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Question 2821Question →

Following a diagnostic lumbar puncture to analyze cerebrospinal fluid, a client arrives on the medical-surgical unit. To effectively mitigate the risk of a post-dural puncture complication, which intervention is most appropriate for the nurse to implement?

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Answer: Maintain the client in a flat, supine posture for four to eight hours.

Answer

The intervention to maintain the client in a flat, supine posture for four to eight hours.
After a lumbar puncture, a significant risk is the development of a post-dural puncture headache caused by the continuous leakage of cerebrospinal fluid from the dural tear. Maintaining the client in a flat, supine position for four to eight hours helps equalize pressure within the central nervous system, minimizes fluid leakage, and significantly reduces the incidence of this debilitating complication.

Step-by-Step Solution

1
Identify the primary risk associated with the recently completed procedure.
The client has undergone a lumbar puncture, which carries a high risk for a post-dural puncture headache (spinal headache) caused by the leakage of cerebrospinal fluid.
Understanding the physiological consequences of the procedure dictates the necessary post-operative care.
2
Determine the appropriate nursing intervention to mitigate this specific risk.
Maintaining a flat position minimizes hydrostatic pressure at the puncture site, effectively reducing cerebrospinal fluid leakage.
Evidence-based practice requires keeping the client flat to equalize intracranial and intraspinal pressure.
3
Evaluate the distractors for contraindicated actions or scope of practice violations.
Semi-upright positioning worsens the fluid leak, fetal positioning is only for the intra-procedure phase, and initial assessments cannot be delegated.
Systematically eliminating options based on positioning principles and delegation rules confirms the correct choice.

Key Concept

Post-Lumbar Puncture Risk Reduction
Question 2822Question →

A community health nurse is planning care for a multi-generational family during a home visit. The household consists of a 68-year-old with stage 3 chronic kidney disease, a 42-year-old female, a 26-year-old who is 28 weeks pregnant, and a 4-month-old infant. Which of the following nursing actions planned for this visit represents primary disease prevention?

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Answer: Administering the tetanus, diphtheria, and acellular pertussis (Tdap) vaccine to the 26-year-old pregnant client.

Answer

The correct answer is administering the tetanus, diphtheria, and acellular pertussis (Tdap) vaccine to the pregnant client.
Primary prevention encompasses interventions that prevent the onset of a targeted condition or disease. Vaccinations provide immunity against specific pathogens, effectively preventing the diseases they cause before they ever occur. Administering the Tdap vaccine during pregnancy (ideally between 27 and 36 weeks gestation) protects the mother and provides vital passive immunity to the newborn against pertussis, making it a definitive primary prevention strategy.

Step-by-Step Solution

1
Define the primary, secondary, and tertiary levels of disease prevention.
Primary prevention prevents disease before it starts. Secondary prevention detects disease early. Tertiary prevention manages existing disease.
Establishing clear definitions is necessary to accurately classify the nursing actions presented in the options.
2
Evaluate the Tdap vaccine intervention for the pregnant client.
Vaccination prevents the onset of infectious diseases (tetanus, diphtheria, pertussis) in both the mother and the newborn.
Because it stops a disease process from initiating, it perfectly aligns with the principles of primary prevention.
3
Evaluate the remaining options to confirm they are not primary prevention.
Screenings (mammogram, Pap, developmental) are secondary prevention. Specialized diets for chronic kidney disease are tertiary prevention.
This confirms the correct classification of all distractors and solidifies the final choice.

Key Concept

Levels of Disease Prevention (Primary, Secondary, Tertiary)
Estimated Time:1m 0s
Question 2823Question →

A nurse is formulating a comprehensive care plan for an 82-year-old client with advanced Alzheimer's disease, severe osteoarthritis, and dysphagia who is currently receiving treatment for aspiration pneumonia. The client is confined to bed, requires continuous intravenous (IV) fluid therapy, and intermittently attempts to remove the IV catheter. Which of the following interventions should the nurse include in the plan of care to address the client's basic care and comfort needs? Select all that apply.

Select all that apply

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Answer: Elevate the head of the bed to 60 degrees and encourage the client to tuck their chin toward their chest during oral intake.; Provide the client with a textured sensory blanket or a soft rolled washcloth to hold in their hands throughout the day.

Answer

The appropriate nursing actions are to elevate the head of the bed and use the chin-tuck maneuver during feeding, and to provide a sensory distraction such as a textured blanket or washcloth to occupy the client's hands.
Elevating the head of the bed and encouraging a chin-tuck maneuver during oral intake safely facilitates swallowing and prevents aspiration. Providing a sensory blanket acts as a non-pharmacological restraint alternative that addresses the client's cognitive needs, provides tactile comfort, and safely distracts them from pulling at the intravenous line.

Step-by-Step Solution

1
Analyze the client's clinical profile and identify the primary safety and comfort risks.
The client is at high risk for repeated aspiration (due to dysphagia and pneumonia) and interruption of medical therapy (due to pulling at the IV line secondary to cognitive impairment).
Identifying the priority risks dictates which basic care interventions are safe and effective.
2
Evaluate the positioning and feeding interventions for aspiration prevention.
Elevating the head of the bed and utilizing the chin-tuck maneuver closes the epiglottis, safely protecting the airway during swallowing.
Clients with dysphagia require specialized basic care strategies during meals to prevent aspiration pneumonia.
3
Evaluate the interventions for protecting the IV site in a cognitively impaired client.
Providing a textured sensory blanket is a non-pharmacological restraint alternative that distracts the client and safely occupies their hands without restricting movement.
Least restrictive comfort measures must always be implemented and documented before considering physical restraints.

Key Concept

In the provision of basic care and comfort, nurses must prioritize aspiration precautions for clients with dysphagia and utilize non-restrictive comfort measures to ensure safety before resorting to physical restraints.
Question 2824Question →

An interdisciplinary team is preparing to discharge a client who recently experienced a left-hemisphere cerebrovascular accident (CVA) with resulting right-sided hemiparesis. The primary nurse is finalizing the client's independent living and self-care directives. Which of the following interventions should the nurse incorporate into the plan of care? Select all that apply.

Select all that apply

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Answer: Instruct the client to put their right arm into shirtsleeves first before dressing the left arm.; Advise the installation of grab bars and the use of a seated shower bench to maximize bathing independence.; Encourage the client to use a rocker knife and plate guard to facilitate independent feeding.

Answer

The correct interventions are instructing the client to dress the right arm first, advising the use of a shower bench and grab bars, and encouraging the use of adaptive feeding tools like a rocker knife.
Promoting self-care after a stroke involves utilizing adaptive strategies that accommodate the client's physical deficits. Because a left-brain stroke causes right-sided weakness, the client should dress the right (affected) side first to avoid excessive manipulation of the impaired limb. Recommending structural adaptations, such as grab bars and a shower bench, and introducing adaptive dining equipment, such as a rocker knife, directly support the client's ability to safely perform activities of daily living (ADLs) independently.

Step-by-Step Solution

1
Analyze the client's pathophysiology.
A left-hemisphere CVA results in right-sided hemiparesis (weakness).
Understanding the specific functional deficits is required to determine the appropriate self-care modifications.
2
Evaluate each dressing and hygiene intervention.
Dressing the affected (right) side first and using shower safety equipment are identified as safe and therapeutic strategies.
These methods accommodate the weakness, prevent joint strain, and reduce fall risk while promoting autonomy.
3
Identify inappropriate or unsafe nursing actions among the choices.
Delegating initial assessment to a UAP, stereotyping cultural preferences, and ignoring acute incontinence as 'normal aging' are identified as incorrect actions.
These actions violate principles of safe delegation, cultural competence, and pathophysiological assessment.

Key Concept

The nurse promotes self-care independence in hemiparetic clients through targeted adaptive equipment, specific sequencing for ADLs (dressing the affected side first), and individualized assessment, while avoiding improper delegation and cultural assumptions.
Question 2825Question →

Following a percutaneous liver biopsy, a client is transferred back to the medical-surgical unit for recovery. To minimize the risk of hemorrhage from the puncture site, what is the most appropriate position for the nurse to place the client in?

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Answer: Right side-lying position with a small towel or pillow placed beneath the puncture site

Answer

Right side-lying position with a small towel or pillow placed beneath the puncture site
Following a percutaneous liver biopsy, the client is at high risk for internal bleeding because the liver is a highly vascular organ located on the right side of the abdomen. Placing the client in a right side-lying position with a small towel or pillow beneath the puncture site applies direct, continuous anatomical pressure to the liver capsule. This mechanical compression promotes hemostasis and significantly reduces the risk of hemorrhage.

Step-by-Step Solution

1
Identify the primary complication associated with a percutaneous liver biopsy.
The liver is highly vascular, making hemorrhage the most significant post-procedure risk.
Understanding the anatomical risks dictates the priority nursing intervention.
2
Determine the physiological mechanism needed to prevent this complication.
Direct external pressure must be applied to the puncture site on the right side of the body.
Mechanical compression promotes hemostasis and clot formation at the site.
3
Select the client position that utilizes body weight to achieve this mechanism.
The right side-lying position with a towel or pillow under the site provides the necessary continuous pressure.
This specific positioning uses gravity and the client's own weight to compress the liver capsule.

Key Concept

Post-procedure positioning to prevent hemorrhage following a liver biopsy
Question 2826Question →

A 52-year-old client is admitted to the recovery area immediately after a percutaneous liver biopsy. The client is currently drowsy but responds appropriately to verbal stimuli. Which nursing interventions must be implemented to minimize the risk of complications? Select all that apply.

Select all that apply

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Answer: Place the client in a right lateral decubitus position with a folded towel beneath the puncture site.; Assess closely for early indicators of internal bleeding, including an increasing heart rate and a decreasing pulse pressure.; Enforce strict bed rest for the timeframe prescribed by the healthcare provider to prevent clot disruption.

Answer

The essential interventions include placing the client in a right lateral decubitus position with a towel under the site, closely monitoring vital signs for early signs of bleeding, and enforcing strict bed rest.
Risk reduction following an invasive liver biopsy centers on preventing and rapidly detecting hemorrhage. Implementing right-sided positioning provides a mechanical tamponade effect, enforcing bed rest prevents clot disruption, and monitoring subtle vital sign trends ensures bleeding is caught before hemorrhagic shock occurs.

Step-by-Step Solution

1
Analyze the procedure to identify the primary physiological risk.
A percutaneous liver biopsy involves a needle puncture into a highly vascular organ, making severe internal bleeding the primary post-procedure risk.
Identifying the highest-priority risk directly guides the necessary protective interventions.
2
Evaluate the mechanical and physiological strategies to prevent this complication.
Direct compression is required to stop bleeding, which is achieved by placing the client on their right side. Strict bed rest further prevents clot dislodgement.
Proper positioning mechanically compresses the liver against the rib cage, serving as an internal pressure dressing.
3
Determine the appropriate scope of practice for monitoring the client.
The registered nurse must personally evaluate the client's baseline post-procedure status and vital signs to detect early physiological decline.
Initial post-procedure assessments demand advanced clinical judgment and cannot be legally delegated to unlicensed personnel.

Key Concept

Post-procedure hemorrhage prevention and monitoring protocols
Question 2827Question →

During a scheduled home visit, a community health nurse is evaluating a 79-year-old client who lives independently. The client's adult children have expressed anxiety about recent alterations in their parent's overall condition, asking what changes represent normal aging. Which of the following clinical observations should the nurse recognize as an acute pathophysiological event demanding immediate medical evaluation?

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Answer: The sudden development of urinary incontinence paired with acute disorientation and an inability to sustain attention.

Answer

The sudden development of urinary incontinence paired with acute disorientation and an inability to sustain attention.
The sudden onset of urinary incontinence, acute disorientation, and inattention are hallmark signs of delirium. In the geriatric population, an acute pathological process such as a urinary tract infection, hypoxia, or sepsis frequently presents atypically as delirium rather than with classic symptoms like a high fever. This is a medical emergency requiring immediate evaluation, as sudden cognitive decline is never a normal part of the aging process.

Step-by-Step Solution

1
Analyze the stem to identify the nurse's primary goal.
The nurse must differentiate between normal, expected physiological adaptations of aging (senescence) and acute pathological emergencies.
Older adults frequently present with atypical signs of acute illness, which can be mistakenly attributed to the normal aging process by both families and clinicians.
2
Evaluate the clinical observation involving urinary incontinence and acute disorientation.
This combination indicates delirium, an acute and fluctuating state of confusion that is often the first sign of a systemic infection (like a urinary tract infection), hypoxia, or medication toxicity in older adults.
Sudden cognitive decline and new-onset incontinence are never part of the normal aging process and require immediate medical investigation.
3
Evaluate the remaining clinical observations (thoracic stiffening, high-frequency hearing loss, reduced GFR).
These represent expected, gradual physiological declines associated with normal aging across the respiratory, sensory, and renal systems.
While these expected changes require ongoing management (e.g., medication adjustments, communication modifications), they are chronic adaptations rather than acute pathophysiological events demanding immediate intervention.

Key Concept

Differentiating normal physiological adaptations of the aging process from atypical presentations of acute pathology (e.g., delirium).
Estimated Time:1m 30s
Question 2828Question →

A nurse is admitting a new client to an inpatient addiction treatment unit for the management of severe opioid use disorder. Arrange the following nursing actions in the correct sequence from first to last.

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Answer

The correct sequence is: 1. Assess airway and initial vital signs, 2. Conduct a search for contraband, 3. Interview the client for substance use history, 4. Evaluate using the Clinical Opiate Withdrawal Scale (COWS), and 5. Administer the prescribed buprenorphine.
The correct sequence strictly follows Maslow's hierarchy of needs and the nursing process tailored to an inpatient addiction setting. Immediate physiological survival (airway, breathing, circulation) is always the first priority. Once the client is medically stable, securing the therapeutic environment by searching for contraband is the most critical safety protocol on a psychiatric or addiction unit. With safety established, the nurse proceeds to a comprehensive assessment (the detailed substance history), followed by a targeted evaluation of current symptoms using a standardized tool (COWS). Finally, based on the objective data gathered, the nurse implements the pharmacological intervention (buprenorphine) safely, ensuring the client is in sufficient withdrawal to avoid precipitating a worse crisis.

Step-by-Step Solution

1
Prioritize physiological safety by checking the ABCs.
Assessing the airway and vital signs rules out acute life-threatening conditions such as respiratory depression.
Life-threatening physiological conditions must be addressed before psychiatric evaluations or unit protocols can begin.
2
Ensure environmental safety by conducting a contraband search.
Searching belongings prevents unauthorized drugs or weapons from entering the locked unit.
The safety of the therapeutic milieu is the immediate next priority in any inpatient addiction setting once the client is physically stable.
3
Gather detailed subjective assessment data.
Obtaining the substance use history identifies the risk profile and timeline for impending withdrawal.
A comprehensive history is required to determine which specific withdrawal protocols and scales the nursing staff will need to utilize.
4
Perform a targeted, objective clinical assessment.
The COWS provides an objective measurement of the client's current withdrawal severity based on physical signs.
Objective data demonstrating active withdrawal is mandatory before initiating specific medication-assisted treatments for opioid dependence.
5
Implement the pharmacological intervention.
Buprenorphine is safely administered based on the documented COWS score.
Administering a partial opioid agonist like buprenorphine too early can precipitate severe, rapid-onset withdrawal, so it must strictly follow the objective assessment.

Key Concept

Prioritization in Addiction Admissions and Opioid Withdrawal Management
Question 2829Question →

A 72-year-old client is 48 hours post-operative following a right above-the-knee amputation (AKA). The client is experiencing intermittent confusion, reports a "burning" sensation in the right foot, and frequently attempts to touch the surgical dressing. Which nursing action is most appropriate to promote the client's basic care, comfort, and safety?

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Answer: Assist the client into a prone position for 20 to 30 minutes every 3 to 4 hours.

Answer

Assist the client into a prone position for 20 to 30 minutes every 3 to 4 hours.
Assisting the client into a prone position is the most appropriate action. Following an above-the-knee amputation, clients are at a high risk for developing hip flexion contractures. Lying prone for 20 to 30 minutes several times a day stretches the flexor muscles of the hip and maintains joint extension, which is crucial for future weight-bearing and successful prosthetic use.

Step-by-Step Solution

1
Analyze the client's post-operative timeline.
The client is 48 hours post-operation for an above-the-knee amputation.
Timing dictates appropriate positioning interventions; standard care interventions change drastically after the first 24 hours.
2
Evaluate the clinical risks associated with the procedure.
A major complication of an above-the-knee amputation is the development of a hip flexion contracture.
Contractures severely impair future mobility and the ability to use a prosthetic limb effectively.
3
Select the intervention that mitigates the primary physiological risk while addressing safety guidelines.
Assisting the client into a prone position several times a day stretches the hip flexors.
This is an evidence-based positioning practice for basic care and comfort in clients with lower extremity amputations, while avoiding improper delegation and premature use of restraints.

Key Concept

Prevention of flexion contractures following lower extremity amputation
Question 2830Question →

A gravid client at 3737 weeks gestation is admitted with severe preeclampsia and requires magnesium sulfate therapy to prevent eclampsia, along with oxytocin for labor induction. The healthcare provider's orders include:

- Strict total intravenous fluid restriction of 125 mL/hour125\text{ mL/hour}.
- Magnesium sulfate maintenance infusion at 2 grams/hour2\text{ grams/hour} (supplied as 20 grams20\text{ grams} in 500 mL500\text{ mL} of 0.9%0.9\% sodium chloride).
- Oxytocin continuous infusion at 12 milliunits/minute12\text{ milliunits/minute} (supplied as 30 units30\text{ units} in 500 mL500\text{ mL} of Lactated Ringer's).
- A primary intravenous line of Lactated Ringer's to run at a rate that maintains the exact total hourly fluid restriction.

What should the nurse set the infusion rate for the primary line of Lactated Ringer's to, in mL/hour\text{mL/hour}? Record your answer as a whole number.

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Answer: 63

Answer

63 mL/hour
To determine the primary line rate, the nurse must calculate the hourly volume of all medication infusions and subtract this total from the maximum fluid restriction. The magnesium sulfate rate is 50 mL/hour and the oxytocin rate is 12 mL/hour, totaling 62 mL/hour. Subtracting 62 from the 125 mL/hour restriction yields 63 mL/hour for the primary maintenance line.

Step-by-Step Solution

1
Calculate the magnesium sulfate infusion rate in mL/hour.
Concentration: 20 g/500 mL=1 g/25 mL20\text{ g} / 500\text{ mL} = 1\text{ g} / 25\text{ mL}. Dose: 2 g/hour×25 mL/g=50 mL/hour2\text{ g/hour} \times 25\text{ mL/g} = 50\text{ mL/hour}.
The infusion pump must be programmed in mL/hour to deliver the prescribed 2 grams per hour.
2
Convert the oxytocin concentration from units to milliunits.
30 units×1,000 milliunits/unit=30,000 milliunits30\text{ units} \times 1,000\text{ milliunits/unit} = 30,000\text{ milliunits}. Concentration: 30,000 milliunits/500 mL=60 milliunits/mL30,000\text{ milliunits} / 500\text{ mL} = 60\text{ milliunits/mL}.
Oxytocin dosing is ordered in milliunits, so the bag concentration must match the ordered unit of measure.
3
Calculate the oxytocin infusion rate in mL/hour.
Dose: 12 milliunits/minute×60 minutes/hour=720 milliunits/hour12\text{ milliunits/minute} \times 60\text{ minutes/hour} = 720\text{ milliunits/hour}. Rate: 720 milliunits/hour÷60 milliunits/mL=12 mL/hour720\text{ milliunits/hour} \div 60\text{ milliunits/mL} = 12\text{ mL/hour}.
Converting the per-minute dose to a per-hour dose allows calculation of the mL/hour pump setting.
4
Determine the total volume of continuous medication infusions per hour.
50 mL/hour (magnesium sulfate)+12 mL/hour (oxytocin)=62 mL/hour50\text{ mL/hour (magnesium sulfate)} + 12\text{ mL/hour (oxytocin)} = 62\text{ mL/hour}.
All intravenous fluids, including medications, count toward the strict fluid restriction in preeclampsia to prevent pulmonary edema.
5
Calculate the primary Lactated Ringer's infusion rate.
125 mL/hour (total restriction)−62 mL/hour (medications)=63 mL/hour125\text{ mL/hour (total restriction)} - 62\text{ mL/hour (medications)} = 63\text{ mL/hour}.
The primary line makes up the difference between the total fluid restriction and the required medication volumes.

Key Concept

Calculation of concurrent medication infusions and fluid restriction management in severe preeclampsia.
Question 2831Question →

A home health nurse is developing a comprehensive care plan for a 72-year-old client who is recovering from a recent ischemic stroke. The nurse incorporates interventions representing various levels of disease prevention. Which of the following planned nursing actions specifically demonstrates a secondary prevention strategy?

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Answer: Administering a standardized screening tool to detect early manifestations of post-stroke depression.

Answer

Administering a standardized screening tool to detect early manifestations of post-stroke depression.
Secondary prevention encompasses screening and early detection measures designed to identify diseases or complications in their earliest stages, often before symptoms are fully apparent. In this scenario, although the client has an established diagnosis of a stroke (which requires tertiary management), administering a depression screening tool aims to detect a new, common complication (post-stroke depression) early on. This explicitly aligns with the definition of secondary prevention.

Step-by-Step Solution

1
Analyze the client's clinical scenario.
The client is a 72-year-old recovering from an ischemic stroke, indicating the presence of an established, chronic health condition.
Understanding the client's baseline health status is necessary to appropriately categorize the planned prevention strategies.
2
Define the levels of disease prevention.
Primary prevention stops disease before it starts. Secondary prevention focuses on early detection (screening) of a new problem. Tertiary prevention rehabilitates and manages existing conditions to prevent complications.
A clear conceptual understanding of the definitions is required to evaluate each nursing action.
3
Evaluate each option against the definitions of prevention levels.
Vaccination is primary. Gait training and support groups are tertiary (rehabilitation and adaptation). Depression screening is secondary.
This systematic process eliminates incorrect options by accurately categorizing them based on epidemiological frameworks.

Key Concept

Levels of Disease Prevention (Primary, Secondary, Tertiary)
Question 2832Question →

During a mobility assessment, a client with left-sided hemiparesis needs to be moved from their bed to a sitting position in a wheelchair. What is the correct sequence of actions the nurse should take to execute this transfer safely?

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Answer

The correct sequence is: position the wheelchair on the unaffected side, lock all wheels, assist the client to sit on the edge of the bed, apply a gait belt, and finally pivot the client into the wheelchair.
When transferring a client with unilateral weakness, safety and maximizing the use of the client's remaining strength are the top priorities. The nurse must first prepare the physical environment by placing the wheelchair on the client's unaffected side and locking all wheels. Next, the client is assisted to a sitting position on the edge of the bed to allow cardiovascular stabilization. Once the client is seated safely, a gait belt is applied for physical support. Finally, the nurse assists the client to stand, bear weight on their unaffected leg, and pivot safely into the chair.

Step-by-Step Solution

1
Place the wheelchair on the client's unaffected side at a 45-degree angle to the bed.
The wheelchair is properly positioned for the transfer.
This allows the client to pivot toward their stronger side, using their unaffected arm and leg to assist with movement.
2
Lock the wheels on both the client's bed and the wheelchair.
Both the bed and wheelchair are stabilized.
Stabilizing the equipment is a fundamental safety step to prevent it from sliding away while the client is bearing weight.
3
Assist the client to a sitting position on the edge of the bed and ensure their feet are flat on the floor.
The client is in a stable, seated position with a solid base of support.
This step prevents orthostatic hypotension and ensures the client regains balance before attempting to stand.
4
Securely apply a transfer gait belt around the client's waist.
The nurse has a safe, secure way to support the client's center of gravity.
The gait belt minimizes the risk of falls and prevents the nurse from inappropriately pulling on the client's weaker arm or shoulder.
5
Instruct the client to bear weight on their unaffected leg and pivot into the wheelchair.
The client is safely seated in the wheelchair.
Pivoting on the strong leg ensures stability and successfully completes the safe transfer process.

Key Concept

Safe Client Transfer Techniques
Estimated Time:1m 15s
Question 2833Question →

A pediatric nurse is caring for a 7-year-old client admitted with a severe asthma exacerbation. The client's parents, who are undergoing a contentious divorce, begin arguing loudly at the bedside about custody arrangements. The client starts crying, and the nurse observes increased work of breathing and audible wheezing. Which nursing action is the priority?

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Answer: Direct the parents to step outside the room immediately while staying to assess and support the client's respiratory status.

Answer

The priority is to direct the parents to step outside the room to remove the environmental trigger, while the nurse remains to assess the client's breathing.
The client is exhibiting acute signs of respiratory distress (wheezing, increased work of breathing) secondary to emotional distress. According to Maslow's hierarchy of needs and the ABCs (Airway, Breathing, Circulation) of nursing prioritization, the immediate physiological threat must be addressed first. By directing the parents out of the room, the nurse removes the acute psychosocial trigger while remaining present to assess and manage the client's compromised airway and breathing.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The 7-year-old client is experiencing acute respiratory distress (increased work of breathing, wheezing) triggered by a stressful environmental stimulus.
Identifying the immediate physiological threat establishes the foundation for prioritizing care based on the ABCs (Airway, Breathing, Circulation).
2
Evaluate the environmental and psychosocial factors.
The parents' contentious behavior is directly contributing to the client's physiological deterioration.
Recognizing the impact of maladaptive family dynamics on the client's health dictates the need for immediate environmental control.
3
Determine the priority nursing intervention.
The nurse must immediately separate the arguing parents from the client and assess the client's respiratory status.
Addressing the immediate physical needs and removing the environmental trigger take precedence over psychosocial counseling, mediation, or teaching.

Key Concept

Managing maladaptive family dynamics and prioritizing physiological safety
Question 2834Question →

While caring for a client requiring intravenous antibiotics, the nurse needs to initiate a secondary intermittent infusion (piggyback) through an active primary IV line. Assuming the secondary tubing has already been primed, arrange the following setup actions in the correct sequence.

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Answer

The correct sequence involves cleansing the port, attaching the tubing, lowering the primary bag, opening the clamp, and setting the rate.
Safe administration of a secondary IV (piggyback) medication requires a sterile connection at the upper Y-site, manipulating hydrostatic pressure by lowering the primary bag, opening the secondary clamp, and properly programming the pump. This fundamental sequence ensures the medication is delivered safely, completely, and without introducing infection.

Step-by-Step Solution

1
Cleanse the upper Y-site port.
The injection port is thoroughly disinfected.
Maintaining strict aseptic technique prevents catheter-related bloodstream infections.
2
Attach the secondary tubing to the Y-site.
The piggyback line is securely connected to the primary infusion line.
This establishes the closed pathway connecting the medication source to the patient's existing IV access.
3
Hang the primary IV fluid bag lower than the secondary bag.
The secondary bag is positioned physically higher than the primary bag on the IV pole.
This creates a hydrostatic pressure differential, ensuring the piggyback medication infuses completely before the primary fluid resumes.
4
Open the roller clamp on the secondary tubing.
The fluid pathway is opened.
This allows the medication to flow from the secondary bag into the primary line so the pump can pull the fluid.
5
Set the prescribed infusion rate on the pump.
The medication begins infusing at the correct speed.
Ensures safe and accurate medication delivery over the provider-prescribed duration.

Key Concept

Intravenous Piggyback (Secondary Infusion) Setup Sequence
Question 2835Question →

A nurse preceptor is observing a newly licensed nurse care for a client who completed an intravenous chemotherapy infusion 24 hours ago. Which action by the newly licensed nurse indicates proper handling of the client's hazardous bodily fluids?

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Answer: Donning a fluid-resistant gown and two pairs of chemotherapy-tested gloves before emptying the client's urinal.

Answer

The nurse must don a fluid-resistant gown and two pairs of chemotherapy-tested gloves before handling the client's bodily fluids.
Chemotherapy drugs and their active metabolites remain in the client's system and are excreted in bodily fluids for at least 48 hours (or longer, depending on the specific drug) after administration. The nurse must implement hazardous drug safe handling precautions to prevent occupational exposure. This protocol specifically includes wearing a disposable, fluid-resistant gown and double-gloving with chemotherapy-tested gloves when emptying urinals, handling emesis, or changing contaminated linens.

Step-by-Step Solution

1
Identify the timeframe and hazard
The client received intravenous chemotherapy 24 hours ago.
Hazardous chemotherapy drugs and their metabolites are excreted in bodily fluids (such as urine, feces, and emesis) for at least 48 hours following administration.
2
Determine appropriate personal protective equipment (PPE)
Standard precautions are insufficient; hazardous drug safe handling precautions are strictly required.
To prevent occupational exposure to hazardous chemicals through skin contact, absorption, or inhalation.
3
Select the action that demonstrates these specialized safety precautions
Wearing a fluid-resistant gown and double-gloving with chemotherapy-tested gloves is the correct procedure.
This specific PPE combination aligns with oncology safe handling guidelines for hazardous bodily fluids.

Key Concept

Safe Handling of Chemotherapy and Hazardous Drugs
Question 2836Question →

A nurse is teaching a client who has a prescribed non-weight-bearing status on the right leg how to ascend stairs using crutches. In what order should the nurse instruct the client to perform the following steps? Arrange the actions in the correct sequence.

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Answer

The correct sequence for ascending stairs is to establish a tripod base, shift weight to the crutches, step up with the unaffected (left) leg, transfer weight to the left leg, and finally bring the crutches and the affected (right) leg up.
When a client is non-weight-bearing on one leg, they must utilize a three-point crutch gait. The standard clinical mnemonic 'up with the good, down with the bad' applies to negotiating stairs. To safely ascend, the client must first establish a stable tripod stance and support their weight entirely with the crutches. This allows them to safely lift their strong, unaffected (left) leg onto the next step. Once the strong leg is securely planted, the client shifts their center of gravity and weight onto it. The strong leg then performs the work of lifting the body, which allows the client to bring the crutches and the affected (right) leg up to the step simultaneously without bearing any weight on the injured limb.

Step-by-Step Solution

1
Identify the client's weight-bearing limitations and required crutch gait.
The client is non-weight-bearing on the right leg, which necessitates a three-point crutch gait.
Understanding the physiological limitation dictates how weight must be distributed to prevent injury during mobility.
2
Apply the standard principles for ascending stairs with assistive devices.
The fundamental rule is 'up with the good,' meaning the unaffected leg must lead the upward movement.
The unaffected leg is required to lift the entire body's weight against gravity.
3
Determine the sequential weight transfer required to safely execute the movement.
The client starts in a tripod stance, shifts weight to the crutches, steps up with the left leg, shifts weight to the left leg, and then lifts the crutches and right leg.
This specific sequence ensures the client maintains a continuous, stable base of support and strictly avoids bearing any weight on the affected limb.

Key Concept

Assistive Devices and Mobility: Crutch Walking (Three-Point Gait)
Question 2837Question →

A nurse on a dual-diagnosis unit is evaluating several clients who were recently admitted. Which client presentation requires the most immediate priority action by the nurse?

Show answer & explanation

Answer: A client with chronic alcohol dependence demonstrating diaphoresis, a resting heart rate of 118 beats per minute, and mild agitation one day post-admission.

Answer

The client with chronic alcohol dependence demonstrating diaphoresis, a resting heart rate of 118 beats per minute, and mild agitation requires the most immediate priority action.
The correct answer is the client exhibiting signs of early alcohol withdrawal. Alcohol withdrawal can cause severe, life-threatening complications including withdrawal seizures and delirium tremens. Symptoms such as autonomic hyperactivity (tachycardia, diaphoresis) and agitation occurring a day after admission indicate the onset of withdrawal and require urgent pharmacological intervention to prevent dangerous progression.

Step-by-Step Solution

1
Analyze the presentations of all four clients to determine the physiological risk associated with their specific substance use disorder or withdrawal syndrome.
Alcohol withdrawal carries a risk of fatal complications, whereas opioid and stimulant withdrawal are typically not physiologically life-threatening.
Safe prioritization requires identifying the client with the highest risk for acute physiological instability or death.
2
Evaluate the specific objective symptoms presented by the client with alcohol dependence.
Diaphoresis, tachycardia (heart rate of 118), and agitation are classic indicators of autonomic hyperactivity associated with early alcohol withdrawal.
Early recognition of these signs is critical to initiate medical treatment (e.g., a benzodiazepine protocol) before the condition progresses to severe withdrawal seizures or delirium tremens.

Key Concept

Alcohol withdrawal is a medical emergency that can progress to life-threatening complications, requiring immediate prioritization and pharmacological intervention over uncomfortable but non-fatal withdrawal syndromes (such as opioids).
Question 2838Question →

A client is admitted with profound hypokalemia, exhibiting a serum potassium level of 2.4 mEq/L (2.4 mmol/L). The healthcare provider prescribes an intravenous (IV) potassium replacement. The prescription reads: 'Potassium chloride 20 mEq in 100 mL of 0.9% sodium chloride IV to infuse over 30 minutes.' The client's only vascular access is a 20-gauge peripheral IV catheter in the right forearm. Which of the following is the priority nursing action?

Show answer & explanation

Answer: Withhold the infusion and contact the healthcare provider to question the prescribed administration rate.

Answer

Withhold the infusion and contact the healthcare provider to question the prescribed administration rate.
Intravenous potassium chloride is a high-alert medication that requires strict adherence to administration protocols. The maximum safe infusion rate for a peripheral IV line is generally 10 mEq/hr. The prescribed order of 20 mEq over 30 minutes equates to a delivery rate of 40 mEq/hr, which is extremely dangerous and can cause severe chemical phlebitis, pain, or fatal cardiac arrhythmias. The nurse's priority is patient safety; therefore, the nurse must withhold this unsafe order and contact the provider to request a decreased infusion rate.

Step-by-Step Solution

1
Analyze the prescribed dosage and time parameters.
The prescription orders 20 mEq of potassium chloride over 30 minutes, which equates to an infusion rate of 40 mEq/hr.
Converting the dose to an hourly rate is necessary to compare it against established pharmacological safety guidelines.
2
Recall the safety parameters for intravenous potassium administration.
The maximum recommended safe infusion rate for potassium chloride through a peripheral IV line is 10 mEq/hr.
Rates exceeding 10 mEq/hr peripherally severely irritate the vein (causing phlebitis) and pose a high risk for life-threatening cardiac arrhythmias.
3
Evaluate the client's current venous access against the prescription.
The client only has a peripheral IV catheter, making the prescribed rate of 40 mEq/hr highly unsafe.
A central venous catheter and continuous cardiac monitoring would be required for higher rates (up to 20 mEq/hr, or rarely 40 mEq/hr in severe emergencies), but the current peripheral access cannot support this order.
4
Determine the priority nursing action based on patient safety.
The nurse must withhold the unsafe medication and immediately contact the prescribing provider.
Nurses have a legal and ethical duty to intervene when a prescription endangers a patient; an unsafe order must never be blindly executed.

Key Concept

Safe Administration of Intravenous Potassium
Estimated Time:1m 0s
Question 2839Question →

A nurse is monitoring a 58-year-old client who returned to the medical-surgical unit one hour ago following a percutaneous left renal biopsy. Which of the following assessment findings indicates an impending physiological complication and requires the most immediate risk mitigation action by the nurse?

Show answer & explanation

Answer: The client's blood pressure changes from 142/86 mm Hg to 128/96 mm Hg, and the heart rate increases from 74 to 98 beats/min.

Answer

The assessment finding that requires immediate action is the blood pressure change to 128/96 mm Hg coupled with the heart rate increase to 98 beats/min.
The correct answer identifies the early, compensatory signs of hemorrhagic shock. Following a highly vascular procedure like a percutaneous renal biopsy, occult retroperitoneal bleeding is a major risk. A narrowing pulse pressure (the difference between systolic and diastolic pressure dropping from 56 to 32 mm Hg) coupled with mild tachycardia indicates that the client's body is actively vasoconstricting to maintain cardiac output in the face of fluid volume loss. This requires immediate provider notification and intervention.

Step-by-Step Solution

1
Calculate and analyze the client's vital sign trends from baseline to current status.
The pulse pressure (Psystolic−PdiastolicP_{systolic} - P_{diastolic}) narrowed significantly. Baseline was 142−86=56142 - 86 = 56 mm Hg; the current reading is 128−96=32128 - 96 = 32 mm Hg. The heart rate simultaneously increased.
Identifying subtle deviations in hemodynamic parameters is critical for the early detection of internal bleeding before profound hypotension occurs.
2
Correlate the vital sign changes with the specific anatomical risks of a percutaneous renal biopsy.
The kidney is a highly vascular organ located in the retroperitoneal space. Bleeding in this area rarely presents with immediate external signs, making vital sign trends the primary objective indicator.
Retroperitoneal hemorrhage is the most life-threatening acute complication of this procedure, requiring rapid recognition to reduce the risk of severe shock.
3
Evaluate the remaining assessment findings to determine if they are expected post-procedure outcomes.
Mild pain (3/10) and slightly pink-tinged urine are expected findings resulting from localized tissue trauma. The supine position with a flank roll is a required prophylactic measure, not an adverse finding.
Differentiating the expected clinical trajectory from true physiological decompensation ensures the nurse prioritizes actions that save lives.

Key Concept

Early recognition of hemorrhagic shock through vital sign trend analysis, specifically narrowing pulse pressure and tachycardia, to reduce the risk of severe post-procedure complications.
Estimated Time:1m 30s
Question 2840Question →

A public health nurse is conducting a home visit for a newly relocated client who reports severe insomnia, daily fatigue, and overwhelming stress related to adapting to the new cultural environment. The client tearfully states, "Everything here is too difficult, and I feel like I will never belong." Which of the following is the priority nursing action?

Show answer & explanation

Answer: Validate the client's feelings of being overwhelmed and assess the coping strategies they have successfully used in the past.

Answer

Validate the client's feelings of being overwhelmed and assess the coping strategies they have successfully used in the past.
The first step in assisting a client with stress management is to assess their current coping mechanisms. By validating the client's feelings, the nurse builds a therapeutic relationship. Exploring previously successful coping strategies empowers the client and provides a baseline for developing a personalized stress management plan.

Step-by-Step Solution

1
Analyze the client's presentation
The client is experiencing severe acculturative stress, presenting with both psychological (feeling overwhelmed) and physiological (insomnia, fatigue) symptoms.
Understanding the holistic impact of stress is required to determine the appropriate intervention.
2
Evaluate the nursing process and therapeutic communication principles
The priority action is to validate the client's feelings and conduct a thorough assessment of their current coping mechanisms.
Before developing a stress management plan, the nurse must assess the client's baseline coping skills and avoid making assumptions.
3
Review the distractors for safety and communication errors
The other options involve false reassurance, cultural stereotyping, and improper delegation.
Eliminating non-therapeutic and unsafe actions confirms the correct choice.

Key Concept

Nursing Assessment of Stress and Coping
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