Examkin

All practice questions

862 questions

All types3,881Multiple choice1,926Multiple select908Numeric119Matching66Ordering862
Question 381Question →

A client on an inpatient psychiatric unit receives a phone call regarding the sudden death of a family member. The client drops the phone, begins pacing the hallway rapidly, hyperventilating, and shouting, "I can't breathe, I'm going to die!" Arrange the following nursing interventions in the correct order of priority. All options must be used.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: isolate from stimuli, establish communication parameters, address physiological symptoms, apply cognitive grounding, and finally use pharmacological intervention.
The correct sequence follows Maslow's hierarchy of needs and psychiatric emergency protocols: secure the environment (safety), establish safe communication, address acute physiological distress (breathing), address psychological distress (grounding), and utilize chemical restraints (medication) only as a last resort.

Step-by-Step Solution

1
Prioritize environmental safety and stimuli reduction.
The client is moved to a quiet, private room.
High-stimulus environments exacerbate severe anxiety and panic. Isolation protects the client and maintains the therapeutic milieu for others.
2
Establish the parameters of therapeutic communication.
The nurse stands at a safe distance and uses brief, directive statements.
Severe panic impairs cognitive processing. Complex sentences or perceived physical threats will escalate the crisis.
3
Intervene to manage acute physiological manifestations of panic.
The nurse coaches the client through controlled, deep breathing.
Hyperventilation must be arrested to prevent physical complications such as tetany or syncope, taking precedence over psychological processing.
4
Implement cognitive grounding strategies.
The client is asked to identify objects in the room (e.g., the 5-4-3-2-1 technique).
Grounding anchors the client in current reality, interrupting the cycle of catastrophic thoughts related to the stressor.
5
Evaluate the need for pharmacological support.
A PRN anxiolytic is offered if previous steps are insufficient.
Following the principle of least restrictive intervention, medications are utilized when behavioral and environmental de-escalation techniques do not resolve the severe distress.

Key Concept

Prioritization of Crisis Intervention and Panic Management
Question 382Question →

A 10-year-old child with a cognitive disability is brought to the emergency department by a caregiver. The child has an actively bleeding scalp laceration, and the nurse observes patterned, defensive bruising on the child's forearms. The caregiver's explanation of the injuries is inconsistent with the physical findings. Arrange the following nursing actions in the correct order of priority from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence prioritizes physiological stability, then immediate safety, followed by assessment, factual documentation, and finally mandatory reporting.
Nursing prioritization follows a strict clinical hierarchy: physiological needs (circulation and bleeding control) must be addressed first, followed immediately by physical safety (separating the suspected abuser). Once the client is medically stabilized and safe, the nurse can conduct a thorough, uncoerced assessment. Objective documentation of these findings must precede external reporting to ensure accurate and factual information is provided to child protective services.

Step-by-Step Solution

1
Apply direct pressure to the actively bleeding scalp laceration.
The active hemorrhage is controlled, achieving physiological stability.
According to the ABCs of resuscitation, physiological survival (circulation) takes immediate precedence over all other interventions.
2
Separate the caregiver from the child using a facility-approved protocol.
The child is placed in a secure environment away from potential intimidation or further harm.
Once medically stable, ensuring the client's immediate physical safety and security is the next priority in Maslow's hierarchy of needs.
3
Complete a full physical assessment and interview the child privately.
Comprehensive clinical data and the client's perspective are gathered safely.
A thorough assessment can only yield accurate, uncoerced information if the suspected abuser is no longer present.
4
Document the objective characteristics of the wounds and the child's exact statements.
An objective legal medical record of the abuse suspicion is created.
Factual documentation provides the essential evidence base required before initiating external communications.
5
Report the suspected child abuse to the designated local child protective services agency.
The legal obligation as a mandated reporter is fulfilled.
External reporting relies on the objective data gathered during the assessment phase and must be completed once safety and stability are ensured.

Key Concept

Prioritization of Care in Suspected Abuse
Question 383Question →

A nurse enters the room of a client with a history of severe opioid use disorder and finds the client unresponsive, cyanotic, and exhibiting a respiratory rate of 4 breaths/min with pinpoint pupils. Arrange the following nursing interventions in the correct order of priority, from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct prioritization sequence is: Activate the rapid response team -> Establish a patent airway -> Initiate rescue breathing with a BVM -> Administer intravenous naloxone -> Reassess the client's status.
The correct sequence strictly adheres to the American Heart Association (AHA) Basic Life Support (BLS) and prioritizing principles (ABCs). Upon discovering an unresponsive client, the nurse must first call for help. Next, physical airway patency must be established, immediately followed by rescue breathing to treat the severe hypoxia caused by the respiratory rate of 4. Only after oxygenation is supported should the nurse administer the pharmacological reversal agent (naloxone). Finally, because naloxone has a short half-life, continuous reassessment is necessary to detect recurrent respiratory depression.

Step-by-Step Solution

1
Activate the facility's rapid response team and request the emergency cart.
Additional clinical support and necessary resuscitation equipment are mobilized.
Basic Life Support (BLS) guidelines dictate that recognizing unresponsiveness must be immediately followed by calling for help before initiating time-intensive physical interventions.
2
Establish a patent airway using a head-tilt/chin-lift maneuver.
The airway is opened, lifting the tongue away from the posterior pharynx.
A patent airway is an absolute prerequisite for effective ventilation and oxygenation.
3
Initiate rescue breathing using a bag-valve-mask (BVM) device with 100% oxygen.
Oxygen is delivered to the client's lungs, correcting severe hypoxia.
The client's respiratory rate of 4 breaths/min is inadequate to sustain life. Immediate mechanical ventilation prevents progression to cardiac arrest.
4
Administer the prescribed dose of intravenous naloxone.
The opioid receptor antagonist begins to reverse the central nervous system and respiratory depression.
While naloxone treats the root cause, preparing and administering the medication takes time; the brain must be oxygenated manually while the drug is given.
5
Reassess the client's respiratory rate, oxygen saturation, and level of consciousness.
The nurse evaluates the effectiveness of the naloxone and the need for further intervention.
Naloxone's duration of action is short (approximately 30 to 90 minutes). The opioid effect may outlast the reversal agent, causing the client to slip back into respiratory depression.

Key Concept

Prioritization of care in opioid overdose emergencies using Basic Life Support (BLS) and Airway, Breathing, Circulation (ABC) principles.
Question 384Question →

A nurse is caring for a client who is receiving an infusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion begins, the client reports sudden lower back pain, chills, and shortness of breath. In which order should the nurse perform the following actions? Arrange the actions from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Stop the transfusion, infuse 0.9% sodium chloride with new tubing, assess vital signs, notify the healthcare provider, and send the blood bag to the blood bank.
When a hemolytic transfusion reaction occurs, characterized by lower back pain, chills, and dyspnea, the absolute first step is to stop the transfusion to prevent further physiological harm. Next, the nurse must maintain a patent IV line with 0.9% sodium chloride using completely new tubing so that residual blood is not pushed into the client. The nurse then quickly assesses vital signs to gather current physiological data. With this information, the nurse notifies the healthcare provider using the SBAR framework to obtain emergency orders. Finally, once the immediate threat is managed, the blood bag and tubing are sent to the blood bank for analysis.

Step-by-Step Solution

1
Identify the primary intervention for a suspected adverse reaction.
Stop the blood transfusion.
Preventing further exposure to the potentially incompatible blood product is the highest priority.
2
Determine the next action to maintain vascular access and stability.
Infuse 0.9% sodium chloride through a new intravenous tubing set.
Patent IV access is critical for emergency drugs, and new tubing prevents residual blood in the old line from entering the client.
3
Determine the action needed before communicating with the medical team.
Assess the client's vital signs and respiratory status.
The provider will need current baseline data to prescribe appropriate emergency interventions.
4
Determine the communication step.
Notify the healthcare provider of the client's condition.
The provider must be informed of the reaction and the assessment findings to direct further medical care.
5
Identify the final administrative and diagnostic step.
Send the blood bag and administration set to the blood bank.
Laboratory analysis of the blood and tubing is necessary to identify the type and cause of the transfusion reaction.

Key Concept

Management of acute hemolytic transfusion reactions
Estimated Time:1m 30s
Question 385Question →

A nurse at a community health center is caring for a client who presents in a state of acute situational crisis after experiencing sudden, unexpected financial ruin. The client is pacing rapidly, crying, and states, 'I have lost absolutely everything; I do not see a way out of this.' Arrange the following crisis interventions in the sequential order the nurse should implement them.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for crisis intervention is to first ensure safety (lethality assessment), then build rapport (therapeutic alliance), assess the problem (precipitating event), evaluate resources (coping mechanisms), and finally plan interventions (action plan).
The established standard of care for crisis intervention follows a structured, priority-based sequence. It begins with ensuring immediate safety by assessing for lethality. Once the client is deemed safe, establishing rapport and trust is the next critical step. Following this, the nurse assesses the specific precipitating event and how the client views it. The nurse then evaluates the client's existing coping skills and support networks. Finally, utilizing these resources, the nurse and client collaboratively develop a concrete, short-term action plan to restore equilibrium.

Step-by-Step Solution

1
Prioritize physiological and psychological safety.
The nurse conducts a lethality assessment to rule out immediate risk of suicide or self-harm.
According to prioritization frameworks, immediate life-threatening risks must be addressed before any other psychological or social assessment.
2
Establish a therapeutic connection.
The nurse uses active listening and empathy to build a trusting relationship.
A safe, supportive environment is required for a client in acute distress to effectively share sensitive information and de-escalate.
3
Assess the nature of the crisis.
The nurse identifies the precipitating event and explores the client's perception of the problem.
Understanding the specific trigger and the client's subjective experience of it is necessary to tailor appropriate interventions.
4
Evaluate available resources.
The nurse explores the client's past coping skills and available social support network.
Identifying existing strengths and external help determines what tools can be leveraged in the recovery process.
5
Develop a structured intervention.
The nurse and client collaborate to create a short-term, concrete action plan.
A collaborative action plan empowers the client, reduces anxiety, and provides clear steps toward restoring pre-crisis baseline functioning.

Key Concept

Prioritization and Sequencing of Crisis Intervention
Question 386Question →

A 65-year-old client with osteomyelitis is receiving long-term antibiotic therapy. The nurse is preparing to administer the next dose of intermittent intravenous (IV) ceftriaxone through the client's open-ended central venous catheter (CVC). The designated lumen is currently capped and has not been used for 12 hours. Place the following steps in the correct chronological order to safely administer the medication and maintain catheter patency.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct chronological sequence follows the SASH protocol: Aspirate for a blood return, flush with saline, administer the medication, flush with saline again, and finish with a heparin lock.
The SASH protocol dictates the safe administration of medications via an open-ended central venous catheter. First, the nurse must scrub the hub and aspirate to confirm placement and patency. Next, a normal saline flush clears the line and confirms there is no resistance. The medication is then administered. A second saline flush is mandatory after the infusion to clear the medication and prevent chemical precipitation with the final step, which is a heparin lock to maintain catheter patency until the next use.

Step-by-Step Solution

1
Scrub the connector, attach a saline syringe, and aspirate for a blood return.
Verifies that the catheter tip is correctly placed in the vein and the lumen is patent.
Pushing fluids without confirming placement can result in severe extravasation or force a clot into the systemic circulation.
2
Flush the catheter with 10 mL of 0.9% sodium chloride using a pulsatile technique.
Clears the lumen of any residual blood or blockages.
Provides a clean, compatible pathway for the medication and allows the nurse to assess for injection resistance.
3
Connect the antibiotic tubing and administer the intermittent IV ceftriaxone.
Delivers the prescribed antibiotic therapy to the client.
The line is now confirmed safe and compatible for infusion.
4
Disconnect the empty tubing, scrub the connector, and flush with 10 mL of 0.9% sodium chloride.
Clears the ceftriaxone from the central venous catheter.
Ensures the full dose reaches the patient and prevents chemical precipitation with the upcoming heparin flush.
5
Scrub the connector, instill the heparin flush solution, and close the catheter clamp.
Locks the open-ended catheter with an anticoagulant.
Prevents blood backflow and thrombus formation inside the lumen between intermittent uses.

Key Concept

The SASH (Saline, Administer, Saline, Heparin) method is the evidence-based standard protocol for administering medications and maintaining patency in open-ended central venous catheters.
Estimated Time:1m 30s
Question 387Question →

A nurse is preparing to safely transfer a client with right-sided hemiparesis (weakness) from the bed to a wheelchair. Arrange the following nursing actions in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The safe order of operations is to first prepare the environment by positioning the wheelchair on the strong side, sit the client up to establish balance, apply the safety gait belt, assist to a standing position using the strong leg, and finally pivot until the client feels the chair before sitting.
According to safe mobility principles, transferring a client with unilateral weakness requires prioritizing environmental readiness and leveraging the client's strong side. Positioning the chair on the unaffected side allows the client to bear weight and pivot safely. Dangling prevents orthostatic hypotension, and applying a gait belt ensures physical control. Finally, standing, pivoting, and using tactile confirmation (knees touching the chair) ensure a safe descent into the wheelchair.

Step-by-Step Solution

1
Prepare the environment and position the wheelchair.
The wheelchair is locked and angled on the client's unaffected side.
Ensures equipment is stable and positioned to take advantage of the client's intact strength before moving the client.
2
Assist the client to dangle at the edge of the bed.
The client is seated with feet flat on the floor.
Prevents orthostatic dizziness and establishes a stable center of gravity.
3
Secure the gait belt.
The transfer belt is fastened snugly around the client's waist.
Provides a safe ergonomic grip for the nurse, preventing musculoskeletal injuries to both the client and the nurse.
4
Stand the client.
The client stands, bearing weight on the strong left leg.
Utilizes the client's functional limb for primary support during the most physically demanding phase of the transfer.
5
Pivot and seat the client.
The client safely transitions into the wheelchair.
Tactile feedback (chair against the knees) confirms spatial alignment, preventing falls to the floor.

Key Concept

Safe Client Transfer Principles and Mobility
Estimated Time:1m 0s
Question 388Question →

A client who recently experienced a cerebrovascular accident has new-onset right-sided hemiparesis. The nurse is preparing to transfer the client from the bed to a wheelchair using a stand-and-pivot technique. The client is currently resting supine in bed. Place the following steps in the correct chronological order to ensure a safe transfer.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence begins with preparing the environment by placing the wheelchair on the strong side, assisting the client to sit, applying safety gear, assisting to stand using the strong arm, and finally pivoting on the strong leg to sit in the wheelchair.
Safe transfer of a client with hemiparesis requires strict adherence to biomechanical principles and environmental safety. The wheelchair must always be positioned on the unaffected (strong) side so the client can use their functional limbs to bear weight and stabilize themselves. The client must first be assisted to a sitting position before the transfer belt is applied to ensure a proper fit. Finally, standing and pivoting rely on the strength of the unaffected leg and arm to safely transition into the chair.

Step-by-Step Solution

1
Position and lock the wheelchair on the left side.
The wheelchair is secured on the client's unaffected side.
Ensures the environment is safe before moving the client and aligns the destination with the client's strong side.
2
Assist the client to sit on the edge of the bed.
The client is in a dangling position.
Allows cardiovascular stabilization to prevent orthostatic hypotension before attempting to stand.
3
Apply non-skid footwear and a transfer belt.
Safety equipment is secured.
Prevents falls from slipping and gives the nurse a safe mechanical hold on the client's center of gravity.
4
Assist the client to stand while they push off the bed with their left hand.
The client achieves a standing position.
Maximizes client independence and safety by utilizing their unaffected upper extremity.
5
Instruct the client to pivot on the strong leg and reach for the armrest.
The client safely transitions into the wheelchair.
Weight-bearing during the pivot must occur on the strong leg to prevent buckling and falls.

Key Concept

Safe Client Transfer Techniques and Hemiparesis Mobility
Question 389Question →

While actively charting in a client's electronic health record (EHR), a registered nurse (RN) encounters a sudden screen lock accompanied by a pop-up message demanding a financial payment to decrypt the files. Arrange the following actions in the priority order the RN should execute them to ensure information security and client safety. (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 actions is: 1. Disconnect the workstation from the network, 2. Notify the nursing supervisor and IT, 3. Implement downtime procedures, 4. Store paper records securely, 5. Retroactively enter data once the system is restored.
In the event of a cyberattack such as ransomware, the immediate nursing priority is containment to protect the broader facility infrastructure. Disconnecting the infected device from the network prevents the malware from spreading to other hospital systems. Following containment, escalating the issue to IT and nursing leadership ensures a coordinated facility response. Because the EHR is inaccessible, the nurse must then implement downtime procedures to maintain client care, ensuring that physical paper records are kept secure to maintain HIPAA compliance. Finally, once the cyber threat is neutralized and systems are restored, all paper documentation must be entered into the EHR to ensure a complete, accurate legal medical record.

Step-by-Step Solution

1
Analyze the scenario to identify the primary threat.
The primary threat is a ransomware attack that compromises the EHR and could spread across the hospital network, jeopardizing all electronic protected health information (ePHI).
Understanding the nature of the cyber threat determines the urgency and prioritization of the initial response.
2
Determine the immediate action to mitigate the spread of the threat.
Disconnecting the affected computer workstation from the network.
Isolating the infected endpoint is the critical first step in cybersecurity incident response to prevent lateral movement of the malware.
3
Identify the next logical steps for reporting and maintaining care.
Reporting the incident to IT and management, followed by initiating downtime procedures.
Once contained, experts must be mobilized to address the system-wide threat, while clinical staff must ensure client care continues without interruption using paper records.
4
Determine how to manage PHI during and after the downtime.
Securing paper records during the outage, then retroactively entering data when the system is safe.
Confidentiality must be maintained continuously, transitioning from electronic to physical safeguards, and finally restoring the complete electronic record for continuity.

Key Concept

Cybersecurity Incident Response and EHR Downtime Procedures
Question 390Question →

A nurse is preparing to contact a healthcare provider regarding a client whose respiratory status has suddenly deteriorated. Arrange the nurse's planned statements in the correct chronological order according to the standard SBAR (Situation, Background, Assessment, Recommendation) communication tool.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Situation, Background, Assessment, and Recommendation.
The SBAR tool is universally structured to quickly and safely convey critical client information to the interdisciplinary team. It must follow the strict chronological sequence of Situation (what is happening right now), Background (what led to this), Assessment (what the nurse observes), and Recommendation (what needs to be done).

Step-by-Step Solution

1
Identify the 'Situation' (S) statement.
The statement introducing the nurse, the client (Ms. Chen), and the acute problem (shortness of breath) is placed first.
Effective interprofessional communication must begin by clearly stating who is calling and why.
2
Identify the 'Background' (B) statement.
The statement detailing the admission diagnosis (pneumonia) and medical history (asthma) is placed second.
Once the problem is stated, the provider needs a brief clinical context to understand the client's baseline.
3
Identify the 'Assessment' (A) statement.
The statement providing the current vital signs (oxygen saturation, respiratory rate) and physical findings (wheezing) is placed third.
The provider needs current objective data to evaluate the severity of the situation described.
4
Identify the 'Recommendation' (R) statement.
The statement requesting a nebulizer treatment and an immediate evaluation is placed last.
After providing all necessary information, the nurse must clearly state what action they need from the provider.

Key Concept

SBAR is a standardized framework used to improve communication and safety among the interdisciplinary healthcare team during client handoffs and critical escalations.
Question 391Question →

A 45-year-old client admitted with pneumonia suddenly removes their intravenous (IV) line and states, 'I am leaving this hospital right now. Nobody is helping me.' Arrange the following nursing actions in the correct 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 assess the client's concerns, then notify the healthcare provider, explain the risks of leaving, ask the client to sign the AMA form, and finally document the event.
When managing a client who wishes to leave Against Medical Advice (AMA), the nurse must follow a logical sequence that prioritizes client care, communication, informed refusal, and legal documentation. The priority is always to assess the client's underlying concerns first to see if the issue can be resolved. If the client insists on leaving, the healthcare provider must be notified immediately. Next, the client must be informed of the risks associated with refusing treatment to ensure their decision is informed. After explaining the risks, the nurse asks the client to sign the AMA form for legal protection. Finally, the nurse must meticulously document the entire sequence of events in the client's medical record.

Step-by-Step Solution

1
Assess the client's reasons for wanting to leave and attempt to address their concerns.
Identifies the root cause of the client's distress.
Addressing the client's immediate concerns is the first priority and may resolve the situation so the client stays for treatment.
2
Notify the healthcare provider of the client's intent to leave against medical advice.
Involves the medical provider in the situation.
The provider must be informed so they can speak with the client, assess competency, or adjust the treatment plan.
3
Explain the potential health risks and consequences of leaving without completing treatment.
Ensures the client makes an informed decision.
Clients have the legal right to refuse treatment, but they must be fully informed of the medical risks involved in doing so.
4
Ask the client to sign the Against Medical Advice (AMA) release form.
Obtains legal documentation of the client's refusal.
Signing the AMA form legally acknowledges that the client understands the risks and releases the healthcare facility from liability.
5
Document the client's statements, the education provided, and the client's departure in the medical record.
Creates a complete legal record of the incident.
Thorough documentation is legally required to prove that the standard of care was met and the client's rights were respected.

Key Concept

Against Medical Advice (AMA) Protocol and Client Rights
Estimated Time:1m 30s
Question 392Question →

A nurse enters the room of a client with chronic obstructive pulmonary disease (COPD) and observes that the client is experiencing acute shortness of breath, using accessory muscles to breathe, and appears highly anxious. Order the following nursing interventions from highest priority (first action) to lowest priority (last action).

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence of actions is: Elevate the head of the bed, assess vital signs and oxygen saturation, administer prescribed oxygen, and finally notify the healthcare provider.
Prioritization in an acute respiratory emergency relies on the Airway-Breathing-Circulation (ABC) framework and the nursing process. Elevating the head of the bed is the fastest, most effective independent action to immediately improve breathing mechanics (Airway/Breathing). Next, the nurse assesses the client (oxygen saturation, vital signs) to determine severity and guide the next steps. After assessment, the nurse implements targeted interventions like administering prescribed oxygen. Finally, once the client is stabilized and clinical data is collected, the nurse notifies the healthcare provider to report the event and obtain any necessary further medical orders.

Step-by-Step Solution

1
Address the immediate Airway/Breathing need.
Elevate the head of the bed to a high-Fowler's position.
According to the ABC (Airway, Breathing, Circulation) framework, addressing respiratory distress is the highest priority. Positioning is the fastest independent intervention to facilitate lung expansion.
2
Apply the nursing process (Assessment).
Assess the client's vital signs and oxygen saturation.
After securing an optimal position for breathing, the nurse must quickly gather clinical data to guide subsequent interventions.
3
Implement specific treatments based on assessment.
Administer the prescribed PRN supplemental oxygen.
With assessment data in hand, the nurse implements the necessary pharmacological or respiratory treatments, such as applying oxygen to correct hypoxemia.
4
Communicate and collaborate.
Notify the healthcare provider of the client's condition.
The provider is notified once the client is stabilized and the nurse has a complete clinical picture to communicate using a standardized format like SBAR.

Key Concept

In acute respiratory distress, the nurse prioritizes immediate, independent airway interventions (positioning) first, followed by rapid assessment, targeted implementation of treatments, and finally provider notification.
Question 393Question →

The nurse receives the morning handoff report for a group of clients on the postpartum unit. In what order should the nurse assess these clients? Arrange the clients from highest priority (first to be seen) to lowest priority (last to be seen).

Drag items to arrange them in the correct order

Show answer & explanation

Answer

Assess the client with a boggy fundus and heavy bleeding first, followed by the client requesting pain medication, then the client needing breastfeeding assistance, and finally the client requiring discharge teaching.
Prioritization in nursing follows established frameworks such as ABCs (Airway, Breathing, Circulation) and Maslow's Hierarchy of Needs. The client with a boggy fundus and heavy bleeding is experiencing a circulatory emergency (postpartum hemorrhage) and must be seen first to prevent hypovolemic shock. The client with acute postoperative pain is seen next to provide relief and prevent complications. The client needing assistance with breastfeeding has a functional, routine physiological need that should be addressed before the lowest-priority task, which is discharge teaching.

Step-by-Step Solution

1
Identify any life-threatening or ABC (Airway, Breathing, Circulation) issues.
The client with a boggy fundus and heavy bleeding has a critical circulation issue (potential hemorrhage).
Airway, breathing, and circulation emergencies take the highest priority in client care.
2
Evaluate the remaining clients for acute, urgent needs such as severe pain or changes in condition.
The post-cesarean client is experiencing acute pain and requires timely administration of medication.
Pain management is a high priority once physiological stability is ensured.
3
Determine which of the stable clients has an immediate functional or physiological need.
The client needing help with newborn latching has a time-sensitive functional need, as feeding should occur on a regular schedule.
Routine physiological needs are prioritized over teaching and discharge planning.
4
Assign the lowest priority to routine tasks, education, and discharge planning.
The client needing car seat safety education is stable and preparing to go home.
Teaching is vital but does not take precedence over physiological instability or acute discomfort.

Key Concept

Prioritization of care based on the ABCs (Airway, Breathing, Circulation) and Maslow's Hierarchy of Needs.
Question 394Question →

While the nurse is changing the tubing on a client's central venous catheter, the client suddenly begins gasping for air, reports sharp chest pain, and becomes lightheaded. The nurse suspects an air embolism. In what order should the nurse perform the following actions? Arrange the actions from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first clamp the catheter, then place the client in a left lateral Trendelenburg position, apply high-flow oxygen, activate the rapid response team, and finally remain with the client to monitor vital signs.
When an air embolism is suspected during a central venous catheter procedure, the nurse must act rapidly using a specific priority framework. The immediate first step is to eliminate the source by clamping the catheter, preventing any more air from entering the central circulation. The second critical step is positioning the client in the left lateral Trendelenburg position (Durant's maneuver); this traps the air bubble in the right atrium and apex of the right ventricle, preventing it from migrating into the pulmonary artery and causing a lethal obstruction. Once the client is positioned safely, the third step is to administer 100% high-flow oxygen, which combats hypoxia and creates a diffusion gradient to help reabsorb the nitrogen trapped in the air bubble. After these independent life-saving interventions are completed, the fourth step is to activate the rapid response team for advanced medical interventions. Finally, the nurse remains with the client to continuously monitor vital signs and respiratory status while awaiting help.

Step-by-Step Solution

1
Identify the immediate threat.
The symptoms indicate an acute central line air embolism, requiring immediate mechanical and respiratory intervention.
Recognizing the specific emergency dictates the priority framework.
2
Stop the source of harm.
Clamp the central venous catheter.
Preventing additional air from entering the bloodstream is the absolute first priority to prevent further deterioration.
3
Implement mechanical protection.
Position the client in the left lateral Trendelenburg position.
This specific position (Durant's maneuver) utilizes gravity to trap the air in the right ventricle, preventing a fatal pulmonary artery occlusion.
4
Provide respiratory support.
Administer high-flow oxygen.
Providing 100% oxygen combats systemic hypoxia and accelerates the resorption of nitrogen from the trapped air embolus.
5
Escalate care.
Activate the rapid response team.
Once initial life-saving stabilizing steps are complete, advanced medical assistance and further diagnostic testing are required.
6
Maintain assessment.
Remain with the client to monitor vital signs.
The nurse must continuously evaluate the client's physiological response to interventions until the response team takes over.

Key Concept

Prioritizing interventions for a central line air embolism involves stopping the air entry, positioning to prevent pulmonary occlusion, oxygenating, and escalating care.
Question 395Question →

A competent adult client is scheduled for an elective surgical procedure. The surgeon has just left the client's room after discussing the surgery. In what chronological order should the nurse perform the following actions to fulfill legal responsibilities regarding informed consent?

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The nurse must first verify the provider gave the explanation, assess the client's understanding, witness the signature, secure the document in the chart, and only then administer preoperative sedatives.
The chronological sequence ensures all legal requirements for informed consent are met in a way that protects the client's rights. The provider's explanation must happen first, followed immediately by the nurse checking the client's understanding. Only when understanding is confirmed can the signature be witnessed. The document must then be charted. Finally, sedatives can be administered; doing so earlier would legally invalidate the consent process.

Step-by-Step Solution

1
Verify that the provider has explained the procedure, risks, benefits, and alternatives.
Confirms the provider met their legal obligation to disclose essential medical information.
The healthcare provider performing the procedure is legally responsible for obtaining informed consent; the nurse's role begins with verifying this occurred.
2
Assess the client's comprehension of the provided information.
Identifies if the client truly understands the procedure or if the provider needs to be called back.
The nurse acts as an advocate to ensure the client is making an informed decision before any signatures are collected.
3
Witness the client's voluntary signature on the informed consent document.
Validates that the correct client signed voluntarily without coercion.
The nurse's signature on the consent form legally attests to the authenticity of the client's signature and their apparent competency.
4
Secure the signed document in the medical record.
Makes the legal consent available for verification.
The surgical team must physically or electronically verify the presence of the signed consent on the chart before initiating the procedure.
5
Administer the preoperative sedative medication.
Prepares the client physically and emotionally for surgery.
Sedatives must only be given after the legal consent process is entirely complete to maintain the client's legal capacity to consent.

Key Concept

The nurse's legal role in informed consent involves verifying provider disclosure, assessing client comprehension, witnessing the signature, and ensuring no mind-altering medications are given prior to signing.
Question 396Question →

An adult client on the oncology unit is scheduled for a bone marrow biopsy in 30 minutes. The nurse enters the room to witness the informed consent signature. The client states, 'The physician talked to me yesterday, but I am feeling overwhelmed and do not remember what was said about the potential complications. Should I just sign it anyway?' Arrange the following nursing actions 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 prioritizes immediate client advocacy (stopping the signature), followed by assessment of the deficit, provider notification, documentation of the delay, and finally witnessing the valid signature.
The correct sequence ensures that the legal and ethical requirements of informed consent are met. The nurse's first duty is to protect the client from signing a document they do not understand, halting the process. Following the nursing process, assessment of the specific knowledge deficit comes next, which guides the implementation phase of calling the appropriate provider. Documentation serves as the legal record of these immediate events. Finally, witnessing the signature is the concluding action once the provider has restored the client's understanding.

Step-by-Step Solution

1
Advise the client to pause the signing process.
Prevents the execution of a legally invalid consent document.
Consent is only valid if the client fully understands the procedure, including its risks and complications.
2
Assess exactly what the client does and does not remember.
Identifies the specific gaps in the client's knowledge.
Allows the nurse to provide an accurate, targeted report to the healthcare provider regarding the client's concerns.
3
Contact the healthcare provider performing the biopsy.
Transfers the responsibility of explaining medical risks back to the provider.
Explaining procedural risks and complications is strictly within the provider's scope of practice, not the registered nurse's.
4
Document the events in the client's medical record.
Creates a legal record of the client's hesitation and the nursing interventions taken.
Maintains accurate, chronological continuity of care and protects the nurse legally.
5
Witness the signature once understanding is restored.
Completes the informed consent process appropriately.
The nurse's signature confirms that the client is competent, acting voluntarily, and has had all questions answered by the provider.

Key Concept

The nurse's role in informed consent is to act as a witness and an advocate, ensuring the client understands the information provided by the practitioner before signing.
Question 397Question →

At the beginning of the shift on a pulmonary step-down unit, the nurse reviews the handover notes for four assigned clients. Order the clients from highest to lowest priority for the initial assessment.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence prioritizes impending respiratory failure first, followed by a critical bleeding complication, an acute systemic infection, and finally a stable client with an expected equipment finding.
The priority of care must strictly follow Maslow's hierarchy of needs and the ABC framework. The client with Guillain-Barré syndrome is losing diaphragmatic function (Breathing), which is fatal within minutes if unaddressed. The client with hemoptysis on heparin has a severe bleeding complication (Circulation). The pneumonia client requires timely medication but is not crashing. The chest tube client exhibits entirely normal equipment function and is stable.

Step-by-Step Solution

1
Analyze the status of the client with Guillain-Barré syndrome.
Identified as the highest priority.
According to the ABC (Airway, Breathing, Circulation) framework, the declining vital capacity signifies impending neuromuscular respiratory failure, which is an immediate life-threatening emergency.
2
Analyze the status of the client with a pulmonary embolism on continuous heparin.
Identified as the second priority.
New-onset hemoptysis indicates a critical circulation and hemorrhage risk that requires immediate intervention, prioritizing it just below direct airway/breathing loss.
3
Analyze the status of the client with bacterial pneumonia.
Identified as the third priority.
Fever and the need for timed antibiotics are urgent to prevent sepsis progression, but the condition does not present an immediate, moment-to-moment threat to life compared to the first two clients.
4
Analyze the status of the client with the chest tube.
Identified as the lowest priority.
Continuous bubbling in the suction control chamber is a normal, expected finding. The nurse only needs to perform a routine assessment, placing this client last.

Key Concept

Prioritization of Care using the ABC Framework and Expected vs. Unexpected Findings
Question 398Question →

An adult client is admitted to the surgical unit for a planned laparoscopic cholecystectomy. While reviewing the preoperative checklist, the nurse notes the consent form is unsigned and hands it to the client. The client remarks, 'I will sign this, but I am still completely confused about how the surgery is actually performed.' In what chronological order should the nurse perform the following actions?

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first withhold the consent form, then notify the surgeon, wait for the surgeon to explain the procedure, verify the client's understanding, and finally witness the signature.
When a client expresses confusion about a procedure, the nurse's first priority is to halt the signing process to protect the client's rights. The nurse must then notify the healthcare provider, as explaining the procedure is the provider's legal responsibility. Once the provider has spoken to the client, the nurse reassesses the client's understanding. Only after verifying comprehension should the nurse witness the signature.

Step-by-Step Solution

1
Withhold the consent form to prevent the client from signing.
The client is protected from signing an invalid consent.
Informed consent is only valid if the client understands the procedure.
2
Notify the primary surgeon regarding the client's confusion.
The surgeon is made aware of their responsibility.
Providing the primary explanation of a procedure is outside the nurse's scope of practice.
3
Wait while the surgeon provides a detailed explanation of the surgery.
The client receives the necessary information directly from the provider.
The provider holds the legal responsibility to inform the client.
4
Verify that the client comprehends the updated information.
The nurse confirms the client is now properly informed.
The nurse advocates for the client by ensuring comprehension before the process proceeds.
5
Witness the client signing the legal consent document.
The consent process is finalized and documented.
The nurse acts as a legal witness to the voluntary and informed signature.

Key Concept

The nurse's role in informed consent is to act as a witness and advocate. If a client lacks understanding, the nurse must halt the process and notify the healthcare provider, who holds the legal responsibility to explain the procedure.
Estimated Time:1m 0s
Question 399Question →

A triage nurse in a busy emergency department is evaluating five newly arrived clients. Based on the principles of prioritization and triage, in what order should the nurse assess these clients? Arrange the clients from highest priority (first) to lowest priority (last).

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence prioritizes the clients from most unstable to most stable: 1) Stridor/drooling (Airway), 2) Pneumonia/confusion (Breathing), 3) Trauma/hypotension (Circulation), 4) DKA/Kussmaul breathing (Metabolic), 5) DVT/calf pain (Routine/Expected).
Prioritization in nursing care is strictly governed by the ABC (Airway, Breathing, Circulation) hierarchy and survival potential. The nurse must first intervene for the client with stridor and drooling, as these are cardinal signs of complete airway obstruction from anaphylaxis. The second priority is the client with pneumonia experiencing acute confusion, which is an early neurological sign of profound hypoxia (Breathing). The third priority is the trauma client exhibiting classic signs of hypovolemic shock (Circulation). Fourth is the client with diabetic ketoacidosis; although this is a critical metabolic emergency requiring continuous IV fluids and insulin, the client's Kussmaul respirations are an expected compensatory mechanism, making them relatively more stable than those with acute, uncompensated ABC failure. The final priority is the client with a DVT, as their localized pain is an expected finding that does not immediately threaten life in the absence of respiratory distress.

Step-by-Step Solution

1
Evaluate each client's presentation systematically against the ABC (Airway, Breathing, Circulation) framework and the expected versus unexpected manifestations of their specific conditions.
The client with stridor has an airway emergency; the client with confusion has a breathing emergency; the trauma client has a circulation emergency; the DKA client has a metabolic emergency with expected compensatory breathing; and the DVT client has a localized, expected finding.
Airway obstruction causes death most rapidly, followed by hypoxic brain injury from inadequate breathing, and then cardiovascular collapse from shock. Metabolic abnormalities and localized pain follow.

Key Concept

In emergency triage and priority setting, the nurse must sequence care based on the urgency of physiological needs, strictly adhering to the Airway-Breathing-Circulation (ABC) algorithm while distinguishing between unexpected, life-threatening deterioration and expected disease manifestations.
Question 400Question →

A nurse is preparing to obtain a client's signature on an informed consent form for an upcoming surgical procedure. The client states, 'I am not really sure what they are going to do to me.' Arrange the following nursing actions in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first assess the client's understanding, then halt the consent process, notify the surgeon, wait for the surgeon to provide the necessary explanation, and finally witness the signature once the client is fully informed.
The legally sound nursing action when a client lacks understanding about a procedure is to immediately stop the consent process. The nurse must assess the knowledge gap, notify the provider (who holds the legal duty to inform), allow the provider to educate the client, and only then act as a witness to the signature.

Step-by-Step Solution

1
Assess the client's level of understanding and identify their specific knowledge deficit regarding the surgery.
The nurse confirms the extent of the client's lack of comprehension.
Assessment is the initial step in the nursing process to evaluate the situation.
2
Halt the consent process and do not ask the client to sign the document.
The client is protected from signing a legally invalid document.
A signature obtained without full understanding does not constitute valid informed consent.
3
Notify the surgeon that the client requires further explanation of the procedure.
The provider responsible for the procedure is informed of the client's questions.
It is beyond the registered nurse's scope of practice to explain the medical procedure; this is the provider's legal duty.
4
Wait for the surgeon to discuss the procedure with the client and answer all questions.
The client receives accurate information directly from the performing provider.
The provider must fulfill their obligation to ensure the client is adequately informed.
5
Witness the client voluntarily signing the informed consent form.
A legally binding and valid informed consent is obtained.
The nurse's legal role is to witness the voluntary signature of a fully informed, competent client.

Key Concept

Informed Consent Process and the Nurse's Legal Role
PreviousPage 20 / 44Next
All practice questions — NCLEX-RN | Examkin