Examkin

Physiological Integrity

1960 soru

Tüm türler1,960Çoktan seçmeli1,004Çoklu seçim425Sayısal102Sıralama429
Soru 801Soru →

An older adult client with a history of heart failure is prescribed daily oral digoxin and furosemide. During the morning rounds, the client reports a new onset of loss of appetite, mild nausea, and seeing a 'yellowish haze' around the lights in the room. Which of the following actions should the nurse take first?

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Cevap: Withhold the scheduled dose of digoxin and obtain a prescription for serum digoxin and potassium levels.

Cevap

The nurse should immediately withhold the scheduled dose of digoxin and prepare to check the client's serum digoxin and potassium levels.
The client's symptoms of anorexia, nausea, and yellow visual halos are hallmark signs of digoxin toxicity. Because the client is also taking furosemide, which causes potassium loss, they are at an exceptionally high risk for this toxicity (as hypokalemia potentiates digoxin). The immediate priority to ensure client safety is to withhold the medication to prevent further harm and to check serum levels to confirm the diagnosis.

Adım Adım Çözüm

1
Analyze the client's reported clinical symptoms.
The combination of anorexia, nausea, and visual disturbances (yellowish haze or halos) is identified as the classic presentation of digoxin toxicity.
Recognizing the adverse effects and toxicity signs of specific pharmacological therapies is essential for patient safety.
2
Correlate the client's current medication regimen with the presenting symptoms.
The client is taking furosemide, a loop diuretic known to cause potassium depletion.
Hypokalemia increases the myocardium's sensitivity to digoxin, significantly elevating the risk of toxicity even if the serum digoxin level is within the normal therapeutic range.
3
Determine the highest priority nursing action based on the assessment.
The nurse must withhold the next dose of digoxin to prevent further absorption and notify the provider to evaluate laboratory values.
Administering the medication would exacerbate the toxicity and could lead to life-threatening cardiac dysrhythmias.

Anahtar Kavram

Digoxin toxicity recognition and the effect of hypokalemia
Soru 802Soru →

A healthcare provider orders haloperidol 5 mg5\text{ mg} intramuscularly for an agitated adult client. The pharmacy dispenses a multi-dose vial labeled haloperidol 2 mg/mL2\text{ mg/mL}. How many  mL\text{ mL} should the nurse draw up to administer the correct dose? Record your answer using one decimal place.

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Cevap: 2.5

Cevap

2.5
Using the standard formula of (Desired / Have) × Volume, dividing the prescribed 5 mg5\text{ mg} by the available concentration of 2 mg2\text{ mg} yields exactly 2.5 mL2.5\text{ mL}.

Adım Adım Çözüm

1
Identify the standard formula for liquid medication calculations.
Formula: DesiredHave×Volume\frac{\text{Desired}}{\text{Have}} \times \text{Volume}
This standard formula ensures accurate conversion from the prescribed mass to the required physical volume.
2
Extract the given values from the prescription and the medication label.
Desired = 5 mg5\text{ mg}; Have = 2 mg2\text{ mg}; Volume = 1 mL1\text{ mL}.
Mapping the known values correctly into the formula prevents fundamental calculation errors.
3
Substitute the values into the formula and solve the equation.
5 mg2 mg×1 mL=2.5 mL\frac{5\text{ mg}}{2\text{ mg}} \times 1\text{ mL} = 2.5\text{ mL}.
Dividing 55 by 22 yields exactly 2.52.5, which represents the correct volume in mL\text{mL}.

Anahtar Kavram

Basic Parenteral Medication Dosage Calculation
Soru 803Soru →

An older adult client is placed on strict bed rest due to severe generalized weakness and fragile skin. Which nursing action is most appropriate to promote comfort and prevent skin breakdown?

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Cevap: Reposition the client using a lift sheet and limit the head of the bed elevation to 30 degrees.

Cevap

The most appropriate action is to reposition the client using a lift sheet and limit the head of the bed elevation to 30 degrees.
Limiting the head of the bed elevation to 30 degrees or less reduces shearing forces on the sacrum and coccyx. Simultaneously, using a lift sheet or draw sheet prevents skin friction during repositioning. These complementary actions are essential for maintaining skin integrity and promoting comfort in vulnerable, immobile clients.

Adım Adım Çözüm

1
Analyze the client's current risk factors based on the clinical presentation.
The client is an older adult on strict bed rest with generalized weakness and fragile skin, indicating a high risk for pressure injuries caused by friction and shearing forces.
Identifying the primary physiological risks determines the priority comfort and safety interventions required in the care plan.
2
Evaluate the proposed positioning and handling techniques for safety and efficacy.
Using a lift sheet prevents skin friction, and keeping the head of the bed at or below 30 degrees prevents shearing forces on the sacrum.
Evidence-based guidelines for pressure injury prevention emphasize minimizing both shear (tissue layers sliding against each other) and friction (skin rubbing against surfaces).
3
Review the remaining options for scope of practice violations or clinical misconceptions.
Delegating skin evaluation to a UAP violates the nurse's scope of practice. Furthermore, dismissing new incontinence as normal aging ignores a potential acute pathology.
Safe nursing practice requires appropriate delegation of tasks and accurate differentiation between normal aging changes and pathological signs.

Anahtar Kavram

Pressure Injury Prevention and Safe Repositioning
Tahmini Süre:1m 0s
Soru 804Soru →

A client with multiple sclerosis is admitted with an acute exacerbation, experiencing severe lower extremity spasticity, profound weakness, and functional incontinence. The healthcare provider prescribes strict bed rest. The nurse is updating the plan of care to promote optimal basic care, comfort, and safety. Which of the following interventions should the nurse include? Select all that apply.

Geçerli olan tümünü seçin

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Cevap: Use a friction-reducing device for repositioning and place trochanter rolls along the client's hips.; Establish a scheduled toileting program by offering the bedpan every 2 hours during waking hours.; Perform passive range-of-motion (ROM) exercises slowly, stopping temporarily if a muscle spasm occurs.

Cevap

The correct interventions are using a friction-reducing device with trochanter rolls, establishing a scheduled toileting program, and performing slow, passive range-of-motion exercises.
The correct interventions focus on safely maintaining skin integrity, promoting joint mobility, and ensuring safe elimination for an immobile client. Using a friction-reducing device with trochanter rolls prevents shearing and maintains neutral hip alignment. Establishing a scheduled toileting program manages functional incontinence proactively, protecting the skin from moisture-associated breakdown. Performing passive range-of-motion exercises slowly, while pausing during spasms, prevents contractures without causing muscle injury or severe pain.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client is completely immobile, has muscle spasticity, and is incontinent, placing them at high risk for skin breakdown, contractures, and deep vein thrombosis (DVT).
Identifying the primary physiological risks guides the selection of safe basic care interventions.
2
Evaluate the interventions for skin integrity and hygiene.
Friction-reducing devices prevent shearing, and scheduled toileting prevents moisture damage. However, delegating the evaluation of skin integrity to a UAP is an unsafe nursing practice.
Skin protection requires appropriate physical tools, proactive hygiene routines, and registered nurse-level assessment.
3
Evaluate the interventions for mobility and positioning.
Trochanter rolls maintain joint alignment, and slow passive ROM prevents contractures. Placing pillows under the popliteal spaces is strictly contraindicated due to the high risk of DVT.
Proper positioning must avoid compromising circulation in a bedbound client.
4
Evaluate the interventions for safety and comfort.
Using restraints to prevent a client from removing incontinence garments is a violation of restraint protocols.
Restraint use is heavily regulated and limited strictly to preventing immediate physical harm when all other alternatives have failed.

Anahtar Kavram

Basic Care and Comfort: Immobility Management
Soru 805Soru →

While assuming care for a client with advanced hepatic cirrhosis who recently underwent a large-volume paracentesis, the nurse evaluates the client's current status. The procedure notes indicate that 44 liters of ascitic fluid were removed. Which assessment finding is the most critical indicator of a developing physiological complication that requires immediate intervention?

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Cevap: A steady increase in heart rate from 8686 to 114114 bpm combined with a narrowing pulse pressure

Cevap

A steady increase in heart rate from 86 to 114 bpm combined with a narrowing pulse pressure
The correct answer identifies classical early compensatory signs of hypovolemic shock. Large-volume paracentesis frequently causes profound intravascular fluid shifts into the peritoneal space. The body compensates for this sudden loss of circulating volume by increasing the heart rate (tachycardia) and increasing peripheral vascular resistance, which manifests as a narrowing pulse pressure. This critical finding demands immediate medical intervention to prevent severe physiological deterioration.

Adım Adım Çözüm

1
Analyze the procedural risks associated with the client's history.
Large-volume paracentesis (removal of significant amounts of fluid, such as 44 liters) can lead to profound and rapid fluid shifts in clients with compromised liver function.
Removing ascitic fluid abruptly decreases intra-abdominal pressure, causing vasodilation and shifting fluid out of the intravascular space (third-spacing).
2
Evaluate the assessment findings against potential physiological complications.
Tachycardia (heart rate increasing to 114114 bpm) and a narrowing pulse pressure are classical early compensatory signs of hypovolemic shock.
The body attempts to compensate for the sudden decrease in circulating intravascular volume by increasing the heart rate and constricting peripheral vessels.
3
Prioritize the findings to determine the most critical indicator.
The hemodynamic instability takes immediate precedence over normal ABGs, therapeutic positioning, and expected mild post-procedural fatigue.
Unrecognized and untreated hypovolemic shock can rapidly progress to vital organ ischemia and cardiovascular collapse, demanding immediate interventions such as IV albumin administration.

Anahtar Kavram

Post-Paracentesis Hemodynamic Monitoring and Shock Recognition
Soru 806Soru →

A nurse is caring for a client who was admitted to the medical unit with a 3-day history of severe, persistent diarrhea. Based on this clinical presentation, which acid-base imbalance is the client at greatest risk of developing?

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Cevap: Metabolic acidosis

Cevap

Metabolic acidosis
Intestinal fluids below the pyloric sphincter are highly alkaline because they are rich in bicarbonate. When a client experiences severe diarrhea, they lose excessive amounts of this base. The depletion of bicarbonate leaves a relative excess of hydrogen ions (acid) in the blood, causing the serum pH to drop and resulting in metabolic acidosis.

Adım Adım Çözüm

1
Identify the primary source and type of fluid loss.
The client has severe diarrhea, meaning they are losing large amounts of lower gastrointestinal fluids.
Different bodily fluids have different pH levels, so the source of the fluid loss determines the resulting acid-base imbalance.
2
Determine the primary solute lost in diarrhea.
Lower intestinal fluids are highly alkaline because they contain large amounts of bicarbonate.
The pancreas secretes bicarbonate into the intestines to neutralize stomach acid.
3
Correlate the solute loss to the corresponding acid-base imbalance.
Loss of a base (bicarbonate) leads to an increasingly acidic environment in the blood, resulting in metabolic acidosis.
When bicarbonate levels drop, the ratio of acid to base increases, lowering the serum pH.

Anahtar Kavram

Acid-base imbalances related to gastrointestinal fluid loss
Soru 807Soru →

A nurse is evaluating a 64-year-old client who is 12 hours postoperative following a massive bowel resection with the creation of a colostomy. The client is receiving continuous intravenous fluids and has a nasogastric (NG) tube connected to low intermittent wall suction. Which of the following assessment findings represent a high-risk physiological complication requiring the nurse's immediate intervention? Select all that apply.

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Cevap: The client's radial pulse is 122 beats/min and thready, with a narrowing pulse pressure.; Arterial blood gas (ABG) results indicate a pH of 7.52, PaCO2 of 42 mm Hg, and HCO3- of 34 mEq/L.; The client exhibits a positive Trousseau's sign when blood pressure is being measured.

Cevap

The findings requiring immediate intervention are the thready tachycardia with narrowing pulse pressure (indicating shock), the severe metabolic alkalosis on the ABG, and the positive Trousseau's sign (indicating hypocalcemia).
A thready heart rate of 122 beats/min with a narrowing pulse pressure indicates early hypovolemic shock, requiring immediate fluid resuscitation. The ABG reveals severe metabolic alkalosis (pH > 7.45, HCO3- > 26 mEq/L) directly caused by the continuous loss of gastric hydrochloric acid from the NG suction. Furthermore, metabolic alkalosis decreases ionized calcium levels in the blood, leading to acute hypocalcemia which manifests as neuromuscular excitability (a positive Trousseau's sign). All three of these findings represent severe physiological decompensation requiring immediate medical intervention.

Adım Adım Çözüm

1
Analyze the clinical scenario
The client is 12 hours post-op from a massive bowel resection and has active NG suction.
Establishing the postoperative timeframe and current therapies helps predict potential complications versus normal findings.
2
Evaluate vital signs for signs of shock
Identified a thready heart rate of 122 beats/min and a narrowing pulse pressure as abnormal.
These are classic early indicators of hypovolemia or hemorrhage, which are high-risk complications after major abdominal surgery.
3
Interpret ABG values in the context of NG suction
Identified a pH of 7.52 and HCO3- of 34 mEq/L as uncompensated metabolic alkalosis.
Continuous low wall suction removes large amounts of hydrochloric acid from the stomach, causing alkalosis.
4
Connect metabolic alkalosis to electrolyte shifts
Identified the positive Trousseau's sign as a manifestation of hypocalcemia.
Alkalemia increases calcium binding to albumin, reducing ionized calcium and causing neuromuscular excitability.
5
Rule out expected postoperative findings and appropriate care
Ruled out the absent bowel sounds, normal PaO2, and semi-Fowler's position.
Absent bowel sounds are expected for 24-72 hours post-op, normal ABG oxygenation needs no intervention, and slight knee flexion reduces abdominal tension appropriately.

Anahtar Kavram

Recognition of life-threatening complications (hypovolemic shock, metabolic alkalosis, and acute hypocalcemia) following massive abdominal surgery and gastric suction.
Soru 808Soru →

A 6565-year-old client is receiving a continuous intravenous (IV) infusion of diltiazem at 15 mg/hr15 \text{ mg/hr} through a single-lumen peripherally inserted central catheter (PICC) for the management of atrial fibrillation. The client suddenly becomes lethargic and diaphoretic. The nurse assesses a heart rate of 32 beats/min32 \text{ beats/min} and a blood pressure of 72/40 mmHg72/40 \text{ mmHg}. The healthcare provider prescribes atropine 1 mg1 \text{ mg} IV push STAT. The client has no other IV access. Which sequence of actions is the safest and most appropriate for the nurse to administer the prescribed atropine?

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Cevap: Stop the diltiazem infusion, aspirate 5 mL5 \text{ mL} of blood from the PICC hub, flush with normal saline, administer the atropine, and flush again.

Cevap

The nurse must first stop the diltiazem infusion, aspirate blood from the PICC hub to clear the residual medication from the catheter dead space, and then flush and administer the atropine.
The correct action safely addresses the medical emergency by prioritizing the administration of the rescue medication while actively preventing further harm. Because the single-lumen PICC is filled with diltiazem (the drug causing the toxicity), the nurse must aspirate the dead space before flushing. This removes the residual drug from the catheter, preventing a rapid bolus of diltiazem from entering the heart.

Adım Adım Çözüm

1
Identify the cause of the client's deterioration.
The client is experiencing symptomatic bradycardia and hypotension, which are life-threatening adverse effects of the continuous diltiazem infusion.
Recognizing drug toxicity dictates the immediate cessation of the offending agent.
2
Determine the safest method to administer the rescue medication (atropine) using the existing single-lumen PICC.
The catheter must be cleared of the offending drug before the rescue medication is given.
Central venous catheters have internal volume (dead space) that holds medication. The nurse must not flush this residual medication into the client.
3
Select the correct sequence of line management.
Stop the pump, attach an empty syringe, aspirate 3-5 mL of blood to remove the residual diltiazem, discard the syringe, flush with normal saline, administer the atropine, and flush again.
This sequence ensures the client receives the life-saving atropine rapidly without inadvertently receiving a dangerous bolus of diltiazem.

Anahtar Kavram

When converting a central line lumen that is infusing a vasoactive or highly potent medication into a port for an emergent IV push, the nurse must aspirate the catheter's dead space to prevent inadvertently administering a rapid, potentially fatal bolus of the continuous medication.
Tahmini Süre:2m 0s
Soru 809Soru →

A client with a history of heart failure is admitted to the progressive care unit. During the night shift, the client suddenly awakens with severe dyspnea, a productive cough with frothy pink sputum, and an oxygen saturation of 84% on room air. The nurse observes profound jugular venous distention and hears diffuse coarse crackles upon auscultation. Arrange the following nursing actions in the correct order of priority from first to last.

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Cevap

The correct priority sequence is to first position the client upright with legs dependent, then apply high-flow oxygen, followed by administering intravenous furosemide, and finally inserting an indwelling urinary catheter.
In acute cardiogenic pulmonary edema, the priority is to immediately improve oxygenation and reduce cardiac workload. Positioning the client in a high-Fowler's position with legs dependent uses gravity to decrease venous return (preload) and allows the lungs to expand more fully. This is the fastest, most immediate independent nursing intervention. Next, applying high-flow oxygen addresses the severe hypoxemia caused by fluid in the alveoli. Once the client's airway and breathing are acutely supported, intravenous furosemide is administered to initiate rapid diuresis, thereby removing fluid and further reducing preload. Finally, inserting a urinary catheter is necessary to accurately track the massive diuresis expected from the furosemide, making it the logical final step in this sequence.

Adım Adım Çözüm

1
Evaluate the client's immediate physiological needs based on ABCs (Airway, Breathing, Circulation).
The client is determined to be in acute respiratory distress due to fluid overload (flash pulmonary edema).
Establishing the primary threat to life dictates the prioritization of all subsequent nursing interventions.
2
Prioritize mechanical respiratory and hemodynamic interventions.
Positioning the client upright with legs dependent is selected as the immediate first action.
Sitting the client up immediately decreases venous return to the heart (reducing preload) and allows for maximum diaphragmatic excursion to ease breathing.
3
Address the acute hypoxemia.
Applying oxygen via a non-rebreather face mask is prioritized as the second action.
The client's oxygen saturation is 84%, requiring immediate high-concentration oxygen therapy to prevent severe tissue hypoxia.
4
Administer pharmacological treatment for the underlying fluid overload.
Intravenous furosemide is given.
Loop diuretics reduce the circulating fluid volume, thereby decreasing pulmonary congestion, but they must be administered after immediate airway and breathing stabilization.
5
Implement necessary monitoring tools for the pharmacological intervention.
An indwelling urinary catheter is inserted.
Accurate measurement of urine output is critical to evaluate the effectiveness of the rapid-acting loop diuretic.

Anahtar Kavram

Prioritization of care in acute cardiogenic pulmonary edema follows the principles of immediate preload reduction and airway management, beginning with physical positioning, followed by oxygenation, pharmacological diuresis, and precise fluid monitoring.
Soru 810Soru →

A nurse is developing a plan of care for an older adult client who is bedbound, has a continuous peripheral IV infusion, and occasionally experiences urinary incontinence. The client's family reports that the client has suddenly become much more confused over the past 24 hours. Which of the following nursing actions should the nurse include in the plan of care? Select all that apply.

Geçerli olan tümünü seçin

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Cevap: Implement a turning schedule to reposition the client at least every 2 hours using pillows for support.; Apply a moisture-repellent barrier cream to the perineal skin after cleansing the area following incontinent episodes.

Cevap

The correct nursing actions are implementing a 2-hour turning schedule with pillows for support and applying a moisture-repellent barrier cream to the perineal skin after incontinent episodes.
The correct nursing actions focus on maintaining skin integrity and promoting comfort through established, evidence-based practices. Implementing a turning schedule every 2 hours with pillow support effectively offloads pressure from vulnerable bony prominences. Additionally, applying a moisture-repellent barrier cream after cleansing incontinent episodes protects the epidermal layer from the caustic effects of urine and feces, preventing incontinence-associated dermatitis.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and identify primary risk factors.
The client is an older adult, bedbound, incontinent, with a peripheral IV, and experiencing a sudden onset of acute confusion. The main risks are skin breakdown, potential infection or delirium, and safety hazards.
Identifying the client's specific vulnerabilities is essential to prioritize safe and effective basic care interventions.
2
Evaluate the proposed interventions for maintaining skin integrity.
Repositioning every 2 hours and using barrier creams are correct, evidence-based practices. Delegating skin assessment and keeping the head of the bed at 60 degrees are incorrect and potentially harmful actions.
Assessment remains strictly an RN responsibility. A 60-degree elevation significantly increases sacral shearing forces, whereas the recommended angle is 30 degrees or less for resting.
3
Evaluate the proposed interventions for managing the client's confusion and safety.
Applying immediate restraints and attributing sudden confusion to normal aging are incorrect actions.
Sudden confusion indicates an acute pathological process (like an infection or delirium), not normal aging. Restraints are strictly a last resort after all other less restrictive measures have failed.

Anahtar Kavram

Basic care and comfort for the bedbound older adult involves prioritizing skin integrity through proper positioning and hygiene, using the least restrictive safety measures, recognizing acute cognitive changes as abnormal, and understanding the legal scope of practice for delegation.
Soru 811Soru →

Upon receiving a prescription for a loading dose of intravenous phenytoin, a nurse evaluates a client's vascular access. The client currently has a single peripheral catheter with 5% dextrose in water (D5W) infusing at 75 mL/hr. Which sequence of actions ensures safe delivery of the antiepileptic?

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Cevap: Suspend the primary fluid, flush the catheter with 0.9% sodium chloride, administer the phenytoin, and flush again with 0.9% sodium chloride.

Cevap

The nurse must suspend the primary dextrose fluid, flush the catheter with 0.9% sodium chloride, administer the phenytoin, and flush again with 0.9% sodium chloride.
Phenytoin is highly incompatible with dextrose-containing solutions and will form a solid precipitate if mixed. To administer the medication safely through a single line currently running a dextrose solution, the nurse must temporarily pause the continuous infusion, flush the line with 0.9% sodium chloride (normal saline) to clear any residual dextrose, administer the phenytoin, and then perform a final flush with normal saline before resuming the primary infusion.

Adım Adım Çözüm

1
Analyze the prescribed medication and the current continuous infusion.
The nurse identifies that intravenous phenytoin is prescribed and 5% dextrose in water (D5W) is currently infusing through the only available vascular access.
Establishing baseline parameters is necessary to determine medication compatibility and safe administration routes.
2
Determine the compatibility of phenytoin with the primary infusion fluid.
The nurse recognizes that phenytoin is highly incompatible with all dextrose-containing solutions.
When mixed with dextrose, phenytoin quickly forms a solid micro-precipitate that can cause a life-threatening embolus.
3
Formulate a safe administration strategy using the existing single peripheral line.
The nurse plans to pause the D5W, flush the line thoroughly with 0.9% sodium chloride (normal saline), administer the drug at a safe rate, and flush again with normal saline before restarting the D5W.
This specific sequence completely separates the incompatible fluids, ensuring the medication safely reaches the client without crystallizing in the tubing.

Anahtar Kavram

Intravenous Compatibility and Safe Phenytoin Administration
Soru 812Soru →

A nurse is delegating care tasks to an unlicensed assistive personnel (UAP) for a client who is receiving continuous enteral tube feedings, wears bilateral sequential compression devices (SCDs), and is on contact precautions for a Clostridioides difficile infection. Which instruction provided by the nurse to the UAP is appropriate?

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Cevap: Remove the sequential compression sleeves during the bed bath and ensure the legs are completely dry before reapplying them.

Cevap

The correct instruction is to remove the sequential compression sleeves for the bed bath and ensure the client's legs are completely dry before reapplying them.
The UAP is permitted to remove and reapply sequential compression devices (SCDs) to perform basic hygiene tasks like a bed bath. Instructing the UAP to ensure the skin is completely dry before reapplication is a correct and necessary intervention to prevent moisture accumulation, which can lead to skin maceration and breakdown. This task safely falls within the UAP's scope of providing basic care and comfort.

Adım Adım Çözüm

1
Analyze the client's risk factors and prescribed therapies.
Identified continuous tube feeding (aspiration risk), SCDs (skin integrity risk), and C. difficile (transmission risk).
Comprehensive care requires addressing mobility, nutrition, and infection control safely during basic care tasks.
2
Evaluate the UAP scope of practice for the suggested interventions.
Determined that operating feeding pumps is outside the UAP's scope, while assisting with hygiene and SCD removal/reapplication is within scope.
Safe delegation requires matching the task to the personnel's legal and educational boundaries.
3
Assess the physical positioning and safety implications of each instruction.
Identified that lowering the bed flat without RN intervention to pause the pump causes aspiration risk, and alcohol rub fails to eradicate C. difficile spores.
Nursing instructions must not inadvertently cause harm or violate standard safety protocols.
4
Select the appropriate basic care instruction.
Selected the instruction regarding SCD removal and skin drying.
This is a safe, delegable basic care task that promotes skin integrity and comfort.

Anahtar Kavram

Delegation of basic care tasks while maintaining safety protocols for enteral feeding, infection control, and skin integrity.
Soru 813Soru →

A client is admitted to the neurotrauma unit following a complete spinal cord injury at the C5 level. Several hours after admission, the nurse assesses the client and finds a blood pressure of 82/46 mm Hg, a heart rate of 44 beats/minute, and warm, flushed skin on the extremities. Based on these clinical findings, which intervention should the nurse anticipate as the highest priority?

Cevabı ve açıklamayı göster

Cevap: Prepare to administer intravenous atropine and a continuous vasopressor infusion.

Cevap

The priority action is to prepare to administer intravenous atropine and a continuous vasopressor infusion.
The client's presentation of hypotension, bradycardia, and warm, flushed skin following a high spinal cord injury indicates neurogenic shock. This life-threatening condition occurs due to a sudden disruption of sympathetic nervous system pathways, leading to massive vasodilation (causing warm skin and hypotension) and unopposed parasympathetic tone (causing bradycardia). The priority intervention is to restore vascular tone using continuous vasopressor infusions and to manage the severe bradycardia with medications such as intravenous atropine.

Adım Adım Çözüm

1
Analyze the client's vital signs and physical assessment findings.
The client is exhibiting profound hypotension (82/46 mm Hg), severe bradycardia (44 beats/min), and warm, flushed skin.
Identifying abnormal vital sign patterns is the first step in recognizing life-threatening complications following a spinal cord injury.
2
Correlate the clinical findings with the mechanism of injury to identify the specific physiological complication.
The combination of a cervical spine injury, hypotension, bradycardia, and warm skin points directly to neurogenic shock, rather than hypovolemic shock.
Neurogenic shock occurs due to a massive loss of sympathetic nervous system tone, which uniquely causes bradycardia and vasodilation (warm skin) instead of the compensatory tachycardia and vasoconstriction seen in other forms of shock.
3
Determine the most appropriate immediate medical intervention to stabilize the client.
The nurse must anticipate administering vasopressors (to cause vasoconstriction and increase blood pressure) and atropine (to block vagal stimulation and increase heart rate).
Because the root cause is a loss of vasomotor tone and unopposed parasympathetic stimulation, treatment must artificially restore vascular resistance and heart rate.

Anahtar Kavram

Neurogenic Shock Recognition and Management
Soru 814Soru →

A client is receiving continuous gastric suctioning via a nasogastric tube following abdominal surgery. Based on the physiological loss of gastric secretions, which acid-base imbalance should the nurse monitor for in this client?

Cevabı ve açıklamayı göster

Cevap: Metabolic alkalosis

Cevap

Metabolic alkalosis is the correct acid-base imbalance to monitor for in this scenario.
Gastric secretions contain a high amount of hydrochloric acid. When these secretions are continuously removed from the body via a nasogastric tube, the body loses a significant amount of hydrogen ions. This direct loss of acid causes a relative increase in circulating blood bicarbonate levels, shifting the body's pH upward and resulting in metabolic alkalosis.

Adım Adım Çözüm

1
Identify the primary physiological fluid being lost.
The client is losing significant amounts of gastric secretions through continuous nasogastric suctioning.
Determining the source and type of fluid loss is necessary to understand which electrolytes and acids or bases are being depleted from the body.
2
Determine the acid-base composition of the lost fluid.
Gastric fluid contains a high concentration of hydrochloric acid.
Knowing the chemical composition of the fluid helps predict the resulting systemic imbalance.
3
Deduce the systemic effect of losing this fluid.
Losing acid from the body leaves a relative excess of base (bicarbonate) in the bloodstream, leading to metabolic alkalosis.
The body's pH shifts toward an alkalotic state when significant amounts of acid are physically removed through the gastrointestinal tract.

Anahtar Kavram

Acid-Base Imbalances: Gastrointestinal Fluid Loss
Soru 815Soru →

A client with right-sided hemiparesis requires assistance moving from the bed to a sitting position in a wheelchair. In which order should the nurse perform the following actions to safely complete this transfer?

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first position the wheelchair on the strong side, lock all brakes, assist the client to sit and dangle, apply the gait belt, and finally have the client pivot on their strong leg.
Safe client transfers require sequential preparation to minimize fall risk. The environment must first be set up correctly by placing the wheelchair on the client's unaffected (strong) side and locking all brakes. Once the environment is secure, the client is brought to a seated position to stabilize blood pressure (dangling). A gait belt is then applied for physical support before the actual physical movement occurs. Finally, the client uses their strong side to bear weight and pivot into the wheelchair.

Adım Adım Çözüm

1
Position the wheelchair on the left side at a 45-degree angle.
The destination is prepared optimally.
Placing the wheelchair on the strong side ensures the client can use their unaffected side to guide the transfer.
2
Lock the brakes on the bed and wheelchair.
The equipment is immobilized.
Prevents shifting of the bed or wheelchair, significantly reducing the risk of a fall.
3
Assist the client to sit on the edge of the bed and dangle.
The client is sitting safely on the bed edge.
Allows for assessment of orthostatic hypotension and stabilizes blood pressure before standing.
4
Apply a gait belt around the waist.
The nurse has a secure way to hold the client.
Provides a safe handhold for the nurse to control the client's center of gravity during the pivot.
5
Instruct the client to bear weight on the left leg and pivot.
The client safely completes the transfer into the wheelchair.
Bearing weight on the strong (left) leg compensates for the right-sided hemiparesis and prevents the knee from buckling.

Anahtar Kavram

Safe client transfer techniques and mobility assistance for hemiparesis.
Soru 816Soru →

A hospitalized client requires an intravenous dose of phenytoin for seizure management. The client's continuous intravenous fluids consist of 5% dextrose in water infusing at 100 mL/hr100\text{ mL/hr} through a single-lumen peripheral catheter. Which action represents the safest method for the nurse to administer this medication?

Cevabı ve açıklamayı göster

Cevap: Pause the continuous intravenous fluids, flush the catheter with 0.9% sodium chloride, administer the medication at a maximum rate of 50 mg/min50\text{ mg/min}, and flush again with 0.9% sodium chloride.

Cevap

Pause the continuous intravenous fluids, flush the catheter with 0.9% sodium chloride, administer the medication at a maximum rate of 50 mg/min50\text{ mg/min}, and flush again with 0.9% sodium chloride.
The correct action involves pausing the dextrose infusion and flushing the line with 0.9% sodium chloride (normal saline) before and after administration. Phenytoin is highly incompatible with dextrose solutions and will form a precipitate if they come into contact. Furthermore, intravenous phenytoin must be administered slowly, not exceeding 50 mg/min50\text{ mg/min}, to prevent cardiovascular toxicity such as severe hypotension and arrhythmias.

Adım Adım Çözüm

1
Identify the primary intravenous fluid currently infusing.
The client is receiving 5% dextrose in water.
Compatibility must be established before administering any intravenous medication.
2
Determine the compatibility of phenytoin with the infusing fluid.
Phenytoin is incompatible with dextrose solutions and will form a precipitate.
Mixing incompatible drugs can cause crystal formation, leading to catheter occlusion or emboli.
3
Determine the correct administration protocol for the medication.
The line must be flushed with normal saline before and after the dose, and the medication must be pushed slowly (max 50 mg/min50\text{ mg/min}).
Normal saline clears the line of dextrose, and a slow administration rate prevents cardiovascular toxicity.

Anahtar Kavram

Phenytoin is highly incompatible with dextrose solutions and must be administered slowly (no faster than 50 mg/min50\text{ mg/min}) using 0.9% sodium chloride to prevent precipitation and cardiovascular adverse effects.
Soru 817Soru →

A nurse is caring for an 80 kg80\text{ kg} adult client experiencing status epilepticus. The healthcare provider prescribes a loading dose of intravenous (IV) phenytoin at 15 mg/kg15\text{ mg/kg}. The client currently has a continuous infusion of 5% dextrose in water (D5W)5\%\text{ dextrose in water (D5W)} running at 50 mL/hr50\text{ mL/hr} via a 22-gauge peripheral IV catheter in the right dorsal hand. Based on the pharmacological properties of phenytoin, which of the following is the most appropriate action by the nurse?

Cevabı ve açıklamayı göster

Cevap: Establish a new 18-gauge IV access in a large proximal vein, dilute the dose in 0.9% sodium chloride0.9\%\text{ sodium chloride}, and infuse over at least 30 minutes.

Cevap

Establish a new 18-gauge IV access in a large proximal vein, dilute the dose in 0.9% sodium chloride0.9\%\text{ sodium chloride}, and infuse over at least 30 minutes.
Intravenous phenytoin requires strict adherence to multiple safety parameters. The total dose is 1200 mg1200\text{ mg} (80 kg×15 mg/kg80\text{ kg} \times 15\text{ mg/kg}). Because the maximum safe administration rate is 50 mg/min50\text{ mg/min}, the absolute minimum infusion time is 24 minutes. Infusing over 30 minutes achieves a safe rate of 40 mg/min40\text{ mg/min}. Furthermore, phenytoin precipitates in dextrose and requires dilution in 0.9% sodium chloride0.9\%\text{ sodium chloride}. Because it is a known vesicant that can cause 'purple glove syndrome' (severe localized ischemia and edema), it must be administered through a large-bore catheter (18- or 20-gauge) in a large proximal vein, avoiding small distal veins like those in the hand.

Adım Adım Çözüm

1
Calculate the total required dose based on the client's weight.
80 kg×15 mg/kg=1200 mg80\text{ kg} \times 15\text{ mg/kg} = 1200\text{ mg} of phenytoin.
Accurate weight-based dosing is critical for determining the total medication volume and subsequent infusion parameters.
2
Determine the minimum safe infusion time based on the maximum allowable rate.
1200 mg÷50 mg/min=24 minutes1200\text{ mg} \div 50\text{ mg/min} = 24\text{ minutes}.
Phenytoin has a strict maximum administration rate of 50 mg/min50\text{ mg/min} in adults to prevent severe hypotension and lethal dysrhythmias.
3
Evaluate the current IV access and fluid compatibility.
The current 22-gauge IV is too small for a vesicant, and the continuous D5W infusion is incompatible with phenytoin.
Phenytoin precipitates in dextrose and is highly irritating to veins, risking purple glove syndrome if given in small distal veins.
4
Select the intervention that meets all safety criteria: dose rate, compatibility, and vascular access.
Inserting a new 18-gauge IV in a large vein, diluting with normal saline, and infusing over 30 minutes (40 mg/min40\text{ mg/min}) is the only completely safe option.
This comprehensively addresses the pharmacological constraints and safety requirements for IV phenytoin administration.

Anahtar Kavram

Safe administration of intravenous phenytoin requires synthesis of weight-based dosing, rate calculation (max 50 mg/min50\text{ mg/min}), fluid compatibility (only 0.9% NaCl0.9\%\text{ NaCl}), and vesicant precautions.
Soru 818Soru →

A nurse is assigned to care for a client who requires a transfusion of packed red blood cells (PRBCs) due to symptomatic anemia. Which of the following actions must the nurse perform to ensure safe administration of the blood product? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Obtain and document the client's baseline vital signs immediately prior to initiating the transfusion.; Verify the client's identity and the blood product information with a second registered nurse at the bedside.; Check the client's medical record to confirm that a signed informed consent document is present.

Cevap

The nurse must obtain baseline vital signs, verify the client and blood product with a second registered nurse, and confirm that informed consent is signed in the medical record.
Safe blood transfusion administration requires strict adherence to core safety protocols. Verifying the client and product with a second nurse prevents catastrophic incompatibility. Taking baseline vital signs establishes a reference point to detect adverse reactions early. Finally, ensuring informed consent is signed protects the client's legal rights and confirms they understand the procedure's risks.

Adım Adım Çözüm

1
Review the prescribed orders and the client's medical record.
The nurse confirms the prescription for PRBCs and verifies that a signed informed consent is present.
Blood transfusions carry significant risks, and legal consent must be documented prior to starting the procedure.
2
Prepare the necessary equipment and perform pre-transfusion assessments.
The nurse primes the blood tubing exclusively with 0.9% sodium chloride and obtains baseline vital signs.
Normal saline is the only compatible fluid for blood transfusions. Baseline vital signs are required to quickly identify any deviations indicating a transfusion reaction.
3
Verify the blood product at the client's bedside.
The nurse and a second registered nurse confirm the client's identity, blood type, and the donor unit numbers.
A two-nurse independent verification is a mandatory safety standard to prevent fatal ABO incompatibility reactions.

Anahtar Kavram

Safe administration protocols for blood products
Soru 819Soru →

A nurse is caring for an alert and oriented client with diabetes mellitus who suddenly reports sweating, palpitations, and feeling hungry. Arrange the following nursing actions in the correct order to manage this acute situation.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first assess the blood glucose, then administer 15 grams of a fast-acting carbohydrate, reassess the blood glucose in 15 minutes, and finally provide a snack with complex carbohydrates and protein.
The correct sequence follows the standard protocol for managing acute hypoglycemia in a conscious client. The nurse first assesses the blood glucose to confirm the condition. Next, 15 grams of a fast-acting carbohydrate is given for rapid absorption. After 15 minutes, the nurse reassesses to evaluate the intervention's effectiveness. Finally, once the glucose level is stable, a complex carbohydrate and protein snack is provided to prevent a secondary hypoglycemic event.

Adım Adım Çözüm

1
Confirm the client's condition.
The capillary blood glucose level is assessed to verify hypoglycemia.
Assessment must precede intervention to ensure the correct protocol is followed.
2
Provide rapid treatment.
15 grams of a fast-acting simple carbohydrate is administered.
A simple carbohydrate quickly absorbs into the bloodstream to rapidly raise the blood glucose level.
3
Evaluate the treatment's effectiveness.
The blood glucose level is reassessed 15 minutes after the fast-acting carbohydrate is given.
Monitoring is required to determine if the blood glucose is rising to a safe level or if the initial treatment needs to be repeated.
4
Sustain the blood glucose level.
A snack containing a complex carbohydrate and protein is provided.
Complex carbohydrates and proteins take longer to digest, which helps maintain the blood glucose level and prevents another sudden drop.

Anahtar Kavram

The 15/15 Rule for Acute Hypoglycemia Management
Soru 820Soru →

A pediatric client weighing 44 lb44\text{ lb} is admitted with a severe lower respiratory tract infection. The healthcare provider prescribes intravenous cefotaxime 50 mg/kg/dose50\text{ mg/kg/dose} every 12 hours. The pharmacy dispenses a reconstituted cefotaxime solution with a concentration of 200 mg/mL200\text{ mg/mL}. How many milliliters (mL\text{mL}) should the nurse administer per dose?

Cevabı ve açıklamayı göster

Cevap: 5

Cevap

The nurse should administer 5 mL5\text{ mL} for each dose.
To determine the correct volume, the weight must first be converted to kilograms (44÷2.2=20 kg44 \div 2.2 = 20\text{ kg}). Then, calculate the required dose in milligrams by multiplying the weight by the prescribed dosage (20 kg×50 mg/kg=1000 mg20\text{ kg} \times 50\text{ mg/kg} = 1000\text{ mg}). Finally, divide the required dose by the concentration of the available solution (1000 mg÷200 mg/mL=5 mL1000\text{ mg} \div 200\text{ mg/mL} = 5\text{ mL}). Since the order specifies '50 mg/kg/dose50\text{ mg/kg/dose}', no further division for administration frequency is needed.

Adım Adım Çözüm

1
Convert the client's weight from pounds to kilograms.
44 lb÷2.2 lb/kg=20 kg44\text{ lb} \div 2.2\text{ lb/kg} = 20\text{ kg}
Medication dosages are calculated based on metric weight (kilograms).
2
Calculate the prescribed dose in milligrams (mg\text{mg}).
20 kg×50 mg/kg/dose=1000 mg/dose20\text{ kg} \times 50\text{ mg/kg/dose} = 1000\text{ mg/dose}
The prescription specifies the amount of medication per kilogram for each individual dose.
3
Calculate the volume in milliliters (mL\text{mL}) to administer.
1000 mg÷200 mg/mL=5 mL1000\text{ mg} \div 200\text{ mg/mL} = 5\text{ mL}
This determines how much of the available solution provides the required milligram dose.

Anahtar Kavram

Pediatric weight-based intravenous medication dosage calculation

Alternatif Yöntem

Dimensional analysis can solve this in a single equation: X mL=1 mL200 mg×50 mg1 kg×1 kg2.2 lb×44 lb=5 mLX\text{ mL} = \frac{1\text{ mL}}{200\text{ mg}} \times \frac{50\text{ mg}}{1\text{ kg}} \times \frac{1\text{ kg}}{2.2\text{ lb}} \times 44\text{ lb} = 5\text{ mL}.
Tahmini Süre:1m 30s
ÖncekiSayfa 41 / 98Sonraki
Physiological Integrity Alıştırma Soruları — NCLEX-RN — Sayfa 41 | Examkin