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Question 621Question →

A practical nurse is caring for a client who is receiving continuous enteral nutrition via a nasogastric tube. The client suddenly begins coughing vigorously, becomes tachypneic, and appears cyanotic. Arrange the following nursing actions in the correct priority order to reduce the client's risk for further complications. (Place the first action at the top and the last action at the bottom.)

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Answer

The correct priority sequence is to first stop the continuous enteral feeding, then turn the client to a lateral side-lying position, next auscultate lung sounds and measure oxygen saturation, and finally notify the supervising Registered Nurse (RN).
When a client exhibits sudden respiratory distress during an enteral feeding, active aspiration is highly suspected. The sequence of actions follows the principle of neutralizing the immediate threat first. The nurse must stop the pump to prevent further aspiration. Next, repositioning the client laterally protects the airway and facilitates drainage. Only after these immediate physical safeguards are in place should the nurse obtain focused assessment data (vital signs, lung sounds) to accurately report the client's condition to the supervising RN for further medical orders.

Step-by-Step Solution

1
Recognize the signs of active aspiration (coughing, cyanosis) and immediately turn off the enteral feeding pump.
Halts the introduction of additional formula into the client's lungs.
Eliminating the cause of the immediate threat is always the highest priority in emergency risk reduction.
2
Reposition the client into a lateral (side-lying) position.
Uses gravity to help clear the airway.
Prevents further downward movement of aspirated fluid and promotes outward drainage of secretions.
3
Perform a focused respiratory assessment, including oxygen saturation and lung auscultation.
Provides objective baseline data regarding the extent of respiratory compromise.
Assessment data is necessary to determine the client's current status only after the immediate airway threat is neutralized.
4
Escalate the findings to the Registered Nurse (RN).
Initiates further medical management.
The practical nurse must report critical changes so the RN can implement advanced interventions, such as ordering a chest radiograph or prescribing oxygen therapy.

Key Concept

In emergency situations such as active aspiration, the practical nurse must prioritize immediate independent interventions that remove the risk (stopping feeding) and protect the airway (positioning) before collecting assessment data or notifying the healthcare team.
Question 622Question →

A practical nurse (PN) is monitoring a client who is receiving a transfusion of packed red blood cells. Fifteen minutes into the transfusion, the client reports sudden lower back pain, chills, and dyspnea. Place the following nursing actions in the correct order of priority.

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Answer

1. Stop the blood transfusion immediately. 2. Initiate an infusion of 0.9% sodium chloride using new intravenous tubing. 3. Obtain a full set of vital signs and assess the client's respiratory status. 4. Notify the charge nurse and the prescribing healthcare provider. 5. Prepare to return the blood bag, tags, and administration set to the blood bank.
In the event of a suspected blood transfusion reaction, the absolute first priority is to stop the transfusion to prevent further administration of incompatible blood. The second step is to maintain a patent IV line for emergency medications and fluid resuscitation; this must be done with 0.9% sodium chloride and completely new tubing to avoid pushing remaining blood from the old tubing into the client. Once the source of harm is stopped and access is secured, the nurse must assess the client's vital signs and respiratory status to gather data. This clinical data is then immediately reported to the charge nurse and healthcare provider. Finally, as a follow-up administrative and diagnostic measure, the remaining blood, tags, and tubing are sent to the blood bank for investigation.

Step-by-Step Solution

1
Recognize the signs of a severe adverse therapy response.
The client is experiencing a potential acute hemolytic transfusion reaction, indicated by lower back pain, chills, and dyspnea.
Early recognition dictates the immediate cessation of the offending agent.
2
Prioritize direct interventions based on removing the source of harm and supporting circulation.
Stopping the transfusion prevents further exposure. Starting normal saline with completely new tubing maintains hemodynamic stability without pushing more blood into the client.
Client safety is the highest priority; flushing the old tubing would actively harm the client.
3
Gather specific clinical data before escalating communication.
Vital signs and respiratory assessment provide a precise baseline of the client's compromised state.
The healthcare provider requires current, objective data to prescribe appropriate emergency pharmacological interventions.
4
Escalate the situation and perform required administrative follow-up.
The charge nurse and provider are notified, and the blood materials are prepared for the blood bank.
Interprofessional communication ensures timely medical intervention, and the blood bank must investigate the cause of the transfusion reaction.

Key Concept

Prioritization of nursing interventions during an acute blood transfusion reaction
Question 623Question →

A practical nurse is caring for a client receiving continuous bladder irrigation following a transurethral resection of the prostate. The client suddenly reports severe lower abdominal cramping, and the nurse observes that there is no fluid draining into the urinary collection bag. In what order should the practical nurse perform the following actions? (Arrange from first to last)

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Answer

The correct sequence is: Inspect the tubing, clamp the infusion, palpate the bladder, and then notify the registered nurse.
When a client on continuous bladder irrigation experiences sudden pain and a lack of output, an obstruction is highly likely. The nurse must first perform the quickest non-invasive check by inspecting the drainage tubing for kinks. If the tubing is clear, the blockage is internal (often a blood clot). The immediate safety priority is to clamp the flow of irrigation to prevent bladder rupture from continuous fluid input. After securing the client's safety, the nurse assesses the physical impact by palpating the bladder to gauge distention. Finally, the nurse reports these comprehensive findings to the registered nurse, who can initiate advanced interventions like manual irrigation to clear the clot.

Step-by-Step Solution

1
Check the external equipment for simple mechanical issues.
Rules out kinks, clamped tubes, or dependent loops as the cause of the obstruction.
This is the fastest, least invasive assessment and can immediately resolve the issue if a kink is found.
2
Halt the continuous bladder irrigation flow.
Prevents any additional fluid from entering the obstructed bladder.
If fluid continues to enter a blocked bladder, it will cause severe pain and risks bladder trauma or rupture. Stopping the harm is the immediate priority.
3
Assess the client physically by palpating the suprapubic area.
Provides objective clinical data regarding the extent of urinary retention.
Physical assessment determines the severity of the client's physiological response to the obstruction.
4
Report the findings to the supervising registered nurse.
Initiates collaborative care for resolving internal obstructions.
Interventions like manual bladder irrigation to remove blood clots typically require RN execution or specific provider orders.

Key Concept

Prioritization in Acute Obstruction
Question 624Question →

A practical nurse (PN) is preparing to administer a large-volume cleansing enema to a client who is experiencing constipation. In what order should the PN perform the following actions? Arrange the steps from first to last.

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Answer

The correct sequence begins with positioning the client, followed by lubricating the tube, inserting it to the correct depth, initiating the flow at the proper height, and finally monitoring for and managing any discomfort such as cramping.
The procedure follows a logical and safe progression: preparation of the client (positioning), equipment preparation (lubrication), safe execution (insertion and controlled fluid flow), and continuous evaluation (monitoring for and responding to cramps).

Step-by-Step Solution

1
Position the client in the left lateral Sims' position.
The client's anatomy is optimally aligned to receive the fluid.
Gravity and the natural anatomical curve of the descending colon help retain the fluid and allow it to flow deeply into the bowel.
2
Lubricate the enema tip.
The tube surface is smoothed.
Lubrication prevents friction and mucosal tearing during insertion through the anal sphincters.
3
Insert the tube 3 to 4 inches into the rectum.
The tube safely passes the internal and external sphincters.
Ensures the fluid is delivered directly into the rectum and not expelled immediately.
4
Elevate the bag 12 to 18 inches and unclamp.
The solution begins to flow steadily into the bowel.
Provides adequate, safe hydrostatic pressure for fluid instillation without causing excessive force.
5
Monitor for cramping and lower or clamp the bag if it occurs.
The flow is adjusted based on client tolerance.
Rapid bowel distention causes severe pain; clamping or lowering the bag slows the instillation rate and relieves cramping.

Key Concept

Administration of a Cleansing Enema
Question 625Question →

A practical nurse is preparing to administer a scheduled crushed medication via a client's nasogastric (NG) tube. To reduce the risk of complications, arrange the following nursing actions in the correct clinical sequence.

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Answer

The correct sequence is: Elevate the head of the bed, verify tube placement, flush with sterile water, administer the medication, and flush again.
Administering medications via a nasogastric tube requires a strict sequence to prevent life-threatening complications such as aspiration pneumonia and to maintain tube integrity. The client must first be positioned safely (head elevated). Next, tube placement is verified to confirm gastric location. A pre-flush ensures patency and clears the line. The medication is then administered by gravity, followed immediately by a post-flush to deliver the full dose and prevent clogs.

Step-by-Step Solution

1
Elevate the head of the bed to at least 30 to 45 degrees.
The client is placed in a semi-Fowler's position.
This utilizes gravity to reduce the risk of gastroesophageal reflux and aspiration into the lungs.
2
Verify correct tube placement by aspirating gastric contents and assessing pH.
Gastric placement is confirmed.
It is critical to ensure the tube has not become dislodged into the respiratory tract before instilling any fluids.
3
Flush the nasogastric tube with 15 to 30 mL of sterile water.
The tube is cleared of contents and patency is established.
Flushing prevents physical incompatibilities between gastric contents and the medication, while ensuring the tube is not blocked.
4
Instill the diluted medication into the syringe barrel, allowing it to flow by gravity.
The medication is delivered into the stomach.
Gravity instillation reduces the risk of applying too much pressure, which could damage the tube or the gastrointestinal mucosa.
5
Flush the nasogastric tube again with 15 to 30 mL of sterile water.
The tube is cleared of all medication residue.
This final flush ensures the client receives the entire medication dose and prevents the tube from becoming occluded by dried medication.

Key Concept

Safe administration of enteral medications requires sequential risk reduction techniques: aspiration prevention, placement verification, and occlusion prevention.
Question 626Question →

A practical nurse is preparing to administer a mixed dose of intermediate-acting (NPH) and short-acting (Regular) insulin to a client with diabetes mellitus. Arrange the following steps in the correct chronological order for mixing these insulins in a single syringe.

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Answer

The correct sequence for mixing insulins is: clean both vials, inject air into the NPH vial, inject air into the Regular vial, draw up the Regular insulin, and finally draw up the NPH insulin.
When mixing short-acting (Regular) and intermediate-acting (NPH) insulin, the correct sequence ensures that the fast-acting insulin is not contaminated with the longer-acting insulin. The standard mnemonic is 'clear before cloudy.' After cleaning the vials, air is injected into the NPH vial first, followed by air into the Regular vial. The Regular (clear) insulin is drawn up first while the needle is already in the vial. Finally, the NPH (cloudy) insulin is drawn up to complete the exact total dose.

Step-by-Step Solution

1
Clean the rubber stoppers of both insulin vials with alcohol swabs.
The stoppers are disinfected.
Maintains aseptic technique before inserting needles into the vials.
2
Inject an amount of air equal to the prescribed dose into the NPH insulin vial.
Pressure is equalized in the NPH vial.
Prevents a vacuum, making it easier to withdraw medication later. This is done first because the needle has not touched any insulin yet.
3
Inject an amount of air equal to the prescribed dose into the Regular insulin vial.
Pressure is equalized in the Regular vial.
Prepares the vial for immediate withdrawal of insulin.
4
Invert the Regular insulin vial and withdraw the prescribed dose into the syringe.
The short-acting insulin is drawn into the syringe.
Clear (Regular) insulin is drawn up first so that the vial is not contaminated with cloudy (NPH) insulin, which could alter the rapid action of future doses drawn from the Regular vial.
5
Insert the needle into the NPH insulin vial and withdraw the prescribed dose.
The total mixed dose is gathered in the syringe.
Cloudy (NPH) insulin is drawn up last. Care must be taken not to inject any Regular insulin into the NPH vial.

Key Concept

Safe Medication Administration: Mixing Insulins (Clear before Cloudy)
Question 627Question →

A practical nurse (PN) is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, pounding headache and blurred vision. The PN observes profuse diaphoresis and flushing above the level of the injury. Arrange the following actions in the order the PN should perform them, from first to last.

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Answer

The correct sequence of actions is: 1) Elevate the head of the bed to a sitting or high-Fowler's position; 2) Measure the client's blood pressure to confirm hypertension; 3) Assess the client's indwelling urinary catheter for kinks or blockages; 4) Notify the registered nurse (RN) or healthcare provider of the client's condition.
The client is exhibiting classic signs of autonomic dysreflexia, a medical emergency in clients with spinal cord injuries above T6. The immediate priority is to lower the blood pressure by utilizing orthostatic changes (elevating the head of the bed). Once repositioned, the blood pressure must be measured to confirm the hypertensive crisis. Next, the PN should assess for and remove the most common triggering stimulus, which is typically bladder distention from a blocked catheter. Finally, the RN must be notified to collaborate on further management and potential pharmacological interventions.

Step-by-Step Solution

1
Recognize the clinical signs of autonomic dysreflexia.
The combination of a T4 spinal cord injury, severe pounding headache, blurred vision, and flushing/diaphoresis indicates a life-threatening hypertensive emergency.
Identifying the condition immediately is critical for selecting the appropriate, time-sensitive interventions.
2
Prioritize interventions based on the immediate threat to life.
Elevating the head of the bed is identified as the first and most critical action.
This utilizes orthostatic changes to rapidly lower blood pressure, mitigating the imminent risk of an intracranial hemorrhage.
3
Determine the sequence of subsequent data collection and source identification.
The blood pressure is measured to confirm the crisis, followed by assessing the catheter.
Objective data must be gathered to confirm the crisis, and then the most common noxious stimulus (bladder distention) must be addressed to halt the dysreflexia.
4
Determine the final step of escalation.
Notifying the RN or provider is the final immediate action.
Collaboration is necessary for ongoing management and to initiate potential pharmacological treatments if removing the stimulus is insufficient.

Key Concept

Prioritization in Acute Neurological Emergencies (Autonomic Dysreflexia)
Question 628Question →

The practical nurse (PN) is assisting a healthcare provider with a lumbar puncture for an adult client on the medical-surgical unit. In what order should the PN perform the following actions to ensure client safety and reduce the risk of complications? Arrange the actions in the correct chronological sequence.

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Answer

The correct sequence is: Obtain baseline vital signs, assist the client into a fetal position, support the client during insertion, apply a sterile dressing, and instruct the client to maintain a flat supine position.
Assisting with a lumbar puncture requires a strict chronological approach to reduce risk. First, baseline data must be collected to allow for accurate post-procedure monitoring. Next, the client is placed in the fetal position to optimally open the intervertebral spaces. During the procedure, the nurse's role is to ensure the client remains completely still to prevent injury. Following needle removal, the site must immediately be covered with a sterile dressing to prevent infection. Finally, placing the client in a flat, supine position reduces the risk of a spinal headache caused by cerebrospinal fluid leakage.

Step-by-Step Solution

1
Obtain the client's baseline vital signs and perform a focused neurological check.
Baseline clinical data is documented prior to the procedure.
Provides a baseline to compare against post-procedure assessments for early detection of complications.
2
Assist the client into a side-lying position with the knees pulled toward the chest.
The client's spine is flexed, opening the intervertebral spaces.
This physical position allows the healthcare provider optimal access to the subarachnoid space and reduces the risk of trauma.
3
Support the client and provide reminders to remain still during the needle insertion.
The client remains completely still during the most critical phase.
Sudden movements can cause the needle to damage surrounding tissues, nerves, or the spinal cord.
4
Place a sterile dressing over the puncture site once the needle is withdrawn.
The puncture site is securely covered.
Maintains a sterile barrier to prevent infection from entering the central nervous system.
5
Instruct the client to maintain a flat, supine position for the prescribed duration.
The client lies flat in bed for several hours.
Reduces hydrostatic pressure on the puncture site, preventing cerebrospinal fluid (CSF) leakage and post-lumbar puncture headache.

Key Concept

Lumbar Puncture Risk Reduction
Question 629Question →

A practical nurse (PN) enters the room of a client receiving a continuous enteral tube feeding. The client is coughing forcefully, appears dyspneic, and is clutching their chest. In which order should the PN perform the following actions? (Arrange the actions from first to last.)

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Answer

The correct sequence is: Stop the continuous enteral feeding pump, elevate the head of the bed to a high-Fowler's position, obtain the client's oxygen saturation and respiratory rate, notify the registered nurse (RN) of the client's status, and then gather equipment for potential oropharyngeal suctioning.
In any clinical emergency, the nurse must prioritize actions using the Airway, Breathing, Circulation (ABC) framework and the nursing process. The absolute first step is to stop the continuous feeding to eliminate the immediate risk of further aspiration (Airway). Second, positioning the client in a high-Fowler's position maximizes lung expansion (Breathing). Third, the nurse assesses the client's respiratory status to gather objective data. Fourth, the nurse reports these findings to the RN for escalation of care. Finally, the nurse anticipates further needs by gathering suction equipment.

Step-by-Step Solution

1
Stop the continuous enteral feeding pump.
The flow of enteral formula is halted immediately.
According to the airway, breathing, circulation (ABC) framework, removing the immediate threat to the airway (potential aspiration of formula) is the absolute highest priority.
2
Elevate the head of the bed to a high-Fowler's position.
The client's chest cavity is optimized for expansion.
An upright position lowers the diaphragm, promotes maximum chest expansion, and uses gravity to prevent further reflux of gastric contents into the airway.
3
Obtain the client's oxygen saturation and respiratory rate.
Focused respiratory data is collected.
After addressing the immediate physical threat, the nurse must assess the client's physiological response to determine the degree of respiratory compromise.
4
Notify the registered nurse (RN) of the client's status.
The supervising nurse is informed of the acute change in condition.
The PN must communicate the objective data and client presentation to the RN, who will coordinate with the healthcare provider for potential medical interventions.
5
Gather equipment for potential oropharyngeal suctioning.
Suction equipment is ready at the bedside.
Anticipating the need to clear secretions or formula from the upper airway ensures preparedness for the next potential intervention.

Key Concept

Prioritization of care for suspected aspiration during enteral tube feeding
Question 630Question →

A practical nurse (PN) is caring for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache and nasal congestion. The PN observes profuse sweating above the level of the spinal injury. Arrange the following nursing actions in the priority order the PN should perform them.

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Answer

The correct priority sequence is to first elevate the head of the bed, followed by measuring the blood pressure, inspecting the urinary catheter, and finally notifying the registered nurse.
Autonomic dysreflexia is a medical emergency characterized by severe hypertension. The absolute first action must be to elevate the head of the bed, which takes seconds and uses gravity to lower blood pressure, preventing a stroke. Next, the PN must obtain a blood pressure reading to confirm the crisis. Once confirmed, the PN should look for the most common cause, which is a distended bladder, by checking the catheter. Finally, the RN is notified to report the event, current vital signs, and seek potential pharmacological interventions.

Step-by-Step Solution

1
Elevate the head of the bed to a sitting or high-Fowler's position.
The client is positioned upright.
Gravity immediately causes orthostatic hypotension, which helps safely lower the dangerously high blood pressure and reduces the immediate risk of a cerebrovascular accident (stroke).
2
Measure the client's blood pressure.
Objective vital sign data is obtained.
Checking the blood pressure confirms the severity of the suspected autonomic dysreflexia and provides a baseline to determine if subsequent interventions are effective.
3
Inspect the urinary catheter tubing for kinks or blockages.
A potential noxious stimulus (bladder distention) is investigated and resolved if found.
Autonomic dysreflexia is triggered by an uninhibited sympathetic response to a noxious stimulus below the level of the injury. A blocked catheter is the most frequent culprit and can be fixed immediately at the bedside.
4
Notify the registered nurse (RN) of the client's status.
The healthcare team is alerted to the medical emergency.
The RN needs the vital signs and assessment findings to coordinate further care, which may include administering emergency antihypertensive medications if relieving the physical stimulus is ineffective.

Key Concept

Prioritization of emergency nursing actions for a client experiencing autonomic dysreflexia.
Question 631Question →

A practical nurse is preparing a combined subcutaneous injection of regular insulin and NPH insulin for a client whose pre-meal capillary blood glucose level is 185 mg/dL. To ensure safe medication preparation and avoid cross-contamination, arrange the following steps in the correct chronological sequence.

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Answer

The correct sequence is to roll the NPH vial, inject air into the NPH vial, inject air into the regular vial, withdraw the regular insulin, and finally withdraw the NPH insulin.
When mixing insulins, the standard safety protocol is 'clear before cloudy' (regular insulin before NPH insulin). This ensures that the short-acting, clear insulin is not contaminated by the intermediate-acting, cloudy insulin. The precise preparation sequence involves injecting air into the NPH vial first, then injecting air into the regular vial, drawing up the regular insulin, and finally drawing up the NPH insulin.

Step-by-Step Solution

1
Roll NPH insulin vial
Insulin suspension is evenly mixed without bubbles.
Ensures accurate dosing of the intermediate-acting insulin.
2
Inject air into NPH vial
Vial pressure is equalized for future withdrawal.
Prevents vacuum formation; done first because the needle must not have regular insulin on it yet.
3
Inject air into regular insulin vial
Regular insulin vial pressure is equalized.
Prepares the vial for immediate fluid withdrawal.
4
Withdraw regular insulin
Clear insulin is drawn into the syringe first.
Drawing clear before cloudy prevents contamination of the rapid-acting insulin with the intermediate-acting insulin.
5
Withdraw NPH insulin
The total mixed dose is completed in the syringe.
The cloudy insulin is safely added last to complete the mixture.

Key Concept

Insulin Mixing Procedure (Clear Before Cloudy)
Question 632Question →

A practical nurse (PN) is walking in the hallway with a client who has a history of seizure disorders. The client suddenly loses consciousness and begins to experience tonic-clonic muscle jerking. In what order should the PN perform the following actions? Arrange the actions in order of priority from first to last.

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Answer

The correct sequence prioritizes immediate physical safety, followed by airway protection, and concludes with assessment and timing.
In any acute emergency, the nurse must prioritize immediate life-saving interventions and injury prevention over assessment. Easing the falling client to the floor prevents immediate trauma. Protecting the head prevents secondary trauma from convulsions. Turning the client on their side protects the airway from aspiration. Only after these immediate physical safeguards are in place should the nurse focus on timing and observing the clinical characteristics of the seizure.

Step-by-Step Solution

1
Guide the client to the floor.
The client is on the ground in a controlled manner.
Prevents severe injury that would occur from a sudden drop.
2
Place a pad or pillow under the head.
The head is cushioned against the hard floor.
Prevents traumatic brain injury or skull fracture during rhythmic convulsions.
3
Turn the client onto their side.
The airway remains clear of secretions and the tongue.
Reduces the risk of aspiration and maintains airway patency.
4
Observe and time the seizure.
Accurate clinical data is gathered.
Provides the healthcare provider with necessary information to determine if emergency medication is required (e.g., status epilepticus).

Key Concept

Acute Seizure Management and Prioritization
Question 633Question →

A practical nurse enters the room of a client receiving a continuous enteral tube feeding and observes the client coughing vigorously and exhibiting sudden tachypnea. In which order should the practical nurse perform the following actions? Arrange the steps from first to last.

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Answer

The correct sequence is to first stop the continuous enteral tube feeding, elevate the head of the bed to a high-Fowler's position, measure the client's oxygen saturation and respiratory rate, report the findings to the supervising registered nurse, and finally document the respiratory event and the client's response.
In any emergency situation involving a continuous infusion or feeding where a severe complication is suspected, the first priority is to stop the source of potential harm. Next, the airway and breathing must be supported through proper positioning. Only after these immediate, risk-reducing interventions are completed should the nurse gather objective assessment data (vital signs) to report to the supervising registered nurse. Documentation is performed last once the client is stabilized and the healthcare team has been notified.

Step-by-Step Solution

1
Stop the enteral tube feeding immediately.
The source of potential aspiration is halted.
Halting the infusion is the most critical first step to prevent further fluid from entering the airway.
2
Elevate the head of the bed.
The client is placed in a high-Fowler's position.
An upright position maximizes lung expansion, aids in clearing the airway, and uses gravity to prevent further aspiration.
3
Assess oxygen saturation and respiratory rate.
Objective respiratory data is collected.
Once the immediate risk is mitigated and the airway is protected, the nurse must quantify the extent of respiratory compromise.
4
Notify the registered nurse.
The healthcare team is alerted to the client's changing condition.
The practical nurse must report the adverse event along with the current vital signs so the registered nurse can assess and escalate to the provider if necessary.
5
Document the event.
The incident is recorded in the electronic health record.
Documentation is always the final step after prioritizing client safety, interventions, and communication.

Key Concept

Prioritization and Risk Reduction in Suspected Aspiration
Question 634Question →

A practical nurse (PN) is caring for a client who is receiving continuous enteral tube feedings. The client suddenly begins to cough severely, becomes dyspneic, and exhibits circumoral cyanosis. Arrange the following nursing actions in the correct order of priority.

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Answer

The correct priority sequence is to first stop the feeding pump, then elevate the head of the bed, auscultate lung sounds, notify the RN, and finally document the event.
In any acute physiological crisis, the nursing process dictates prioritizing actions that eliminate the immediate threat to life (Airway, Breathing, Circulation). For suspected aspiration, stopping the feeding pump directly halts the threat. Positioning the client upright is the next immediate physical intervention to support the airway and breathing. Once these rapid physical interventions are complete, the nurse collects focused assessment data (lung sounds, oxygen saturation) to understand the severity of the event. This data is then reported to the RN to coordinate further care. Documentation is always the final administrative step in the nursing process.

Step-by-Step Solution

1
Stop the continuous enteral feeding pump.
The flow of enteral formula is halted.
Prevents any additional formula from being aspirated into the lungs, addressing the root cause of the immediate threat.
2
Elevate the head of the bed to a high-Fowler's position.
The client is positioned upright at 90 degrees.
Utilizes gravity to keep remaining gastric contents down, promotes optimal diaphragmatic excursion, and improves oxygenation.
3
Auscultate the client's lung sounds and obtain oxygen saturation.
Objective respiratory data is collected.
Provides essential clinical information regarding airway clearance and oxygenation status to guide further treatment.
4
Notify the registered nurse (RN) of the acute change in condition.
The clinical team is alerted to the emergency.
Ensures the client receives advanced interventions beyond the PN scope if needed, communicating the objective data just gathered.
5
Document the respiratory event and the interventions performed.
The legal medical record is updated.
Maintains continuity of care and fulfills legal requirements for nursing practice.

Key Concept

Prioritization of Care During Acute Enteral Feeding Aspiration
Question 635Question →

A practical nurse (PN) is preparing to collect a urine specimen for culture and sensitivity from a client with an indwelling urinary catheter. Arrange the steps of this procedure in the correct chronological order to minimize the risk of contamination and client injury. All options must be used.

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Answer

First clamp the drainage tubing, then cleanse the specimen port, attach a sterile syringe to withdraw the urine, transfer the urine into a sterile cup, and finally unclamp the drainage tubing.
Collecting a urine specimen from an indwelling catheter requires maintaining a closed, sterile system to reduce the risk of infection and ensure an accurate laboratory result. First, the tubing must be clamped to allow fresh urine to collect. Once sufficient urine is present, the port is cleansed immediately before access to ensure sterility. The urine is then aspirated with a sterile syringe and safely transferred to a sterile cup. The most critical safety step concludes the procedure: unclamping the tubing to restore urinary flow and prevent dangerous bladder distention.

Step-by-Step Solution

1
Clamp the drainage tubing below the specimen port for 15 to 30 minutes.
Fresh urine accumulates in the tubing above the clamp.
Urine in the drainage bag is stagnant and not suitable for a culture; fresh urine must be collected directly from the closed system.
2
Cleanse the specimen port with an antiseptic wipe and allow it to dry.
Surface pathogens are eliminated from the access port.
Prevents the introduction of bacteria into the catheter system and the specimen during syringe attachment.
3
Attach a sterile syringe to the port and withdraw the urine sample.
A sterile urine sample is safely extracted.
Maintains the sterility of the closed urinary drainage system.
4
Transfer the urine into a sterile specimen cup without touching the inside.
The sample is secured for transport to the laboratory.
Prevents environmental contamination of the culture specimen.
5
Unclamp the drainage tubing to restore urine flow to the collection bag.
Normal urinary drainage resumes.
Failing to unclamp the tubing can cause severe bladder distention, pain, autonomic dysreflexia, and kidney damage.

Key Concept

Maintaining a closed urinary drainage system and preventing complications during specimen collection.
Question 636Question →

A licensed practical nurse is caring for a client who has a closed-wound drainage system (Jackson-Pratt) in place following a mastectomy. The nurse needs to empty the device to maintain continuous negative pressure. In what order should the nurse perform the following actions? (Arrange the steps in the correct sequence.)

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Answer

The correct sequence is to don gloves and open the port, empty the drainage, compress the bulb, replace the plug while the bulb is compressed, and finally measure and document the drainage.
To effectively reduce the risk of surgical site complications, a closed-wound drain must maintain constant negative pressure. The nurse first applies gloves and opens the system to empty the collected fluid. Next, the nurse must compress the bulb to expel ambient air and immediately cap it while it remains compressed. This action creates the vacuum necessary to pull exudate from the wound. Finally, the collected fluid is measured and documented to track output and monitor for abnormal bleeding or infection.

Step-by-Step Solution

1
Put on clean gloves and open the port on the drainage bulb.
The system is opened safely.
Standard precautions prevent exposure to bloodborne pathogens, and opening the port breaks the vacuum to allow fluid removal.
2
Empty the bulb's contents into a graduated measuring container.
The drainage is cleared from the bulb.
Fluid must be removed to clear the reservoir and to measure the output accurately.
3
Squeeze the bulb completely flat to expel all air.
Air is pushed out of the bulb.
Expelling air is necessary to prepare the device for negative pressure suction.
4
Replace the plug securely into the port while maintaining pressure on the bulb.
The system is sealed under vacuum.
Sealing the device while flat locks in the negative pressure, which actively draws fluid from the surgical site to reduce hematoma risk.
5
Measure the drainage amount at eye level and document the findings.
Output is recorded accurately.
Accurate documentation is necessary for evaluating the client's fluid status and risk for hemorrhage or infection.

Key Concept

Proper maintenance of a closed-wound drainage system requires establishing a vacuum to actively pull fluid from the surgical site, reducing the risk of fluid accumulation and infection.
Estimated Time:1m 0s
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