Tüm alıştırma soruları

A triage nurse in the emergency department is evaluating four clients, each with a history of substance use. Based on the presenting clinical findings, which client should the nurse identify as the highest priority for immediate medical intervention?

A critical care nurse is managing a client diagnosed with severe diabetic ketoacidosis. The client is currently receiving intravenous $0.9\%$ sodium chloride and a continuous regular insulin infusion. Clinical assessment reveals lethargy and a regular, deep respiratory rate of $32$ breaths per minute. The most recent laboratory results indicate:

• Arterial blood gas: pH $7.26$, PaCO $_2$ $29$ mmHg, HCO $_3^-$ $12$ mEq/L, PaO $_2$ $94$ mmHg
• Serum glucose: $242$ mg/dL ($13.4$ mmol/L)
• Serum potassium: $3.1$ mEq/L ($3.1$ mmol/L)

Which intervention should the nurse perform first to mitigate the risk of a fatal physiological complication?

A client admitted with community-acquired pneumonia is receiving a continuous intravenous infusion of 5% dextrose in water. The healthcare provider orders a scheduled dose of intravenous levofloxacin. What is the priority nursing action before attaching the secondary medication to the existing intravenous line?

A client arrives at the emergency department after sustaining a large laceration with significant blood loss. The bleeding is now controlled. Which vital sign change represents the body's earliest physiological adaptation to maintain adequate tissue perfusion?

An ambulatory care nurse is monitoring a 61-year-old client who underwent a percutaneous needle biopsy of the liver one hour ago. The client is currently lying supine with the head of the bed elevated and reports a new onset of dull right shoulder ache. The current heart rate is 112 beats per minute with a blood pressure of 98/62 mm Hg. Pre-procedure baseline vital signs were a heart rate of 78 beats per minute and a blood pressure of 128/76 mm Hg. Which action is the priority for the nurse to take?

A nurse is caring for a client who is receiving treatment for severe sepsis secondary to a perforated bowel. Upon assessment, the client is restless with cold, clammy skin. Vital signs include a heart rate of 134 beats/min, a blood pressure of 82/46 mm Hg, and a respiratory rate of 36 breaths/min with deep, rapid inspirations. The latest arterial blood gas (ABG) results are: pH 7.23, PaCO2 27 mm Hg, PaO2 84 mm Hg, and HCO3- 12 mEq/L. Based on these findings, which conclusion correctly directs the nurse's immediate priorities?

During the initial recovery period following a percutaneous coronary intervention via the right femoral approach, a client reports a new, deep ache in the right lower back. Vital sign trending over the past 30 minutes shows the heart rate increasing from 82 to 114 bpm and the blood pressure decreasing from 128/74 to 104/58 mm Hg. Which action is the priority?

A registered nurse is evaluating a client being treated for severe bacterial pneumonia. Over the past hour, the client has become visibly agitated and restless. Current assessment parameters include a heart rate of 118 beats per minute, a respiratory rate of 32 breaths per minute, and cool, diaphoretic extremities. Arterial blood gas (ABG) analysis on room air yields the following: pH 7.50, PaCO2 26 mm Hg, PaO2 54 mm Hg, and HCO3 22 mEq/L. Which of the following is the priority nursing intervention?

A nurse is assuming care for a client who underwent a lumbar puncture 30 minutes ago. Which of the following positions should the nurse maintain to minimize the client's risk of developing a post-procedure complication?

Following a diagnostic spinal tap, a client is transported back to the clinical unit. The client is alert and reports a dull ache near the lumbar insertion site. To promote client comfort and minimize the risk of procedural complications, which of the following actions should the nurse take?

A nurse is caring for a client admitted to the emergency department with a severe asthma exacerbation. Initially, the client was tachypneic with a respiratory rate of 34 breaths/min, and the initial arterial blood gas (ABG) revealed a pH of 7.50, PaCO2 of 28 mm Hg, and PaO2 of 72 mm Hg. Two hours after receiving continuous nebulized bronchodilators and intravenous corticosteroids, the client remains diaphoretic, is using accessory muscles to breathe, and has significantly diminished breath sounds bilaterally. A repeat ABG shows a pH of 7.38, PaCO2 of 42 mm Hg, and PaO2 of 64 mm Hg. Based on these findings, which of the following is the most accurate interpretation of the client's condition and the priority nursing action?

An older adult client with severe chronic obstructive pulmonary disease (COPD) is admitted for acute hypercapnic respiratory failure and requires continuous bilevel positive airway pressure (BiPAP). The client becomes intensely agitated, repeatedly attempting to remove the BiPAP mask and grasp at an indwelling arterial line. The healthcare provider prescribes bilateral soft wrist restraints and PRN intravenous lorazepam for severe agitation. Which intervention should the nurse implement to best maintain client safety?

A nurse receives the shift report for a group of assigned clients on a medical-surgical trauma unit. Which client requires the nurse's immediate assessment and intervention?

A nurse is caring for a client admitted 12 hours ago with severe acute pancreatitis. The client's current assessment reveals pale, diaphoretic skin and a total urine output of 25 mL over the past two hours. Current vital signs are: blood pressure 84/50 mm Hg, heart rate 136 beats/min, and respiratory rate 28 breaths/min. Arterial blood gas (ABG) results show a pH of 7.28, PaCO2 of 31 mm Hg, and HCO3- of 15 mEq/L. What is the priority nursing action?

The registered nurse (RN) is managing care delivery on an acute neurovascular step-down unit. Which task assignment demonstrates adherence to the principles of safe delegation?

While receiving total parenteral nutrition (TPN) through a single-lumen peripherally inserted central catheter (PICC), a client suddenly develops a high fever. The healthcare provider prescribes an immediate dose of intravenous ceftriaxone. What is the most appropriate action for the nurse to take?

A client is preparing for discharge following a 4-week hospitalization for severe Guillain-Barré syndrome. While the client's respiratory function is now stable, they exhibit significant residual weakness in their intrinsic hand muscles, preventing them from grasping eating utensils or manipulating buttons on clothing. The client's spouse expresses feeling overwhelmed about managing these daily care tasks at home and states, 'I do not know how we will afford all the special tools the doctor said we might need.' Which interdisciplinary collaboration action by the nurse is the most appropriate?

A registered nurse (RN) and an unlicensed assistive personnel (UAP) are working together on a nephrology unit. Which of the following client care activities is most appropriate for the RN to delegate to the UAP?

A client with newly diagnosed severe coronary artery disease is scheduled for a coronary artery bypass graft. The nurse brings the informed consent document to the client's room for a signature. The client states, "The doctor said I need this surgery, but I do not really understand what the alternative treatments are or what will happen if I refuse it. I will sign it anyway because I want to get better." Which of the following is the most appropriate action by the nurse?

A client with an intra-abdominal infection is receiving a continuous intravenous infusion of metronidazole. The client reports severe nausea, and the healthcare provider prescribes a dose of intravenous ondansetron. The client has a single peripheral intravenous line. After consulting a pharmacological reference, the nurse identifies that metronidazole and ondansetron are incompatible at the Y-site. Which action should the nurse take to safely administer the prescribed antiemetic?