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Question 181Question →

A nurse is caring for a client with a history of heart failure who suddenly develops severe dyspnea, extreme anxiety, and a cough producing pink, frothy sputum. The nurse suspects acute pulmonary edema. In what order should the nurse perform the following actions? (Arrange the actions in the correct sequence from first to last)

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Answer

The correct sequence is: Position the client in a high-Fowler's position, Administer high-flow oxygen via a face mask, Assess vital signs and auscultate lung sounds, Administer prescribed intravenous furosemide, and finally, Document the clinical findings and response to interventions.
In an acute respiratory crisis such as pulmonary edema, the nurse must prioritize immediate, non-pharmacological life-saving actions. Positioning the client upright is the fastest intervention to improve breathing mechanics and reduce preload. This is immediately followed by oxygen administration to correct hypoxia. Once the airway and breathing are mechanically supported, the nurse must obtain baseline vital signs to ensure the client's blood pressure can tolerate the subsequent administration of intravenous loop diuretics. Finally, after the client is stabilized and interventions are implemented, the nurse documents the entire event.

Step-by-Step Solution

1
Position the client in a high-Fowler's position.
The diaphragm lowers and venous return decreases.
This immediate, equipment-free action maximizes lung expansion and reduces preload, directly addressing the pathophysiology of pulmonary edema.
2
Administer high-flow oxygen via a face mask.
Alveolar oxygen concentration increases.
The client is experiencing severe gas exchange impairment. Oxygen must be administered immediately after positioning to treat life-threatening hypoxia.
3
Assess vital signs and auscultate lung sounds.
Baseline clinical data is obtained.
Objective data must be gathered before administering medications to ensure the client is hemodynamically stable enough to receive diuretics.
4
Administer prescribed intravenous furosemide.
Diuresis is initiated.
Loop diuretics remove excess fluid and further decrease preload, which is the definitive treatment for acute cardiogenic pulmonary edema, but must follow ABC interventions and baseline assessment.
5
Document the clinical findings and response to interventions.
The medical record is updated.
Documentation is always the final step of the nursing process after completing acute interventions and stabilization.

Key Concept

Prioritization of acute pulmonary edema management follows the ABCs (Airway, Breathing, Circulation) and the nursing process, moving from immediate physical interventions to pharmacological treatments and concluding with documentation.
Question 182Question →

A registered nurse (RN) is prioritizing care and delegating tasks to a licensed practical nurse (LPN/VN) and an unlicensed assistive personnel (UAP) on a medical-surgical unit. Place the following actions in the order of priority the RN should perform them, from highest to lowest priority.

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Answer

The correct sequence prioritizes life-threatening emergencies first, followed by time-sensitive delegation, routine delegation, and finally, evaluation of delegated interventions.
The correct sequence accurately applies both the ABC prioritization framework and the National Council of State Boards of Nursing (NCSBN) five rights of delegation. The RN first addresses the immediate life-threatening physiological need (ABC). Once the emergency is managed, the RN initiates the delegation process by assigning a time-sensitive medication task to the LPN/VN (Right Person/Right Task). Next, the RN ensures safety by providing specific reporting parameters to the UAP (Right Direction/Communication). Routine tasks are then delegated. Finally, the RN closes the delegation loop by retaining accountability for evaluating the client's response to the medication (Right Supervision/Evaluation), which must logically occur last.

Step-by-Step Solution

1
Identify the most unstable client requiring immediate RN intervention.
The client with pink, frothy sputum is prioritized first due to a potential airway/breathing emergency (pulmonary edema).
Airway, Breathing, and Circulation (ABC) principles always take precedence over routine or delegated care.
2
Delegate time-sensitive tasks for stable clients to appropriate personnel.
The LPN/VN is assigned to administer the scheduled oral pain medication.
Delegating appropriately (Right Task, Right Person) allows the RN to maximize team efficiency while managing higher-acuity needs.
3
Provide specific communication and parameters for monitoring tasks.
The UAP is directed to report a systolic blood pressure below 90 mm Hg.
The 'Right Direction/Communication' principle ensures the UAP understands specific limits and when to escalate findings to the RN.
4
Delegate routine, low-priority tasks.
The UAP is assigned to distribute water pitchers.
Basic care tasks without the need for nursing judgment are the lowest priority to assign and fit the UAP scope of practice.
5
Complete the delegation process by evaluating the outcomes.
The RN evaluates the effectiveness of the pain medication administered by the LPN/VN.
Evaluation is strictly an RN responsibility and must chronologically follow the administration of the intervention.

Key Concept

Delegation Process and Prioritization
Question 183Question →

A progressive care unit nurse is responding to a client with a history of Graves' disease who has abruptly developed severe delirium, a temperature of 40.6∘C40.6^\circ\text{C} (105.1∘F105.1^\circ\text{F}), and a heart rate of 178 beats per minute. Determine the priority sequence in which the nurse should implement the following collaborative interventions.

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Answer

The correct sequence is to first apply supplemental oxygen, then administer intravenous propranolol, followed by propylthiouracil (PTU), and finally administer potassium iodide solution.
In a life-threatening acute deterioration, interventions must strictly follow the Airway-Breathing-Circulation (ABC) framework, integrated with disease-specific safety protocols. Oxygenation addresses the immense hypermetabolic demand (Airway/Breathing). Propranolol stabilizes the hyperdynamic cardiovascular system to prevent circulatory collapse (Circulation). Once ABCs are secured, the underlying endocrine crisis is treated. Propylthiouracil must be given first to halt new hormone synthesis. Potassium iodide is given last because if it is administered before the synthesis pathway is blocked, the iodine will act as a substrate to create more thyroid hormone, exacerbating the thyrotoxicosis.

Step-by-Step Solution

1
Address Airway and Breathing.
Supplemental oxygen is applied.
Extreme hypermetabolism drives massive cellular oxygen demand; hypoxia can quickly lead to irreversible organ damage.
2
Stabilize Circulation.
Intravenous propranolol is administered.
Cardiovascular collapse from severe tachycardia is a primary cause of mortality in thyrotoxic crisis. Beta-blockade rapidly decreases heart rate and blocks peripheral conversion of T4 to T3.
3
Inhibit hormone synthesis.
Propylthiouracil (PTU) is administered.
The thyroid's hormone production factory must be shut down before addressing stored hormone.
4
Inhibit hormone release.
Potassium iodide is administered.
Must strictly follow PTU administration by at least one hour to prevent the iodine from being used as a substrate to synthesize new thyroid hormone.

Key Concept

Prioritizing ABCs (Airway, Breathing, Circulation) followed by the strict pharmacological sequencing required to safely manage thyrotoxic crisis (Thyroid Storm).
Question 184Question →

A client is in the preoperative holding area for an elective hernia repair. As the nurse prepares to administer a prescribed preoperative sedative, the client states, 'I have changed my mind. I do not want to go through with this surgery.' Arrange the following nursing actions in the correct chronological sequence from first to last.

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Answer

The correct sequence is to first withhold the sedative, then assess the client's concerns, followed by notifying the healthcare provider, and finally documenting the event.
When a client revokes consent, the immediate priority is to prevent any actions that would proceed with the procedure or alter the client's competent state. Therefore, withholding the sedative is first. Next, the nurse acts as an advocate by exploring the client's concerns. After gathering this information, the nurse must notify the provider who is ultimately responsible for the consent process. Finally, all events must be legally documented.

Step-by-Step Solution

1
Identify the immediate safety priority regarding the pending medication.
Withhold the preoperative sedative.
Administering a sedative to a client who wants to revoke consent would impair their legal competence and violate their fundamental right to refuse treatment.
2
Determine the next appropriate nursing action to support the client.
Explore the client's concerns.
The nurse acts as an advocate by listening to the client and understanding the root cause of their hesitation before communicating with the broader team.
3
Identify the required interdisciplinary communication.
Notify the healthcare provider.
The surgeon must be informed because they are ultimately responsible for the surgical consent process and must address the client's concerns or cancel the procedure.
4
Identify the final administrative requirement.
Document the situation.
Accurate legal documentation of the client's refusal and the nurse's actions is required after the immediate clinical and communication needs are met.

Key Concept

Nursing actions for revocation of informed consent
Question 185Question →

A registered nurse (RN) is preparing to delegate a routine clinical task to an unlicensed assistive personnel (UAP). Arrange the following steps of the delegation process in the correct chronological order.

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Answer

The correct sequence for the delegation process is: 1) Assess the client and identify the task, 2) Verify the UAP's competency, 3) Provide clear directions, and 4) Evaluate the outcome.
Delegation is a systematic process based on the National Council of State Boards of Nursing (NCSBN) guidelines. It begins with the RN assessing the client to ensure the task is appropriate (Right Task/Right Circumstance). Next, the RN must verify that the chosen delegatee is competent (Right Person). Then, the RN must communicate explicit instructions (Right Direction/Communication). Finally, the RN must supervise and assess the outcome (Right Supervision/Evaluation).

Step-by-Step Solution

1
Identify the initial assessment phase.
The nurse must first assess the client's stability and determine if a task is safe to delegate.
The RN retains accountability for the client and must ensure the 'Right Task' and 'Right Circumstance' before proceeding.
2
Determine the step involving the delegatee's qualifications.
The nurse verifies the UAP's competency and scope of practice.
This fulfills the 'Right Person' principle of delegation, ensuring the UAP is capable of performing the specific task.
3
Locate the communication phase.
The nurse provides clear, specific directions and expected outcomes to the UAP.
This aligns with the 'Right Direction/Communication' principle, ensuring the UAP knows exactly what to do and when to report back.
4
Identify the final evaluation phase.
The nurse evaluates the completed task and the client's overall response.
The RN maintains ultimate accountability for client care and must evaluate the results of the delegated task.

Key Concept

The delegation process requires sequential application of the Five Rights of Delegation: assessing the situation, determining delegatee competency, communicating clearly, and finally evaluating the outcome.
Question 186Question →

A nurse is performing a sterile vaginal examination on a client in active labor who has just experienced a spontaneous rupture of membranes. The nurse palpates a soft, pulsating mass in the vaginal vault. The electronic fetal monitor demonstrates severe, recurrent variable decelerations. Arrange the following nursing actions in the priority order they should be performed.

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Answer

The correct sequence of actions is: 1. Apply upward pressure to the fetal presenting part, 2. Call for emergency assistance, 3. Reposition into a knee-chest or Trendelenburg position, 4. Administer oxygen, 5. Prepare for emergency cesarean birth.
Umbilical cord prolapse is an acute, life-threatening obstetric emergency characterized by the cord slipping ahead of the fetal presenting part. The overarching goal is to prevent fetal hypoxia. The nurse must first manually relieve cord compression (the immediate physiological threat). While maintaining this pressure, the nurse secures help. Repositioning utilizes gravity to assist. Oxygen is then administered to optimize fetal oxygenation before preparing for the definitive surgical delivery.

Step-by-Step Solution

1
Apply upward manual pressure to the fetal presenting part.
Relieves mechanical compression on the umbilical cord.
Immediate restoration of umbilical blood flow is the most critical life-saving intervention to prevent irreversible fetal hypoxia.
2
Direct staff to call for emergency assistance and notify the provider.
Activates the obstetric emergency response team.
Additional personnel are required to perform subsequent interventions while the primary nurse maintains continuous manual pressure on the presenting part.
3
Assist the client into a knee-chest or extreme Trendelenburg position.
Uses gravity to shift the fetus toward the uterine fundus.
This positional change further reduces the risk of cord compression, supplementing the manual pressure being applied.
4
Administer supplemental oxygen at 8 to 10 L/min via a nonrebreather mask.
Increases maternal circulating blood oxygen tension.
Maximizes the oxygen available for placental transfer to the compromised fetus.
5
Prepare the client for an immediate emergency cesarean birth.
Readies the client for surgical intervention.
Surgical delivery is the definitive treatment for cord prolapse to safely extract the fetus when a vaginal birth is not immediately imminent.

Key Concept

Nursing management and prioritization for umbilical cord prolapse
Question 187Question →

A nurse is independently discontinuing a right subclavian central venous catheter for a 64-year-old client recovering from severe pneumonia. Immediately upon removal of the catheter, the client gasps, becomes intensely diaphoretic, and reports crushing chest pain. Suspecting a central line-associated air embolism, in what order should the nurse perform the following interventions? Arrange from first action to last.

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Answer

The correct sequence of actions is to first occlude the insertion site, then place the client in the left lateral Trendelenburg position, apply 100% oxygen, activate the rapid response team, and finally auscultate heart sounds.
The correct sequence for managing a suspected air embolism requires the nurse to prioritize immediate, life-saving mechanical interventions over standard ABCs and delegation. The nurse must first occlude the insertion site to prevent further air entry. Second, the left lateral Trendelenburg position is used to trap the air in the right atrium. Third, high-flow oxygen is administered to treat hypoxemia and wash out nitrogen. Fourth, the rapid response team is activated for advanced support. Finally, once the client is stabilized, further diagnostic assessments like auscultation are performed.

Step-by-Step Solution

1
Occlude the catheter insertion site.
Prevents additional ambient air from entering the central venous system.
Source control is the absolute highest priority to stop the ongoing physiological insult.
2
Place the client in the left lateral Trendelenburg position.
Traps the existing air in the right atrium.
This specific position (Durant's maneuver) utilizes gravity and buoyancy to keep the air bubble away from the right ventricular outflow tract, preventing fatal pulmonary artery occlusion.
3
Initiate 100% oxygen therapy.
Combats hypoxemia and promotes nitrogen washout.
High concentrations of oxygen decrease the partial pressure of nitrogen in the blood, helping to shrink the air bubble while simultaneously treating tissue hypoxia.
4
Activate the rapid response team.
Mobilizes advanced life support personnel.
Once immediate life-saving physical maneuvers are complete, the nurse must summon the healthcare provider and emergency team for further stabilization.
5
Auscultate heart sounds.
Assesses for a 'mill wheel' murmur and cardiopulmonary compromise.
Detailed diagnostic assessment is performed after the client is stabilized and help has been summoned.

Key Concept

Management of a central line-associated venous air embolism prioritizes immediate source control (occlusion) and specific physiological positioning (left lateral Trendelenburg) before standard oxygenation and team notification.
Question 188Question →

While responding to a high-pressure equipment alarm on a respiratory step-down unit, the charge nurse enters a client's room and observes a float registered nurse (RN) from the psychiatric unit attempting to silence a continuous positive airway pressure (CPAP) machine. The client is visibly dyspneic, diaphoretic, and has not yet been assessed by the float RN. Arrange the following actions the charge nurse should take in the correct priority order.

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Answer

The correct order prioritizes immediate patient safety (assessment then intervention), followed by correcting unit assignments (transferring the unstable client, then reassigning the float RN), and concludes with supervisory communication and administrative reporting.
In any clinical management scenario, the nurse must prioritize based on Maslow's Hierarchy of Needs, the ABCs (Airway, Breathing, Circulation), and the Nursing Process. 1) Assessment of the dyspneic client's ABCs is the absolute first priority. 2) Intervening to resolve the airway/breathing compromise follows assessment. 3) Once the client is stable, the charge nurse must immediately correct the unsafe assignment by transferring the complex client to a competent respiratory step-down RN. 4) The float RN must then be given a safe assignment matching their skill set. 5) With patient safety secured, the charge nurse conducts private supervisory feedback. 6) Finally, the institutional incident report is completed, as paperwork is always the lowest priority in an emergency situation.

Step-by-Step Solution

1
Prioritize immediate patient survival using the ABCs and Nursing Process.
The charge nurse assesses the client and then intervenes to stabilize the respiratory status.
Life-threatening issues take precedence over all other duties. Assessment must always precede intervention.
2
Ensure a safe environment by correcting inappropriate assignments.
The unstable client is transferred to a competent RN, and the float RN is reassigned to stable clients.
An RN floated from a psychiatric unit does not have the competency to manage acute respiratory failure on CPAP. The assignment must be modified to protect both the clients and the float RN's license.
3
Fulfill supervisory and administrative responsibilities.
The charge nurse provides private feedback to the float RN and then completes an incident report.
Direct communication and education should occur promptly after safety is assured, while formal paperwork is always the final administrative step.

Key Concept

Prioritization frameworks (ABCs, Nursing Process) must be applied to delegation and supervision tasks. Patient safety is always addressed before staff assignments, education, or administrative documentation.
Question 189Question →

A nurse is performing an assessment on a client who is 1 hour postpartum following a spontaneous vaginal birth. The nurse observes a sudden, heavy gush of vaginal bleeding. Upon palpation, the uterus is boggy and displaced to the right of the umbilicus. Arrange the following nursing interventions in the priority order of execution.

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Answer

The correct sequence of actions is: 1) Firmly massage the uterine fundus, 2) Assist the client to empty the bladder, 3) Administer a prescribed uterotonic medication, 4) Increase the flow rate of intravenous fluids, and 5) Weigh the perineal pads.
In the event of postpartum hemorrhage due to uterine atony, immediate manual stimulation via fundal massage is the absolute first priority to stop bleeding. The observation of a uterus displaced to the right indicates a full bladder, which must be emptied next because it physically impedes the uterus from staying contracted. After manual and anatomical corrections, uterotonic medications are administered to sustain the contraction. Fluid resuscitation follows to address the physiological impact of the blood loss, and finally, exact quantification of blood loss is performed to guide ongoing therapy.

Step-by-Step Solution

1
Massage the uterine fundus.
The uterus is mechanically stimulated to contract.
Uterine atony is the leading cause of postpartum hemorrhage. Immediate manual stimulation is the fastest way to induce contractions and compress bleeding vessels.
2
Empty the bladder.
The physical obstruction preventing the uterus from remaining contracted is removed.
A fundus that is displaced to the right indicates a full bladder. A full bladder prevents the uterus from contracting effectively, leading to continued bleeding.
3
Administer uterotonic medications.
Sustained chemical stimulation of the uterine muscle is achieved.
Once mechanical causes (atony and bladder distension) are addressed, medications like oxytocin are necessary to maintain the contraction and prevent recurrent atony.
4
Increase intravenous fluids.
Intravascular volume is expanded.
The client has experienced a heavy gush of bleeding. Increasing IV fluids helps maintain cardiac output, tissue perfusion, and prevents hypovolemic shock.
5
Quantify blood loss.
An accurate measurement of the hemorrhage is obtained.
Measuring blood loss by weighing pads (1 gram = 1 mL) is necessary to evaluate the effectiveness of interventions and determine if further treatments (e.g., blood transfusion) are required.

Key Concept

Prioritization of nursing interventions for postpartum hemorrhage caused by uterine atony and bladder distension.
Question 190Question →

A nurse is assessing a client who is receiving a continuous peripheral intravenous (IV) infusion of norepinephrine. The nurse notes that the IV insertion site is blanched, cool to the touch, and swollen. The client reports a severe burning sensation at the site. Arrange the following nursing actions in the exact sequence they should be performed, from first to last.

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Answer

The correct sequence for managing a vasopressor extravasation is to first stop the infusion, then aspirate the residual medication, notify the healthcare provider, administer the antidote through the existing catheter, and finally remove the catheter.
When a vesicant like norepinephrine extravasates, the immediate priority is to stop the infusion to prevent further tissue damage. Crucially, the catheter must be left in place initially. This allows the nurse to attach a syringe and aspirate any residual drug from the line and the subcutaneous tissue. The provider is then notified to obtain an order for an antidote, typically phentolamine. The antidote is administered directly through the existing IV line to ensure it reaches the exact site of extravasation and reverses the vasoconstriction. Finally, once the antidote is delivered, the catheter is removed and the extremity is elevated.

Step-by-Step Solution

1
Stop the norepinephrine infusion immediately.
The flow of the vesicant into the subcutaneous tissue is halted.
Continuing the infusion will cause further vasoconstriction, severe ischemia, and subsequent tissue necrosis.
2
Aspirate the residual medication from the intravenous catheter.
Remaining norepinephrine is removed from the catheter and localized tissue.
Aspiration minimizes the total volume of the vesicant that the tissue is exposed to, reducing the severity of the injury.
3
Notify the healthcare provider to obtain a prescription for an antidote.
A prescription for phentolamine is obtained.
Nurses cannot prescribe medications; an order is required to administer the specific pharmacological antidote for alpha-adrenergic extravasation.
4
Administer phentolamine through the existing intravenous catheter.
The antidote reaches the exact site of the extravasation.
Phentolamine induces localized vasodilation, counteracting the severe vasoconstriction caused by norepinephrine. Giving it through the existing line ensures direct delivery to the compromised tissue.
5
Remove the intravenous catheter and elevate the extremity.
The source of the infiltration is removed, and edema is managed.
The catheter has fulfilled its purpose of delivering the antidote and must be removed to prevent infection and allow the site to heal.

Key Concept

Management of Vesicant Extravasation
Question 191Question →

A nurse is preparing to mix and administer regular insulin and NPH insulin in a single syringe for a client with diabetes mellitus. Arrange the following steps in the correct chronological order to ensure safe and effective medication preparation.

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Answer

The correct sequence is to first inject air into the NPH vial, then inject air into the regular vial, withdraw the regular insulin, and finally withdraw the NPH insulin.
When mixing intermediate-acting (NPH, cloudy) and short-acting (regular, clear) insulin, the standard safety protocol is 'clear before cloudy'. First, air is injected into the NPH vial, then air is injected into the regular vial. The regular insulin is then withdrawn first, followed by the NPH insulin. This precise sequence prevents the longer-acting NPH insulin from accidentally contaminating the vial of short-acting regular insulin, which could affect the onset and peak times of future doses.

Step-by-Step Solution

1
Determine the order for injecting air into the vials.
Air must be injected into the cloudy (NPH) vial first, followed by the clear (regular) vial.
Injecting air equalizes the pressure inside the vials. Doing the NPH vial first ensures the needle does not carry regular insulin into the NPH vial prematurely.
2
Determine the order for withdrawing the medication.
The clear (regular) insulin is withdrawn first, followed by the cloudy (NPH) insulin.
Drawing up the clear insulin before the cloudy insulin prevents accidental contamination of the rapid/short-acting insulin vial with intermediate-acting insulin.

Key Concept

Safe Preparation of Mixed Insulin (Clear Before Cloudy)
Question 192Question →

A client with a seizure disorder is currently receiving a continuous infusion of 5% dextrose in water (D5W) through a single peripheral IV catheter. The healthcare provider prescribes an immediate dose of intravenous phenytoin. Knowing that phenytoin forms a precipitate when mixed with dextrose solutions, arrange the following nursing actions in the correct chronological sequence to safely deliver the medication.

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Answer

The correct sequence is to first pause the incompatible infusion, flush the line with normal saline, administer the phenytoin slowly, flush again with normal saline at the exact same slow rate, and finally resume the continuous infusion.
When administering an IV push medication that is incompatible with a continuous IV infusion, the nurse must utilize the Saline-Administer-Saline method. First, the continuous infusion must be paused to stop the flow of the incompatible fluid. The line is then aspirated and flushed with a compatible solution (normal saline) to clear the existing fluid from the tubing. Next, the medication is administered at its recommended safe rate. Crucially, the subsequent flush must be administered at the exact same rate as the medication to ensure the drug residing in the tubing dead space is not rapidly flushed into the client's circulation. Finally, the primary infusion can be safely resumed.

Step-by-Step Solution

1
Pause the primary continuous IV infusion pump.
The flow of the incompatible D5W solution is completely stopped.
This is the first essential step to prevent the mixing of phenytoin and dextrose, which causes immediate crystallization.
2
Aspirate for a blood return and flush the IV line with 10 mL of 0.9% sodium chloride.
IV patency is confirmed and the tubing is cleared of D5W.
Confirming patency ensures the medication will enter the vein safely. Normal saline is compatible with phenytoin and clears the incompatible fluid.
3
Administer the IV phenytoin at a rate not exceeding 50 mg/min.
The medication is delivered safely into the saline-primed line.
Rapid administration of phenytoin can cause severe hypotension, bradycardia, and cardiovascular collapse.
4
Flush the IV line again with 10 mL of 0.9% sodium chloride at the same rate the medication was administered.
The medication remaining in the dead space of the IV tubing is cleared into the patient.
If the second flush is given rapidly, the patient receives a rapid bolus of the residual phenytoin in the line, leading to adverse cardiovascular effects.
5
Resume the primary continuous IV infusion of 5% dextrose in water.
The client continues to receive their prescribed continuous IV therapy.
The line is now clear of phenytoin, making it safe to reintroduce the dextrose solution.

Key Concept

Administration of an IV push medication incompatible with the primary continuous IV fluid requires pausing the pump and using the Saline-Administer-Saline method, ensuring the final flush is administered at the same rate as the medication to prevent rapid bolusing of residual drug in the dead space.
Question 193Question →

A client with acute kidney injury is exhibiting profound muscle weakness. The bedside cardiac monitor suddenly displays a widened QRS complex and tall, peaked T waves. The laboratory reports a stat serum potassium level of 7.8 mEq/L7.8\text{ mEq/L}. The healthcare provider has prescribed several urgent interventions. Arrange the following pharmacological actions in the priority sequence the nurse must implement them.

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Answer

The correct priority sequence is to first stabilize the myocardium with calcium gluconate, second shift potassium intracellularly with insulin and dextrose, third remove potassium from the body with sodium polystyrene sulfonate, and finally evaluate the client's response with follow-up laboratory tests.
The pathophysiology of severe hyperkalemia demands a specific sequence of interventions. The most immediate threat to life is cardiac toxicity, manifested by widened QRS complexes and peaked T waves. Therefore, calcium gluconate is always the first line of treatment to raise the threshold potential and stabilize the myocardium. Next, fast-acting agents like IV insulin and dextrose are used to rapidly shift potassium into cells. Slower-acting agents like sodium polystyrene sulfonate are then given for definitive removal from the body. Finally, evaluation of the therapy is required.

Step-by-Step Solution

1
Administer intravenous calcium gluconate.
Myocardial excitability is decreased and the cell membrane is stabilized.
This is the immediate life-saving intervention to prevent lethal ventricular arrhythmias caused by severe hyperkalemia.
2
Administer intravenous regular insulin concurrently with 50% dextrose.
Potassium is rapidly driven from the intravascular space into the intracellular fluid.
This provides a rapid, albeit temporary, reduction in the circulating serum potassium level, buying time for excretion therapies to work.
3
Administer sodium polystyrene sulfonate via retention enema.
Potassium is exchanged for sodium in the large intestine and excreted in feces.
This provides permanent removal of potassium from the body, but is given after stabilizing medications because its onset of action takes hours.
4
Obtain a follow-up serum potassium level.
Current serum electrolyte status is documented.
The nurse must evaluate if the applied medical therapies were effective or if further interventions, such as emergent hemodialysis, are required.

Key Concept

In the presence of hyperkalemia with ECG changes, immediate myocardial stabilization with calcium gluconate must precede therapies that lower serum potassium.
Question 194Question →

A nurse is preparing to administer an intravenous piggyback (IVPB) dose of a prescribed antibiotic through a client's continuous primary intravenous infusion of 0.9% sodium chloride. In what order should the nurse perform the following actions? Arrange the steps from first to last.

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Answer

The correct sequence is to first verify compatibility, then spike the bag, prime the tubing, scrub the primary line port, and finally connect the secondary tubing while lowering the primary fluid bag.
The correct sequence prioritizes safety, infection control, and proper fluid dynamics. Compatibility must always be verified first to prevent precipitation. Once verified, the equipment is prepared by clamping and spiking the bag, followed by priming to eliminate air. After the equipment is ready, the access port is scrubbed to ensure asepsis immediately prior to connection. Finally, connecting the tubing and lowering the primary bag allows the secondary medication to infuse via gravity.

Step-by-Step Solution

1
Verify the compatibility of the prescribed antibiotic with the primary intravenous fluid.
The nurse confirms it is safe to administer the medications together.
Checking compatibility is the first critical safety step to prevent adverse chemical reactions or precipitation in the intravenous line.
2
Close the roller clamp on the secondary tubing and spike the antibiotic infusion bag.
The secondary bag is successfully connected to the tubing without spilling medication.
Closing the clamp ensures the medication does not immediately run through the line and spill out before the nurse is ready to prime it.
3
Prime the secondary tubing by slowly opening the roller clamp to clear air from the line.
The secondary tubing is filled with fluid and free of air bubbles.
Removing air from the intravenous tubing is essential to prevent a potentially fatal air embolism.
4
Scrub the uppermost Y-port on the primary intravenous tubing with an antiseptic swab.
The injection port is disinfected.
Cleansing the access port with friction removes pathogens and prevents the introduction of microorganisms into the bloodstream.
5
Connect the secondary tubing to the primary line and lower the primary fluid bag using an extension hook.
The intravenous piggyback is correctly attached and positioned for gravity infusion.
Lowering the primary bag ensures the piggyback medication, positioned higher, will overcome the hydrostatic pressure of the primary line and infuse completely before the primary fluid resumes.

Key Concept

Safe administration of intravenous piggyback (IVPB) medications requires verifying compatibility, maintaining aseptic technique, preventing air embolisms, and utilizing gravity principles.
Question 195Question →

A clinic nurse is providing education to new parents about the sequence of expected motor skill progression during early childhood development. Place the following fine motor milestones in the chronological order in which they are typically achieved. Arrange the items from the earliest acquired skill to the latest.

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Answer

The correct chronological sequence of fine motor milestone acquisition is: maintaining hands closed in a fist (1 month), bringing hands to the midline (3-4 months), transferring objects between hands (7 months), utilizing a crude pincer grasp (9 months), and finally constructing a tower of two blocks (12-15 months).
Fine motor development progresses in a predictable proximodistal pattern (from the center of the body outward to the fingertips). The infant begins with involuntary reflexes (fists closed at 1 month), progresses to bilateral midline play (3-4 months), develops unilateral voluntary control to transfer objects (7 months), refines finger dexterity to a pincer grasp (9 months), and finally achieves the precision and deliberate release required to stack blocks (12-15 months).

Step-by-Step Solution

1
Identify the earliest milestone associated with the neonatal period.
Maintaining hands in a tight fist is selected first.
This is a primitive reflex characteristic of a 1-month-old infant before voluntary fine motor control develops.
2
Determine the next milestone as voluntary bilateral control begins.
Bringing hands to the midline is placed second.
As the grasp reflex fades by 3-4 months, infants begin to deliberately engage both hands together.
3
Identify the milestone that requires independent control of each hand.
Transferring an object from one hand to the other is placed third.
By 7 months, infants master the ability to grasp with one hand and voluntarily release it into the other.
4
Locate the milestone indicating refined finger dexterity.
Utilizing a crude pincer grasp is placed fourth.
By 9 months, infants transition from grasping with the whole palm to using the thumb and index finger.
5
Identify the most advanced milestone requiring precise object placement.
Constructing a small tower using two blocks is placed last.
This requires highly controlled intentional release and spatial coordination, typical of a 12 to 15-month-old toddler.

Key Concept

Fine Motor Development Timeline
Question 196Question →

A nurse is preparing to enter the room of a client who requires contact and droplet precautions. In what order should the nurse don (put on) the required personal protective equipment (PPE)? Arrange the steps in the correct sequence from first to last.

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Answer

The correct sequence for donning PPE is: 1) Perform hand hygiene, 2) Put on the isolation gown, 3) Put on the surgical mask, 4) Put on eye protection, and 5) Put on clean gloves.
According to the Centers for Disease Control and Prevention (CDC) guidelines, when full PPE is required, the correct donning sequence begins with hand hygiene to ensure clean hands are used to handle the equipment. The gown is applied first to cover the torso, followed by the mask to protect the respiratory tract, and eye protection to protect the mucous membranes. Gloves are always donned last so they can be pulled securely over the cuffs of the isolation gown, completing the protective barrier without gaps.

Step-by-Step Solution

1
Identify the necessary PPE based on the prescribed isolation precautions.
Contact precautions require a gown and gloves; droplet precautions require a surgical mask and eye protection.
Correctly identifying the required equipment ensures comprehensive protection against specific transmission routes.
2
Apply the Centers for Disease Control and Prevention (CDC) sequence for donning PPE.
The sequence follows the principle of covering the body first, then the face/respiratory tract, and finally the hands.
This standardized sequence minimizes the risk of self-contamination during the donning process and ensures gloves overlap the gown cuffs.

Key Concept

Standard transmission-based precautions and correct sequencing for donning Personal Protective Equipment (PPE).
Question 197Question →

A nurse is preparing to enter the room of a client who requires both contact and droplet precautions. Arrange the following steps for donning personal protective equipment (PPE) in the correct chronological order, starting with the first action.

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Answer

The correct sequence is: perform hand hygiene, put on the isolation gown, apply the surgical mask, position the face shield or goggles, and finally put on clean gloves.
According to the Centers for Disease Control and Prevention (CDC), the correct sequence for donning PPE ensures maximum protection and prevents self-contamination during the process. Hand hygiene must always occur first. The gown is donned first among the garments because of its size and the need to tie it at the back. The mask follows to secure respiratory protection. Eyewear is next to protect the eyes, and gloves are always placed last so they can overlap the gown cuffs to seal the wrists.

Step-by-Step Solution

1
Perform hand hygiene.
Hands are clean and ready to handle uncontaminated equipment.
Prevents the transfer of pathogens to the clean PPE garments.
2
Put on the isolation gown.
The torso and arms are protected.
The gown is donned first as it is the largest garment and requires reaching behind the neck and waist to fasten the ties.
3
Apply the surgical mask.
The nose and mouth are protected.
The mask is secured next to protect the respiratory system from droplet transmission.
4
Position the face shield or goggles.
The eyes are protected.
Eyewear is placed after the mask so it can sit securely, often resting slightly over the mask's upper edge.
5
Put on clean gloves.
The hands are protected and the wrists are sealed.
Gloves are put on last so they can be stretched over the cuffs of the isolation gown, ensuring no exposed skin at the wrists.

Key Concept

Standard donning sequence for personal protective equipment (PPE)
Question 198Question →

A nurse is preparing to obtain a blood specimen for laboratory testing from a client's central venous catheter (CVC). A continuous intravenous infusion is currently running through the lumen. Arrange the following steps in the correct chronological order for safely drawing the blood specimen using the discard method.

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Answer

The correct sequence is: Pause the continuous infusion, scrub the connector hub, aspirate and discard the initial 5 mL of blood, withdraw the required specimen, flush the catheter with normal saline, and finally resume the continuous infusion.
To maintain patient safety, specimen integrity, and line patency, the nurse must first stop any fluids that could alter the sample. Strict infection control (scrubbing the hub) is applied next. The discard step guarantees the drawn specimen is pure blood and not diluted with the prior infusion. After the clean sample is collected, the line must be flushed to prevent blood from clotting in the catheter before the continuous therapy is safely resumed.

Step-by-Step Solution

1
Pause the continuous IV infusion.
The flow of fluid and medication into the bloodstream is temporarily stopped.
Prevents mixing of the IV fluid with the blood specimen, which would alter laboratory results.
2
Scrub the hub with antiseptic.
Pathogens are removed from the entry point.
Maintains strict asepsis and prevents the introduction of bacteria into the central circulation.
3
Aspirate and discard 5 mL of blood.
Residual fluid within the catheter space is removed.
Ensures the subsequent sample is undiluted whole blood.
4
Withdraw the diagnostic specimen.
An accurate, uncontaminated blood sample is obtained.
Provides reliable data for clinical decision-making.
5
Flush the catheter with 0.9% sodium chloride.
The catheter lumen is cleared of all blood.
Prevents the blood from clotting inside the lumen and maintains catheter patency.
6
Restart the continuous infusion.
The client's parenteral therapy continues.
Ensures there is no prolonged interruption in the client's prescribed medical treatment.

Key Concept

Central Venous Catheter (CVC) Blood Specimen Collection
Estimated Time:1m 0s
Question 199Question →

A client with a complete transection spinal cord injury at the T4 level suddenly reports a severe, pounding headache and blurred vision. Upon evaluation, profuse diaphoresis is noted above the level of the injury alongside a blood pressure reading of 215/115 mm Hg. Arrange the following nursing actions in the priority order they should be performed, from first to last.

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Answer

The correct sequence is to first elevate the head of the bed, loosen restrictive clothing, assess the bladder, examine the bowel, and finally administer antihypertensive medication.
Autonomic dysreflexia is a medical emergency characterized by uncontrolled hypertension in clients with spinal cord injuries at or above T6. The priority sequence follows a strict 'immediate safety first, then treat the cause' approach: rapidly lowering blood pressure via orthostasis (sitting up) is always the immediate first action. This is followed by systematically identifying and removing the offending noxious stimuli, starting from the most external and common (tight clothing, full bladder) to the next most common (bowel impaction). Pharmacological intervention is the final step if mechanical removal of stimuli fails.

Step-by-Step Solution

1
Elevate the head of the bed to a high Fowler's position.
Takes advantage of orthostatic hypotension to lower blood pressure.
The client is experiencing a hypertensive emergency due to autonomic dysreflexia. The most immediate mechanical way to lower blood pressure and prevent stroke is to utilize gravity.
2
Loosen any restrictive clothing or tight devices.
Reduces external skin stimulation.
Tight clothing, tight sheets, or restrictive devices act as noxious sensory stimuli below the level of injury, driving the exaggerated sympathetic response.
3
Assess the urinary drainage system for kinks or bladder distention.
Identifies or rules out the primary cause of autonomic dysreflexia.
A distended bladder is the single most common cause of autonomic dysreflexia. Emptying the bladder often abruptly stops the crisis.
4
Examine the rectum for the presence of a fecal impaction.
Identifies or rules out the secondary cause of autonomic dysreflexia.
If the bladder is not the source, the bowel is the next most likely culprit. This must be checked to remove the noxious stimulus.
5
Administer a rapidly acting intravenous antihypertensive medication.
Pharmacologically lowers the blood pressure.
Medications are used only when conservative measures fail to eliminate the noxious stimuli or if the blood pressure remains critically elevated despite removing the trigger.

Key Concept

Prioritization and Management of Autonomic Dysreflexia
Estimated Time:1m 30s
Question 200Question →

A nurse is caring for a client who is receiving total parenteral nutrition via a central venous catheter. The nurse discovers that the catheter tubing has become disconnected. The client suddenly develops severe dyspnea, a cough, chest pain, and extreme tachycardia. Arrange the following nursing interventions in the most appropriate order of priority.

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Answer

The correct sequence is to first clamp the catheter, then place the client in the left lateral Trendelenburg position, administer oxygen, notify the rapid response team, and finally assess vital signs and heart sounds.
The client's presentation of a disconnected central line with sudden severe respiratory distress and tachycardia is a hallmark sign of a central line-associated air embolism. The nurse's actions must prioritize immediate, independent life-saving interventions before gathering more data or calling for help. The very first action is to clamp the central line to stop the influx of air. Immediately following this, placing the client in the left lateral Trendelenburg position (Durant's maneuver) is critical, as it traps the air in the apex of the right ventricle, preventing it from entering the pulmonary circulation. Providing 100% oxygen treats the resulting hypoxia and helps dissolve the nitrogen in the air embolus. After these immediate stabilization steps, the nurse must notify the rapid response team and the healthcare provider for advanced support. Finally, obtaining a complete set of vital signs and auscultating for a classic 'mill wheel' murmur provides necessary data to guide further treatment.

Step-by-Step Solution

1
Clamp the central venous catheter.
Prevents additional air from being drawn into the central venous system.
Eliminating the source of the complication is the absolute first priority in emergency management.
2
Place the client in the left lateral Trendelenburg position.
Traps the air in the right ventricle.
This specific positioning utilizes gravity to keep the air bubble away from the pulmonary valve, preventing a catastrophic pulmonary embolism.
3
Administer 100% oxygen via a non-rebreather mask.
Treats hypoxia and promotes nitrogen washout.
Room air is primarily nitrogen. High-flow oxygen creates a concentration gradient that helps the nitrogen bubble dissolve faster.
4
Notify the rapid response team and the healthcare provider.
Summons advanced medical assistance.
The client requires critical care, continuous hemodynamic monitoring, and potential interventions (like needle aspiration) that are outside the nurse's independent scope of practice.
5
Obtain a complete set of vital signs and auscultate heart sounds.
Provides baseline data and checks for clinical signs of an air embolism.
Once life-saving interventions are established, ongoing assessment is necessary to monitor the client's stability and response.

Key Concept

The priority management of a suspected central line air embolism follows the sequence of stopping the source, positioning the client to prevent further harm, providing supplemental oxygenation, and escalating care.
Estimated Time:1m 30s
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