presents with an injury that is inconsistent with the caregivers' explanation (such as a spiral fracture resulting from a simple fall), the nurse's priority legal responsibility is to report the suspicion to the designated child protective services immediately to ensure the child's safety.

Adım Adım Çözüm

1
Analyze the clinical presentation.
The nurse identifies a discrepancy between the reported cause of injury (a simple fall) and the actual injury (a spiral fracture, which typically requires a twisting force).
Recognizing red flags for non-accidental trauma is essential for identifying potential abuse.
2
Determine the legal responsibility in the scenario.
The nurse recognizes that healthcare professionals have a legal mandate to protect vulnerable populations.
All jurisdictions legally require nurses to act as mandated reporters for suspected child abuse.
3
Select the appropriate intervention.
The nurse chooses the action that fulfills the legal obligation to report the suspicion to the appropriate authorities immediately.
Immediate reporting ensures the safety of the child, whereas delaying for proof or confronting the parents can cause further harm.

Anahtar Kavram

Mandatory Reporting of Child Abuse
Soru 1970Soru →

A nurse enters a client's room and discovers that the intravenous tubing has completely disconnected from the hub of the client's central venous catheter. The client is suddenly coughing, pale, and reporting severe chest pain and shortness of breath. Arrange the following nursing interventions in the correct order of priority to prevent further injury.

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Cevap

The correct priority sequence is to first clamp the catheter, then position the client on their left side in Trendelenburg, followed by administering 100% oxygen, calling the rapid response team, and finally assessing vital signs.
An open and disconnected central venous catheter creates a direct pathway for atmospheric air to enter the vascular space, creating a high risk for a fatal air embolism. The immediate priority is always to physically stop the flow of air by clamping the catheter. Next, placing the client in the left lateral Trendelenburg position (Durant's maneuver) utilizes gravity to encourage the air bubble to rise to the apex of the right ventricle, preventing it from obstructing the pulmonary outflow tract. Administering 100% oxygen addresses the resulting severe hypoxia and assists in washing out nitrogen, which reduces the size of the air bubble. After securing these immediate, life-saving measures, the nurse must activate the rapid response team to secure advanced medical support. Finally, obtaining a complete set of vital signs provides necessary data to monitor for hemodynamic collapse while awaiting the emergency team.

Adım Adım Çözüm

1
Stop the source of the hazard.
The central venous catheter is clamped.
Prevents any further introduction of atmospheric air into the venous system.
2
Trap the air embolus anatomically.
The client is placed in the left lateral Trendelenburg position.
Keeps the air bubble confined within the right atrium and right ventricle, preventing a fatal pulmonary artery occlusion.
3
Treat hypoxia and reduce embolus size.
Oxygen is applied via a non-rebreather mask.
Addresses the ventilation-perfusion mismatch and speeds up the resorption of nitrogen gas from the bubble.
4
Summon advanced help.
The rapid response team is activated.
The client requires emergency medical evaluation and potential advanced interventions for hemodynamic collapse.
5
Monitor the client's status.
Vital signs and oxygen saturation are measured.
Provides objective data on the client's condition and their physiological response to the initial interventions.

Anahtar Kavram

Management of a suspected central line air embolism requires immediate mechanical prevention of further air entry, anatomical trapping of the embolus, and correction of hypoxia.
Soru 1971Soru →

A home-dwelling older adult with advanced Alzheimer's disease is admitted to the medical-surgical unit for sepsis. During the initial physical assessment, the nurse observes distinct, patterned thermal burns on the client's posterior thorax. The client's adult child, who is the legally designated healthcare proxy, becomes highly agitated, demanding that the nurse immediately apply bilateral wrist restraints "to stop them from ripping out the IV." The adult child then insists the nurse send the unlicensed assistive personnel (UAP) to feed the client their arrival meal immediately. Which response by the nurse represents the legally and professionally sound course of action?

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Cevap: Implement alternative safety measures instead of restraints, perform the initial feeding assessment personally, and immediately initiate an external report regarding the thermal injuries.

Cevap

Implement alternative safety measures instead of restraints, perform the initial feeding assessment personally, and immediately initiate an external report regarding the thermal injuries.
The correct response demonstrates a comprehensive understanding of multiple competing legal and ethical priorities. The nurse correctly identifies that a healthcare proxy cannot legally mandate restraints without clinical justification and a provider order. The nurse also protects their license and the client's safety by refusing to delegate an initial swallowing assessment in a client with altered mental status. Finally, the nurse fulfills the absolute legal mandate to report suspected elder abuse immediately upon discovery, without waiting for physician validation.

Adım Adım Çözüm

1
Evaluate the legal validity of the healthcare proxy's demand for physical restraints.
Determine that restraints cannot be applied solely based on family demand.
Restraint application requires an independent clinical assessment demonstrating danger to self/others, failure of less restrictive alternatives, and a specific provider order.
2
Determine the legality of delegating the initial feeding task in this specific clinical scenario.
Identify that the feeding cannot be delegated to a UAP.
The client is a new admission with altered mental status, requiring an RN to perform the initial assessment of swallowing function and aspiration risk.
3
Establish the priority legal response to the discovery of patterned thermal burns.
Initiate an immediate mandatory report to Adult Protective Services or the designated state authority.
Nurses possess an independent, legal mandate to report suspected elder abuse immediately; this duty cannot be deferred to a physician or delayed for further internal investigation.

Anahtar Kavram

Synthesis of complex legal responsibilities including mandatory abuse reporting, scope of practice in delegation, and the legal parameters of restraint application.
Soru 1972Soru →

An older adult client with a history of severe rheumatoid arthritis is preparing for discharge to an assisted living facility. The client has intact swallowing reflexes but has been steadily losing weight over the past week. During meals, the nurse observes that severe joint deformities in the client's hands prevent them from holding standard forks and spoons. Which action should the nurse take to most appropriately address this clinical issue?

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Cevap: Arrange for an occupational therapy evaluation to obtain adaptive feeding devices.

Cevap

The most appropriate action is to arrange for an occupational therapy evaluation so the client can receive adaptive feeding devices.
The correct action directly addresses the root cause of the client's weight loss. Occupational therapists specialize in maximizing independence in activities of daily living (ADLs). By evaluating the client for adaptive feeding devices, such as built-up or weighted utensils, the therapist can help bypass the severe joint deformities caused by rheumatoid arthritis, allowing the client to feed themselves safely and effectively.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and identify the root cause of the weight loss.
The root cause is a mechanical inability to hold utensils due to rheumatoid arthritis, not a lack of available calories or a swallowing deficit.
Identifying the exact barrier to nutrition is required to select the appropriate interdisciplinary intervention.
2
Determine which interdisciplinary team member possesses the scope of practice to address the specific mechanical barrier.
An occupational therapist is identified as the correct professional.
Occupational therapists are experts in fine motor skills and adapting activities of daily living (ADLs) through environmental modifications and adaptive equipment.
3
Evaluate the other options for safety, delegation rules, and therapeutic communication standards.
Delegating evaluation to a UAP violates scope of practice, assuring the client the staff will feed them uses false reassurance, and a dietitian consult misses the mechanical priority.
Ruling out distractors confirms that the occupational therapy referral is the only safe, effective, and collaborative choice.

Anahtar Kavram

Occupational Therapy Scope of Practice for ADLs
Soru 1973Soru →

A nurse is assessing a client who was admitted 24 hours ago with a severe traumatic brain injury (TBI) following a fall. Based on the principles of prioritization, which of the following assessment findings represent an acute deterioration requiring the nurse to intervene immediately? Select all that apply.

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Cevap: Core body temperature increasing to 102.6°F (39.2°C) over the last hour; Urine output totaling 950 mL of pale urine over the past two hours; Right pupil measuring 7 mm and completely unresponsive to light

Cevap

The findings requiring immediate intervention are the rapidly increasing core body temperature, the massive urine output (950 mL in 2 hours), and the newly fixed, dilated right pupil.
The correct findings represent acute, unexpected, and life-threatening complications of a traumatic brain injury. A rapidly increasing core temperature significantly raises cerebral metabolic demand and intracranial pressure. A massive urine output indicates the onset of central Diabetes Insipidus, which quickly leads to hypovolemic shock and decreased brain perfusion. A fixed and dilated pupil is an ominous sign of uncal herniation and brainstem compression. All three require immediate life-saving medical intervention.

Adım Adım Çözüm

1
Analyze the client's primary diagnosis (Traumatic Brain Injury) and current timeline (24 hours post-injury).
The client is in the acute phase of recovery, placing them at high risk for secondary brain injuries, increased intracranial pressure (ICP), and endocrine disruptions.
Understanding the timeline helps anticipate potential life-threatening complications versus baseline neurological deficits.
2
Evaluate each assessment finding using the unexpected versus expected and acute versus stable prioritization frameworks.
Hyperthermia, sudden massive polyuria, and a fixed/dilated pupil are unexpected, dynamic deteriorations indicating neurogenic fever, Diabetes Insipidus, and brain herniation. A stable GCS and amnesia are expected or stable baseline findings for this injury.
Prioritization requires identifying signs that signal active physiological deterioration or impending instability.
3
Apply the Airway, Breathing, Circulation (ABC) and severe neurological impairment criteria to the dynamic changes.
The fixed/dilated pupil indicates imminent herniation (brainstem compression); massive polyuria threatens Circulation via hypovolemia; hyperthermia exacerbates ICP. All three are highest priority emergencies.
Life-threatening complications involving massive fluid loss, rising ICP, and brain herniation must be addressed before managing stable or expected neurological deficits.

Anahtar Kavram

When establishing priorities for a client with a traumatic brain injury, the nurse must rapidly differentiate between stable, expected neurological deficits and dynamic, unexpected findings that indicate secondary brain injury, such as increased ICP, herniation, or central endocrine disruption.
Soru 1974Soru →

A nurse is preparing an older adult client with severe rheumatoid arthritis for discharge to home. The client has significant joint deformities in both hands and expresses frustration, stating, "I cannot even hold a fork or button my own shirt anymore." Which of the following is the most appropriate action for the nurse to take?

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Cevap: Initiate a referral to an occupational therapist to evaluate the client for adaptive devices for activities of daily living.

Cevap

The most appropriate action is to initiate a referral to an occupational therapist to assist the client with adaptive devices for activities of daily living.
An occupational therapist specializes in helping clients achieve independence in activities of daily living (ADLs), such as feeding and dressing, often by recommending and teaching the use of adaptive equipment. This directly addresses the client's impaired fine motor skills.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and stated concerns.
The client is experiencing specific difficulty with fine motor skills and activities of daily living (ADLs), such as holding a fork and buttoning a shirt.
Identifying the specific functional deficit is necessary to determine which interdisciplinary team member is most appropriate for a referral.
2
Select the appropriate interprofessional team member to address the deficit.
The occupational therapist (OT) is the expert in helping clients regain independence in ADLs through the use of adaptive equipment and fine motor rehabilitation.
Occupational therapy focuses on fine motor skills and daily living tasks, whereas other disciplines have different clinical scopes.

Anahtar Kavram

Occupational Therapy Role in Activities of Daily Living
Soru 1975Soru →

A client is scheduled for a cardiac catheterization in 30 minutes. The healthcare provider has already obtained signed informed consent. While the nurse is preparing to administer the prescribed pre-procedure sedative (midazolam), the client states, "I changed my mind. I do not want this procedure. The doctor said I could have a stroke." What is the priority sequence of nursing actions? Arrange the actions in the order they should be performed, from first to last.

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Cevap

The correct sequence is to first withhold the sedative, second assess the client's specific concerns, third notify the healthcare provider, and fourth document the event.
When a client explicitly revokes consent, the nurse's immediate priority is to halt any interventions related to the procedure, particularly mind-altering medications like sedatives that would impair decision-making capacity. Next, the nurse assesses the client's specific concerns. Then, the nurse acts as an advocate by notifying the provider, who holds the responsibility for addressing medical risks and re-evaluating consent. Finally, the nurse thoroughly documents the entire sequence of events.

Adım Adım Çözüm

1
Withhold the administration of the prescribed pre-procedure midazolam.
The preoperative process is halted, and the client's cognitive status remains unaltered.
Administering a sedative after a client expresses a desire to withdraw consent would violate their autonomy and render them legally incompetent to make further decisions regarding the procedure.
2
Inquire about the client's specific concerns regarding the risk of a stroke.
The nurse gathers specific data about the client's fears and knowledge deficit.
Assessment is the next sequential step in the nursing process to understand the root cause of the refusal before communicating with the provider.
3
Notify the healthcare provider of the client's statement of refusal.
The provider is informed of the change in the client's consent status.
The nurse cannot independently resolve medical concerns or re-establish informed consent; the provider must address the risks (e.g., stroke) and determine if the client still wishes to proceed.
4
Document the client's exact words, the withheld medication, and the provider notification.
A legally sound medical record is established.
Accurate and timely documentation protects the client's rights and the nurse's legal liability, but it should only occur after immediate safety and communication needs are met.

Anahtar Kavram

Revocation of Informed Consent and Nurse Advocacy
Soru 1976Soru →

The charge nurse on a busy surgical trauma step-down unit is planning care assignments for the upcoming shift. The staffing mix includes a core trauma registered nurse (RN), an RN floated from the inpatient psychiatric unit, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP). Which of the following delegation and assignment decisions are appropriate? Select all that apply.

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Cevap: Assigning the psychiatric float RN to care for a client who is 2 days post-operative from a femur fracture repair and is exhibiting severe acute alcohol withdrawal delirium; Assigning the core trauma RN to conduct hourly neurological assessments on a client with a skull fracture who developed sluggish pupillary responses during the previous shift; Delegating the performance of sterile tracheostomy care to the LPN for a client whose tracheostomy was placed 5 days ago and is currently hemodynamically stable

Cevap

The correct assignments include assigning the psychiatric float RN to the client with alcohol withdrawal, assigning the core trauma RN to the client with sluggish pupillary responses, and delegating sterile tracheostomy care for an established stoma to the LPN.
The appropriate delegation decisions prioritize client stability, adhere to legal scopes of practice, and leverage specialized skills. The psychiatric float RN is uniquely qualified to manage the behavioral complexities of acute alcohol withdrawal in a surgically stable client. The core RN is correctly assigned to the client with acute neurological deterioration. Furthermore, sterile tracheostomy care on an established, 5-day-old stoma in a stable client is a safe and appropriate task for an experienced LPN.

Adım Adım Çözüm

1
Analyze the client assigned to the psychiatric float RN.
The client is surgically stable but has acute alcohol withdrawal delirium.
Float nurses should be assigned clients whose conditions align with their core competencies or who are highly stable; a psychiatric RN is uniquely qualified to manage severe withdrawal delirium safely.
2
Evaluate the task delegated to the LPN regarding the client with a suspected tension pneumothorax.
The client is highly unstable and awaiting emergent intervention.
Regardless of the simplicity of the delegated task, LPNs must be assigned to stable clients with predictable outcomes. A client with a tension pneumothorax requires immediate RN oversight.
3
Assess the delegation of oxygen titration to the UAP.
Titrating oxygen requires clinical judgment based on oxygen saturation readings.
UAPs can perform standard, unchanging tasks but cannot evaluate responses or adjust medical treatments based on changing clinical parameters.
4
Review the assignment for the core trauma RN.
The client has acute neurological changes following a skull fracture.
Unstable clients experiencing acute changes require the advanced assessment and critical thinking skills of the core RN.
5
Evaluate the delegation of sterile tracheostomy care to the LPN.
The tracheostomy is 5 days old, and the client is stable.
While initial tracheostomy care on a fresh stoma is often an RN responsibility, sterile care on an established, stable tracheostomy falls well within the LPN scope of practice.
6
Analyze the delegation of teaching aspiration precautions to the UAP.
Teaching is outside the scope of practice for a UAP.
The RN must retain all teaching responsibilities and cannot delegate educational tasks to unlicensed personnel.

Anahtar Kavram

Delegation requires matching client needs with staff competencies (such as floating a psychiatric RN to manage delirium), assessing overall client stability regardless of task simplicity, and strictly adhering to the scope of practice for LPNs and UAPs.
Soru 1977Soru →

A registered nurse on a pediatric high-acuity unit is receiving the morning hand-off report for four assigned clients. Based on the provided clinical data, which client should the nurse assess first?

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Cevap: A 6-year-old client with acute poststreptococcal glomerulonephritis who has a blood pressure of 145/95 mm Hg and reports a sudden, severe headache

Cevap

The 6-year-old client with acute poststreptococcal glomerulonephritis who has a blood pressure of 145/95 mm Hg and reports a sudden, severe headache.
The correct answer identifies a severe, unexpected complication. Acute poststreptococcal glomerulonephritis causes fluid retention and subsequent hypertension. For a 6-year-old, a blood pressure of 145/95 mm Hg is dangerously high (normal is approximately 95-105/60-70 mm Hg). The addition of a sudden, severe headache indicates hypertensive encephalopathy, a medical emergency that can rapidly lead to cerebral edema, seizures, or a cerebrovascular accident (stroke) if intravenous antihypertensives are not administered immediately.

Adım Adım Çözüm

1
Analyze the clinical data for each pediatric client to establish expected baseline findings versus unexpected complications.
Three clients present with expected manifestations of their underlying illness, while one presents with a lethal complication.
Prioritization requires distinguishing between loud, expected symptoms and subtle, life-threatening acute changes.
2
Evaluate the respiratory status of the toddler with RSV.
Tachypnea (44 breaths/min), mild retractions, and a 92% oxygen saturation are determined to be stable, expected baselines for this condition.
Airway and breathing are priorities, but stable, expected respiratory distress does not override an active, unexpected emergency.
3
Assess the vital signs and neurological status of the 6-year-old with glomerulonephritis.
A blood pressure of 145/95 mm Hg is identified as severe hypertension for a 6-year-old. The sudden headache indicates neurological compromise.
Acute poststreptococcal glomerulonephritis can lead to sudden hypertensive crisis, which can rapidly progress to hypertensive encephalopathy.
4
Prioritize the client with the most immediate threat to life.
The client with glomerulonephritis is selected as the highest priority.
Impending seizures or stroke from hypertensive encephalopathy demands immediate medical intervention.

Anahtar Kavram

In pediatric triage, nurses must synthesize age-appropriate vital sign norms with disease pathology to prioritize clients experiencing unexpected, life-threatening complications (e.g., hypertensive encephalopathy) over those with loud but expected manifestations of their disease process (e.g., mild retractions in RSV, irritability in Kawasaki disease).
Soru 1978Soru →

A competent adult client admitted for an acute exacerbation of heart failure states, "I am tired of being here. I am going home right now." The client begins to gather their belongings. In what order should the registered nurse (RN) perform the following actions? Arrange the actions from first to last.

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Cevap

The correct chronological sequence is: 1) Explore the client's reasons, 2) Explain the health risks, 3) Contact the healthcare provider, 4) Ask the client to sign the AMA document, and 5) Remove the IV catheter.
Handling an Against Medical Advice (AMA) situation requires balancing client autonomy with the duty to provide safe care. The nurse must first act as an advocate by assessing the client's reasons and attempting to resolve them. If unsuccessful, the nurse ensures informed refusal by explaining the risks. The provider is then notified so they can intervene or prepare a safe outpatient plan. The AMA form is signed for legal protection, and finally, the client is safely discharged with their medical equipment (like IVs) removed.

Adım Adım Çözüm

1
Assess the client's concerns.
The root cause of the desire to leave is identified and potentially resolved.
Assessment is always the first step in the nursing process. Resolving the concern may prevent the AMA discharge entirely.
2
Educate the client on the risks of leaving.
The client achieves informed refusal.
Clients have the right to autonomy, but their refusal of treatment must be informed. The nurse must clearly state the medical risks of leaving.
3
Notify the healthcare provider.
The provider is informed of the client's status.
The provider must be aware of the change in condition and intent to leave, allowing them an opportunity to speak with the client or prescribe outpatient treatments.
4
Obtain the AMA signature.
Legal documentation of the client's decision is secured.
The AMA form provides legal protection for the hospital and staff by proving the client left against advice of their own volition.
5
Remove medical equipment and provide discharge instructions.
The client leaves the facility safely.
Refusal to remove an IV could be considered battery, and preventing the client from leaving is false imprisonment. The nurse must facilitate a safe exit even if it is AMA.

Anahtar Kavram

Client Autonomy and Against Medical Advice (AMA) Procedures
Soru 1979Soru →

A nurse is caring for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache and blurred vision. The nurse observes profuse diaphoresis and flushing above the level of the injury. The client's blood pressure is 210/110210/110 mmHg and heart rate is 5252 beats/min. In what order should the nurse perform the following interventions? Arrange the actions from first (highest priority) to last (lowest priority).

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Cevap

The correct sequence is to first elevate the head of the bed, then assess the urinary catheter for obstruction, followed by checking for a fecal impaction, administering a prescribed antihypertensive medication if symptoms persist, and finally documenting the event.
Autonomic dysreflexia is a medical emergency characterized by uncontrolled hypertension and bradycardia in clients with spinal cord injuries at or above T6. The immediate priority is to lower the blood pressure by elevating the head of the bed to a high Fowler's position, which uses orthostatic principles to reduce cerebral pressure. Once the client is repositioned, the nurse must quickly locate and remove the noxious stimulus causing the sympathetic surge. Bladder distention is the most common cause, so checking the catheter for kinks is the second step. If the bladder is not the issue, the nurse checks for bowel impaction, the second most common cause. If these non-pharmacological interventions fail to lower the blood pressure, administering a prescribed rapid-acting antihypertensive is the fourth step. Finally, documenting the critical event is completed after the client is stable.

Adım Adım Çözüm

1
Recognize the clinical signs of autonomic dysreflexia.
The nurse identifies the medical emergency based on the severe headache, hypertension, bradycardia, and diaphoresis in a client with a high spinal cord injury.
Accurate recognition dictates the immediate need for a specific sequence of emergency interventions to prevent stroke.
2
Elevate the head of the bed to 90 degrees.
The client's upper body is positioned upright.
This utilizes gravity to pool blood in the lower extremities, inducing orthostatic hypotension and immediately lowering the dangerously high blood pressure.
3
Identify and remove the noxious stimulus, starting with the urinary system.
The nurse checks the catheter for kinks or assesses for bladder distention.
Bladder distention is the most frequent trigger for autonomic dysreflexia. Resolving it often aborts the crisis.
4
Assess for gastrointestinal triggers if the urinary system is clear.
The nurse performs a rectal examination for fecal impaction.
Bowel impaction is the second most common trigger; it must be assessed if the bladder is not the cause.
5
Administer pharmacologic therapy if conservative measures fail.
The nurse gives a prescribed short-acting antihypertensive medication.
If removing noxious stimuli does not resolve the hypertension, medication is required to prevent a cerebrovascular accident.
6
Document the incident.
The event, interventions, and outcomes are recorded in the client's medical chart.
Documentation provides a legal record and informs the healthcare team, but it is always the final step after client safety is secured.

Anahtar Kavram

Prioritization of interventions for autonomic dysreflexia: Position, find the cause, treat, document.
Soru 1980Soru →

A client is receiving a continuous intravenous heparin infusion for an acute deep vein thrombosis (DVT) in the left lower extremity. When organizing the daily care plan, which instruction from the registered nurse (RN) to the unlicensed assistive personnel (UAP) represents appropriate delegation?

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Cevap: Assist the client with morning hygiene while ensuring the use of a soft-bristled toothbrush and an electric razor.

Cevap

The correct instruction is to assist the client with morning hygiene while ensuring the use of a soft-bristled toothbrush and an electric razor.
Assisting a client with activities of daily living (ADLs), such as personal hygiene, is entirely within the UAP's scope of practice. By specifically directing the UAP to use a soft-bristled toothbrush and an electric razor, the RN is correctly applying the 'Right Direction/Communication'. The RN has adapted a routine, delegable task to safely accommodate the client's high risk for bleeding due to the continuous heparin infusion.

Adım Adım Çözüm

1
Analyze the client's clinical status and associated risks.
The client has a DVT and is on a continuous heparin infusion, establishing a high risk for spontaneous bleeding and a risk for pulmonary embolism if the thrombus is dislodged.
Understanding the client's physiological vulnerabilities is required to determine the 'Right Circumstance' for delegation.
2
Evaluate the scope of practice for the Unlicensed Assistive Personnel (UAP).
UAPs can perform routine, standard procedures (like ADLs and hygiene) on stable clients but cannot perform assessments, teaching, or evaluation (EAT), nor can they perform tasks requiring clinical nursing judgment.
Delegation must strictly align with the established NCSBN boundaries for assistive personnel.
3
Critique each instruction against the five rights of delegation and DVT safety protocols.
Monitoring and evaluating are RN-only functions. Using the knee-gatch is physically dangerous for a DVT. Assisting with hygiene using specific bleeding precautions is safe and delegable.
Eliminating inappropriate or dangerous tasks isolates the single safe delegation choice.

Anahtar Kavram

Delegation of tasks to UAP considering clinical contraindications and bleeding precautions
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