Tüm alıştırma soruları

A nurse is analyzing the physiological data of a client who is $36$ hours post-operative following an exploratory laparotomy for an ischemic bowel. The client is intubated, mechanically ventilated, and has an arterial line and a central venous catheter in place. The latest assessment data reveals the following:

Based on these findings, which of the following conclusions and corresponding nursing actions are correct? (Select all that apply)

A nurse is assessing a client who is 4 hours post-operative following a total thyroidectomy. Which assessment findings should indicate to the nurse that the client is developing a severe physiological complication requiring immediate intervention? Select all that apply.

A nurse is developing a discharge plan for a client with advanced heart failure. The client requires home oxygen therapy equipment, needs to learn energy conservation techniques for bathing, and requires initial education on a strict low-sodium diet. The client expresses anxiety about managing these changes at home. Which collaborative actions should the nurse include in the plan of care? (Select all that apply.)

While completing morning rounds, a nurse assesses a client who underwent a partial colectomy the previous day. The client is receiving continuous intravenous fluids and utilizing a morphine patient-controlled analgesia (PCA) device. The nurse observes that the client is profoundly somnolent, minimally responsive to tactile stimuli, and exhibits shallow respirations at a rate of 7 breaths per minute with an oxygen saturation of 85% on room air. Which immediate interventions are appropriate to mitigate further physiological risk? Select all that apply.

A registered nurse coordinating an occupational health and wellness program at a corporate facility is planning activities for the upcoming fiscal year. Which of the proposed activities should the nurse classify as primary prevention strategies? Select all that apply.

A 65-year-old client is admitted to the progressive care unit 2 hours after a cardiac catheterization utilizing the right femoral artery approach. The provider prescribes strict supine bed rest with the affected extremity kept straight for 6 hours. The client reports a severe backache, feels hungry, and states an urgent need to void. Which nursing actions are appropriate to address the client's basic care and comfort needs? Select all that apply.

A client is admitted to the inpatient medical unit with severe abdominal cramping and frequent watery stools. Laboratory results confirm an active Clostridioides difficile (C. diff) infection. Which of the following infection control measures should the nurse implement? Select all that apply.

A critically ill client admitted with diabetic ketoacidosis (DKA) has a serum potassium level of $2.8$ mEq/L. The healthcare provider prescribes an intravenous infusion of $20$ mEq potassium chloride (KCl) in $100$ mL of $0.9\%$ sodium chloride to be administered over $1$ hour. The client has a double-lumen central venous catheter (CVC) in the right internal jugular vein. A continuous regular insulin infusion is actively running through the distal lumen. Which of the following actions should the nurse take regarding the potassium chloride administration? (Select all that apply.)

An interdisciplinary team is conducting rounds on a medical-surgical unit housing clients with various infectious diseases. Which of the following observed practices indicate correct adherence to transmission-based precautions? Select all that apply.

A nurse is evaluating a client who was intubated and placed on mechanical ventilation $2$ hours ago for acute respiratory failure. Current assessment findings include a heart rate of $132$ bpm, blood pressure of $86/52$ mm Hg, and cool, pale extremities. The latest arterial blood gas (ABG) results are pH $7.26$, $PaCO_2$ $62$ mm Hg, $HCO_3^-$ $25$ mEq/L, and $PaO_2$ $58$ mm Hg. Based on these assessment findings, which of the following clinical judgments and nursing actions are appropriate? Select all that apply.

A nurse assumes care for a client with severe Crohn's disease who is malnourished and receiving Total Parenteral Nutrition (TPN) via a peripherally inserted central catheter (PICC). The client's current vital signs are stable, and the continuous infusion is running on an electronic pump. Which of the following nursing actions must be included in the client's plan of care? Select all that apply.

A registered nurse (RN) on a neurology step-down unit is assigning tasks for the upcoming shift. The nursing team includes the RN, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP). Which of the following tasks are appropriate for the RN to delegate? Select all that apply.

A registered nurse (RN) enters a preoperative staging area to witness the surgical consent signature for a 65-year-old client scheduled for a pacemaker insertion. The client's spouse and an unlicensed assistive personnel (UAP) are present. The RN notes the client is acutely lethargic and disoriented, which the spouse reports began shortly after the client received a preoperative dose of intravenous midazolam. The surgeon is waiting to proceed and requests the RN to witness the signature immediately so the surgical schedule is not delayed. Which actions by the RN are appropriate in this situation? (Select all that apply.)

A nurse is caring for a young adult client who was voluntarily admitted to an inpatient psychiatric unit three days ago with severe major depressive disorder. This morning, the client suddenly appears remarkably peaceful, gives their favorite watch to a peer, and states, 'Everything makes sense now. I am leaving this hospital today.' The client demands their personal belongings and attempts to exit the locked unit. Which of the following actions are legally and ethically required by the nurse? Select all that apply.

A 71-year-old client on a surgical unit is preparing for a bowel resection later today. The client received an intravenous (IV) dose of morphine 45 minutes ago to manage acute abdominal pain. The healthcare provider has asked the registered nurse (RN) to witness the client's signature on the informed consent document. Upon entering the room, the client states, "I am willing to have the surgery, but I honestly do not remember what other options the doctor discussed with me." Which actions should the RN take? Select all that apply.

A registered nurse is reviewing the transmission-based precaution requirements for clients on a medical-surgical unit. Which of the following clients require the nurse to don a fit-tested N95 respirator and ensure placement in a negative-pressure room? Select all that apply.

While conducting an infection control audit across a multispecialty acute care facility, the nursing supervisor observes several staff members interacting with clients on transmission-based precautions. Which of the following observed actions require the nursing supervisor to intervene? (Select all that apply)

During morning rounds, the healthcare team is reviewing isolation protocols for an adult client with a sacral pressure injury that is actively draining and cultured positive for Methicillin-resistant Staphylococcus aureus (MRSA). Which of the following interventions must be included in the client's plan of care? (Select all that apply)

During a midday interdisciplinary huddle on a neurology acute care unit, the nursing staff reviews sudden changes in the conditions of several assigned clients. Which of the following client situations require immediate nursing intervention? Select all that apply.

An alert and oriented 78-year-old client with end-stage heart failure is admitted to the progressive care unit. The client explicitly requests a "Do Not Resuscitate" (DNR) status and refuses any future mechanical ventilation. The client's adult child, who is the legally designated healthcare proxy, arrives and demands that the healthcare team "do everything possible," including intubation if necessary. Which of the following ethical nursing actions should the nurse take? Select all that apply.