Physiological Integrity

1960 soru

Soru 881Soru →

A nurse is preparing to perform a routine capillary blood glucose test for a client with diabetes mellitus. Arrange the following steps of the procedure in the correct chronological order to ensure accurate diagnostic results and minimize the risk of infection.

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Cevap

The correct chronological sequence is to first cleanse the site, allow it to air dry, puncture the skin, wipe away the first drop of blood, and finally apply the second drop to the test strip.
Proper sequencing of capillary blood glucose testing is essential for risk reduction and diagnostic accuracy. Cleansing and drying the site prevents infection and chemical interference from the alcohol. Wiping away the first drop of blood removes serous fluid that can dilute the sample, ensuring that the second drop used for the test provides an accurate and reliable measurement.

Adım Adım Çözüm

1
Cleanse and dry the puncture site.
The site is free of surface pathogens and residual alcohol.
Prevents infection and ensures alcohol does not falsely alter the glucose reading.
2
Puncture the skin and wipe away the first drop of blood.
Interstitial fluid from the trauma of the puncture is removed.
The first drop contains tissue fluid that dilutes the blood, leading to inaccurate diagnostic results.
3
Collect the second drop of blood on the test strip.
Pure capillary blood is analyzed by the glucometer.
Provides the most accurate reflection of the client's current systemic blood glucose level, reducing the risk of inappropriate insulin dosing.

Anahtar Kavram

Capillary Blood Glucose Collection Technique
Soru 882Soru →

A client diagnosed with community-acquired pneumonia is scheduled to receive a 0.5-gram0.5\text{-gram} dose of oral amoxicillin. The unit medication supply contains a liquid suspension with a concentration of 250 mg/5 mL250\text{ mg}/5\text{ mL}. How many milliliters must the nurse administer to provide the required dose?

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Cevap: 10 mL10\text{ mL}

Cevap

The nurse should administer 10 mL10\text{ mL} of the oral suspension.
The correct volume is 10 mL10\text{ mL}. To find this, the prescribed dose of 0.5 g0.5\text{ g} is first converted to 500 mg500\text{ mg}. Using the dosage formula (Desired/Have)×Quantity(Desired / Have) \times Quantity, the calculation is (500 mg/250 mg)×5 mL(500\text{ mg} / 250\text{ mg}) \times 5\text{ mL}, which equals 10 mL10\text{ mL}.

Adım Adım Çözüm

1
Convert the prescribed dose from grams to milligrams.
0.5 g=500 mg0.5\text{ g} = 500\text{ mg}
The available medication concentration is measured in milligrams, so the units must match before performing the calculation.
2
Apply the standard dosage formula: (Desired/Have)×Quantity(Desired / Have) \times Quantity.
(500 mg/250 mg)×5 mL=10 mL(500\text{ mg} / 250\text{ mg}) \times 5\text{ mL} = 10\text{ mL}
This determines the exact fluid volume needed to deliver the required mass of the medication.

Anahtar Kavram

Basic Dosage Calculation and Metric Conversions
Soru 883Soru →

A nurse is assessing a client who is 4 hours postoperative following a total thyroidectomy. Which of the following assessment findings indicate a potential life-threatening complication and require immediate intervention? Select all that apply.

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Cevap: High-pitched, harsh respiratory sound during inspiration; Frequent, spontaneous swallowing motions while resting; Tingling and numbness around the lips and fingertips

Cevap

The findings that require immediate intervention are the high-pitched respiratory sound, frequent swallowing motions, and tingling around the lips and fingertips.
The correct options represent life-threatening complications of a total thyroidectomy. A high-pitched, harsh respiratory sound (stridor) indicates airway obstruction. Frequent swallowing suggests internal bleeding and hematoma formation. Tingling around the lips and fingers is an early sign of hypocalcemia (due to parathyroid damage), which can lead to life-threatening tetany.

Adım Adım Çözüm

1
Analyze the client's postoperative timeframe and surgical procedure.
The client had a total thyroidectomy 4 hours ago, placing them at high risk for airway compromise, hemorrhage, and hypocalcemia.
Identifying procedure-specific risks is essential for focused assessment.
2
Evaluate each assessment finding against expected versus abnormal postoperative outcomes.
Stridor, frequent swallowing, and circumoral tingling are abnormal and dangerous. Scant drainage and a sore throat are expected.
Differentiating normal physiological responses from complications guides clinical judgment.
3
Prioritize the findings that require immediate intervention based on physiological risks.
The respiratory sound, swallowing motions, and tingling represent immediate threats to the airway and physiological stability.
Prioritization ensures life-threatening complications are addressed first.

Anahtar Kavram

Postoperative complications of thyroidectomy include airway obstruction (stridor), hemorrhage (frequent swallowing), and hypocalcemia (tingling/tetany).
Soru 884Soru →

A nurse is creating a comprehensive basic care and comfort plan for an older adult client with advanced dementia who is bedbound, has a history of sacral pressure injuries, and is receiving continuous enteral tube feedings. Which of the following nursing interventions should be included in the client's plan of care? Select all that apply.

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Cevap: Maintain the head of the bed elevated between 30 and 45 degrees to balance aspiration precautions with the prevention of sacral shearing forces.; Reposition the client using a 30-degree lateral inclined position, alternating between the right and left sides to minimize pressure on the greater trochanters.; Apply a protective moisture barrier cream to the client's perineal and sacral areas after cleansing following each episode of incontinence.

Cevap

The correct interventions are maintaining the head of the bed between 30 and 45 degrees, repositioning using a 30-degree lateral incline, and applying a moisture barrier cream after incontinence episodes.
The correct interventions directly address the client's competing physiological needs. Maintaining a 30 to 45-degree head-of-bed elevation prevents aspiration from the enteral feeding while minimizing sacral shearing forces. The 30-degree lateral inclined position effectively offloads pressure from the high-risk sacral and trochanteric areas. Applying a moisture barrier cream is an essential proactive measure to prevent incontinence-associated dermatitis and subsequent pressure injuries.

Adım Adım Çözüm

1
Analyze the client's clinical profile and risk factors.
The client is bedbound, has a history of sacral pressure injuries, receives continuous enteral feedings, and has advanced dementia.
Identifying overlapping risk factors (aspiration risk vs. skin breakdown risk) is necessary to prioritize conflicting interventions.
2
Evaluate positioning strategies for enteral feeding alongside pressure injury prevention.
A 30 to 45-degree head of bed elevation prevents aspiration while avoiding the severe sacral shearing forces caused by a 90-degree high Fowler's position. The 30-degree lateral incline is best for side-lying.
Evidence-based practice requires balancing respiratory/gastrointestinal safety with tissue integrity.
3
Assess delegation and age-related physiological principles.
Skin assessment cannot be delegated to UAP, and new-onset severe incontinence must be investigated as a pathological symptom, not dismissed as normal aging.
Maintaining scope of practice and accurate clinical judgment ensures safe care delivery.

Anahtar Kavram

Complex Care Coordination: Balancing Aspiration Precautions and Tissue Integrity in the Bedbound Client
Soru 885Soru →

A client is admitted to the intensive care unit with diabetic ketoacidosis (DKA). At admission, the client's serum glucose was 720 mg/dL720\text{ mg/dL} (40.0 mmol/L40.0\text{ mmol/L}) and serum potassium was 5.2 mEq/L5.2\text{ mEq/L} (5.2 mmol/L5.2\text{ mmol/L}). The client was started on a continuous intravenous (IV) regular insulin infusion and fluid resuscitation with 0.9%0.9\% sodium chloride.

Four hours later, the client's serum glucose is 245 mg/dL245\text{ mg/dL} (13.6 mmol/L13.6\text{ mmol/L}) and serum potassium is 3.7 mEq/L3.7\text{ mEq/L} (3.7 mmol/L3.7\text{ mmol/L}). The anion gap remains elevated at 18 mEq/L18\text{ mEq/L} (normal: 8−12 mEq/L8-12\text{ mEq/L}). Which of the following modifications to the client's parenteral therapy should the nurse anticipate next?

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Cevap: Change the continuous IV fluid to include 5%5\% dextrose and add intravenous potassium chloride.

Cevap

The nurse should anticipate changing the continuous IV fluid to include 5%5\% dextrose and adding intravenous potassium chloride.
The correct action is to add 5%5\% dextrose to the IV fluids and initiate potassium supplementation. In the treatment of DKA, insulin resolves both hyperglycemia and ketoacidosis. However, blood glucose normalizes much faster than ketones are cleared. When glucose falls below 250 mg/dL250\text{ mg/dL}, 5%5\% dextrose must be added to the IV fluids. This provides a carbohydrate source, preventing hypoglycemia while allowing the nurse to keep the insulin infusion running to close the elevated anion gap. Furthermore, insulin shifts potassium into the cells. With a potassium level of 3.7 mEq/L3.7\text{ mEq/L} and an active insulin drip, potassium replacement is critical to prevent cardiac dysrhythmias.

Adım Adım Çözüm

1
Evaluate the current serum glucose trend.
Glucose has dropped from 720 mg/dL720\text{ mg/dL} to 245 mg/dL245\text{ mg/dL}.
In DKA management, a glucose level crossing below the 250 mg/dL250\text{ mg/dL} threshold indicates the critical need for dextrose supplementation.
2
Assess the status of the ketoacidosis.
The anion gap is 18 mEq/L18\text{ mEq/L}, indicating that active ketoacidosis is still present.
An elevated anion gap means the continuous insulin infusion must be maintained to suppress lipolysis and ketone production.
3
Evaluate the serum potassium trend.
Potassium has dropped from 5.2 mEq/L5.2\text{ mEq/L} to 3.7 mEq/L3.7\text{ mEq/L}.
Insulin facilitates the intracellular shift of potassium. As the level falls to the lower end of normal, prophylactic IV potassium must be initiated to prevent severe hypokalemia and fatal arrhythmias.
4
Synthesize the findings to determine the correct therapy adjustment.
Add dextrose to prevent hypoglycemia, continue insulin to close the anion gap, and add potassium to maintain electrolyte balance.
This combination directly addresses all active physiological derangements in this specific transitional phase of DKA.

Anahtar Kavram

In DKA management, when blood glucose falls below 250 mg/dL250\text{ mg/dL} (13.9 mmol/L13.9\text{ mmol/L}), IV fluids must be transitioned to include 5%5\% dextrose. This allows the continuation of the IV insulin drip, which is essential to close the anion gap and clear ketones, while preventing dangerous hypoglycemia. Concurrently, potassium must be proactively replaced to counteract insulin-driven intracellular shifts.
Soru 886Soru →

A nurse is caring for a client with acute decompensated heart failure who is prescribed a continuous intravenous infusion of dobutamine at 5 mcg/kg/min5\text{ mcg/kg/min}. The client weighs 187 lbs187\text{ lbs}. The pharmacy provides dobutamine as 500 mg500\text{ mg} mixed in 250 mL250\text{ mL} of 5% dextrose in water5\%\text{ dextrose in water} (D5W). How many mL/hr\text{mL/hr} should the nurse set the infusion pump to deliver? (Record your answer to the nearest tenth.)

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Cevap: 12.8

Cevap

12.8
To determine the correct infusion pump setting in mL/hr\text{mL/hr}, the nurse must perform a multi-step calculation involving unit conversions for both weight (pounds to kilograms) and time (minutes to hours). After establishing that the client needs 25.5 mg25.5\text{ mg} of dobutamine every hour, dividing by the concentration of the IV bag (2 mg/mL2\text{ mg/mL}) provides the accurate volume of 12.75 mL/hr12.75\text{ mL/hr}, which rounds to 12.8 mL/hr12.8\text{ mL/hr}.

Adım Adım Çözüm

1
Convert the client's weight from pounds to kilograms.
187÷2.2=85 kg187 \div 2.2 = 85\text{ kg}
The medication dosage is prescribed based on kilograms of body weight.
2
Calculate the per-minute dobutamine dose for this specific client.
85 kg×5 mcg/kg/min=425 mcg/min85\text{ kg} \times 5\text{ mcg/kg/min} = 425\text{ mcg/min}
This establishes the exact amount of medication the client needs to receive every minute.
3
Convert the minute dose to an hourly dose.
425 mcg/min×60 min/hr=25,500 mcg/hr425\text{ mcg/min} \times 60\text{ min/hr} = 25,500\text{ mcg/hr}
Intravenous infusion pumps are programmed in milliliters per hour, so the dose must reflect an hourly rate.
4
Convert the hourly dose from micrograms to milligrams.
25,500 mcg/hr÷1000 mcg/mg=25.5 mg/hr25,500\text{ mcg/hr} \div 1000\text{ mcg/mg} = 25.5\text{ mg/hr}
The supplied medication from the pharmacy is measured in milligrams, so the units must match.
5
Calculate the concentration of the provided IV bag.
500 mg÷250 mL=2 mg/mL500\text{ mg} \div 250\text{ mL} = 2\text{ mg/mL}
This determines how many milligrams of dobutamine are in each milliliter of the IV fluid.
6
Determine the final infusion rate in mL/hr.
25.5 mg/hr÷2 mg/mL=12.75 mL/hr25.5\text{ mg/hr} \div 2\text{ mg/mL} = 12.75\text{ mL/hr}
Dividing the required hourly medication dose by the medication concentration yields the fluid volume needed per hour.
7
Round the final value to the nearest tenth as instructed.
12.8 mL/hr12.8\text{ mL/hr}
Standard rounding rules dictate that a 5 in the hundredths place rounds the tenths place up.

Anahtar Kavram

Weight-based continuous intravenous infusion dosage calculation requiring conversion between units of mass and time.
Soru 887Soru →

A nurse is preparing to access an implanted venous port (port-a-cath) for a client who is scheduled to receive intravenous chemotherapy. Arrange the following actions in the correct sequence to safely access the device. (All steps must be used).

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Cevap

The correct sequence is: (1) Don a mask and position the client's head, (2) Don sterile gloves and scrub with chlorhexidine, (3) Allow to air dry completely, (4) Stabilize the port, (5) Insert the non-coring needle at 90 degrees, and (6) Aspirate for blood return and flush.
The standard of care for accessing an implanted venous port prioritizes infection control and device integrity. The nurse first protects the site from respiratory droplets by masking and positioning the client. Next, sterile technique is initiated by donning sterile gloves and cleansing the site with chlorhexidine. The antiseptic must air dry completely to be effective. Once dry, the nurse stabilizes the port to prevent movement and inserts a non-coring needle perpendicularly to protect the septum from damage. Finally, before any fluids are administered, the nurse must aspirate for blood to confirm correct intravascular placement.

Adım Adım Çözüm

1
Don a face mask and instruct the client to turn their head.
The risk of respiratory droplet contamination is minimized.
Establishing a safe environment is the first priority before any sterile supplies are opened.
2
Don sterile gloves and scrub the site with chlorhexidine.
The skin over the port is aseptically prepared.
Strict sterile technique is required to prevent central line-associated bloodstream infections.
3
Allow the chlorhexidine solution to air dry completely.
The antiseptic achieves its full bactericidal effect.
Chlorhexidine requires complete drying to be fully effective; fanning or blowing compromises sterility.
4
Stabilize the implanted port reservoir with the non-dominant hand.
The port is immobilized.
The port must be held firmly in place to ensure accurate, single-attempt needle insertion.
5
Insert a non-coring needle at a 90-degree angle until it touches the bottom.
The needle successfully accesses the port reservoir.
A non-coring needle prevents damage to the silicone septum, and the 90-degree angle ensures straight entry.
6
Aspirate for a blood return and flush the catheter.
Correct intravascular placement is confirmed.
Aspiration verifies patency and placement before any medication or flush is pushed into the central line.

Anahtar Kavram

Accessing an implanted venous port requires strict aseptic technique, the use of a non-coring (Huber) needle to preserve the septum, and verification of blood return prior to administration of any fluids or medications.
Tahmini Süre:1m 30s
Soru 888Soru →

Following a right-sided total hip arthroplasty using a posterior approach, a client arrives at the postoperative surgical unit. Which positioning intervention should the nurse implement to minimize the risk of joint dislocation?

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Cevap: Securing an abduction pillow between the client's lower extremities.

Cevap

Securing an abduction pillow between the client's lower extremities.
After a posterior total hip arthroplasty, it is critical to prevent hip adduction, internal rotation, and flexion greater than 90 degrees. Securing an abduction pillow between the legs ensures the hips remain slightly separated (abducted) and prevents the client from inadvertently crossing their legs or midline, thereby substantially reducing the risk of joint dislocation.

Adım Adım Çözüm

1
Identify the surgical procedure and its associated risks.
The client had a total hip arthroplasty via a posterior approach, which carries a high risk of posterior dislocation if standard hip precautions are not followed.
Understanding the specific surgical approach dictates which physical movements must be restricted to protect the new joint.
2
Determine the contraindicated movements for a posterior hip replacement.
Hip flexion greater than 90 degrees, adduction across the midline, and internal rotation are contraindicated.
These specific movements put outward pressure on the posterior joint capsule, potentially dislocating the newly placed prosthesis.
3
Evaluate the given positioning interventions against the required precautions.
Using an abduction pillow prevents adduction. Elevating the head to 90 degrees causes excessive flexion. Crossing ankles causes adduction. A pillow under the knee causes flexion and venous stasis.
Matching each nursing action to the physiological constraints isolates the correct risk reduction strategy.

Anahtar Kavram

Postoperative Hip Precautions (Posterior Approach)
Soru 889Soru →

A nurse is planning care for a client who has just returned to the medical-surgical unit following a lumbar puncture. Which of the following positions should the nurse maintain for this client immediately after the procedure?

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Cevap: Supine with the head of the bed flat

Cevap

Supine with the head of the bed flat
Following a lumbar puncture, the client should be maintained in a flat, supine position for a prescribed period (typically 4 to 8 hours). This position minimizes the pressure on the dural puncture site, preventing the leakage of cerebrospinal fluid (CSF) and significantly reducing the risk of a post-dural puncture headache.

Adım Adım Çözüm

1
Identify the procedure the client underwent.
The client had a lumbar puncture, which involves puncturing the dura mater to access cerebrospinal fluid (CSF).
Specific post-operative complications are associated with different procedures.
2
Recall the potential complications of a lumbar puncture.
A major complication is a CSF leak from the puncture site, leading to a severe spinal headache.
Understanding the risk guides the primary nursing intervention.
3
Determine the appropriate position to prevent this complication.
Keeping the client flat distributes CSF pressure evenly and minimizes hydrostatic pressure at the dural puncture site.
Gravity exacerbates CSF leakage if the head is elevated.

Anahtar Kavram

Post-procedure positioning to prevent complications (Lumbar Puncture)
Tahmini Süre:45s
Soru 890Soru →

A client arrives at the medical unit after undergoing a diagnostic lumbar puncture. Which positioning instruction is the most appropriate for the nurse to provide?

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Cevap: Remain completely flat in bed for the duration prescribed by the provider.

Cevap

The client should remain completely flat in bed for the duration prescribed by the provider.
Following a lumbar puncture, the standard of care requires the client to remain flat (supine) in bed for a specified duration, typically 1 to 8 hours depending on provider orders. This flat position minimizes hydrostatic pressure at the dural puncture site, significantly reducing the risk of cerebrospinal fluid (CSF) leakage and the development of a post-dural puncture headache.

Adım Adım Çözüm

1
Identify the procedure the client just underwent.
The client had a diagnostic lumbar puncture.
Different procedures require specific post-operative or post-procedure positioning to prevent complications.
2
Determine the primary risk following a lumbar puncture.
The main risk is leakage of cerebrospinal fluid (CSF) from the dural puncture site, which causes a severe spinal headache.
Understanding the complication guides the appropriate nursing intervention.
3
Select the position that minimizes this risk.
Lying completely flat reduces pressure on the dural tear, preventing CSF leakage.
Gravity exacerbates the pressure on the puncture site when the head is elevated.

Anahtar Kavram

Post-Lumbar Puncture Positioning
Soru 891Soru →

A client is receiving a continuous intravenous (IV) infusion of unfractionated heparin. The nurse must administer a scheduled dose of an IV push medication that is chemically incompatible with heparin. The client has a single peripheral IV access line. Arrange the following actions in the correct sequence to safely administer the medication.

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Cevap

The correct sequence is to first stop the continuous infusion pump, then clamp the tubing above the lowest port and flush with normal saline, followed by administering the IV push medication. After administration, flush again with normal saline at the same rate the medication was given, and finally unclamp and restart the continuous infusion.
When administering an IV push medication through a single peripheral line with an incompatible continuous infusion, the nurse must first stop the pump to halt the primary fluid. The tubing must be clamped immediately above the lowest injection port (closest to the client) to prevent retrograde flow. A pre-flush of normal saline clears the line of the incompatible drug to avoid precipitation. The medication is then administered at the prescribed rate. Crucially, the post-flush must also be administered at the exact same slow rate as the medication because the lower tubing still contains the active drug. Rapid flushing would push the residual drug into the client too quickly, risking speed shock. Finally, the tubing is unclamped and the continuous infusion is restarted.

Adım Adım Çözüm

1
Stop the continuous heparin infusion.
The flow of the incompatible medication is temporarily halted.
This prevents the incompatible medications from mixing in the line during the procedure.
2
Clamp the primary tubing and flush the lowest injection port with normal saline.
The line below the port and the IV catheter are cleared of heparin.
Clamping prevents the flush from traveling retrogradely up the line. Flushing clears the physical space of the incompatible drug to prevent dangerous precipitation.
3
Administer the IV push medication.
The medication is delivered into the cleared IV line.
The medication is given at the prescribed rate to ensure safety and therapeutic effect.
4
Flush the line with normal saline at the same rate the medication was administered.
The remaining medication in the dead space of the IV tubing and catheter is safely delivered.
Flushing too quickly would result in rapid bolus delivery (speed shock) of the residual medication still present in the tubing.
5
Unclamp the tubing and restart the continuous infusion.
The primary heparin infusion resumes.
This restores the continuous therapeutic delivery of the primary medication.

Anahtar Kavram

Safe administration of an IV push medication through a line with an incompatible continuous infusion requires isolating the injection site, adequately clearing the line before and after administration, and carefully controlling flush rates to prevent speed shock.
Soru 892Soru →

A nurse is instructing a client on the proper procedure for a 24-hour urine collection for creatinine clearance. In what chronological order should the nurse instruct the client to perform the following steps? Arrange the steps in the correct sequence.

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Cevap

The correct sequence is to first discard the initial void, document the start time, collect all subsequent urine for 24 hours, void one final time at the 24-hour mark, and finally transport the specimen to the laboratory.
For a 24-hour urine collection, the bladder must first be emptied and that urine discarded so the collection period begins with an empty bladder. The exact time is then recorded as the start time. All subsequent urine voided over the next 24 hours is saved in a designated container, which is typically kept on ice or refrigerated. Exactly 24 hours after the start time, the client voids one last time and adds it to the container to complete the collection. Finally, the complete specimen is transported to the laboratory.

Adım Adım Çözüm

1
Empty the bladder completely into the toilet and discard this initial urine.
The bladder is emptied.
Ensures the collected urine only reflects what is produced from the start time onward.
2
Document the exact time of the discarded void as the official start time.
The start time is recorded.
Establishes the precise beginning of the 24-hour timeframe.
3
Collect all subsequent urine voids in the designated refrigerated specimen container.
Urine is continuously collected and preserved.
Captures all urine produced during the collection period while maintaining specimen integrity.
4
Void one final time exactly 24 hours after the start time and add it to the container.
The 24-hour collection is completed.
Ensures the total volume represents exactly one full day of urine production.
5
Transport the completed collection container to the laboratory.
The specimen is delivered for testing.
Allows the laboratory to analyze the complete 24-hour sample.

Anahtar Kavram

Diagnostic Test Preparation and Specimen Collection
Tahmini Süre:1m 0s
Soru 893Soru →

A 74-year-old client is admitted to the progressive care unit with a large acute pulmonary embolism and is receiving a continuous intravenous (IV) heparin infusion. The nurse is creating a plan of care to monitor for and reduce the risk of potential physiological complications. Which of the following actions should the nurse include in the plan of care? Select all that apply.

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Cevap: Establish a secondary peripheral intravenous access site for the administration of other prescribed intermittent medications.; Monitor the client for early physiological indicators of hemodynamic compromise, such as a narrowing pulse pressure and unexplained tachycardia.; Ensure that the specific antidote, protamine sulfate, is readily available on the unit.

Cevap

The correct interventions are establishing a secondary IV access for other medications, monitoring for early signs of shock like a narrowing pulse pressure, and ensuring protamine sulfate is available on the unit.
Establishing a secondary peripheral IV line is necessary because continuous heparin infusions must run on a dedicated line to prevent inadvertent bolusing and medication incompatibilities. Monitoring for a narrowing pulse pressure and tachycardia allows for the early detection of obstructive shock, a life-threatening complication of a large pulmonary embolism. Ensuring protamine sulfate is available is a crucial safety measure to rapidly reverse heparin in the event of severe hemorrhage.

Adım Adım Çözüm

1
Analyze the client's diagnosis and current treatments.
The client has a pulmonary embolism (high risk for hypoxemia and obstructive shock) and is on a continuous heparin infusion (high risk for hemorrhage and drug incompatibilities).
Identifying the primary physiological threats guides the selection of targeted risk reduction strategies.
2
Evaluate each intervention for its ability to safely mitigate these physiological risks.
Maintaining a dedicated heparin line, securing the antidote, and closely monitoring for early shock indicators (tachycardia, narrowing pulse pressure) directly reduce the risk of mortality and medication errors.
These actions prioritize airway, breathing, circulation, and medication safety.
3
Identify and eliminate contraindicated or unsafe actions.
Placing the dyspneic client supine, delegating complex nursing assessments to a UAP, and dismissing altered mental status as normal aging are dangerous missteps.
A supine position impairs breathing, UAPs cannot perform clinical evaluations, and confusion indicates severe, acute hypoxemia.

Anahtar Kavram

Risk reduction in clients with pulmonary embolism focuses on maintaining oxygenation (high-Fowler's position), preventing hemorrhage (dedicated heparin line, readily available antidotes), and early detection of hemodynamic compromise or hypoxemia (recognizing subtle vital sign changes and altered mental status).
Soru 894Soru →

A nurse is preparing to administer an intravenous loading dose of phenytoin to an adult client who was recently admitted for status epilepticus. The client is currently stable but requires the medication to prevent recurrent seizure activity. The client has a continuous peripheral intravenous (IV) infusion of 5% dextrose in water5\% \text{ dextrose in water} (D5WD_5W) running at 75 mL/hr75\text{ mL/hr}. Which of the following nursing actions is essential for the safe administration of this medication?

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Cevap: Stop the primary infusion, flush the line with 0.9% sodium chloride0.9\% \text{ sodium chloride}, and administer the phenytoin at a maximum rate of 50 mg/min50\text{ mg/min}.

Cevap

Stop the primary infusion, flush the line with 0.9% sodium chloride, and administer the phenytoin at a maximum rate of 50 mg/min.
Phenytoin is physically incompatible with all dextrose solutions and will form a dangerous precipitate if they are mixed. Because the client is receiving a continuous D5WD_5W infusion, the nurse must pause the primary infusion and flush the line completely with normal saline (0.9% sodium chloride0.9\% \text{ sodium chloride}) before and after administration. Furthermore, to prevent severe cardiovascular toxicity including profound hypotension and dysrhythmias, intravenous phenytoin must be administered slowly, never exceeding a rate of 50 mg/min50\text{ mg/min} in adult clients.

Adım Adım Çözüm

1
Review the prescribed medication and its compatibility with the current continuous intravenous fluid.
Phenytoin is highly incompatible with dextrose solutions like D5WD_5W and will precipitate.
Verifying IV fluid compatibility is essential to prevent crystallization in the catheter, which could lead to an embolism or loss of IV access.
2
Determine the correct procedure for administration through a line running an incompatible fluid.
The primary D5WD_5W infusion must be paused, and the line must be flushed thoroughly with 0.9% sodium chloride0.9\% \text{ sodium chloride} (normal saline) both before and after giving the drug.
Normal saline is the only compatible IV fluid for flushing and diluting phenytoin.
3
Identify the safe administration rate and necessary patient monitoring.
The medication must be administered at a rate no faster than 50 mg/min50\text{ mg/min} by the registered nurse.
Rapid infusion causes cardiovascular collapse, and the required complex assessments cannot be delegated to a UAP.

Anahtar Kavram

Safe administration parameters for intravenous phenytoin
Soru 895Soru →

A nurse is preparing to administer a prescribed intravenous (IV) infusion of potassium chloride to a client who has a serum potassium level of 2.9 mEq/L and is experiencing premature ventricular contractions (PVCs). Which actions are safe and appropriate for the nurse to implement? Select all that apply.

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Cevap: Ensure the potassium chloride solution is administered using an electronic infusion pump.; Verify that the client has a urine output of at least 30 mL/hr before initiating the infusion.; Set the peripheral IV infusion rate to deliver a maximum of 10 mEq of potassium per hour.

Cevap

The safe and appropriate actions are to administer the solution using an electronic infusion pump, verify adequate urine output prior to the infusion, and limit the peripheral infusion rate to a maximum of 10 mEq per hour.
Intravenous potassium chloride is a high-alert medication. Safe administration requires using an electronic infusion pump to prevent accidental boluses. Because potassium is excreted by the kidneys, the nurse must verify adequate urine output (at least 30 mL/hr) prior to administration to prevent hyperkalemia. Additionally, to avoid cardiac toxicity and severe vein irritation, the infusion rate through a peripheral line should never exceed 10 mEq per hour.

Adım Adım Çözüm

1
Analyze the prescribed medication and the client's clinical presentation.
The client has severe hypokalemia (2.9 mEq/L) with cardiac manifestations (PVCs) and requires intravenous potassium chloride, which is a high-alert medication.
Identifying high-alert medications is critical for determining the required safety protocols for administration.
2
Evaluate the safe administration parameters for intravenous potassium chloride.
Safe parameters include always using an infusion pump, ensuring a maximum peripheral rate of 10 mEq/hr, and confirming renal function (urine output >30 mL/hr).
Adhering to strict administration parameters prevents fatal arrhythmias and hyperkalemia.
3
Identify and reject unsafe practices from the available options.
Rapid infusion rates and failing to check IV compatibility are identified as severe safety risks and are rejected.
Potassium given too quickly directly causes cardiac arrest, and incompatible IV medications can cause dangerous precipitation in the line.

Anahtar Kavram

Safe administration protocols for high-alert intravenous medications, specifically potassium chloride.
Soru 896Soru →

A nurse is monitoring a client receiving a transfusion of packed red blood cells. Fifteen minutes after the infusion begins, the client suddenly develops severe lower back pain, chills, and dyspnea. Suspecting an acute hemolytic transfusion reaction, arrange the following nursing actions in the correct priority sequence from first to last.

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Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first stop the transfusion, then replace the tubing to infuse normal saline, assess the client, notify the provider and blood bank, and finally send the materials to the lab.
In any acute medical emergency caused by an external agent, the first priority is to remove or stop the causative agent. Therefore, stopping the transfusion is step one. Maintaining IV access with normal saline using new tubing is step two, ensuring a lifeline is available without worsening the reaction. Step three is assessing the client to determine the exact physiological impact. Step four is notifying the provider using the gathered assessment data. Step five, the final administrative and diagnostic step, is sending the materials to the lab.

Adım Adım Çözüm

1
Identify the primary source of harm and intervene immediately.
The blood transfusion is stopped.
Continuing the transfusion, even for a few more seconds, exacerbates the acute hemolytic reaction.
2
Maintain vascular access without administering more of the offending agent.
New IV tubing is attached and normal saline is infused.
Using the existing blood tubing would push the remaining blood into the client. Normal saline maintains line patency for emergency drugs.
3
Determine the client's physiological baseline following the insult.
Vital signs and respiratory status are assessed.
Objective data is required to communicate the client's status to the provider and anticipate necessary interventions (e.g., oxygen, epinephrine, diuretics).
4
Communicate the crisis to the interdisciplinary team.
The healthcare provider and blood bank are notified.
The provider must prescribe medical interventions, and the blood bank must initiate their internal investigation protocols.
5
Facilitate diagnostic investigation.
Blood bag, tubing, and client samples are sent to the laboratory.
This confirms the type of reaction and determines if a systemic error occurred, but it is the lowest priority compared to client stabilization.

Anahtar Kavram

Priority Management of Suspected Transfusion Reactions
Tahmini Süre:1m 30s
Soru 897Soru →

A client in the cardiac intensive care unit requires a continuous intravenous infusion of dobutamine at 10 \mug/kg/min10\text{ \mu g/kg/min} for severe ventricular dysfunction. The client currently has only one functioning peripheral venous access site. After assessing new-onset bilateral crackles and an oxygen saturation of 88%88\%, the healthcare provider prescribes an immediate 80 mg80\text{ mg} intravenous bolus of furosemide. Which of the following actions is the safest and most appropriate method to administer the prescribed diuretic?

Cevabı ve açıklamayı göster

Cevap: Establish a second peripheral intravenous access site and administer the diuretic steadily over 4 minutes.

Cevap

The safest action is to establish a second peripheral IV site and administer the furosemide slowly over 4 minutes.
The correct action addresses three critical pharmacology and safety principles simultaneously: dobutamine cannot be paused due to its short half-life and the risk of hemodynamic collapse, furosemide is highly incompatible with dobutamine and will precipitate if mixed, and a high dose of furosemide (80 mg80\text{ mg}) must be pushed slowly over at least 4 minutes (maximum 20 mg/minute20\text{ mg/minute}) to prevent permanent ototoxicity. Establishing a second line is the only action that fulfills all of these safety requirements.

Adım Adım Çözüm

1
Analyze the physical compatibility of the two medications.
Furosemide and dobutamine are physically incompatible and will immediately precipitate if mixed in the same IV tubing.
Administering incompatible medications together can cause catheter occlusion and life-threatening emboli, requiring separation of the medications.
2
Determine the pharmacokinetics of the continuous vasoactive infusion.
Dobutamine has an extremely short half-life of approximately 2 minutes.
Pausing the dobutamine infusion for a flush-push-flush sequence would cause a rapid, dangerous drop in cardiac output and systemic perfusion.
3
Calculate the safe administration rate for the intravenous bolus of furosemide.
The maximum safe rate for intravenous furosemide is 20 mg/minute20\text{ mg/minute}. An 80 mg80\text{ mg} dose must be administered over at least 4 minutes.
Rapid administration of high-dose loop diuretics significantly increases the risk of permanent ototoxicity.
4
Synthesize the findings to determine the priority nursing action.
Because the medications cannot be mixed, the continuous infusion cannot be safely paused, and the diuretic must be pushed slowly, a second IV line is absolutely necessary.
Establishing a second line ensures that the client receives the critical diuretic at the safe rate without interrupting life-sustaining cardiac support.

Anahtar Kavram

Parenteral therapy safety requires simultaneous evaluation of drug compatibility, safe administration rates, and the hemodynamic consequences of interrupting continuous vasoactive infusions.
Soru 898Soru →

An older adult client is brought to the emergency department after awaking with severe orthopnea and a frothy, pink-tinged cough. The client appears extremely agitated and has a respiratory rate of 34 breaths/minute. Arterial blood gas (ABG) values on room air are pH 7.26, PaCO2 62 mm Hg, PaO2 52 mm Hg, and HCO3 24 mEq/L. Which of the following actions should the nurse implement? (Select all that apply.)

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Cevabı ve açıklamayı göster

Cevap: Position the client upright with the legs dangling over the edge of the bed.; Prepare the client for immediate noninvasive positive pressure ventilation (NIPPV).; Administer prescribed intravenous loop diuretics.

Cevap

The correct actions include positioning the client upright with legs dangling, preparing for noninvasive positive pressure ventilation, and administering intravenous loop diuretics.
The client's presentation of a frothy, pink-tinged cough and extreme orthopnea indicates acute pulmonary edema, a life-threatening complication of heart failure. The ABG results demonstrate uncompensated respiratory acidosis with severe hypoxemia. Priority nursing actions focus on reducing venous return (preload) by positioning the client upright with legs dangling, reducing fluid volume with loop diuretics, and improving gas exchange using noninvasive positive pressure ventilation to force fluid out of the alveoli and clear retained carbon dioxide.

Adım Adım Çözüm

1
Analyze the clinical presentation (orthopnea, frothy pink-tinged cough, agitation, tachypnea).
The findings strongly indicate acute pulmonary edema, a life-threatening complication of heart failure characterized by fluid in the alveoli.
Identifying the underlying pathophysiology is required to select interventions that reduce fluid volume rather than increase it.
2
Interpret the arterial blood gas (ABG) values: pH 7.26 (acidotic), PaCO2 62 mm Hg (elevated/acidotic), PaO2 52 mm Hg (hypoxemic), HCO3 24 mEq/L (normal).
The ABG indicates uncompensated respiratory acidosis with severe hypoxemia.
Understanding the acid-base imbalance guides respiratory interventions and prevents inappropriate administration of metabolic buffers.
3
Select interventions that safely address both the fluid overload and the acute respiratory failure.
Appropriate actions include dependent positioning to reduce preload, NIPPV to improve gas exchange and clear CO2, and loop diuretics to remove excess fluid. Inappropriate actions include administering fluids, giving bicarbonate, or improperly delegating assessments.
Nursing care must rapidly reverse the physiological decompensation while adhering to the RN scope of practice.

Anahtar Kavram

Management of Acute Pulmonary Edema and Respiratory Acidosis
Soru 899Soru →

A nurse is finalizing the plan of care for a client who is scheduled to undergo a bedside percutaneous liver biopsy. Identify the actions the nurse must implement to minimize the client's risk for procedure-related complications. (Select all that apply.)

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Cevabı ve açıklamayı göster

Cevap: Verify that the client's most recent prothrombin time and platelet count are within acceptable parameters.; Instruct the client to exhale and hold their breath when the biopsy needle is inserted.; Maintain the client on strict bed rest for the prescribed duration following the biopsy.

Cevap

The correct interventions are verifying coagulation parameters, instructing the client on the exhalation and breath-holding technique, and enforcing post-procedure bed rest.
The correct actions involve reducing bleeding and puncture risks. Verifying coagulation studies ensures the client's blood can clot normally. Having the client hold their breath after exhaling elevates the diaphragm, protecting the lungs. Maintaining bed rest ensures the newly formed clot at the puncture site is not disrupted.

Adım Adım Çözüm

1
Analyze the physiological risks associated with a percutaneous liver biopsy.
The primary risks are hemorrhage (due to the liver's high vascularity) and pneumothorax (due to the liver's proximity to the diaphragm and lungs).
Understanding the potential complications dictates which preventive actions are necessary.
2
Evaluate the pre-procedure and intra-procedure options for safety.
Checking coagulation labs (PT, platelets) mitigates bleeding risk. Having the client hold their breath after exhaling elevates the diaphragm, mitigating pneumothorax risk.
These actions directly address and reduce the most common severe complications.
3
Evaluate the post-procedure options for safety and recovery.
Bed rest stabilizes the clot. Conversely, deep palpation can destroy the clot, and left-sided positioning fails to apply necessary pressure to the liver.
Post-procedure care must focus on maintaining hemostasis at the puncture site.

Anahtar Kavram

Reduction of Risk Potential: Liver Biopsy Complications
Tahmini Süre:1m 0s
Soru 900Soru →

A client admitted with a severe bacterial infection has a single peripheral intravenous (IV) catheter in the left forearm. A continuous infusion of Lactated Ringer's is currently running at 100 mL/hr100\text{ mL/hr}. The healthcare provider prescribes a stat dose of intravenous ceftriaxone 1 g1\text{ g} mixed in 50 mL50\text{ mL} of 0.9%0.9\% sodium chloride, to be infused over 30 minutes30\text{ minutes}. Which of the following is the most appropriate action by the nurse?

Cevabı ve açıklamayı göster

Cevap: Stop the continuous infusion, flush the line thoroughly with 0.9% sodium chloride, infuse the antibiotic, and flush the line again before restarting.

Cevap

The primary continuous infusion of Lactated Ringer's must be stopped, and the IV line must be flushed with 0.9% sodium chloride before and after the ceftriaxone administration.
Ceftriaxone binds with calcium to form fatal precipitates. Because Lactated Ringer's contains calcium, the two must never mix in the IV line. Stopping the infusion and flushing the line with 0.9% sodium chloride (normal saline) before and after the ceftriaxone dose completely clears the tubing of calcium, allowing safe administration through a single IV site.

Adım Adım Çözüm

1
Analyze the prescribed medications and the client's current continuous IV fluids.
The client is receiving Lactated Ringer's continuously, and ceftriaxone is prescribed to be administered via the same line.
Identifying all substances that will pass through a single IV access site is the first step in ensuring medication safety.
2
Evaluate the physical compatibility between ceftriaxone and Lactated Ringer's.
Ceftriaxone is strictly incompatible with any calcium-containing solutions, including Lactated Ringer's, because they form crystalline precipitates.
Preventing the administration of incompatible IV solutions is critical to avoid life-threatening emboli.
3
Determine the safest method of administration given the single peripheral IV access.
The nurse must stop the Lactated Ringer's, flush the line with a compatible fluid (0.9% sodium chloride), administer the antibiotic, and flush again before resuming the fluids.
This 'sandwich' method ensures that the incompatible solutions never come into contact within the IV tubing.

Anahtar Kavram

Intravenous Compatibility and Calcium-Ceftriaxone Precipitation
ÖncekiSayfa 45 / 98Sonraki
Physiological Integrity Alıştırma Soruları — NCLEX-RN — Sayfa 45 | Examkin