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Question 201Question →

A nurse is admitting a client who has a history of frequent, uncontrolled generalized tonic-clonic seizures. Which of the following interventions should the nurse implement to promote accident and injury prevention? (Select all that apply.)

Select all that apply

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Answer: Verify that functioning suction equipment and supplemental oxygen are available at the bedside.; Apply padding to the bed's side rails to protect the client from impact.; Keep the client's bed in the lowest position with the wheels locked.

Answer

The correct interventions for seizure precautions are verifying the presence of functioning oxygen and suction equipment, applying padding to the side rails, and keeping the bed in the lowest locked position.
Safe and effective seizure precautions involve altering the environment to prevent injury during involuntary movements. Maintaining the bed in the lowest position with locked wheels reduces fall-related injuries. Padding the side rails protects the client from blunt force trauma. Having supplemental oxygen and functioning suction readily available at the bedside is critical to manage the airway and clear secretions immediately following the seizure.

Step-by-Step Solution

1
Evaluate the client's clinical presentation and diagnosis.
The client has a history of frequent, uncontrolled generalized tonic-clonic seizures.
Identifying the primary seizure risk establishes the need for comprehensive environmental safety measures to prevent traumatic injury and aspiration.
2
Analyze each proposed intervention for its appropriateness in promoting safety during a seizure.
Oxygen/suction availability, padded side rails, and a low/locked bed actively prevent secondary injury and manage immediate complications. Applying restraints and inserting objects into the mouth are actively harmful. Initial nursing assessments cannot be delegated.
Seizure precautions aim to protect the client from trauma and maintain airway patency without causing iatrogenic harm or violating the nursing scope of practice.
3
Select all options that represent evidence-based, safe seizure precautions.
The correct safety interventions are selected.
This directly fulfills the objective of accident and injury prevention for a high-risk neurological client.

Key Concept

Standard seizure precautions focus on preventing traumatic injury and ensuring airway safety without restricting the client's movements or introducing objects into the oral cavity.
Estimated Time:1m 0s
Question 202Question →

The hospital bed placement coordinator is assigning rooms for four clients awaiting admission from the emergency department. The facility currently has only one available airborne infection isolation room (AIIR). Based on standard and transmission-based precaution guidelines, which client must be prioritized for assignment to this specific room?

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Answer: A client receiving immunosuppressive therapy for a renal transplant who presents with a painful, fluid-filled vesicular rash confined to the right lumbar dermatome.

Answer

The client receiving immunosuppressive therapy who presents with a localized vesicular rash.
According to the Centers for Disease Control and Prevention (CDC), clients who are immunocompromised and develop localized herpes zoster (shingles) must be placed on both Airborne and Contact Precautions. Because their immune system cannot effectively contain the varicella-zoster virus, they are at a high risk for viral dissemination, which can aerosolize and spread via the airborne route. Therefore, this client requires placement in a negative-pressure Airborne Infection Isolation Room (AIIR) until a disseminated infection is definitively ruled out or all lesions have completely crusted over.

Step-by-Step Solution

1
Evaluate the isolation requirements for the client with localized herpes zoster.
Because the client is immunosuppressed, the localized shingles infection carries a high risk of systemic dissemination. Both Airborne and Contact Precautions (and an AIIR) are required.
Immunocompromised clients cannot effectively contain the varicella-zoster virus, allowing it to spread systemically and aerosolize.
2
Evaluate the isolation requirements for the client with rubella.
Rubella requires Droplet Precautions, meaning a regular private room is sufficient.
Rubella (German measles) is transmitted via large respiratory droplets, unlike rubeola (measles) which requires Airborne Precautions.
3
Evaluate the isolation requirements for the client with inhalation anthrax.
Inhalation anthrax requires only Standard Precautions.
Despite being contracted via airborne spores, the disease is not transmissible from person-to-person.
4
Evaluate the isolation requirements for the client with a history of night sweats and three negative AFB smears.
Airborne Precautions can be discontinued.
Three consecutive negative AFB sputum smears (collected 8-24 hours apart) indicate the client is no longer infectious for pulmonary tuberculosis.

Key Concept

Immunocompromised clients with localized herpes zoster must be placed on both Airborne and Contact Precautions due to the high risk of viral dissemination.
Question 203Question →

A pediatric nurse is coordinating the discharge plan for an 8-year-old client newly diagnosed with type 1 diabetes mellitus. The client's parents have limited English proficiency and express high levels of anxiety regarding home management. Which of the following actions indicate appropriate interdisciplinary collaboration and delegation? Select all that apply.

Select all that apply

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Answer: Consult a registered dietitian to incorporate the family's cultural food preferences into a carbohydrate counting education plan.; Refer the family to a medical social worker to assess their financial capacity to obtain necessary medications and home supplies.; Include a professional medical interpreter in all teaching sessions to ensure accurate bidirectional communication.

Answer

The correct actions involve consulting a registered dietitian, referring to a medical social worker, and arranging for a professional medical interpreter.
The correct actions properly utilize the interdisciplinary team's expertise to provide safe, comprehensive care. Consulting a registered dietitian provides specialized nutritional teaching; referring the family to a medical social worker addresses potential financial and resource barriers; and utilizing a professional medical interpreter ensures accurate communication for a family with limited English proficiency.

Step-by-Step Solution

1
Identify the client's complex discharge needs based on the scenario.
The client requires education on a new chronic illness, cultural dietary planning, financial assessment, and dedicated language support.
A comprehensive assessment determines which interdisciplinary team members are necessary for a safe discharge.
2
Determine the appropriate roles of interdisciplinary team members.
A dietitian handles specialized meal planning, a social worker addresses financial resources, and a professional interpreter bridges the language gap.
Collaborating with the right professionals ensures safe and effective care that addresses all psychosocial and physiological needs.
3
Evaluate the appropriateness of delegated tasks and communication strategies.
Initial assessments and teaching must remain with the registered nurse, and therapeutic communication must be maintained without using false reassurance.
Improper delegation and non-therapeutic communication compromise patient safety and fail to address the core problem.

Key Concept

Interdisciplinary collaboration involves utilizing the specialized skills of various healthcare team members (e.g., dietitians, social workers, interpreters) to provide comprehensive care while strictly adhering to the RN scope of practice for delegation and teaching.
Question 204Question →

Following the morning bedside report on a progressive care unit, the nursing team, which includes a registered nurse (RN) and an unlicensed assistive personnel (UAP), begins organizing the shift tasks. Which of the following client care activities is most appropriate for the RN to assign to the UAP?

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Answer: Assisting a client with chronic Parkinson's disease, who has a documented stable swallowing pattern, with their morning meal

Answer

Assisting a client with chronic Parkinson's disease, who has a documented stable swallowing pattern, with their morning meal
The correct answer involves assisting a stable client with a routine activity of daily living (feeding). Because the client has a documented stable swallowing pattern, the outcome is predictable and the task requires no specialized nursing assessment or judgment, making it safe and appropriate to delegate to a UAP.

Step-by-Step Solution

1
Analyze the role and scope of practice of the unlicensed assistive personnel (UAP).
Identify that UAPs are trained to perform standard, routine tasks and assist with activities of daily living (ADLs) for stable clients with predictable outcomes.
Understanding scope of practice is essential for safe delegation.
2
Evaluate each task against the Five Rights of Delegation and the core RN responsibilities (Assessment, Clinical Judgment, Teaching, Evaluation).
Identify that teaching, post-procedure evaluation, and pain assessment require RN clinical judgment.
Tasks involving nursing judgment, initial assessment, or patient education cannot be safely or legally delegated to a UAP.
3
Determine the stability and predictability of the client described in the correct option.
The client with Parkinson's disease has a documented stable swallowing pattern, making meal assistance a safe, routine task with a predictable outcome.
Delegation is only appropriate when the client's condition is stable and the risk of complications from the delegated task is minimal.

Key Concept

Delegation of tasks to Unlicensed Assistive Personnel (UAP)
Question 205Question →

A nurse is caring for a client admitted with an exacerbation of myasthenia gravis. During the morning assessment, the client reports increasing generalized muscle fatigue and new-onset difficulty swallowing (dysphagia) when eating breakfast. To promote safe and effective care, which of the following actions by the nurse represents the most appropriate interdisciplinary collaboration?

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Answer: Request a speech-language pathologist to conduct a comprehensive swallowing evaluation and recommend diet modifications.

Answer

The nurse should request a speech-language pathologist to conduct a comprehensive swallowing evaluation and recommend diet modifications.
A speech-language pathologist (SLP) is specially trained to evaluate the mechanics of swallowing, perform diagnostic tests (such as a modified barium swallow study), and determine the safest diet consistency for clients experiencing dysphagia. Consulting an SLP directly addresses the client's mechanical deficit and prioritizes airway protection, which is essential for a client with myasthenia gravis experiencing muscle fatigue.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client with myasthenia gravis has new-onset dysphagia (difficulty swallowing), which places them at a high risk for aspiration and airway compromise.
Identifying the primary physiological threat (airway and breathing) dictates the necessary interventions and team member referrals.
2
Determine the appropriate interdisciplinary team member for the specific deficit.
A speech-language pathologist (SLP) specializes in the mechanics of swallowing and speech.
Proper delegation and collaboration require matching the client's specific clinical need with the allied health professional's designated scope of practice.
3
Select the action that represents safe and effective collaboration.
Requesting an SLP consultation directly addresses the mechanical swallowing issue, whereas delegating to a UAP is unsafe, and dietitians do not evaluate mechanical swallowing safety.
This ensures the client receives specialized care to protect the airway while avoiding out-of-scope delegation.

Key Concept

Interdisciplinary Collaboration for Dysphagia
Question 206Question →

An infection control nurse is interviewing a client recently diagnosed with active pulmonary tuberculosis. The client is highly distressed and states, "You cannot tell anyone outside this clinic about my illness. I am terrified of the social stigma and could lose my housing." Which response or action by the nurse correctly applies the principles of client confidentiality?

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Answer: Inform the client that healthcare facilities are legally mandated to report active tuberculosis cases to the public health department.

Answer

The nurse must inform the client that healthcare facilities are legally mandated to report active tuberculosis cases to the public health department.
The Health Insurance Portability and Accountability Act (HIPAA) strictly protects client health information, but it includes specific legal exceptions. Healthcare providers are legally mandated to report certain communicable diseases, including active pulmonary tuberculosis, to the local or state public health department. This reporting is required to track outbreaks and protect public safety, and it does not constitute a breach of client confidentiality. The nurse's duty is to transparently inform the client of this legal requirement.

Step-by-Step Solution

1
Analyze the client's diagnosis and the request for privacy.
The client has active pulmonary tuberculosis and is requesting strict confidentiality out of fear of social stigma.
Identifying the conflict between a client's desire for privacy and legal obligations is the first step in ethical and legal decision-making.
2
Evaluate the legal exceptions to the Health Insurance Portability and Accountability Act (HIPAA).
Mandatory reporting of certain communicable diseases to public health authorities is a designated legal exception that overrides standard HIPAA privacy protections.
Healthcare workers must protect broader public health while balancing individual privacy rights, as required by state and federal laws.
3
Determine the appropriate nursing action based on these legal mandates.
The nurse must honestly educate the client about the facility's legal obligation to report the disease.
Providing factual information about legal limits to confidentiality maintains professional integrity and avoids making false promises.

Key Concept

Mandatory Reporting Exceptions to Confidentiality
Question 207Question →

An oncology nurse is caring for a 55-year-old client who underwent a hematopoietic stem cell transplant two weeks ago. During the morning assessment, the nurse discovers a weeping, clustered vesicular rash strictly following the T10 dermatome on the client's right side. Based on these clinical findings, which infection control and care actions are required? Select all that apply.

Select all that apply

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Answer: Coordinate a transfer to an isolation room equipped with negative-pressure directional airflow.; Assign a dedicated stethoscope, sphygmomanometer, and thermometer for exclusive use in this client's care area.; Secure a standard surgical mask over the client's nose and mouth if leaving the clinical unit for imaging.

Answer

The required actions are transferring the client to a negative-pressure room, assigning dedicated medical equipment, and placing a surgical mask on the client during transport.
The correct interventions reflect strict adherence to Airborne and Contact Precautions. Severely immunocompromised clients with localized herpes zoster must be treated as having disseminated disease, necessitating a negative-pressure room. Dedicated equipment prevents contact transmission from weeping lesions, and placing a surgical mask on the client during transport provides necessary source control.

Step-by-Step Solution

1
Analyze the client's systemic immune status.
The client is two weeks post-hematopoietic stem cell transplant, making them severely immunocompromised.
Immune status dictates the severity and potential spread of viral infections.
2
Evaluate the clinical presentation.
The client has a weeping, clustered vesicular rash localized to the right T10 dermatome, indicating herpes zoster (shingles).
Identifying the pathogen and its presentation determines the necessary isolation precautions.
3
Determine the appropriate transmission-based precautions.
Airborne and Contact Precautions are required.
Although the rash is currently localized, the client's severely immunocompromised state creates a high risk for disseminated disease. The CDC mandates both Airborne and Contact Precautions for immunocompromised clients with localized zoster.
4
Select interventions that align with Airborne and Contact Precautions.
The client needs a negative-pressure room (Airborne), dedicated equipment (Contact), and must wear a surgical mask if transported (Airborne source control).
These specific actions break the chain of infection for pathogens transmitted via aerosols and direct contact.

Key Concept

In severely immunocompromised clients, localized herpes zoster requires both Airborne and Contact Precautions due to the high risk of dissemination. Furthermore, clients on airborne precautions wear standard surgical masks for transport, not N95 respirators.
Question 208Question →

The charge nurse on an inpatient respiratory unit is coordinating the care assignments for the upcoming shift. The nursing team includes registered nurses (RNs) and one experienced licensed practical/vocational nurse (LPN/VN). Which client is the most appropriate to assign to the LPN/VN?

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Answer: A client with chronic bronchitis who requires scheduled administration of oral corticosteroids and a routine metered-dose inhaler.

Answer

The client with chronic bronchitis requiring scheduled oral medications and a routine inhaler.
The most appropriate assignment for an LPN/VN is a client with a stable, chronic condition with expected outcomes who requires routine pharmacological interventions. Administering oral and inhaled medications to a stable client safely aligns with the LPN/VN scope of practice.

Step-by-Step Solution

1
Analyze the scope of practice for an LPN/VN.
An LPN/VN can care for stable clients with predictable outcomes and can administer standard medications (like oral and inhaled drugs).
Understanding professional boundaries is required for safe delegation.
2
Evaluate the stability and needs of each client.
The asthma client is unstable. The thoracentesis client needs initial assessment. The discharge client needs new teaching. The chronic bronchitis client is stable and needs routine care.
Applying the principles of 'Right Circumstance' and 'Right Task' to the scenarios.
3
Select the assignment that matches the LPN/VN scope of practice.
The stable client with chronic bronchitis is the correct assignment.
It avoids delegating assessment, teaching, or the care of unstable clients to the LPN/VN.

Key Concept

Delegation and Scope of Practice for LPN/VNs
Question 209Question →

A competent adult client admitted with an acute exacerbation of heart failure abruptly demands to leave the facility against medical advice (AMA) to care for a pet at home. The client's attending provider is currently unavailable. Which action by the nurse demonstrates appropriate ethical and legal practice?

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Answer: Explore the client's concerns, explain the clinical risks of leaving without treatment, and provide the AMA paperwork.

Answer

The correct answer is to explore the client's concerns, educate them about the clinical risks of leaving, and provide the AMA paperwork.
The correct choice upholds the ethical principle of autonomy by recognizing the competent adult client's right to refuse treatment. Exploring the client's concerns allows the nurse to advocate for potential alternative solutions (e.g., having a social worker arrange pet care), while explaining the clinical risks ensures the client's decision is fully informed before providing the AMA paperwork.

Step-by-Step Solution

1
Assess the client's capacity and underlying motivation.
The nurse identifies the root cause of the client's distress (worry over a pet).
Understanding the client's concern allows the healthcare team to advocate for the client and potentially resolve the barrier to treatment without violating autonomy.
2
Provide clear education regarding the risks of refusing treatment.
The client is fully informed about the potential health consequences (e.g., worsening heart failure, death) of leaving.
To make a legally and ethically sound autonomous decision, a competent client must possess informed knowledge of the risks and benefits.
3
Facilitate the Against Medical Advice (AMA) process if the client insists on leaving.
The client signs the AMA form and leaves the facility.
Competent adults have the legal and ethical right (autonomy) to refuse medical treatment, even if the healthcare team disagrees with the decision.

Key Concept

Client Autonomy, Informed Decision-Making, and Against Medical Advice (AMA)
Question 210Question →

A client recovering on a step-down cardiac unit becomes acutely delirious and repeatedly attempts to grasp and remove their temporary epicardial pacing wires. Despite frequent verbal redirection, the behavior escalates and poses an immediate threat to the client's life. Arrange the following nursing actions in the correct chronological sequence, progressing from the least restrictive initial interventions to the emergency application and immediate post-application requirements for physical restraints. All options must be used.

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Answer

The correct sequence begins with the least restrictive alternatives (concealing wires, then one-to-one observation). Once these fail and the life-sustaining device is at immediate risk, the nurse applies the restraints (secured to the movable frame), immediately checks the mechanical fit (two fingers), verifies physiological safety (distal circulation), and finally contacts the provider for the mandatory emergency prescription.
In accordance with safety and legal standards, nursing care must progress from non-invasive environmental changes to human supervision, and finally to physical restraints as a last resort. In a life-threatening emergency, the registered nurse has a duty to apply the restraint first to secure the client, immediately ensure mechanical fit and physiological safety to prevent iatrogenic injury, and subsequently fulfill the legal requirement of obtaining the provider's prescription within the mandated timeframe.

Step-by-Step Solution

1
Attempt environmental modification by concealing the pacing wires.
Behavior may be mitigated without restricting the client's freedom of movement.
Regulatory standards mandate that the least restrictive measures must be exhausted before escalating care.
2
Assign continuous one-to-one observation.
Human intervention is utilized to physically redirect the client.
Direct observation is highly restrictive regarding privacy but does not mechanically restrict movement, serving as the final alternative before physical restraints.
3
Apply the soft wrist restraints in an emergency capacity.
The client is mechanically prevented from pulling the life-sustaining epicardial wires.
Nurses have the authority to initiate restraints without a prior order strictly in emergency situations where there is an imminent threat to life.
4
Verify fit by sliding two fingers under the straps.
Proper strap tension is confirmed.
This is an integral part of the application procedure to prevent immediate physical trauma to the skin and superficial nerves.
5
Assess radial pulses and capillary refill.
Adequate distal tissue perfusion is verified.
The nurse must ensure that the mechanical application has not compromised physiological blood flow to the extremities before leaving the bedside.
6
Contact the healthcare provider for a face-to-face evaluation and prescription.
The emergency application is legally documented and formally prescribed.
Federal and facility guidelines require a provider's prescription within one hour of initiating an emergency restraint.

Key Concept

Prioritization and Legal Requirements in Emergency Restraint Application
Question 211Question →

A nurse on an infectious disease unit is reviewing the clinical status of four assigned clients. Which client requires immediate intervention by the nurse?

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Answer: A client with a severe soft tissue infection whose blood pressure decreased from 122/78 mmHg to 88/50 mmHg over the past two hours.

Answer

The client with a severe soft tissue infection whose blood pressure decreased significantly requires immediate intervention.
The correct answer identifies the client experiencing a sudden and significant drop in blood pressure. In the context of a severe soft tissue infection, this hypotensive trend strongly suggests the development of septic shock. Under the Airway, Breathing, and Circulation (ABC) prioritization model, establishing and maintaining adequate circulation is a life-saving priority that takes precedence over expected disease manifestations.

Step-by-Step Solution

1
Analyze each client's clinical presentation to determine if the findings are expected or unexpected for their diagnosis.
The clients with tuberculosis, meningitis, and cellulitis are exhibiting expected, stable manifestations of their respective diseases. The client with a soft tissue infection is exhibiting an unexpected, acute change in vital signs.
Prioritization requires differentiating between chronic/expected findings and acute/unexpected deteriorations.
2
Apply the Airway, Breathing, and Circulation (ABC) framework to the unexpected finding.
A blood pressure drop to 88/50 mmHg indicates a severe circulatory issue (hypotension), likely secondary to septic shock.
The ABC framework dictates that physiological needs related to survival, such as systemic circulation and perfusion, take the highest priority.

Key Concept

Prioritizing acute, unexpected circulatory complications (like shock) over expected, stable disease manifestations using the ABC framework.
Question 212Question →

A client with a newly casted right fractured tibia is prescribed non-weight-bearing status for the right leg. The nurse is educating the client on how to safely stand up from a wheelchair using axillary crutches. In which order should the nurse instruct the client to perform the following actions? Arrange the steps from first to last.

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Answer

The correct sequence is to first move to the edge of the chair with the unaffected foot flat, hold both crutches in the hand of the affected side, place the unaffected hand on the armrest, push up using the unaffected arm and leg, and finally transfer the crutches into the tripod position.
Standing safely with crutches requires maximizing the strength of the unaffected limbs. The client must position themselves at the edge of the seat with the strong foot grounded. By holding both crutches on the affected side, the strong arm is free to push off the armrest simultaneously with the strong leg. Once standing and balanced, the crutches are repositioned under both arms.

Step-by-Step Solution

1
Slide to the front edge of the wheelchair.
The client's center of gravity is shifted forward.
Proper positioning is required to allow the strong leg to bear the full body weight during the lift.
2
Hold both crutches in the right hand.
The crutches are secured on the side of the affected leg.
This leaves the strong, unaffected arm free to push off the chair while the crutches provide support on the weaker side.
3
Place the left hand on the left armrest.
The client is anchored for the lift.
The unaffected arm has the strength required to assist the unaffected leg in lifting the body's entire weight.
4
Push up to a stand using the left arm and left leg.
The client rises to a standing position.
Weight is strictly kept off the right fractured tibia, maintaining the prescribed non-weight-bearing status.
5
Position one crutch on each side to form a tripod stance.
The client is balanced and ready to ambulate.
The tripod position provides a wide base of support necessary for safe mobilization.

Key Concept

Basic Care and Comfort: Safe mobility and assistive device utilization for non-weight-bearing clients.
Question 213Question →

A nurse is caring for a client who was admitted 72 hours ago for a severe respiratory infection. The client suddenly becomes extremely agitated, exhibits profuse diaphoresis, and frantically states, "There are spiders crawling all over the walls!" The client's spouse reports that the client usually drinks a pint of vodka daily but abruptly stopped on the day of admission. Arrange the following nursing actions in the correct prioritized sequence from first to last.

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Answer

The correct sequence is to first remain with the client and call for help, followed by assessing airway and vital signs, then administering the intravenous benzodiazepine, establishing bedside seizure precautions, and finally decreasing environmental stimuli.
The sequence follows standard NCLEX prioritization frameworks: Safety first (calling for help while staying with the client), followed by the Nursing Process (assessing vital signs before intervening), followed by Maslow's Hierarchy of Needs (treating the acute physiological threat with medication, preparing for physiological complications like seizures, and finally addressing the environmental/psychosocial needs).

Step-by-Step Solution

1
Ensure immediate safety (Remain with the client and call for assistance).
The client is protected from sudden self-harm and additional staff are available to assist.
In acute delirium tremens, the client is highly unpredictable. A nurse must never leave an acutely delirious and hallucinating client alone.
2
Assess physiological status (Assess airway and vital signs).
Baseline autonomic stability is evaluated.
Applying the nursing process, assessment must precede intervention to determine the extent of tachycardia, hypertension, and respiratory status.
3
Implement primary treatment (Administer IV benzodiazepine).
Central nervous system irritability is suppressed.
Pharmacological therapy is the definitive treatment for severe alcohol withdrawal to prevent progression to seizures or cardiovascular collapse.
4
Prevent complications (Verify suction and oxygen).
Seizure precautions are strictly enforced.
Even with medication, the risk of seizures remains high. Preparing the environment for a potential airway emergency is the next highest physiological priority.
5
Provide psychosocial milieu management (Decrease environmental stimuli).
Sensory triggers for hallucinations are minimized.
Once life-threatening physiological and safety priorities are addressed, calming the environment addresses the client's psychological distress.

Key Concept

Prioritization in acute alcohol withdrawal (Delirium Tremens) utilizing the Safety and Nursing Process (ADPIE) frameworks.
Question 214Question →

A nurse is managing the disposal and handling of various items during a clinical shift. Which of the following actions demonstrate the correct protocol for handling hazardous and infectious materials? (Select all that apply)

Select all that apply

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Answer: Placing a surgical dressing that is saturated and dripping with blood into a red biohazard waste bag; Disposing of an intact, empty glass medication vial into a rigid, puncture-resistant sharps container; Engaging the safety shield on a used syringe needle before discarding it immediately into the sharps container

Answer

The correct actions are placing blood-saturated dressings in a red biohazard bag, disposing of intact glass vials in a sharps container, and engaging the needle safety shield prior to disposal.
The correct actions reflect strict adherence to standard precautions and waste management protocols. Items saturated with blood or body fluids that can be released upon compression meet the definition of regulated medical waste and require red biohazard bags. Glass vials pose a puncture risk and must be placed in rigid sharps containers regardless of whether they are intact. Engaging the safety mechanism on needles immediately after use prevents accidental needlestick injuries.

Step-by-Step Solution

1
Evaluate the requirement for red biohazard bags.
Identify that only items saturated with blood or other potentially infectious materials that release fluid upon compression require biohazard disposal, whereas routine urine or feces go in standard trash.
To properly segregate regulated medical waste from standard waste and adhere to infection control standards.
2
Determine proper sharps disposal procedures.
Identify that both used needles (with safety shields engaged) and intact glass vials must go into rigid sharps containers.
To prevent puncture and laceration injuries to healthcare workers and environmental services staff.
3
Assess transport and environmental containment protocols.
Recognize that specimen containers must be clean on the outside before transport and that routine double-bagging of isolation trash is unnecessary.
To minimize fomite transmission, ensure safe delegation, and follow evidence-based guidelines.

Key Concept

Segregation of regulated medical waste, sharps disposal, and biohazard containment
Estimated Time:1m 30s
Question 215Question →

A client with end-stage chronic obstructive pulmonary disease (COPD) is admitted to the palliative care unit. The client is experiencing severe dyspnea at rest, anxiety, and reports feeling "like I cannot get enough air." The goal of care has shifted entirely to comfort measures. Which nursing actions are appropriate to include in the plan of care? Select all that apply.

Select all that apply

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Answer: Administer prescribed low-dose oral morphine sulfate.; Direct a small electric fan to blow cool air gently across the client's face.; Assist the client into a high Fowler position with the arms resting on an overbed table.

Answer

The correct actions include administering low-dose oral morphine sulfate, directing a cool fan across the client's face, and assisting the client into an orthopneic (high Fowler with arms resting forward) position.
In end-of-life care for severe respiratory disease, the primary goal shifts from disease modification to symptom management. Dyspnea is a distressing symptom that should be treated aggressively to ensure comfort. Low-dose opioids, such as morphine, reduce the central respiratory drive and alleviate the sensation of breathlessness. Non-pharmacological interventions, including positioning the client in an orthopneic position (high Fowler with arms resting forward on a table) and using a fan to blow cool air across the face, stimulate the trigeminal nerve, maximize lung expansion, and decrease the perception of dyspnea.

Step-by-Step Solution

1
Identify the primary goal of care based on the clinical scenario.
The goal of care has shifted to comfort measures only, meaning interventions should focus on symptom management rather than disease modification.
Establishing the goal of care dictates the appropriateness of all subsequent nursing interventions.
2
Evaluate each intervention for its effectiveness in managing terminal dyspnea.
Morphine, fan therapy, and orthopneic positioning directly relieve the subjective sensation of breathlessness.
These are evidence-based palliative interventions specifically recommended for respiratory distress at the end of life.
3
Identify contraindicated or inappropriate actions among the choices.
Continuous oxygen saturation monitoring, providing false reassurance to the family, and delegating respiratory assessment to the UAP are rejected.
These actions violate principles of palliative comfort, therapeutic communication, and safe delegation practices.

Key Concept

Palliative management of dyspnea and end-of-life comfort measures
Question 216Question →

An advanced practice registered nurse conducts a comprehensive wellness examination for a 77-year-old client who lives independently. The client's caregiver provides a list of observed physical and behavioral changes that have occurred over the past year. Which of the following findings should the nurse identify as expected, age-related developmental and physiological transitions rather than pathological concerns? Select all that apply.

Select all that apply

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Answer: Increased difficulty distinguishing between blue and green color shades in dim lighting.; Requiring extended time to recall a specific word or name while maintaining an intact overall vocabulary.; Frequent reminiscing about past accomplishments and sharing repetitive historical narratives with younger family members.

Answer

The expected age-related transitions are increased difficulty distinguishing blue and green colors, requiring extended time for word retrieval, and frequent reminiscing about past life events.
Normal aging encompasses specific, predictable transitions: physiologically, the ocular lens yellows leading to poor blue/green discrimination; cognitively, processing speed slows leading to delayed word retrieval while vocabulary remains intact; and psychosocially, older adults engage in life review (reminiscing) to fulfill Erikson's developmental stage of Ego Integrity.

Step-by-Step Solution

1
Analyze the question requirements.
The question requires identifying normal physiological and psychosocial developmental transitions of aging (77-year-old), separating them from disease processes.
Recognizing the boundary between healthy aging and pathology prevents both overtreatment of normal changes and undertreatment of actual diseases.
2
Evaluate the physiological options.
Altered color perception (blue/green) is a normal transition due to lens yellowing. Incontinence, however, is a common pathological condition, not a normal developmental expectation.
Many clinicians and clients falsely assume incontinence is a normal part of aging, which represents a critical knowledge deficit.
3
Evaluate the cognitive options.
Slower word retrieval with intact vocabulary represents normal age-related cognitive slowing. Sudden disorientation represents a severe pathological state (delirium/dementia).
Normal aging affects processing speed but preserves crystallized intelligence and semantic memory.
4
Evaluate the psychosocial options based on developmental frameworks.
Reminiscing aligns with Erikson's Ego Integrity stage and is healthy. Abrupt withdrawal and feelings of uselessness indicate depression (Despair).
Successful transition through the older adult stage requires finding meaning in one's life history rather than succumbing to isolation.

Key Concept

Differentiating normal physiological and psychosocial aging processes from pathological conditions in the older adult.
Question 217Question →

A nurse is preparing to administer routine medications via a nasogastric (NG) tube to a clinically stable client. One of the prescribed medications is a solid oral tablet designated by the facility as a hazardous drug. Which action is the safest and most appropriate for the nurse to take?

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Answer: Contact the pharmacy to request the hazardous medication be dispensed as a ready-to-use liquid formulation.

Answer

The safest action is to contact the pharmacy to request a ready-to-use liquid formulation of the hazardous medication.
Manipulating (e.g., crushing or splitting) hazardous drugs poses a significant risk of occupational exposure through aerosolized dust. The safest and most appropriate action is to eliminate the hazard entirely by requesting a commercially available or pharmacy-compounded liquid formulation, preventing exposure at the point of care.

Step-by-Step Solution

1
Identify the occupational risk associated with the prescribed medication.
Recognize that the medication is a designated hazardous drug, meaning that altering its solid form (crushing or splitting) can release dangerous aerosolized dust.
Inhalation or skin contact with hazardous drug particles can cause serious acute and chronic health effects.
2
Evaluate the required route of administration.
Determine that the medication must be given via a nasogastric (NG) tube, which strictly requires a liquid or dissolved formulation.
Solid tablets cannot pass through an NG tube and will cause an occlusion.
3
Determine the safest method to obtain the required liquid formulation.
Decide to contact the pharmacy to provide a commercially prepared or pharmacy-compounded liquid alternative.
This strategy follows the hierarchy of hazard controls by eliminating the nurse's need to manipulate the drug on the clinical unit, completely preventing the aerosolization risk.

Key Concept

Safe Handling of Hazardous Drugs
Question 218Question →

A client is admitted to the inpatient psychiatric unit with major depressive disorder and active suicidal ideation. After five days of refusing meals, isolating in their room, and avoiding staff interactions, the client suddenly emerges into the dayroom smiling. The client hands a cherished watch to a peer and states, "The heavy cloud has finally lifted. I know exactly what I have to do now, and everything will be at peace." Which of the following is the priority nursing action?

Show answer & explanation

Answer: Maintain direct, continuous one-to-one observation of the client.

Answer

The correct action is to maintain direct, continuous one-to-one observation of the client to ensure immediate safety.
The client is exhibiting classic red flags for imminent suicide risk: a sudden and unexplained lifting of a severely depressed mood, giving away cherished personal items, and making definitive, cryptic statements about the future. Because the risk of self-harm is critical and immediate, the priority behavioral intervention is to ensure the client is placed on or remains on direct, continuous one-to-one observation by qualified staff.

Step-by-Step Solution

1
Analyze the client's behavioral changes and statements.
Identify that the sudden mood improvement, giving away possessions, and cryptic statements about peace are high-risk indicators of an organized suicide plan.
When severe depression suddenly lifts, it often means the client has made the decision to die by suicide, providing them with a sense of relief and the energy to carry out the act.
2
Determine the priority nursing intervention based on the assessed risk level.
Select the intervention that provides the highest level of immediate physical safety.
Client safety is the paramount concern in acute psychiatric care. High-risk suicidal behaviors require continuous visual monitoring without delegation to unlicensed staff.

Key Concept

Recognizing paradoxical mood improvement as an indicator of imminent suicide risk and implementing strict safety measures.
Question 219Question →

A nurse is caring for a client who is receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes after the infusion begins, the client suddenly reports severe lower back pain, chills, and shortness of breath. What is the priority sequence of nursing actions to minimize the risk of further physiological deterioration? Arrange the steps in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct priority sequence is to first stop the transfusion immediately, then maintain IV access with normal saline using new tubing, assess the client's vital signs, notify the provider and blood bank, and finally return the materials to the blood bank for analysis.
In the event of a suspected acute hemolytic transfusion reaction (indicated by lower back pain, chills, and shortness of breath), the overarching priority is risk reduction through immediately stopping the source of harm. Once the transfusion is stopped, maintaining a patent IV line with normal saline and completely new tubing is essential for administering emergency medications. Only after stabilizing the IV line should the nurse assess the client fully, followed by notifying the provider and blood bank to initiate emergency orders and investigations based on the assessment findings. Finally, the remaining blood and tubing are returned to the blood bank for procedural analysis.

Step-by-Step Solution

1
Stop the blood transfusion immediately.
The infusion of the incompatible blood product is halted.
This is the most critical step to prevent further incompatible cells from entering the client's circulation, mitigating the risk of cardiovascular collapse.
2
Disconnect the blood tubing and initiate 0.9% sodium chloride using new tubing.
Patency of the intravenous line is maintained without administering more blood.
Vascular access is needed for emergency drugs. New tubing must be used to prevent flushing residual reactive blood from the old tubing into the client.
3
Assess the client's vital signs and respiratory status.
The nurse obtains baseline data on the severity of the acute reaction.
This information is necessary to communicate the client's current physiological state to the healthcare provider so they can prescribe appropriate interventions.
4
Notify the healthcare provider and the blood bank.
The medical team is alerted to the adverse event.
The provider will prescribe interventions (e.g., epinephrine, fluids, antihistamines, corticosteroids), and the blood bank must initiate a transfusion reaction protocol.
5
Return the blood bag, attached tubing, and labels to the blood bank.
The physical evidence of the transfusion is sent for laboratory analysis.
This allows the blood bank to type and crossmatch the blood again to identify the specific error or unexpected antibody.

Key Concept

Management of Acute Hemolytic Transfusion Reactions
Question 220Question →

A nurse is managing the care of a 78-year-old client who is in balanced suspension skeletal traction following a comminuted right femur fracture. The client, who has a history of osteoarthritis, reports a new onset of dull, aching pain in the right heel and increasing stiffness in the lower back. Which of the following nursing actions is the most appropriate?

Show answer & explanation

Answer: Place a rolled towel under the right calf to suspend the heel off the bed and encourage the use of the overhead trapeze bar for repositioning.

Answer

The correct action is to place a rolled towel under the right calf to suspend the heel off the bed and encourage the use of the overhead trapeze bar for repositioning.
Placing a rolled towel under the calf successfully 'floats' the heel, entirely removing the pressure that is causing the ischemic ache. Additionally, utilizing the overhead trapeze bar allows the client to lift their upper body and buttocks off the mattress. This safely relieves pressure on the sacrum and lower back without changing the angle of the bed or disrupting the continuous pull of the traction weights.

Step-by-Step Solution

1
Assess the source and implication of the client's reported heel and lower back pain.
The nurse identifies the dull heel ache as an early sign of a pressure injury and the back stiffness as a complication of immobility.
Continuous pressure on bony prominences during bedrest leads to tissue ischemia, which presents as pain or aching before skin breakdown becomes visible.
2
Determine the constraints of providing comfort measures while maintaining balanced suspension skeletal traction.
The nurse recognizes that the head of the bed cannot be elevated above 20 to 30 degrees, and traction weights must never be removed, lifted, or supported.
Altering the bed angle significantly or relieving weight tension disrupts the continuous therapeutic pull required for proper fracture alignment and healing.
3
Select an appropriate intervention that relieves pressure without violating traction principles.
The nurse floats the heel using a rolled towel under the calf and instructs the client to independently shift their weight using the trapeze bar.
This provides effective basic care and comfort, safely relieving sacral and heel pressure while preserving the exact orthopedic alignment required.

Key Concept

Basic Care and Comfort in Skeletal Traction
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