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A nurse is caring for a client who is 4 hours postoperative following a coronary artery bypass grafting (CABG) procedure. The client suddenly exhibits profound hypotension, pronounced jugular venous distention, muffled heart sounds, and a precipitous drop in mediastinal chest tube drainage. Arrange the following nursing actions in the priority order they should be executed.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: 1) Assess the mediastinal chest tubes for kinks, 2) Activate the rapid response team and notify the surgeon, 3) Administer a rapid intravenous crystalloid bolus, 4) Prepare for an immediate bedside echocardiogram, and 5) Gather the pericardiocentesis tray and prepare for sternotomy.

Cardiac tamponade post-CABG is a form of obstructive shock. The priority sequence reflects the nursing process and emergency prioritization: rapidly identify and reverse simple mechanical causes (kinked tubes), mobilize the emergency surgical team, support hemodynamics with increased preload (crystalloid fluids), assist with diagnostics (echocardiogram), and prepare for definitive surgical decompression.

Step-by-Step Solution

Assess the mediastinal chest tubes for kinks or dependent loops.

Ensures there is no mechanical obstruction preventing pericardial drainage.

Resolving an obstruction is the quickest, least invasive way to reverse the accumulating fluid causing the tamponade. Independent nursing assessment of the equipment takes priority.

Activate the rapid response team and notify the cardiothoracic surgeon.

Mobilizes necessary medical personnel for an escalating emergency.

Cardiac tamponade is a lethal surgical complication requiring advanced interventions beyond the independent nursing scope of practice.

Administer a rapid intravenous crystalloid bolus as prescribed.

Increases right ventricular preload and systemic venous pressure.

Elevating filling pressures is hemodynamically essential to temporarily overcome the restrictive pericardial pressure and maintain cardiac output until the fluid can be drained.

Prepare the client for an immediate bedside echocardiogram.

Facilitates diagnostic confirmation of pericardial effusion.

The provider must visually confirm the presence and severity of the tamponade before proceeding with high-risk invasive procedures.

Gather the pericardiocentesis tray and prepare for a potential emergent sternotomy.

Readies the clinical environment for definitive treatment.

Evacuation of the pericardial fluid is the ultimate curative step, requiring sterile equipment and immediate surgical readiness.

Key Concept

Cardiac Tamponade Recognition and Prioritization

Question 322Question →

A client is admitted to the medical unit with a history of peptic ulcer disease and reports of passing dark, tarry stools for the past two days. The client is currently resting in a supine position.

Vital signs upon admission (3 hours ago): Blood pressure $138/80$ mm Hg, heart rate $78$ beats/min, respiratory rate $14$ breaths/min.

Current assessment findings:
- Blood pressure $112/84$ mm Hg
- Heart rate $112$ beats/min
- Respiratory rate $24$ breaths/min
- SpO $_2$ $96\%$ on room air
- The client reports feeling restless and slightly lightheaded.
- Arterial Blood Gas (ABG): pH $7.49$ , PaCO $_2$ $29$ mm Hg, PaO $_2$ $92$ mm Hg, HCO $_3^-$ $23$ mEq/L

Based on these findings, which of the following is the priority nursing intervention?

Coach the client to perform slow, diaphragmatic breathing exercises.

Elevate the head of the bed to 90 degrees to facilitate optimal lung expansion.

Initiate a rapid bolus of the prescribed intravenous isotonic crystalloid solution.

Administer a prescribed PRN dose of intravenous lorazepam for acute restlessness.

Show answer & explanation

Answer: Initiate a rapid bolus of the prescribed intravenous isotonic crystalloid solution.

Answer

The priority intervention is to initiate a rapid bolus of the prescribed intravenous isotonic crystalloid solution.

The client is exhibiting signs of compensatory (early) hemorrhagic shock due to an upper gastrointestinal bleed. Although the systolic blood pressure remains

>100

mm Hg, the narrowing pulse pressure (dropping from

58

mm Hg to

28

mm Hg), tachycardia, tachypnea, and restlessness are hallmark indicators of sympathetic nervous system activation in response to volume depletion. The immediate priority is to restore intravascular volume and cardiac output by administering isotonic crystalloid fluids.

Step-by-Step Solution

Analyze the vital sign trends to identify physiological changes.

The pulse pressure has narrowed from

58

mm Hg to

28

mm Hg, accompanied by new-onset tachycardia (

112

bpm) and tachypnea (

24

breaths/min).

A narrowing pulse pressure is one of the earliest signs of compensatory shock, preceding a drop in systolic blood pressure.

Interpret the Arterial Blood Gas (ABG) values.

The ABG indicates uncompensated respiratory alkalosis (pH

7.49

, PaCO

_2

29

mm Hg).

In early shock, sympathetic nervous system activation and tissue hypoxia trigger hyperventilation, blowing off carbon dioxide.

Evaluate the clinical symptoms in the context of the medical history.

The client with a suspected gastrointestinal bleed is exhibiting restlessness and lightheadedness.

These are early neurological indicators of decreased cerebral perfusion caused by hypovolemia.

Determine the highest priority nursing intervention.

Administering isotonic crystalloid fluids is selected as the first action.

Restoring intravascular volume is the critical first step in managing hemorrhagic shock and preventing cardiovascular collapse.

Key Concept

Early recognition and fluid resuscitation in compensatory hemorrhagic shock

Question 323Question →

A client is receiving care in the intensive care unit four days after a severe subarachnoid hemorrhage. The client, previously alert and oriented, suddenly becomes extremely restless and confused. Current assessment findings include a blood pressure of 82/46 mm Hg, heart rate of 126 beats/minute, and a central venous pressure (CVP) of 1 mm Hg. The client's urine output over the past 4 hours was 1,600 mL.

The nurse reviews the most recent laboratory results:

Laboratory Test	Result	Reference Range
Serum sodium	119 mEq/L	135-145 mEq/L
Serum osmolality	256 mOsm/kg	275-295 mOsm/kg
Spot urine sodium	120 mEq/L	20-40 mEq/L

Based on these findings, which of the following prescribed interventions is the highest priority for the nurse to implement?

Restrict the client's total fluid intake to 800 mL over the next 24 hours.

Administer intravenous desmopressin acetate (DDAVP).

Initiate a rapid intravenous infusion of 0.9% sodium chloride.

Transport the client immediately for a stat non-contrast computed tomography (CT) scan of the head.

Show answer & explanation

Answer: Initiate a rapid intravenous infusion of 0.9% sodium chloride.

Answer

Initiate a rapid intravenous infusion of 0.9% sodium chloride.

The correct intervention is to administer rapid isotonic fluids because the clinical picture indicates Cerebral Salt Wasting (CSW). CSW is a rare but life-threatening complication of subarachnoid hemorrhage characterized by primary renal sodium wasting, leading to severe hyponatremia and profound hypovolemia (evidenced by the low CVP, hypotension, and tachycardia). The immediate priority is restoring intravascular volume to prevent cerebral ischemia and multi-organ failure.

Step-by-Step Solution

Analyze the vital signs and hemodynamic parameters.

The blood pressure of 82/46 mm Hg, heart rate of 126 beats/minute, and CVP of 1 mm Hg indicate profound hypovolemic shock.

Identifying the primary life-threat (circulatory collapse) dictates the immediate prioritization of care.

Evaluate the laboratory values and intake/output data.

The client has severe hyponatremia (119 mEq/L), low serum osmolality (256 mOsm/kg), inappropriate renal sodium wasting (urine sodium 120 mEq/L), and massive polyuria (1,600 mL/4 hours).

These specific values are required to differentiate between neuro-endocrine complications common after brain injury.

Synthesize the data to identify the underlying physiological adaptation failure.

The combination of severe hypovolemia, hyponatremia, and polyuria in a neurosurgical client confirms Cerebral Salt Wasting (CSW), eliminating SIADH (which is euvolemic/hypervolemic with oliguria) and Diabetes Insipidus (which causes hypernatremia).

Accurate pattern recognition prevents the administration of contraindicated therapies.

Determine the highest priority nursing intervention.

The nurse must immediately restore intravascular volume with an isotonic crystalloid solution like 0.9% sodium chloride.

Failure to rapidly correct the hypovolemia will lead to cerebral hypoperfusion, vasospasm, and irreversible brain damage.

Key Concept

Cerebral Salt Wasting (CSW) vs. SIADH Differentiation and Management

Question 324Question →

A nurse is caring for a multiparous client who experienced a precipitous vaginal delivery of a macrosomic newborn 4 hours ago. The nurse asks the unlicensed assistive personnel (UAP) to obtain the client's vital signs. The UAP reports a blood pressure of 108/86 mmHg, heart rate of 114 beats/min, and respiratory rate of 20 breaths/min. The client reports feeling slightly lightheaded when attempting to sit up. Which of the following is the priority nursing action?

Assess the client's uterine fundus and current amount of lochia.

Reassure the client that mild tachycardia and dizziness are expected fluid shift responses.

Instruct the UAP to assist the client to the bathroom to empty her bladder.

Elevate the head of the bed to a high Fowler's position to relieve the lightheadedness.

Show answer & explanation

Answer: Assess the client's uterine fundus and current amount of lochia.

Answer

The correct action is to immediately assess the client's uterine fundus and current amount of lochia.

The correct answer involves immediately assessing the client's uterine fundus and lochia. The client possesses multiple risk factors for postpartum hemorrhage, including multiparity, precipitous delivery, and uterine overdistention from a macrosomic newborn. The vital signs reveal a narrowed pulse pressure and tachycardia, accompanied by lightheadedness. These are classic early signs of hypovolemic shock secondary to blood loss. According to the nursing process, the priority is to directly assess the source of the suspected bleeding (uterine atony) to guide appropriate resuscitation and medical management.

Step-by-Step Solution

Analyze the client's obstetric history for risk factors.

The client has a history of multiparity, precipitous delivery, and delivering a macrosomic newborn.

These three factors independently and synergistically increase the risk of uterine atony and subsequent postpartum hemorrhage.

Evaluate the current assessment findings and vital signs.

The client exhibits a narrowed pulse pressure (22 mmHg), tachycardia (114 beats/min), and lightheadedness.

These findings are early compensatory indicators of hypovolemic shock, suggesting significant concealed or overt blood loss.

Determine the priority intervention based on the nursing process.

The nurse must prioritize assessing the fundus and lochia.

Before initiating treatments for shock or delegating tasks, the registered nurse must assess the source of the suspected hemorrhage to guide targeted, life-saving interventions.

Key Concept

Postpartum Hemorrhage Risk Recognition and Priority Assessment

Question 325Question →

A registered nurse is preparing to admit a client diagnosed with disseminated herpes zoster. Which of the following transmission-based precaution interventions should the nurse implement? Select all that apply.

Select all that apply

Assign the client to a private room with negative pressure airflow.

Put on a fit-tested N95 respirator prior to entering the client's room.

Don a disposable gown and clean gloves only when anticipating direct contact with the client's lesions.

Keep the door to the client's room slightly open to allow for frequent observation.

Place a standard surgical mask on the client if transport to another department is required.

Delegate room stocking to an unlicensed assistive personnel (UAP) who lacks documented immunity to varicella.

Show answer & explanation

Answer: Assign the client to a private room with negative pressure airflow.; Put on a fit-tested N95 respirator prior to entering the client's room.; Place a standard surgical mask on the client if transport to another department is required.

Answer

The correct interventions are assigning the client to a private room with negative pressure airflow, putting on a fit-tested N95 respirator prior to entering, and placing a standard surgical mask on the client during transport.

Disseminated herpes zoster requires both Airborne and Contact precautions because the virus can be transmitted through respiratory aerosols and direct contact with blister fluid. An airborne infection isolation room (AIIR) with negative pressure airflow and a fit-tested N95 respirator are mandatory airborne precautions. Placing a standard surgical mask on the client during necessary transport provides essential source control to prevent transmission outside the isolation room.

Step-by-Step Solution

Identify the pathogen and its mode of transmission.

Disseminated herpes zoster (shingles) is highly contagious and transmitted via airborne aerosols as well as direct contact with lesion fluid.

Understanding the specific transmission mechanisms dictates which tier of precautions must be implemented.

Determine the required transmission-based precautions.

Both Airborne and Contact precautions must be implemented concurrently until the lesions are dry and crusted.

Airborne precautions manage the respiratory/aerosol risk, while Contact precautions manage the risk of physical transmission from the vesicles.

Evaluate each provided intervention against Airborne and Contact precaution standards.

Negative pressure rooms, N95 respirators, and patient masking are correct Airborne measures. Delaying gown/glove use, opening the door, or allowing susceptible staff to enter violate the combined protocols.

Ensures all selected interventions strictly comply with evidence-based infection control guidelines.

Key Concept

Standard and Transmission-Based Precautions for Disseminated Herpes Zoster

Question 326Question →

A registered nurse realizes that an incorrect intravenous (IV) high-alert medication has just been initiated for an adult client. Arrange the following nursing actions in the priority sequence the nurse should perform them to mitigate harm and manage the error.

Drag items to arrange them in the correct order

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Answer

The correct priority sequence is to first stop the infusion, then assess the client, notify the healthcare provider, implement prescribed interventions, and finally complete an incident report.

When a medication error occurs, the nursing process and safety principles dictate a specific priority framework. First, stop the source of harm immediately (stop the IV). Second, assess the client for adverse effects to gather data. Third, notify the healthcare provider using the gathered assessment data. Fourth, carry out any new emergency prescriptions or interventions to stabilize the client. Finally, complete administrative reporting only after the client's physiological needs are met.

Step-by-Step Solution

Stop the intravenous infusion of the incorrect medication immediately.

Further administration of the harmful agent is halted.

The absolute first priority in any active adverse event is to remove or stop the source of harm.

Assess the client's vital signs and monitor for adverse physiological reactions.

Baseline clinical status and any immediate adverse reactions are identified.

Assessment data is necessary to determine the extent of harm and to accurately inform the healthcare provider.

Notify the healthcare provider of the error and the client's current status.

The provider is informed of the error and the client's condition.

The provider must evaluate the assessment data to determine if antidotes or supportive therapies are required.

Administer prescribed antidotes or supportive interventions as ordered.

The client receives necessary treatment for any adverse effects.

Immediate physiological stabilization and treatment are prioritized over administrative duties.

Complete a facility incident or variance report detailing the event.

The event is formally documented for facility safety review.

Incident reporting is essential for identifying systemic errors and preventing future occurrences, but it must never delay direct client care.

Key Concept

Prioritization of Care Following a Medication Error

Question 327Question →

During the continuous electronic fetal monitoring of a client in active labor, the nurse observes recurrent, abrupt decreases in the fetal heart rate that drop 30 beats per minute below the baseline. These decreases reach their lowest point in less than 30 seconds, return to baseline rapidly, and do not demonstrate a consistent relationship with the onset of uterine contractions. Which action should the nurse take first?

Assist the client to change position to a lateral recumbent or knee-chest posture.

Document the fetal heart rate pattern as an expected, benign physiological response to head compression.

Direct the unlicensed assistive personnel (UAP) to apply oxygen via a nonrebreather mask.

Activate the rapid response team to prepare the client for an immediate emergency cesarean birth.

Show answer & explanation

Answer: Assist the client to change position to a lateral recumbent or knee-chest posture.

Answer

The priority nursing action is to assist the client to change position to a lateral recumbent or knee-chest posture.

The scenario describes variable decelerations, which are defined as visually apparent, abrupt decreases in the fetal heart rate that may or may not be associated with uterine contractions. This pattern is indicative of umbilical cord compression. The priority, first-line nursing intervention is to reposition the mother (e.g., side-lying, lateral recumbent, or knee-chest) to relieve the mechanical compression on the umbilical cord, thereby rapidly restoring uteroplacental blood flow and fetal oxygenation.

Step-by-Step Solution

Analyze the fetal heart rate monitor tracing described in the scenario.

The pattern shows abrupt decreases in heart rate that are independent of uterine contractions.

Identifying the specific type of deceleration is required to determine the underlying physiological cause.

Correlate the fetal heart rate pattern with its physiological cause.

Abrupt, variable decreases (variable decelerations) indicate umbilical cord compression.

Using frameworks like the VEAL CHOP mnemonic helps link the pattern to the specific physiological problem.

Determine the highest priority nursing intervention to resolve the specific problem.

The immediate action is to reposition the client to relieve mechanical pressure on the umbilical cord.

Nursing interventions must follow a prioritized approach, starting with the least invasive, most direct method to restore oxygenation before escalating to more complex or invasive steps.

Key Concept

Management of variable fetal heart rate decelerations

Question 328Question →

A nurse working at the emergency department triage desk receives a telephone call from an unknown individual stating that an explosive device has been placed in the hospital. Arrange the following actions in the correct priority sequence the nurse should take according to standard emergency response protocols. (Order from first action to last action)

Drag items to arrange them in the correct order

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Answer

The correct sequence of actions for a bomb threat call is to first keep the caller on the line, then signal a coworker to contact security, followed by asking specific questions about the device, noting caller characteristics, and finally completing the formal documentation checklist after the call ends.

In the event of a telephonic bomb threat, the overarching goal of the emergency response plan is to maximize information gathering while simultaneously activating security protocols. Keeping the caller on the line is the absolute first priority. Signaling a coworker allows for immediate security dispatch without interrupting the flow of the call. Asking direct questions about the bomb and noting background noises are active listening tasks performed during the conversation. Finally, formal documentation must occur immediately after disconnection to preserve accurate memories.

Step-by-Step Solution

Maintain the phone connection.

The caller remains on the line.

Gathering intelligence is the primary goal; hanging up ends the opportunity to obtain life-saving information.

Discreetly alert a coworker.

Security and law enforcement are notified.

Emergency response must be initiated concurrently without interrupting the caller or causing them to hang up.

Interrogate the caller for details.

Information about the device's location and timing is obtained.

Specific details are required to determine the necessary scope of hospital evacuation and immediate danger zones.

Analyze voice and background sounds.

Investigative clues are identified.

Characteristics like accents, machinery, or traffic noise can help authorities locate the caller and assess the threat's validity.

Document the incident on a standardized checklist.

A permanent record is created for investigators.

Writing down the details immediately ensures accuracy for the police investigation before memory fades in a high-stress situation.

Key Concept

Internal Emergency Response Plan: Bomb Threat Telephone Protocols

Question 329Question →

A nurse is planning care for a client who is 48 hours post-operative following a right above-the-knee amputation (AKA) due to complications of peripheral arterial disease. Which of the following positioning interventions is most appropriate to include in the client's plan of care?

Elevate the right residual limb on a pillow while the client is resting in a supine position.

Maintain the client in a high Fowler's position while in bed to facilitate deep breathing.

Assist the client into a prone position for 30 minutes three to four times a day.

Position a trochanter roll alongside the right thigh to maintain external rotation of the hip.

Show answer & explanation

Answer: Assist the client into a prone position for 30 minutes three to four times a day.

Answer

Assist the client into a prone position for 30 minutes three to four times a day.

Following an above-the-knee amputation, the client is at high risk for developing a hip flexion contracture, which can permanently impair mobility and the ability to bear weight on a prosthesis. Assisting the client into a prone position for 20 to 30 minutes, 3 to 4 times a day, actively extends the hip joint and stretches the flexor muscles, effectively preventing contractures.

Step-by-Step Solution

Analyze the client's surgical procedure and timeline.

The client had a right above-the-knee amputation (AKA) 48 hours ago.

The timeline is critical because therapeutic positioning rules change drastically after the first 24 hours post-operation.

Identify the primary positioning complication associated with an AKA.

Hip flexion contracture is a severe structural complication that can prevent the client from using a prosthesis.

Understanding the complication risk guides the selection of appropriate preventative positioning.

Evaluate the given options based on their effect on the hip joint.

Elevation and high Fowler's position promote hip flexion. Prone positioning actively promotes hip extension.

Nursing interventions must counter the physiological tendency of the hip flexor muscles to tighten and contract.

Key Concept

Prevention of hip flexion contractures following an above-the-knee amputation

Question 330Question →

A nurse is caring for a client at $31$ weeks of gestation who is experiencing preterm labor. The healthcare provider prescribes a continuous intravenous infusion of magnesium sulfate at a rate of $3\text{ g/hr}$ for fetal neuroprotection. The pharmacy dispenses a premixed IV bag containing $20\text{ g}$ of magnesium sulfate in $500\text{ mL}$ of sterile water. At what rate in $\text{mL/hr}$ should the nurse set the intravenous infusion pump? (Record your answer as a whole number.)

Show answer & explanation

Answer: 75

Answer

To determine the correct infusion rate, first find the concentration of the medication. Divide the total amount of the drug (

20\text{ g}

) by the total volume of the IV fluid (

500\text{ mL}

) to get

0.04\text{ g/mL}

. Next, divide the prescribed dose (

3\text{ g/hr}

) by the concentration to find the correct rate of

75\text{ mL/hr}

. Alternatively, dimensional analysis can be used:

(500\text{ mL} / 20\text{ g}) \times (3\text{ g} / 1\text{ hr}) = 1500 / 20 = 75\text{ mL/hr}

Step-by-Step Solution

Determine the concentration of the magnesium sulfate solution.

20\text{ g} / 500\text{ mL} = 0.04\text{ g/mL}

Establishing the amount of medication per milliliter of IV fluid is required to calculate the correct fluid delivery rate.

Calculate the infusion rate in

\text{mL/hr}

3\text{ g/hr} \div 0.04\text{ g/mL} = 75\text{ mL/hr}

Dividing the prescribed hourly dose by the concentration yields the volume of fluid that must be infused each hour.

Key Concept

Intravenous medication dosage calculation for continuous infusions during preterm labor.

Question 331Question →

While attending an off-duty community event at a large indoor stadium, a structural collapse occurs, resulting in mass casualties. A nurse establishes a preliminary triage area for the victims. Based on the START (Simple Triage and Rapid Treatment) algorithm, which individual should the nurse classify as an immediate priority?

An individual with an open femur fracture who is screaming in pain, has a respiratory rate of 28 breaths/min, and a capillary refill of 1.5 seconds.

An individual with multiple superficial abrasions who is walking around the scene frantically asking about the location of their family members.

An individual with a head contusion who has a respiratory rate of 26 breaths/min, a palpable radial pulse, but is unable to follow the command to open their eyes.

An individual without spontaneous respirations who remains apneic after the nurse manually utilizes the jaw-thrust maneuver to open the airway.

Show answer & explanation

Answer: An individual with a head contusion who has a respiratory rate of 26 breaths/min, a palpable radial pulse, but is unable to follow the command to open their eyes.

Answer

The individual with a head contusion who has a respiratory rate of 26 breaths/min, a palpable radial pulse, but is unable to follow the command to open their eyes.

The correct answer identifies a client who fails the mental status component of the START (Simple Triage and Rapid Treatment) algorithm. After confirming the client is not ambulatory, the nurse assesses Respirations (RR < 30 is stable), Perfusion (palpable radial pulse is stable), and Mental Status. Because the client cannot follow simple commands, they require an immediate priority classification (red tag).

Step-by-Step Solution

Assess ambulatory status.

The individual who is walking around the scene is categorized as 'Green' (minor/minimal priority).

Ambulatory clients are directed away from the immediate scene to clear space and are considered the walking wounded.

Assess the respiratory effort of the remaining non-ambulatory victims.

The apneic victim remains without respirations after airway positioning and is tagged 'Black' (expectant). The other two victims have respiratory rates under 30 breaths/min.

Victims who do not breathe after airway maneuvers are deceased or expectant; resources cannot be expended on them during a mass casualty event. Respiratory rates over 30 require a 'Red' tag.

Assess perfusion in the victims breathing less than 30 times per minute.

Both remaining victims have adequate perfusion (capillary refill < 2 seconds or a palpable radial pulse).

Inadequate perfusion (capillary refill > 2 seconds or absent radial pulse) would require immediate hemorrhage control and a 'Red' tag.

Assess mental status in victims with adequate respirations and perfusion.

The victim with the femur fracture is alert (screaming/vocalizing) and receives a 'Yellow' tag. The victim with the head contusion cannot follow simple commands and receives a 'Red' tag.

An inability to follow simple commands indicates a significant neurological compromise or inadequate cerebral perfusion, categorizing the client as an immediate life threat requiring a 'Red' tag.

Key Concept

Disaster Triage and the START Algorithm (RPM Method)

Estimated Time:1m 15s

Question 332Question →

A nurse is caring for a client who is receiving continuous enteral tube feedings and requires repositioning every 2 hours to prevent pressure injuries. Which of the following actions is the most appropriate for the nurse to take when turning the client?

Maintain the head of the bed at a 45-degree angle throughout the turning process.

Delegate the turning procedure to the unlicensed assistive personnel (UAP) without interrupting the feeding.

Pause the continuous enteral feeding before lowering the head of the bed.

Lower the head of the bed flat and quickly turn the client to the right side to promote gastric emptying.

Show answer & explanation

Answer: Pause the continuous enteral feeding before lowering the head of the bed.

Answer

Pause the continuous enteral feeding before lowering the head of the bed.

Pausing the enteral feeding before lowering the head of the bed is essential to prevent pulmonary aspiration of gastric contents. Repositioning requires the bed to be lowered to minimize shearing forces on the client's skin and to maintain proper body mechanics for the staff. However, because enteral feeding must always be stopped when the head of the bed is lower than 30 degrees, pausing the pump is the necessary first step.

Step-by-Step Solution

Identify the primary physiological risk for a client receiving continuous enteral feedings.

The highest risk is pulmonary aspiration of gastric contents if the head of the bed is lowered.

Enteral nutrition introduces liquid directly into the stomach, increasing the volume of gastric contents and the potential for reflux.

Determine the proper mechanics for safely turning a client in bed.

The head of the bed should be lowered to flat or nearly flat before turning.

Turning a client with the head of the bed elevated creates severe shearing forces on the sacrum, which causes pressure injuries and makes turning ergonomically difficult for the nurse.

Combine the safety requirements of both interventions (feeding and turning).

The feeding must be temporarily stopped so the head of the bed can be safely lowered for turning.

This dual approach prevents aspiration while also adhering to safe mobility and skin integrity practices.

Key Concept

Aspiration Prevention during Enteral Feeding and Mobility

Question 333Question →

An acute care facility activates its emergency response plan after receiving a tornado warning indicating a severe storm is imminent. The charge nurse on a progressive care unit is coordinating immediate safety measures. Which of the following actions should the nurse implement? Select all that apply.

Select all that apply

Close all window blinds and drapes in client rooms.

Relocate ambulatory clients to interior hallways.

Assign unlicensed assistive personnel to identify which clients are stable enough to move.

Cover bedbound clients with thick blankets and pillows.

Begin immediate vertical evacuation of all clients to the basement level.

Attach red triage tags to clients requiring continuous cardiac monitoring.

Show answer & explanation

Answer: Close all window blinds and drapes in client rooms.; Relocate ambulatory clients to interior hallways.; Cover bedbound clients with thick blankets and pillows.

Answer

The correct actions include closing window blinds and drapes, relocating ambulatory clients to interior hallways, and covering bedbound clients with thick blankets and pillows.

In the event of an imminent tornado, the standard emergency response is to shelter in place. The main priorities are keeping individuals away from windows and protecting them from flying debris. Safe actions include moving those who can walk to interior corridors, shutting doors and drawing heavy window coverings to catch glass, and using thick blankets to shield clients who must remain in bed.

Step-by-Step Solution

Analyze the nature of the emergency.

The event is a tornado warning, meaning a tornado is imminent or occurring, necessitating immediate shelter-in-place protocols.

Understanding the threat type dictates whether to evacuate or shelter in place.

Identify the primary risks to clients.

High winds and flying debris, especially shattered glass, are the most immediate threats.

Interventions must directly mitigate the highest priority risks according to Maslow's physiological safety needs.

Select interventions that protect clients from identified risks.

Moving ambulatory clients to windowless corridors, closing window coverings, and shielding immobilized clients directly address the threat of flying debris.

These actions form the core of standard severe weather response plans in healthcare facilities.

Key Concept

During a severe weather emergency, nurses must initiate rapid shelter-in-place protocols focused on protecting clients from structural damage and flying debris without initiating unsafe or time-consuming evacuations.

Question 334Question →

A nurse is evaluating a client who had an open abdominal surgery 6 hours ago. The client reports feeling dizzy, anxious, and extremely thirsty. The nurse assesses the vital signs: heart rate 124 beats/min, blood pressure 98/74 mm Hg (baseline 130/80 mm Hg), and respiratory rate 24 breaths/min. The client's skin is pale and cool to the touch. Which of the following is the priority nursing action?

Position the client supine with the legs elevated and notify the healthcare provider.

Administer the prescribed intravenous opioid analgesic to manage the client's anxiety and discomfort.

Draw a sample for arterial blood gas analysis to assess for the development of metabolic acidosis.

Provide the client with small sips of clear liquids to alleviate the reports of extreme thirst.

Show answer & explanation

Answer: Position the client supine with the legs elevated and notify the healthcare provider.

Answer

Position the client supine with the legs elevated and notify the healthcare provider.

The client is exhibiting hallmark signs of early hypovolemic (hemorrhagic) shock, including tachycardia, a narrowed pulse pressure, tachypnea, pale and cool skin, dizziness, and extreme thirst. The body's compensatory mechanisms are attempting to maintain organ perfusion. The immediate priority is to enhance venous return to the heart by positioning the client supine with legs elevated (modified Trendelenburg) and to notify the healthcare provider immediately for further life-saving orders, such as intravenous fluid resuscitation or blood products.

Step-by-Step Solution

Analyze the client's clinical presentation and vital signs.

The client has tachycardia, a narrowed pulse pressure (24 mm Hg), tachypnea, pale/cool skin, dizziness, and extreme thirst.

To identify deviations from baseline and recognize signs of physiological deterioration.

Correlate the findings with potential postoperative complications.

These findings are classic indicators of early hypovolemic (hemorrhagic) shock due to internal bleeding.

Tachycardia and peripheral vasoconstriction (pale/cool skin) are compensatory mechanisms attempting to maintain cardiac output.

Determine the priority nursing intervention based on the ABCs (Airway, Breathing, Circulation).

The immediate priority is to support circulation and venous return while obtaining medical intervention.

Hypovolemic shock is a life-threatening emergency requiring rapid fluid resuscitation and potential surgical exploration.

Key Concept

Recognition and initial management of hypovolemic shock

Question 335Question →

While evaluating the labor progress of a gravida 2, para 1 client receiving oxytocin augmentation, the nurse identifies a gradual, symmetric decrease in the fetal heart rate that begins consistently after the peak of successive contractions. The heart rate returns to baseline only after the contraction has fully resolved. Which intervention is the most appropriate initial action?

Page the obstetric provider immediately to report the findings.

Stop the intravenous oxytocin administration.

Record the rhythm as a benign finding caused by cranial compression.

Set up the room for an immediate amnioinfusion.

Show answer & explanation

Answer: Stop the intravenous oxytocin administration.

Answer

The correct action is to stop the intravenous oxytocin administration to improve uteroplacental perfusion.

The fetal heart rate pattern described indicates late decelerations, which are a sign of uteroplacental insufficiency. When a client is receiving an oxytocin infusion, the medication forces the uterus to contract, which further decreases blood flow to the placenta. Therefore, the absolute first priority is to stop the oxytocin infusion to decrease uterine activity, thereby improving blood flow and oxygenation to the compromised fetus.

Step-by-Step Solution

Analyze the described fetal heart rate (FHR) pattern.

The gradual decrease starting after the contraction peak and recovering after the contraction ends defines a late deceleration.

Accurate interpretation of electronic fetal monitoring is essential to distinguish between benign and pathological patterns.

Determine the physiological cause of the identified pattern.

Late decelerations are caused by uteroplacental insufficiency, meaning the fetus is not receiving adequate oxygen during contractions.

Understanding the cause dictates the appropriate clinical intervention.

Prioritize the necessary nursing interventions for intrauterine resuscitation.

The immediate priority is to maximize fetal oxygenation by removing stressors (stopping oxytocin), repositioning the mother, and administering oxygen.

According to the ABCs and prioritization principles, direct actions that restore physiological stability take precedence over documentation or provider notification.

Key Concept

Intrauterine Resuscitation and Electronic Fetal Monitoring Interpretation

Question 336Question →

A nurse is establishing a plan of care for an older adult client who is recovering from a right-sided modified radical mastectomy with axillary lymph node dissection. Which nursing intervention best addresses the client's basic care and comfort needs while preventing complications?

Turn the client onto the right side-lying position every two hours to facilitate drainage from the surgical site.

Delegate the evaluation of the surgical dressing and right arm capillary refill to the unlicensed assistive personnel (UAP).

Support the client's right arm on pillows to maintain elevation slightly above the level of the heart.

Secure the client's right arm with a soft wrist restraint immediately if they become disoriented to prevent disruption of the surgical site.

Show answer & explanation

Answer: Support the client's right arm on pillows to maintain elevation slightly above the level of the heart.

Answer

The most appropriate intervention is to support the client's affected arm on pillows to keep it elevated above the level of the heart.

Elevating the affected arm on pillows slightly above the level of the heart utilizes gravity to promote lymphatic and venous drainage. This essential basic care measure prevents lymphedema, reduces postoperative edema, and minimizes pain in the affected extremity, promoting overall comfort.

Step-by-Step Solution

Analyze the client's postoperative status following a mastectomy with axillary lymph node dissection.

Recognize that the surgical removal of axillary lymph nodes places the client at a high risk for lymphedema and painful swelling in the right arm.

Understanding the anatomical and physiological alterations is necessary to plan safe and effective comfort care.

Evaluate the proposed nursing interventions against safety guidelines and evidence-based practice.

Identify that elevating the affected arm is a safe, non-pharmacologic comfort measure that actively prevents a major postoperative complication.

Elevation utilizes gravity to enhance venous and lymphatic return, addressing the root cause of potential swelling.

Key Concept

Postoperative Basic Care and Comfort

Question 337Question →

A registered nurse is preparing to enter the airborne infection isolation room (AIIR) of a client admitted with disseminated varicella-zoster virus. The client requires both airborne and contact precautions. Arrange the following steps for donning personal protective equipment (PPE) in the correct chronological order from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for donning PPE is: 1) Perform hand hygiene, 2) Don isolation gown, 3) Place N95 respirator, 4) Apply face shield or goggles, 5) Put on clean gloves.

According to CDC guidelines, the standard sequence for donning PPE begins with hand hygiene to prevent contaminating the clean PPE. Next, the isolation gown is applied to cover the body. The N95 respirator is placed next to ensure a proper seal against the face, followed by eye protection (goggles or face shield). Finally, gloves are donned last so they can securely cover the cuffs of the gown, completing the barrier.

Step-by-Step Solution

Identify the appropriate transmission-based precautions for disseminated varicella-zoster virus.

Determine that Airborne and Contact precautions, plus standard precautions, are required.

Disseminated varicella spreads through both aerosolized airborne particles and direct contact with lesions.

Select the first action in the standard CDC PPE donning sequence.

Identify hand hygiene as the starting step.

Hands must be clean before touching clean PPE to prevent transmission of pathogens onto the equipment.

Select the first piece of physical PPE to don.

Identify the isolation gown.

The gown covers the torso and arms, providing the largest area of protection, and is secured at the neck and waist before applying facial gear.

Determine the correct order for facial protection.

Place the N95 respirator first, followed by the face shield or goggles.

The N95 respirator must be applied directly to the face to ensure an adequate seal; eye protection is then placed over the top.

Identify the final step in the sequence.

Put on clean gloves.

Gloves are placed last so they can be pulled up and over the cuffs of the isolation gown, closing any gaps at the wrists.

Key Concept

Standard and Transmission-Based Precautions: PPE Donning Sequence

Question 338Question →

A specialized medical task force arrives at the site of a severe passenger train derailment. As part of the initial disaster response team utilizing the Simple Triage and Rapid Treatment (START) algorithm, which casualty should the nurse categorize as requiring immediate, life-saving intervention?

A casualty with a large abdominal laceration who is breathing 22 times per minute, obeys commands, and has an absent radial pulse.

A casualty trapped under debris who exhibits no spontaneous respirations after attempts to manually open the airway.

A casualty with a suspected spinal cord injury who is unable to move their legs, breathes 18 times per minute, has a capillary refill of 1 second, and correctly states their name.

A casualty who self-extricated from the wreckage, is supporting a deformed right wrist, and is visibly distressed but breathing unlabored.

Show answer & explanation

Answer: A casualty with a large abdominal laceration who is breathing 22 times per minute, obeys commands, and has an absent radial pulse.

Answer

The casualty with the abdominal laceration and an absent radial pulse should be categorized for immediate intervention.

The casualty with an absent radial pulse requires an Immediate (Red) tag. The START algorithm prioritizes casualties based on Respiration, Perfusion, and Mental Status (RPM). Although this casualty is breathing normally and obeys commands, the absent radial pulse indicates severe circulatory compromise and shock, meaning they require immediate life-saving intervention.

Step-by-Step Solution

Assess for casualties who are able to walk away from the incident.

The casualty with the deformed wrist can walk and is categorized as Minimal (Green tag).

Separating the 'walking wounded' immediately reduces the number of casualties requiring complex triage in the hot zone.

Evaluate the respiratory status of the remaining non-ambulatory casualties.

The casualty trapped under debris remains apneic after airway repositioning and is categorized as Expectant (Black tag).

In a mass casualty incident, extensive resources like CPR are not initiated for apneic clients in order to ensure the most good is done for the greatest number of people.

Assess the circulation and perfusion of the casualties who are breathing effectively.

The casualty with the abdominal laceration has an absent radial pulse, meeting criteria for Immediate (Red tag).

An absent radial pulse indicates severe systemic shock and hemodynamic instability, taking precedence over their stable respiratory rate.

Evaluate the mental status of casualties with intact airway, breathing, and circulation.

The casualty with the suspected spinal cord injury has stable vitals and obeys commands, making them Delayed (Yellow tag).

Although the mechanism of injury is severe, the casualty is physiologically stable enough to wait for transport while life-threatening injuries in others are addressed.

Key Concept

Disaster Triage (START Algorithm)

Question 339Question →

A nurse is assisting with the delivery of a newborn. Immediately after birth, the newborn is apneic and limp. Arrange the following neonatal resuscitation interventions in the correct chronological sequence according to standard clinical guidelines.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first warm, dry, and stimulate the newborn; then evaluate the respiratory effort and heart rate; next, initiate positive-pressure ventilation if needed; followed by chest compressions if the heart rate remains critically low; and finally, administer epinephrine if all previous steps fail.

The Neonatal Resuscitation Program (NRP) algorithm dictates a step-wise approach based on the newborn's response. The foundational steps are to provide warmth, dry, and stimulate. This is immediately followed by an evaluation of heart rate and breathing. If the infant is apneic or the heart rate is less than 100 beats/min, positive-pressure ventilation (PPV) is the critical next intervention. If the heart rate falls below 60 beats/min despite effective PPV, chest compressions are initiated. Finally, if the heart rate remains below 60 beats/min despite PPV and compressions, epinephrine is administered.

Step-by-Step Solution

Perform initial steps of resuscitation.

The newborn is placed on a radiant warmer, dried, and stimulated.

These actions prevent cold stress, clear the airway, and encourage spontaneous respirations.

Assess the newborn's physiological status.

Respiratory effort and heart rate are evaluated.

Assessment determines the need for advanced resuscitation measures based on the standard algorithm.

Provide ventilatory support.

Positive-pressure ventilation (PPV) is initiated.

PPV is required if the newborn remains apneic, is gasping, or has a heart rate less than 100 beats/min.

Perform circulatory support.

Chest compressions are started.

Compressions are indicated if the heart rate remains less than 60 beats/min despite effective PPV.

Administer emergency medications.

Epinephrine is administered.

Medication is used as a last resort when the heart rate remains less than 60 beats/min despite PPV and compressions.

Key Concept

Neonatal Resuscitation Program (NRP) Algorithm

Question 340Question →

A nurse is caring for a client who just underwent a percutaneous liver biopsy and is now prescribed a packed red blood cell (PRBC) transfusion for acute blood loss. Which interventions are essential for the nurse to implement to prevent accidents, errors, and injury? Select all that apply.

Select all that apply

Verify the client's identity, blood type, and the PRBC unit with a second registered nurse at the bedside.

Ensure the blood product is administered through a dedicated IV line primed only with 0.9% sodium chloride.

Position the client on their right side with a rolled towel placed under the biopsy site.

Delegate the continuous monitoring of the client during the first 15 minutes of the transfusion to an unlicensed assistive personnel (UAP).

Piggyback a scheduled IV antibiotic into the PRBC infusion line to guarantee timely medication delivery.

Place the client in a high-Fowler's position immediately following the procedure to promote optimal chest expansion.

Show answer & explanation

Answer: Verify the client's identity, blood type, and the PRBC unit with a second registered nurse at the bedside.; Ensure the blood product is administered through a dedicated IV line primed only with 0.9% sodium chloride.; Position the client on their right side with a rolled towel placed under the biopsy site.

Answer

The correct actions are to verify the client and blood product with a second registered nurse, ensure the use of a dedicated IV line with 0.9% sodium chloride, and position the client on their right side with a towel under the biopsy site.

Preventing injury after a liver biopsy requires positioning the client on their right side to apply direct pressure to the liver capsule, minimizing the risk of hemorrhage. Safe administration of blood products requires dual verification by two registered nurses at the bedside to prevent fatal ABO incompatibility errors. Additionally, blood products must only be infused with 0.9% sodium chloride to prevent hemolysis of the red blood cells in the IV tubing.

Step-by-Step Solution

Evaluate the safety and infection control requirements for blood administration.

Identify the need for dual registered nurse verification and a dedicated line primed only with normal saline.

Strict protocol adherence prevents life-threatening ABO incompatibility and hemolysis of the transfused cells.

Determine the optimal post-procedural safety positioning for a liver biopsy.

Select right-side positioning with direct pressure applied to the area.

The liver is a highly vascular organ; applying direct pressure to the biopsy site is critical to prevent internal hemorrhage.

Assess the appropriateness of task delegation during the high-risk initiation of a transfusion.

Recognize that the registered nurse must personally conduct the continuous 15-minute monitoring.

Monitoring for subtle, early signs of an adverse transfusion reaction requires independent clinical judgment that cannot be delegated to a UAP.

Key Concept

Integration of safe blood administration protocols, appropriate delegation, and post-procedural injury prevention.

Estimated Time:1m 30s

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