Examkin

All practice questions

862 questions

All types3,881Multiple choice1,926Multiple select908Numeric119Matching66Ordering862
Question 361Question →

An adult client requires a morning dose of both short-acting (regular) and intermediate-acting (NPH) insulin. The nurse is drawing up both medications into a single syringe. Place the steps of this preparation process in the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct chronological sequence is to roll the NPH insulin vial, inject air into the NPH vial, inject air into the regular insulin vial, withdraw the regular insulin, and finally withdraw the NPH insulin.
The standard sequence for mixing insulins ensures the safety and purity of the short-acting medication. By injecting air into the NPH first, then air into the regular, the nurse can draw up the regular insulin ('clear') before the NPH insulin ('cloudy'). This universally accepted 'clear before cloudy' principle prevents the NPH insulin from inadvertently altering the rapid-acting profile of the regular insulin vial.

Step-by-Step Solution

1
Roll the NPH insulin vial between the palms.
The cloudy suspension is mixed evenly.
Rolling prevents the formation of air bubbles that can occur if the vial is shaken, ensuring an accurate dose.
2
Inject air into the NPH insulin vial and withdraw the needle.
The vial is pressurized without withdrawing any medication.
Injecting air first equalizes pressure and prevents regular insulin from being pushed into the NPH vial later.
3
Inject air into the regular insulin vial and leave the needle inserted.
The clear insulin vial is pressurized and ready for withdrawal.
This sets up the syringe to immediately draw the regular insulin.
4
Withdraw the exact dose of regular insulin.
The clear insulin is safely inside the syringe.
Drawing the clear (regular) insulin first guarantees that it will not be contaminated by the cloudy (NPH) insulin.
5
Insert the needle back into the NPH vial and withdraw the exact dose.
The combined insulin dose is ready for administration.
This completes the mixture. Care must be taken not to push any regular insulin into the NPH vial during this step.

Key Concept

Insulin Mixing Procedure (Clear before Cloudy)
Estimated Time:45s
Question 362Question →

A client with a history of aggressive behavior becomes visibly agitated in the dayroom, pacing rapidly with clenched fists and shouting profanities at peers. Arrange the following nursing interventions in order from the least restrictive to the most restrictive approach.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence from least to most restrictive is: engaging verbally, moving to an unlocked quiet room, offering voluntary oral medication, administering involuntary IM medication, and finally applying physical restraints.
The principle of the least restrictive environment mandates that nursing interventions for an escalating client must begin with the approach that preserves the most autonomy. The hierarchy strictly progresses from verbal interventions, to voluntary environmental changes, to voluntary chemical interventions (oral PRNs), to involuntary chemical restraints (IM injections), and finally to physical mechanical restraints.

Step-by-Step Solution

1
Determine the baseline least restrictive intervention.
Verbal engagement is selected as the first step.
Verbal communication preserves complete autonomy and is always the first line of behavioral de-escalation.
2
Evaluate environmental versus pharmacological interventions.
Voluntary relocation to a quiet room is sequenced second.
Moving to a quiet area reduces stimuli without chemical alteration, making it less restrictive than medication administration.
3
Differentiate between voluntary and involuntary pharmacological interventions.
Oral PRN is placed third, and involuntary IM is placed fourth.
Accepting an oral medication maintains the client's choice, whereas an involuntary IM injection (chemical restraint) violates autonomy.
4
Identify the absolute most restrictive measure.
Mechanical restraints are sequenced last.
Mechanical restraints entirely eliminate freedom of movement and are the absolute last resort for imminent safety threats.

Key Concept

Least Restrictive Environment and Restraint Hierarchy
Question 363Question →

An oncology registered nurse is preparing to obtain a blood specimen from a client's implanted venous access port. The nurse has gathered all necessary supplies. Arrange the following steps for accessing the port and drawing the blood specimen in the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: apply sterile PPE, cleanse the port site, access the port with a non-coring needle, discard the initial 5 mL of blood waste, withdraw the required sample, and finally flush the port with saline and heparin.
Accessing an implanted venous access port requires precise chronological execution of parenteral safety standards. The nurse must first ensure strict asepsis by donning a mask and sterile gloves, followed by vigorously cleansing the site with chlorhexidine and allowing it to completely air dry. Next, the port is accessed using a non-coring (Huber) needle to prevent damage to the septum. Before the actual laboratory sample is collected, the nurse must aspirate and discard approximately 5 mL of blood; this clears the catheter of the heparin or saline locking solution that would otherwise contaminate the specimen. After the correct sample volume is obtained in a new syringe, the port must be flushed with a minimum of 10 to 20 mL of 0.9% sodium chloride to clear any remaining blood and prevent catheter occlusion, followed by a heparin flush to maintain patency if the port is being de-accessed or locked.

Step-by-Step Solution

1
Establish a sterile field and prepare the insertion site.
The nurse dons sterile PPE and cleanses the area with chlorhexidine.
Implanted ports are central venous access devices; accessing them requires strict asepsis to prevent life-threatening infections.
2
Access the implanted port.
A non-coring needle is inserted through the skin into the port's septum.
Using a non-coring needle prevents mechanical damage to the port's silicone seal, ensuring its longevity.
3
Clear the line of previous locking solutions.
The nurse aspirates and discards the first 5 mL of blood.
Failing to discard this initial volume will result in a specimen diluted with saline or contaminated with heparin, causing inaccurate lab values.
4
Collect the specimen and secure the line.
The diagnostic sample is drawn, and the line is flushed with saline and heparin.
Vigorous saline flushing removes residual red blood cells from the catheter, and heparin prevents clot formation within the lumen.

Key Concept

Implanted Venous Access Port Management and Blood Sampling
Estimated Time:1m 30s
Question 364Question →

A nurse in a surgical intensive care unit is responding to a spouse who just learned their partner sustained a severe traumatic brain injury. The spouse is pacing the hallway, crying uncontrollably, and states, "I do not know what to do. I cannot live without them." Arrange the following nursing interventions in the correct order of priority according to the principles of crisis intervention. (Place the first action at the top and the last action at the bottom.)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence of interventions is: 1) Assess for immediate self-harm potential, 2) Guide to a private consultation room, 3) Encourage expression of feelings, 4) Identify support systems, and 5) Collaborate on a short-term plan.
Crisis intervention follows a highly structured approach emphasizing immediate physical safety above all else. Because the spouse made a statement suggesting a risk to self, a lethality assessment is the absolute first priority. Once safety is confirmed, the nurse should provide a secure, low-stimulus environment to build rapport and decrease panic. Next, the nurse assesses the individual's perception of the crisis by allowing them to express their feelings. After understanding the emotional state and perception, the nurse helps identify and mobilize external support systems. Finally, the nurse and client collaborate on a simple, short-term plan (e.g., calling a sibling, sitting by the bed) to restore a sense of control and manage the immediate future.

Step-by-Step Solution

1
Assess for immediate self-harm potential.
Ensures the immediate physical safety of the individual.
The individual's statement of not being able to live without their partner is a red flag for self-harm, making a lethality assessment the highest priority.
2
Guide to a private, quiet consultation room.
Decreases environmental stimuli and provides psychological safety.
Moving the individual away from the busy hallway helps de-escalate anxiety and provides a secure setting for therapeutic communication.
3
Encourage expression of feelings and understanding.
Identifies the client's perception of the precipitating event.
The nurse must understand how the individual views the crisis and allow them to release emotional tension before attempting to move toward solutions.
4
Identify available personal support systems.
Mobilizes external resources to assist the individual.
During an acute crisis, the individual's normal coping mechanisms are overwhelmed. Activating support networks is critical for stabilization.
5
Collaborate on a concrete, short-term plan.
Restores a sense of control and provides immediate direction.
Crisis intervention focuses on the "here and now." A simple, manageable plan helps the individual transition from panic to structured coping.

Key Concept

Principles of crisis intervention prioritize immediate safety and lethality assessment first, followed by psychological stabilization, assessing the individual's perception of the problem, exploring support systems, and finally formulating a concrete short-term plan.
Question 365Question →

A nurse is caring for a client receiving parenteral nutrition via a subclavian central venous catheter (CVC). Upon entering the room, the nurse discovers the IV tubing has disconnected from the catheter hub. The client is suddenly grasping their chest, gasping for air, and reporting a feeling of impending doom. Arrange the following nursing actions in the correct order of priority to manage this life-threatening complication.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

First, clamp the catheter; second, position the client in left lateral Trendelenburg; third, administer oxygen; fourth, notify the healthcare provider; and finally, obtain vital signs.
In the event of a disconnected CVC and suspected air embolism, the nurse must prioritize actions using the ABCs and immediate life-saving physical interventions. The sequence must proceed from stopping the source of the harm (clamping), mitigating the anatomical damage (left lateral Trendelenburg positioning), supporting physiological function (oxygen), escalating care (calling for help), and finally, gathering systemic data (vital signs).

Step-by-Step Solution

1
Clamp the CVC
Stops further air entry into the vascular system.
Preventing the embolus from enlarging is the most critical first step in risk reduction.
2
Position in left lateral Trendelenburg
Traps the air in the right atrium.
Prevents the air bubble from acting as a complete mechanical obstruction in the right ventricular outflow tract.
3
Administer 100% oxygen
Alleviates tissue hypoxia and reduces bubble size.
Increases the diffusion gradient, helping nitrogen wash out of the air bubble, causing it to shrink.
4
Notify HCP and Rapid Response
Summons advanced medical intervention.
The client may require vasopressors, intubation, or needle aspiration of the air by a physician.
5
Obtain vital signs
Establishes a baseline for ongoing monitoring.
Provides data to the arriving response team about the client's hemodynamic stability following the initial interventions.

Key Concept

Emergency Management of Central Line Air Embolism
Question 366Question →

During a shift on the behavioral health unit, a client diagnosed with acute mania begins pacing aggressively, clenching their fists, and shouting threats at peers. Place the following nursing interventions in the correct sequence from first action to last action, prioritizing milieu safety and the principle of least restrictive care.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence begins with securing the environment, followed by verbal de-escalation, offering voluntary medication, calling for team support, and utilizing seclusion strictly as a last resort.
The sequence follows the strict psychiatric nursing protocol of prioritizing immediate physical safety of bystanders first, then applying interventions to the escalating client in order of least restrictive (verbal) to most restrictive (seclusion/restraint).

Step-by-Step Solution

1
Secure the milieu.
Other clients are moved out of harm's way.
Ensuring the physical safety of innocent bystanders is the absolute first priority when a client makes violent threats.
2
Apply the least restrictive direct intervention.
Verbal de-escalation is attempted.
Communication and limit-setting without physical or chemical force respect the client's autonomy and often resolve the crisis.
3
Escalate to voluntary chemical intervention.
PRN oral medication is offered.
If words fail, offering oral medication gives the client a chance to voluntarily manage their escalating symptoms.
4
Prepare for potential violence.
The crisis response team is summoned.
If the client refuses medication and remains threatening, staff must prepare to safely manage a physical altercation.
5
Implement the most restrictive intervention.
Seclusion or restraints are utilized.
This is strictly reserved for situations where all other less restrictive measures have failed and imminent harm is occurring.

Key Concept

Least Restrictive Environment and Crisis Management
Estimated Time:1m 30s
Question 367Question →

A client with advanced dementia is admitted to the medical-surgical unit with severe aspiration pneumonia. The client lacks decision-making capacity and is rapidly declining. The adult children are arguing at the bedside regarding whether to insert a percutaneous endoscopic gastrostomy (PEG) tube or transition exclusively to comfort measures. Arrange the following nursing actions in the most appropriate sequence to address this end-of-life conflict.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to assess the family's understanding, identify the legal healthcare proxy, coordinate a multidisciplinary meeting, support the surrogate in substituted judgment, and document the final care orders.
In psychosocial end-of-life care, prioritizing nursing actions relies on the nursing process and ethical-legal guidelines. Assessment is always the first step; the nurse must evaluate what the feuding family members currently understand about the client's poor prognosis. Second, the nurse must identify who actually holds the legal authority to make decisions (via advance directive or durable power of attorney) before formal discussions occur. Third, a multidisciplinary meeting is coordinated to align the medical team and the family on the realities of the client's condition. Fourth, the nurse supports the legal surrogate in making choices that reflect the client's values (substituted judgment). Finally, all decisions, including comfort measures and DNR status, must be clearly documented to direct ongoing care.

Step-by-Step Solution

1
Evaluate the family members' comprehension of the client's terminal prognosis and current clinical trajectory.
Establishes a baseline for communication and identifies knowledge deficits.
The nursing process always begins with assessment. Understanding what the family knows prevents miscommunication and defensive reactions.
2
Determine the existence of an advance directive or a legally appointed durable power of attorney for healthcare.
Identifies the legally recognized decision-maker.
Ethical and legal standards require medical decisions for an incapacitated client to be made by the legally appointed surrogate, preventing unauthorized family members from dictating care.
3
Coordinate a multidisciplinary family meeting with the healthcare provider and palliative care team to discuss care goals.
Facilitates collaborative and transparent goal setting.
Complex end-of-life conflicts require comprehensive input from the medical team, palliative specialists, and the family to ensure all options are clearly explained.
4
Guide the designated surrogate to base their treatment decisions on the client's previously stated values and wishes.
Promotes the ethical principle of substituted judgment.
The surrogate's role is to make the decision the client would have made if competent, rather than making choices based solely on the surrogate's own desires.
5
Verify that the finalized goals of care, including any comfort measures and resuscitation status, are documented in the medical record.
Ensures continuity of care and legal protection.
Proper documentation guarantees that the entire healthcare team is aware of and legally bound to honor the client's established end-of-life wishes.

Key Concept

Resolution of family conflict during end-of-life care requires a sequential approach: assessing knowledge, verifying legal authority, facilitating multidisciplinary communication, and supporting substituted judgment.
Question 368Question →

A nurse is preparing to insert a nasogastric (NG) tube for a client who requires enteral tube feedings. To reduce the risk of respiratory complications and aspiration, arrange the following nursing actions in the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first position the client upright, measure the correct length of the tube, safely advance the tube while the client swallows with their neck flexed, perform an initial bedside pH check, and finally verify placement with a radiograph before use.
Safe insertion of a nasogastric tube requires a systematic approach to prevent respiratory trauma and aspiration. The process begins with proper anatomical positioning (high Fowler's) and measuring the necessary length to reach the stomach. Advancing the tube with the neck flexed during swallowing protects the airway. Finally, while bedside methods like pH testing provide preliminary data, radiographic confirmation is mandatory before using the tube to eliminate the risk of administering feedings into the lungs.

Step-by-Step Solution

1
Place the client in a high Fowler's position.
The client is sitting upright.
This minimizes aspiration risk and uses gravity to assist with the tube's descent.
2
Measure the tube from the tip of the nose to the earlobe, and then to the xiphoid process.
The target insertion length is identified and marked on the tube.
This ensures the tube is advanced exactly to the stomach, preventing coiling or dangerous misplacement.
3
Instruct the client to flex their head toward their chest and swallow as the tube is advanced.
The tube passes the oropharynx and enters the esophagus.
Flexing the neck anatomically protects the airway by causing the epiglottis to cover the tracheal opening.
4
Secure the tube to the client's nose and aspirate gastric contents to test the pH.
Initial bedside verification indicates a highly acidic gastric environment.
A pH of less than 5 strongly suggests the tube is in the stomach rather than the respiratory tract or intestines.
5
Obtain a radiograph to definitively confirm tube placement before initiating feedings.
Absolute visual confirmation of placement is achieved.
This is the only definitive method to ensure the tube is not in the respiratory tract before administering anything through it, strictly reducing the risk of fatal pulmonary aspiration.

Key Concept

Nasogastric Tube Insertion Safety and Verification
Question 369Question →

An older adult client with a history of mild neurocognitive disorder is admitted to a bustling medical-surgical unit. During the chaotic shift change, the client becomes acutely agitated, yells that "strangers are attacking," and attempts to climb over the raised bed rails. The nurse recognizes the client is experiencing acute delirium exacerbated by sensory overload. Arrange the following nursing actions in the chronological priority order they should be performed.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct priority order is to first secure physical safety, second communicate therapeutically, third reduce environmental stimuli, fourth perform a physiological assessment, and finally document the event.
In any acute clinical scenario, the nursing prioritization framework dictates that immediate life safety and injury prevention come first. Stopping the client from falling over the bed rails addresses an immediate safety threat. Once the client is physically secure, de-escalation via therapeutic communication and environmental modification helps resolve the sensory overload causing the behavioral disturbance. Only after the crisis is stabilized should the nurse transition to investigating the underlying physiological causes (assessment) and completing administrative tasks (documentation).

Step-by-Step Solution

1
Intercept the client's attempt to climb out of bed.
The client's immediate risk of falling and sustaining a traumatic injury is neutralized.
According to Maslow's Hierarchy of Needs and basic survival principles, preventing imminent physical harm always takes absolute priority.
2
Address the client by name in a calm, reassuring voice.
The nurse establishes a non-threatening presence and begins reality orientation.
Once the physical fall is prevented, the nurse must immediately begin de-escalation techniques to manage the client's panic-level anxiety.
3
Decrease sensory stimuli (turn off TV, close door).
The chaotic environment exacerbating the client's sensory overload is minimized.
Sensory overload contributes heavily to agitation in clients with cognitive impairment; modifying the environment removes the trigger.
4
Perform a targeted physiological assessment (oxygenation, pain, elimination).
Potential reversible physiological causes for the acute delirium are identified.
Although assessment is typically the first step of the nursing process, emergency safety interventions supersede it. Once safe, the nurse must assess for root causes like hypoxia or infection.
5
Document the incident in the electronic health record.
The behavioral change and nursing interventions are legally and medically recorded.
Documentation is a vital nursing responsibility but must always follow direct client care and stabilization.

Key Concept

Prioritization of Nursing Care for Acute Delirium and Sensory Overload
Question 370Question →

A client who recently experienced a cerebrovascular accident has residual right-sided weakness. The nursing staff is planning to assist the client from the bed into a wheelchair for the first time. Arrange the following steps in the correct chronological sequence to execute a safe stand-pivot transfer.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first position the wheelchair on the unaffected left side, then assist the client to sit and apply the transfer belt, brace the weak right leg, assist the client to stand and pivot on the strong left foot, and finally instruct the client to reach back with their left hand before sitting.
The correct sequence prioritizes client safety by leveraging their intact mobility. Placing the wheelchair on the unaffected (left) side ensures the client can bear weight and pivot safely on their strong leg. Once the environment is prepared, the client is brought to a seated position to safely apply the transfer belt. The nurse must then brace the hemiparetic right leg to prevent it from buckling during the standing phase. Finally, the client uses their strong left arm to reach for the armrest, which prevents them from falling abruptly into the chair.

Step-by-Step Solution

1
Position the wheelchair on the client's left side at a 45-degree angle to the bed and lock the wheels.
The destination is safely secured and accessible via the client's strong side.
Transferring toward the unaffected side allows the client to bear their own weight and assist with the movement.
2
Assist the client to sit on the edge of the bed with feet flat on the floor and apply a transfer belt.
The client is in a stable starting position with a secure grip point for the nurse.
A transfer belt must be applied while seated to ensure it is snug and will not slide up the rib cage during lifting.
3
Stand facing the client and brace their right knee and foot with your own knee and foot.
The hemiparetic leg is physically blocked from collapsing.
Clients with hemiparesis lack the muscle tone to keep the affected leg extended; bracing it provides essential joint stability.
4
Grasp the transfer belt, assist the client to a standing position, and guide them to pivot on their left foot.
The client successfully rotates their body toward the wheelchair.
Weight is borne primarily by the intact, strong leg during the pivot motion to prevent a fall.
5
Instruct the client to reach back with their left hand to grasp the wheelchair armrest before lowering into the seat.
The client safely and slowly sits down.
Using the strong arm provides stability and controls the speed of the descent, preventing the client from dropping abruptly.

Key Concept

During a bed-to-chair transfer for a client with hemiparesis, equipment must be placed on the unaffected side, and the nurse must brace the affected extremity to prevent buckling.
Question 371Question →

A client is brought to the emergency department by law enforcement exhibiting extreme agitation, paranoia, severe diaphoresis, and aggressive behavior after a suspected ingestion of a synthetic stimulant. The client's initial tympanic temperature is 104.2°F (40.1°C). Arrange the following nursing actions in the most appropriate order of priority from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first secure the environment and obtain staff assistance, followed by administering a prescribed intramuscular benzodiazepine, initiating continuous cardiac monitoring, implementing rapid external cooling measures, and finally collecting diagnostic laboratory specimens.
The priority of care for a client experiencing severe synthetic stimulant toxicity follows the principles of safety, chemical restraint, physiological monitoring, and targeted symptom management. Securing the environment and gathering adequate staff is the absolute first step to ensure physical safety. Once safe, administering a benzodiazepine is the critical medical intervention to decrease the extreme agitation that is driving the life-threatening hyperthermia and metabolic demand. After the client is chemically sedated and compliant, the nurse can safely apply continuous cardiac monitoring to detect lethal arrhythmias. With monitoring in place, rapid cooling measures are applied to treat the critical hyperthermia (104.2°F). Finally, collecting diagnostic specimens is performed to guide ongoing treatment once the client is stabilized.

Step-by-Step Solution

1
Prioritize physical safety and containment.
Secure the immediate environment and request additional staff assistance.
Extreme agitation and paranoia from sympathomimetic toxicity pose an immediate physical threat to the client and the healthcare team. Physical safety must precede medical interventions.
2
Control the acute behavioral and physiological hyperactivity.
Administer a prescribed fast-acting intramuscular benzodiazepine.
Chemical sedation is urgently required to prevent self-harm, halt the progression of hyperthermia resulting from extreme muscle exertion, and allow for safe medical assessment and intervention.
3
Assess cardiovascular status.
Initiate continuous cardiac monitoring and continuous pulse oximetry.
Synthetic stimulants cause severe cardiovascular stress. Once the client is safely sedated, continuous monitoring must be established immediately to detect imminent myocardial ischemia or lethal arrhythmias.
4
Address the life-threatening hyperthermia.
Implement rapid external cooling measures.
A core temperature of 104.2°F (40.1°C) can rapidly lead to protein denaturation and multi-organ failure. Cooling is initiated once monitoring is in place to track physiological responses.
5
Investigate the underlying metabolic and toxicological state.
Collect blood and urine specimens for comprehensive toxicology and metabolic testing.
Laboratory results will guide definitive, longer-term medical management once the immediate life threats have been stabilized.

Key Concept

Prioritization of emergency nursing care for acute synthetic stimulant toxicity.
Question 372Question →

An emergency department nurse is caring for a client who recently experienced a devastating house fire. The client is trembling, disorganized, and repeatedly states, "Everything is gone. I should have just stayed in the house." Arrange the following crisis intervention steps in the correct order from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct order is to first assess the risk for self-harm, establish a therapeutic relationship, explore the client's perception of the event, identify supports and coping mechanisms, and finally collaborate on a short-term action plan.
In crisis intervention, the nurse must follow a structured approach to ensure client safety and promote stabilization. According to established crisis intervention models, the first priority is always a lethality and safety assessment, particularly when the client expresses thoughts of wishing they were dead. Once safety is confirmed, the nurse establishes therapeutic rapport to build trust. Following this, the nurse assesses the client's perception of the precipitating event (the problem) and then explores available situational supports and coping mechanisms. Finally, the nurse and client collaborate to formulate a concrete, short-term action plan to restore equilibrium.

Step-by-Step Solution

1
Determine the highest priority need.
The client made a statement implying they wished they had died in the fire.
Client safety and lethality assessment is always the first step in crisis intervention.
2
Identify the next foundational step for therapeutic interaction.
Establishing rapport and a therapeutic relationship.
A trusting relationship is required for the client to openly share their feelings and engage in problem-solving.
3
Sequence the assessment of the crisis components.
Explore the perception of the event, followed by assessing available supports.
Understanding what the event means to the client must occur before the nurse can help identify appropriate coping resources.
4
Determine the final acute intervention.
Develop a short-term action plan.
After all assessments and resource identification, a concrete plan for the immediate future restores a sense of control.

Key Concept

Crisis Intervention Sequencing
Question 373Question →

A nurse is responding to a client on an inpatient psychiatric unit who is pacing the hallway, speaking loudly, and visibly clenching their fists. Arrange the following therapeutic communication and de-escalation interventions 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 therapeutic de-escalation is to first approach calmly, then acknowledge feelings, offer choices, set limits if necessary, and finally explore triggers when calm.
The correct order follows the evidence-based principles of therapeutic crisis intervention. Safety and non-verbal posture must be established first. This is followed by empathetic validation to build trust. Once acknowledged, offering choices helps the client self-regulate. If this fails, clear limits protect the milieu. Finally, processing the event can only happen when the client is neurologically capable of reasoning, which is after they have calmed down.

Step-by-Step Solution

1
Identify the initial priority in a crisis scenario.
The nurse must first ensure safety and establish a non-threatening presence.
Approaching with a calm posture and safe distance sets the foundation for a therapeutic interaction without increasing the client's anxiety.
2
Determine the first verbal intervention.
The nurse should acknowledge the client's emotional state.
Brief, empathetic reflection validates the client's feelings and begins the de-escalation process.
3
Select the next step to promote client stabilization.
The nurse offers a simple, concrete choice.
Agitated clients feel out of control; offering a choice helps them regain autonomy and redirects their focus.
4
Decide on the intervention if agitation escalates.
The nurse must establish firm, non-threatening limits.
Limit setting is required when earlier de-escalation attempts are ineffective and safety boundaries must be maintained.
5
Identify the final phase of the intervention.
The nurse explores triggers once the client is calm.
Processing the event and discussing coping strategies can only occur when the client has returned to their baseline emotional state.

Key Concept

Therapeutic De-escalation Sequence
Question 374Question →

A nurse is administering a newly prescribed intravenous antibiotic. Ten minutes into the infusion, the client reports severe shortness of breath, a tight feeling in the throat, and dizziness. The client's blood pressure is 82/5082/50 mm Hg and heart rate is 128128 bpm. Arrange the following nursing interventions in the correct order of priority.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to stop the triggering agent, secure the airway and provide oxygen, administer the first-line medication (epinephrine), support circulation with positioning and fluids, and finally administer adjunctive medications.
In any medical emergency involving a continuous intravenous triggering agent, the first and most critical action is to stop the infusion. Following this, the nurse must adhere to the ABC (Airway, Breathing, Circulation) framework. Ensuring a patent airway and providing oxygen addresses the most immediate threat to life (laryngeal edema and hypoxia). Once the airway is supported, intramuscular epinephrine is the absolute priority pharmacological intervention, as it directly reverses bronchospasm and severe vasodilation. After epinephrine administration, circulatory support is provided through leg elevation and rapid isotonic fluid boluses to treat distributive shock. Finally, adjunctive medications such as antihistamines and corticosteroids are administered to alleviate ongoing symptoms and prevent biphasic allergic reactions.

Step-by-Step Solution

1
Identify the immediate threat and remove the cause.
The intravenous antibiotic infusion is stopped immediately.
Halting the exposure to the allergen prevents the anaphylactic reaction from rapidly worsening.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework.
A patent airway is maintained, and high-flow oxygen is administered.
Hypoxia and complete airway occlusion from laryngeal edema represent the most immediate threats to life.
3
Administer life-saving primary pharmacotherapy.
Intramuscular epinephrine is administered into the vastus lateralis.
Epinephrine directly counteracts anaphylaxis by causing rapid bronchodilation and vasoconstriction, thereby improving the airway and blood pressure.
4
Manage the profound distributive shock (Circulation).
The lower extremities are elevated, and a rapid intravenous fluid bolus is initiated.
Anaphylaxis causes massive vasodilation and capillary leak. Positioning and volume replacement help restore adequate venous return and systemic perfusion.
5
Administer secondary supportive treatments.
Intravenous diphenhydramine and corticosteroids are administered.
These adjunctive medications block further histamine release and reduce inflammation, helping to prevent a delayed biphasic reaction.

Key Concept

Prioritization of clinical interventions in acute anaphylactic shock utilizing the ABC framework.
Question 375Question →

A rapid response code is called in the psychiatric emergency department for a client demonstrating imminent physical violence. The provider verbally orders immediate four-point mechanical restraints. Arrange the following nursing actions in the correct chronological sequence of implementation.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: 1) Assemble a team of at least five personnel, 2) Designate a leader to communicate with the client, 3) Secure restraints to the bed frame, 4) Assess peripheral circulation, and 5) Document the precipitating behaviors.
Applying mechanical restraints is a high-risk, last-resort intervention requiring a strict chronological protocol to ensure safety and legal compliance. First, a sufficient team (minimum of 5) must be assembled. Second, a single leader must explain the action to the client to maintain therapeutic communication and minimize trauma. Third, the restraints are physically applied using safe techniques (quick-release knots attached to the non-moving bed frame). Fourth, immediate physiological assessment (circulation and skin integrity) is required to prevent neurovascular damage. Finally, once the client is safe and secured, comprehensive documentation of the emergency and the failed alternatives is completed.

Step-by-Step Solution

1
Identify the primary nursing priority in an acute psychiatric emergency requiring restraints.
The priority is physical safety for both the client and the staff through proper preparation.
Approaching a violent client without adequate support can result in severe injury.
2
Determine the first chronological action to ensure safety.
Assemble a coordinated team of at least five trained personnel.
Standard protocol requires five staff members (one for each limb and one for the head) to safely physically manage a violent client.
3
Identify the immediate next step before physical contact is initiated.
Designate a single team leader to communicate the reason for the intervention.
Having one person speak calmly prevents sensory overload and respects the client's rights by explaining the procedure, even in an emergency.
4
Select the action related to the physical application of the intervention.
Secure the restraint straps to the non-moving parts of the bed frame using quick-release knots.
Restraints must be tied to a stable part of the bed (not side rails) with a knot that can be untied instantly in case of a medical emergency.
5
Determine the most critical nursing assessment immediately following application.
Assess the client's peripheral pulses, skin temperature, and capillary refill in all extremities.
Mechanical restraints pose a significant risk of neurovascular compromise; circulation must be verified immediately.
6
Identify the final administrative step once the situation is physically stabilized.
Document the precipitating behaviors and the specific alternative interventions that failed.
Legal and ethical standards require comprehensive documentation of the rationale and the failure of less restrictive measures, which is completed after the client is safe.

Key Concept

Psychiatric Emergency Restraint Protocol
Question 376Question →

A 65-year-old client admitted with heart failure reports acute, severe nausea. The client's current vital signs include a blood pressure of 118/74 mmHg and a heart rate of 82 bpm. The healthcare provider prescribes 4 mg of ondansetron to be administered via intravenous (IV) push through an existing intermittent peripheral IV catheter (saline lock). Arrange the following steps in the correct chronological order for safely administering this parenteral medication.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for administering an IV push medication via a saline lock is to clean the port, assess patency with a saline flush, clean the port again, administer the medication, and perform a final saline flush at the medication's administration rate.
The standard sequence for administering medication via an intermittent IV lock utilizes the SAS method (Saline, Administer, Saline) while prioritizing infection control and patient safety. The nurse must scrub the hub before every connection. First, patency is verified with a saline flush. Next, the medication is administered at the appropriate rate. Finally, a post-administration flush clears the line, which must be given at the same rate as the medication to prevent a rapid bolus of the residual drug.

Step-by-Step Solution

1
Clean the injection port of the intermittent IV catheter with an antimicrobial swab.
The port is effectively disinfected.
Prevents the introduction of microorganisms from the environment into the client's bloodstream.
2
Attach a syringe containing normal saline, aspirate for a blood return, and flush the line.
Intravenous catheter patency is confirmed.
Ensures the IV catheter is properly located in the vein and has not infiltrated before administering a potentially irritating medication.
3
Clean the injection port again with a new antimicrobial swab and attach the medication syringe.
The port is re-disinfected prior to medication attachment.
Maintains strict asepsis, as the port was exposed when the previous saline syringe was removed.
4
Administer the prescribed ondansetron slowly over the recommended amount of time.
The medication is safely delivered into the bloodstream.
Pushing medication at the correct rate prevents adverse reactions such as speed shock or hemodynamic instability.
5
Clean the injection port and flush the catheter with normal saline at the same rate the medication was administered.
The medication is completely cleared from the tubing and the lock is maintained.
Flushing clears the medication line. Pushing the final flush at the same rate as the medication ensures that any residual drug in the catheter is not inadvertently delivered as a rapid bolus.

Key Concept

Safe administration of intravenous push medications via an intermittent peripheral IV lock requires strict aseptic technique, verification of catheter patency, and proper flushing protocols.
Question 377Question →

A 55-year-old client is 3 days postoperative following an exploratory laparotomy. During a forceful coughing episode, the client reports a sudden "popping" sensation in the abdomen. The nurse inspects the surgical site and observes an abdominal evisceration. Place the following nursing interventions in the correct priority order to minimize the risk of severe physiological complications. (Arrange the steps from first to last.)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct priority sequence is: 1) Call for immediate assistance, 2) Position the client in a low Fowler's position with flexed knees, 3) Cover the viscera with sterile moist dressings, 4) Assess vital signs, and 5) Prepare the client for emergency surgery.
In the event of an abdominal evisceration, the overarching goal is to reduce the risk of bowel ischemia, infection, and shock. The nurse must first call for immediate assistance to obtain sterile supplies and alert the surgeon, ensuring they do not leave the unstable client. Before supplies arrive, placing the client in a low Fowler's position with flexed knees immediately relaxes the abdominal musculature, minimizing further organ protrusion. Once the sterile saline and dressings arrive, the nurse covers the exposed viscera to maintain moisture and viability. After securing the physical defect, the nurse evaluates the client's hemodynamic status by checking vital signs to detect early hypovolemic shock. Finally, the nurse verifies intravenous access and prepares the client for the definitive treatment, which is emergency surgical closure.

Step-by-Step Solution

1
Call for immediate assistance and instruct a colleague to bring sterile supplies and notify the surgeon.
The nurse secures additional help and necessary supplies without leaving the client's bedside.
An evisceration is a surgical emergency. The nurse cannot leave the client alone to gather supplies, so mobilizing the team is the first necessary action.
2
Position the client in a low Fowler's position with the hips and knees flexed.
Intra-abdominal pressure is rapidly reduced.
Flexing the knees and raising the head of the bed slightly relaxes the abdominal muscles, reducing tension on the wound and preventing further organ protrusion while waiting for supplies to be brought to the room.
3
Cover the protruding viscera with sterile dressings moistened with sterile normal saline.
The exposed internal organs are protected from the external environment.
Moist, sterile dressings prevent the viscera from drying out, which could lead to severe ischemia and necrosis, while also reducing the risk of bacterial contamination.
4
Assess the client's vital signs and monitor for clinical indicators of shock.
The client's hemodynamic status is systematically evaluated.
Evisceration can lead to rapid fluid shifts and hypovolemic shock. Once the physical wound is stabilized, assessing vital signs is the next critical priority.
5
Verify peripheral intravenous access and prepare the client for emergency surgery.
The client is readied for definitive surgical management.
The only resolution for an evisceration is surgical repair. Ensuring patent IV access allows for fluid resuscitation and administration of preoperative medications.

Key Concept

Abdominal Evisceration Emergency Management Sequence
Question 378Question →

A nurse is preparing to discontinue a client's peripheral intravenous (IV) catheter. Place the following steps 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 is: perform hand hygiene and don gloves, clamp tubing and remove dressing, withdraw the catheter, apply firm pressure, and finally inspect the catheter tip.
The correct sequence ensures patient safety, infection control, and proper hemostasis during the discontinuation of a peripheral IV line. Standard precautions must be taken first. Then, the site is freed from securement devices so the catheter can be withdrawn smoothly without causing trauma. Once removed, immediate direct pressure prevents bleeding and hematoma formation. Finally, inspecting the catheter ensures that no fragments have broken off into the patient's circulatory system.

Step-by-Step Solution

1
Initiate standard precautions by performing hand hygiene and applying gloves.
The nurse is protected, and the patient is safe from contamination.
Infection control is the foundational first step for any procedure involving potential blood exposure.
2
Stop the flow of fluids by clamping the tubing and remove the adhesive dressing.
The IV catheter is no longer secured to the patient's skin.
The dressing must be removed before the catheter can be physically withdrawn.
3
Pull the catheter out of the vein in a smooth, straight motion.
The catheter is completely removed from the patient's arm.
Removing it parallel to the skin prevents injury to the vein wall.
4
Immediately place a sterile gauze pad over the site and hold firm pressure.
Bleeding stops and a clot begins to form.
Direct pressure is required to achieve hemostasis and prevent a hematoma.
5
Look closely at the tip of the removed IV catheter.
The nurse confirms the entire catheter was removed.
A missing tip indicates a catheter embolus, which is a medical emergency requiring immediate intervention.

Key Concept

Discontinuation of a Peripheral Intravenous (IV) Catheter
Question 379Question →

A 68-year-old client is admitted to the medical unit with a history of recurrent syncope, dehydration, and the recent initiation of a new antihypertensive medication. The healthcare provider prescribes orthostatic vital sign measurements. To ensure accurate assessment and reduce the risk of a potential fall, arrange the following procedural steps in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence requires obtaining a resting supine baseline, then measuring vital signs in the supine position, followed by standing the client, waiting for a brief period, and taking the final standing measurements.
Measuring orthostatic vital signs is a key diagnostic procedure to reduce the risk of syncope and falls in vulnerable clients. The correct sequence ensures standard baseline measurements are obtained while supine, followed by a controlled position change, an appropriate delay for the body's physiological response, and a final measurement to identify significant hemodynamic changes.

Step-by-Step Solution

1
Establish a resting baseline state.
The client is placed in a supine position for 5 to 10 minutes.
This allows hemodynamics to stabilize before any initial measurements are taken.
2
Obtain baseline vital signs.
Blood pressure and heart rate are measured and recorded.
This provides the critical comparison values for subsequent position changes.
3
Change the client's position to induce an orthostatic challenge.
The client is assisted to a standing position.
Gravity causes blood to pool in the lower extremities, challenging the cardiovascular system's compensatory mechanisms.
4
Allow time for physiological compensation.
The nurse waits 1 to 3 minutes.
This provides time for baroreceptors to detect the drop in blood pressure and attempt to increase heart rate and vascular resistance.
5
Reassess vital signs.
Blood pressure and heart rate are measured again.
This allows identification of a drop in systolic blood pressure of 20 mm Hg or more, or a diastolic drop of 10 mm Hg or more.

Key Concept

Orthostatic Vital Sign Assessment Sequence
Question 380Question →

A nurse is preparing to draw a blood specimen from a client's central venous catheter (CVC). To maintain catheter patency, prevent infection, and ensure accurate laboratory results, arrange the following steps in the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to disinfect the hub, flush to confirm patency, draw and discard the waste blood, obtain the required diagnostic specimen, and finally perform a thorough flush to prevent line occlusion.
Following this exact sequence ensures three critical risk reduction goals: preventing infection by scrubbing first, ensuring accurate diagnostics by clearing the line of fluids before sampling, and maintaining the integrity of the device by flushing away residual blood to prevent thrombosis.

Step-by-Step Solution

1
Disinfect the access hub.
Microorganisms are removed from the connector surface.
Prevents the direct introduction of pathogens into the central circulation.
2
Flush the catheter with normal saline.
Line patency is verified.
Ensures the line is functioning properly and clears residual medications.
3
Aspirate and discard the initial volume of blood.
Mixed blood and saline is removed from the catheter.
Prevents laboratory results from being falsely altered by fluid dilution.
4
Withdraw the required blood specimen.
A pure, undiluted blood sample is collected.
Provides an accurate sample for necessary diagnostic laboratory analysis.
5
Perform a final flush of the catheter.
Residual blood is completely cleared from the line.
Prevents blood from clotting inside the catheter, maintaining patency for future use.

Key Concept

Reduction of risk potential during central venous catheter blood sampling involves strict aseptic technique, proper clearing of line fluids to ensure accurate diagnostics, and thorough flushing to prevent catheter occlusion.
PreviousPage 19 / 44Next
All practice questions — NCLEX-RN | Examkin