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Question 421Question →

A 45-year-old client admitted to the medical-surgical unit is receiving intravenous (IV) antibiotics for severe community-acquired pneumonia. The client states, 'I am feeling much better and I need to go home right now to take care of my dog.' The client is alert, oriented, and demonstrates decision-making capacity. Arrange the following nursing actions in the correct chronological order.

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Answer

The correct sequence is to first assess and address the client's underlying concern, followed by explaining the medical risks of leaving. Next, the nurse should notify the healthcare provider, request the client's signature on the AMA form, and finally remove the IV catheter and document the entire event.
The proper response to a client wanting to leave Against Medical Advice (AMA) follows the nursing process and legal principles of client autonomy. First, the nurse must assess the underlying reason to see if it can be resolved. If the client insists on leaving, the nurse must immediately ensure they are informed of the health risks. Following this, the healthcare provider is notified so they can intervene or adjust the care plan. The nurse then asks the client to sign the AMA form for legal documentation. Finally, the nurse removes invasive devices, provides any necessary instructions, and documents the entire encounter objectively.

Step-by-Step Solution

1
Assess and address the root cause.
Explores if the client's concern can be mitigated without them leaving the hospital.
Resolving the modifiable issue (care for the dog) is the most effective way to keep the client safe and ensure treatment completion.
2
Educate the client on potential medical risks.
Fulfills the nurse's ethical and legal obligation for informed refusal.
The client must understand the severe consequences of stopping treatment prematurely to make a legally valid decision.
3
Communicate with the healthcare provider.
Informs the medical team of the client's decision.
The provider must be notified to offer further medical intervention or arrange for alternative care, such as oral antibiotics.
4
Obtain the AMA signature.
Secures legal documentation of the client's informed refusal.
Signing the AMA form legally protects the hospital and healthcare providers from malpractice claims if the client deteriorates after leaving.
5
Perform safe discharge procedures and document.
Ensures the client leaves safely and the event is permanently recorded.
The nurse must safely discontinue therapies (like IVs) and thoroughly document the facts, the education provided, and the client's capacity.

Key Concept

Nursing Management of Against Medical Advice (AMA) Refusal of Care
Question 422Question →

A registered nurse is caring for a competent adult client who is receiving intravenous (IV) antibiotics for bacterial pneumonia. The client suddenly packs their belongings, states they are missing an important family event, and declares they are leaving the hospital immediately. Arrange the following nursing actions in the correct chronological order to handle this against medical advice (AMA) event safely and legally.

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Answer

The correct sequence is to first assess the client's reasons, then explain the health risks, notify the healthcare provider, have the client sign the official AMA form, and finally remove the IV and provide discharge instructions.
The correct chronological sequence aligns with the nursing process and legal requirements for informed refusal. The nurse must first assess the 'why' (assessment), educate the client on the dangers (implementation), collaborate with the provider to ensure medical risks are explained (collaboration), secure legal documentation of the refusal (documentation), and finally provide safe termination of care (safe practice).

Step-by-Step Solution

1
Inquire about the client's specific reasons for wanting to leave.
The nurse understands the root cause of the client's desire to leave.
Basic nursing process dictates assessing the situation first, as the nurse may be able to intervene and resolve the issue (e.g., managing pain, contacting family) so the client stays.
2
Discuss the potential health risks and complications.
The client is fully informed about the dangers of leaving.
Nurses have a legal obligation to ensure clients understand the consequences of their actions before they refuse life-saving or necessary medical treatment.
3
Notify the primary healthcare provider.
The provider is aware and can speak to the client.
The healthcare provider is legally responsible for the medical treatment plan and must be given the opportunity to discuss the medical risks of leaving with the client.
4
Request the client to sign the AMA document.
Legal documentation of the client's informed refusal is secured.
This document protects the healthcare team and the facility from legal liability if the client suffers adverse health outcomes after leaving.
5
Remove the IV access and provide discharge instructions.
The client leaves the facility safely.
Clients retaining decision-making capacity have the right to leave at any time; the nurse must still practice safely by removing invasive devices and offering discharge education.

Key Concept

Against Medical Advice (AMA) Legal Procedures
Estimated Time:1m 0s
Question 423Question →

A client is in the preoperative unit awaiting an elective percutaneous transluminal coronary angioplasty (PTCA). The client has not received any premedication. As the nurse prepares to witness the informed consent signature, the client states, 'I am not sure I want to go through with this if there is a risk I could have a heart attack during the procedure.' Arrange the following nursing actions in the correct chronological sequence.

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Answer

The correct sequence is to instruct the client not to sign, assess their specific concerns, contact the cardiologist, witness the signature after clarification, and finally document the event.
When a client expresses doubts or a lack of understanding about a procedure, the nurse must act as an advocate. The immediate priority is to stop the consent process to prevent an invalid signature. Next, the nurse assesses the client to understand exactly what needs clarification. The nurse then contacts the healthcare provider, as it is the provider's legal duty to explain risks and benefits. Once the provider has answered the client's questions and the client is ready, the nurse witnesses the signature. Finally, comprehensive documentation of the delay, the provider's intervention, and the completed consent is entered into the medical record.

Step-by-Step Solution

1
Instruct the client not to sign the consent form.
Prevents the execution of an invalid informed consent.
A client must be fully informed and clear about risks before signing; halting the process protects the client's legal rights.
2
Ask the client to elaborate on their specific concerns.
Identifies the exact nature of the client's knowledge deficit.
The nurse needs clear information to accurately communicate the client's needs to the healthcare provider.
3
Contact the cardiologist to return and provide further clarification.
Transfers the responsibility of explaining procedural risks back to the provider.
It is outside the registered nurse's scope of practice to explain the primary risks and alternatives of a medical procedure.
4
Witness the client's signature once concerns are addressed.
Finalizes the informed consent process legally.
The nurse's role is to verify that the signature is voluntary, authentic, and obtained while the client is competent and informed.
5
Document the entire event in the medical record.
Creates a permanent legal and medical record of the interaction.
Accurate documentation of client care, including advocacy and provider notification, is a standard of nursing practice.

Key Concept

Informed Consent and Nurse Advocacy
Question 424Question →

A client arrives at the emergency department triage area displaying severe dyspnea, a temperature of 102.4°F (39.1°C), and a blood pressure of 86/48 mm Hg. The provider prescribes several immediate interventions for suspected sepsis. In what sequence should the nurse perform the following actions? Arrange the actions in the order they should be implemented, from first to last.

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Answer

The correct sequence is to first administer oxygen, followed by establishing intravenous access, then obtaining blood cultures, and finally infusing the broad-spectrum antibiotic.
The correct sequence adheres strictly to the Airway, Breathing, Circulation (ABC) framework and evidence-based sepsis protocols. Supporting breathing with oxygen is the absolute first step. Next, establishing circulation via intravenous access allows for subsequent treatments. Finally, drawing blood cultures must precede the administration of broad-spectrum antibiotics to ensure accurate pathogen identification.

Step-by-Step Solution

1
Evaluate the client's physiological needs using the Airway, Breathing, Circulation (ABC) framework.
Dyspnea is identified as a Breathing issue, which takes precedence over Circulation issues.
The ABC framework dictates that oxygenation and ventilation are the highest priorities to sustain life.
2
Address the next highest priority according to the ABC framework.
Intravenous access is established to support Circulation.
The client is hypotensive and requires circulatory support and medication administration.
3
Determine the correct pharmacological sequence for a client with suspected sepsis.
Blood cultures are drawn prior to antibiotic administration.
Administering antibiotics before drawing blood cultures can inhibit bacterial growth in the sample, leading to false-negative results and inappropriate long-term antibiotic therapy.

Key Concept

Prioritization using the ABC framework and the standard sequence of sepsis interventions (cultures before antibiotics).
Question 425Question →

A registered nurse (RN) is preparing to delegate the task of assisting a client with early ambulation on the first postoperative day to an unlicensed assistive personnel (UAP). In what order should the RN perform the following steps to ensure safe and effective delegation? Arrange the actions in the correct sequence from first to last.

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Answer

The correct sequence for safe delegation follows the nursing process and NCSBN delegation guidelines: first assess the client, then verify the delegatee's competence, provide clear instructions, monitor the execution of the task, and finally evaluate the client's outcome.
The correct sequence adheres to the National Council of State Boards of Nursing (NCSBN) guidelines for the delegation process. The RN must first assess the client's needs (Right Circumstance). Second, the RN verifies the delegatee's competence (Right Person). Third, the RN communicates clear instructions (Right Direction). Fourth, the RN monitors the task execution (Right Supervision). Finally, the RN evaluates the outcome and the client's response.

Step-by-Step Solution

1
Assess the client's clinical condition and stability.
The RN determines if the client's needs match the criteria for safe delegation.
Assessment is always the first step and cannot be delegated. The RN must ensure the 'Right Circumstance' exists before proceeding.
2
Verify the competence of the UAP.
The RN confirms the UAP is allowed and capable of performing the specific task.
This satisfies the 'Right Person' principle of delegation, ensuring the delegatee has the necessary skills and training.
3
Provide clear direction and communication.
The UAP understands exactly what is expected, including what parameters and symptoms to report immediately.
This ensures the 'Right Direction/Communication' is established, significantly reducing the risk of errors or missed clinical changes.
4
Supervise the delegated task.
The RN remains available and monitors the process as needed based on the situation.
The RN retains overall accountability for the task and must provide the 'Right Supervision' based on the client's needs and task complexity.
5
Evaluate the overall outcome.
The RN checks on the client's response to ambulation and reviews the UAP's documentation.
Evaluation is an RN responsibility to determine if the desired clinical outcome was achieved safely and to provide feedback to the UAP.

Key Concept

The Five Rights of Delegation and the NCSBN Delegation Decision-Making Process
Question 426Question →

Thirty minutes after initiating a transfusion of packed red blood cells (PRBCs), the nurse observes the client exhibiting sudden dyspnea, tachypnea, and severe flank pain. The client states, "I feel freezing cold." Arrange the following nursing interventions in the prioritized order they should be performed, from first to last.

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Answer

The correct sequence of interventions is: 1) Stop the blood transfusion completely, 2) Disconnect the blood tubing and infuse 0.9% sodium chloride through a new intravenous administration set, 3) Obtain the client's current vital signs and auscultate lung sounds, 4) Notify the healthcare provider and the institutional blood bank, 5) Return the discontinued blood bag and administration set to the blood bank.
In any acute emergency involving an infusing substance, the absolute highest priority is to stop the offending agent immediately to prevent further harm. Following acute survival priorities, the nurse must stop the blood first. Second, the nurse must secure a patent IV line with new tubing to avoid flushing remaining blood into the client. Third, the nurse assesses the client to gather critical data. Fourth, the provider is notified for medical orders using the gathered data. Finally, the nurse follows institutional protocol by sending the equipment for diagnostic analysis.

Step-by-Step Solution

1
Stop the blood transfusion completely.
Prevents further antigen exposure to the client.
Airway, Breathing, and Circulation (ABC) principles prioritize stopping the direct cause of a life-threatening physiological reaction before any other action.
2
Disconnect the blood tubing and infuse 0.9% sodium chloride through a new intravenous administration set.
Secures a patent intravenous line for emergency drug administration.
The old tubing contains blood; flushing it would push more incompatible blood into the client. Normal saline is compatible and prevents hemolysis while maintaining access.
3
Obtain the client's current vital signs and auscultate lung sounds.
Establishes a clinical baseline of the reaction's severity.
Objective assessment data is required to inform the healthcare provider and guide the immediate pharmacological treatment plan.
4
Notify the healthcare provider and the institutional blood bank.
Initiates medical management and institutional emergency protocols.
Collaborative care is required for emergency pharmacological interventions (e.g., epinephrine, steroids) and for investigating the transfusion error.
5
Return the discontinued blood bag and administration set to the blood bank.
Facilitates laboratory investigation of the adverse event.
Analyzing the remaining blood product and the tubing confirms the type of reaction (e.g., acute hemolytic) and prevents similar errors.

Key Concept

Prioritization of interventions during an acute blood transfusion reaction.
Estimated Time:2m 0s
Question 427Question →

A registered nurse finds a paper containing a client's handoff report left unattended on a table in the public hospital cafeteria. Arrange the following actions the nurse should take in the correct order, from first to last.

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Answer

The correct sequence is to first retrieve and conceal the document, then identify the responsible unit, deliver the document to the appropriate charge nurse, and finally file a formal incident report.
In any security breach involving Protected Health Information (PHI), the nurse's first priority is always to contain the breach and secure the information. Once the immediate risk to privacy is mitigated, the nurse can take steps to identify the owner, return the property, and fulfill administrative reporting requirements.

Step-by-Step Solution

1
Secure the exposed document.
The ongoing exposure of Protected Health Information (PHI) is stopped.
Patient privacy is the immediate priority in any breach scenario.
2
Identify the document's origin.
The nurse determines which unit the client belongs to.
The document must be returned to the correct location.
3
Return the document to the charge nurse.
The responsible unit reclaims the PHI and is made aware of the incident.
Continuity of care and unit-level awareness of the breach are necessary.
4
File an incident report.
The breach is officially documented.
Institutional policy and federal laws require tracking of privacy breaches.

Key Concept

Immediate containment of a HIPAA breach followed by appropriate chain-of-command reporting.
Question 428Question →

A client receiving a packed red blood cell (PRBC) transfusion suddenly reports severe lower back pain, shortness of breath, and chills. The nurse suspects an acute hemolytic reaction. In what order should the nurse perform the following actions? (Arrange from first action to last action)

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Answer

The correct order of actions is: 1) Stop the blood transfusion, 2) Maintain IV access with normal saline and new tubing, 3) Assess vital signs and respiratory status, 4) Notify the healthcare provider.
When a severe transfusion reaction is suspected, the immediate priority is to stop the source of harm (the blood). The next priority is to maintain an open IV line with normal saline using new tubing, as the old tubing contains the offending blood that would be pushed into the client. Once the client's IV line is secured and the harmful agent is stopped, the nurse assesses vital signs to determine the extent of hemodynamic instability. Finally, the nurse contacts the healthcare provider armed with the current assessment data to receive emergency medical orders.

Step-by-Step Solution

1
Identify the immediate threat to the client.
The client is experiencing a suspected acute hemolytic transfusion reaction.
Recognizing the life-threatening nature of the reaction dictates immediate, rapid intervention over routine data gathering.
2
Determine the first priority action to remove the threat.
Stopping the transfusion.
The priority is to prevent any more incompatible blood from entering the client's circulatory system and worsening the reaction.
3
Determine the next action to physiologically stabilize the client.
Maintaining IV access with normal saline using new tubing.
Patent IV access is critical for administering emergency medications and fluids to manage hypotension and shock.
4
Determine the action needed to gather data for reporting.
Assessing vital signs and clinical status.
The nurse needs current physiological data (e.g., blood pressure, oxygen saturation) to communicate the severity of the reaction effectively.
5
Determine the action for collaborative management.
Notifying the healthcare provider.
The provider must be informed to order specific interventions, but the nurse must first stabilize the client and gather assessment data.

Key Concept

Prioritization in Emergency Situations: Blood Transfusion Reaction
Question 429Question →

A clinical nurse needs to urgently consult the palliative care advanced practice registered nurse (APRN) regarding a client with end-stage heart failure. The client is experiencing intractable dyspnea despite receiving maximal medical management. In what order should the nurse deliver the following statements to adhere to the Situation, Background, Assessment, Recommendation (SBAR) communication tool?

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Answer

The correct sequence follows the SBAR format: Situation (immediate problem), Background (clinical context), Assessment (current objective and subjective findings), and Recommendation (requested action).
The SBAR framework requires a specific sequence for effective interdisciplinary communication. It begins with the Situation (identifying the immediate problem), follows with the Background (providing clinical context), details the Assessment (sharing current clinical data), and concludes with the Recommendation (requesting a specific action).

Step-by-Step Solution

1
Identify the 'Situation' statement.
The statement introducing the client and the immediate problem of unrelenting shortness of breath is placed first.
SBAR begins by clearly stating the core reason for the communication to immediately orient the receiving practitioner to the problem.
2
Identify the 'Background' statement.
The statement detailing the history of end-stage heart failure and recent lack of response to diuretics is placed second.
Background information provides the necessary clinical context for the current situation.
3
Identify the 'Assessment' statement.
The statement reporting the respiratory rate, oxygen saturation, and acute distress is placed third.
The assessment shares the most recent, relevant clinical data and the nurse's evaluation of the client's current state.
4
Identify the 'Recommendation' statement.
The statement requesting an evaluation for palliative interventions is placed last.
The communication concludes with a clear, actionable request to address the client's needs collaboratively.

Key Concept

The SBAR (Situation, Background, Assessment, Recommendation) framework is a standardized communication tool used to share critical information accurately and concisely within the interdisciplinary healthcare team.
Question 430Question →

A client was admitted to the emergency department with a complex femur fracture. Initially, the client was disoriented due to hypovolemia, and the client's legally authorized representative (spouse) signed the informed consent for an open reduction and internal fixation (ORIF). After receiving intravenous fluids, the client becomes fully alert and oriented. As the transport team arrives to take the client to the operating room, the client states, 'I changed my mind. I am not having surgery; I just want a splint.' Place the following nursing actions in the correct chronological order.

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Answer

The correct order of nursing actions is to first halt the transport, then assess the client's capacity and rationale, assure the client of their rights, notify the surgeon, and finally document the event.
The correct sequence follows the nursing process and prioritizes immediate safety. Stopping the transport (implementation) prevents battery. Assessing capacity (assessment) ensures the refusal is legally sound. Assuring the client (advocacy) supports autonomy. Notifying the surgeon (communication) allows for medical counseling on risks. Documenting (administrative) creates the legal record.

Step-by-Step Solution

1
Instruct the transport team to hold the transfer to the operating room.
The client remains in the emergency department, and the surgical preparation is paused.
The immediate priority is to prevent battery by ensuring an invasive procedure is not performed on a client who is actively revoking consent.
2
Assess the client's orientation, cognitive status, and rationale for refusing the procedure.
The nurse confirms that the client is fully alert, oriented, and capable of understanding their medical decisions.
A client who regains decision-making capacity regains the right to make their own healthcare choices, which legally supersedes a surrogate's previous authorization. This capacity must be assessed before proceeding.
3
Assure the client that their right to withdraw consent will be respected.
The client feels supported and their autonomy is validated.
This fulfills the nurse's ethical obligation to act as a client advocate, especially when the client's wishes conflict with a previously signed consent form.
4
Notify the orthopedic surgeon of the client's refusal so they can explain the risks of not having surgery.
The surgeon is informed of the cancellation and comes to evaluate the client.
While the nurse advocates for the client's decision, it is the provider's legal responsibility to explain the risks, benefits, and alternatives of refusing the surgery.
5
Document the client's return of capacity, the revocation of consent, and the provider notification in the medical record.
A clear chronological timeline of events is recorded in the client's chart.
Documentation provides a legal and professional record of the client's change in clinical status, the nursing interventions, and interdisciplinary communication.

Key Concept

When a temporarily incapacitated client regains decision-making capacity, their autonomous healthcare choices legally supersede any previous consent provided by a surrogate.
Question 431Question →

The registered nurse (RN) has just received the morning shift report for four clients on a medical-surgical step-down unit. In what order should the RN prioritize the assessment of these clients? Arrange the clients from the highest priority (first to be assessed) to the lowest priority (last to be assessed).

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Answer

The RN should assess the client with asthma first, followed by the client with the spinal cord injury, then the client on the heparin infusion, and finally the client with cirrhosis.
Prioritization in nursing follows the ABCs (Airway, Breathing, Circulation) and severity of the threat to life. The asthma client has an airway/breathing emergency ('silent chest' and lethargy). The spinal cord injury client has a circulatory/neurological emergency (autonomic dysreflexia). The heparin client has an urgent circulatory risk (potential for severe hemorrhage). The cirrhosis client is stable and requires routine care. Therefore, the sequence from most to least critical is: Asthma -> Spinal Cord Injury -> Heparin -> Cirrhosis.

Step-by-Step Solution

1
Evaluate the clients using the Airway, Breathing, Circulation (ABC) prioritization framework.
The client with asthma has diminished breath sounds and lethargy, indicating a critical airway and breathing compromise.
Airway and breathing failures are the most immediate threats to life and must always be addressed first.
2
Identify any life-threatening circulatory or neurological emergencies among the remaining clients.
The client with the T4 spinal cord injury is exhibiting signs of autonomic dysreflexia (headache, flushing).
Autonomic dysreflexia is a severe medical emergency that can cause a catastrophic hypertensive crisis, stroke, or death if not rapidly treated.
3
Differentiate between urgent physiological risks and stable chronic conditions.
The client with an aPTT of 120 seconds has an acute risk for hemorrhage, while the client with cirrhosis has a chronic, expected symptom.
An urgently abnormal laboratory value with clinical signs (IV site oozing) takes precedence over routine administration of PRN symptom-management medications for stable, chronic conditions.

Key Concept

Prioritization of care requires evaluating clients based on the ABC (Airway, Breathing, Circulation) framework, followed by addressing systemic medical emergencies, and finally managing urgent physiological risks versus routine chronic needs.
Question 432Question →

A nurse approaches a computer workstation in the hospital hallway to document client care and notices the previous nurse left a client's electronic health record (EHR) open and unattended. Arrange the following actions the nurse should take in the correct chronological order from first to last.

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Answer

The correct sequence is to first close the open record, then log out the previous user, log in with personal credentials, and finally document the care.
When an unattended, open EHR is discovered, the nurse's first priority is to mitigate the immediate breach of confidentiality by closing the visible record. Next, the nurse must ensure system security by completely logging out the previous user. Only after securing the workstation can the nurse log in using their own unique credentials to establish a proper audit trail, and finally, proceed with documenting their own client care.

Step-by-Step Solution

1
Close the open record
Protected Health Information (PHI) is hidden from public view
Immediate mitigation of the active privacy breach is the top priority.
2
Log out the previous user
The unsecured session is terminated
Prevents charting errors and secures the overall system.
3
Log in with personal credentials
A secure, accountable session is started
Facility policies require an accurate audit trail for all EHR access.
4
Document care
The nursing task is completed safely
Fulfills the nurse's clinical responsibilities using the proper legal record.

Key Concept

Immediate mitigation of privacy breaches and maintaining secure, accountable access to electronic health records.
Question 433Question →

An emergency department nurse is managing a client admitted with severe diabetic ketoacidosis (DKA). The client is lethargic, with a blood pressure of 82/48 mm Hg, heart rate of 128 beats/minute, and Kussmaul respirations. Initial laboratory results reveal a blood glucose of 780 mg/dL (43.3 mmol/L), serum pH of 7.15, and serum potassium of 3.1 mEq/L (3.1 mmol/L). Arrange the following prescribed interventions in the correct chronological sequence of execution from first to last.

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Answer

The correct sequence is: Fluid resuscitation (0.9% NaCl), followed by Potassium replacement, then Intravenous Regular Insulin, later adding 5% Dextrose when glucose drops, and finally Subcutaneous Basal Insulin before discontinuing the drip.
The priority in DKA is always ABCs and perfusion; thus, isotonic fluid resuscitation is the first action for a client with severe hypotension. The critical secondary priority is electrolyte management. Because insulin drives potassium into cells, starting insulin with a baseline potassium of 3.1 mEq/L is highly dangerous. Potassium replacement must precede or accompany the insulin infusion. Once the client is hemodynamically stable and electrolytes are safe, insulin is initiated. As glucose approaches 250 mg/dL, dextrose is added to prevent hypoglycemia while allowing continuous insulin to resolve the acidosis. Finally, subcutaneous insulin is given prior to stopping the drip to maintain baseline glycemic control.

Step-by-Step Solution

1
Administer 0.9% sodium chloride bolus.
Restores intravascular volume and organ perfusion.
Osmotic diuresis causes profound hypovolemia, which takes precedence over correcting the metabolic derangements.
2
Administer potassium chloride intravenous rider.
Increases serum potassium levels.
Insulin administration drives potassium into the intracellular space. With a baseline potassium of 3.1 mEq/L, administering insulin first would cause profound, lethal hypokalemia.
3
Initiate continuous intravenous regular insulin.
Stops lipolysis and ketogenesis, lowering blood glucose.
Once perfusion and electrolytes are secured, insulin addresses the root pathophysiology of DKA.
4
Add 5% dextrose to intravenous fluids.
Maintains blood glucose between 150-200 mg/dL.
Added when glucose reaches 250 mg/dL to prevent hypoglycemia and cerebral edema, as insulin must continue running until the acidosis (anion gap) resolves.
5
Administer subcutaneous basal insulin.
Provides long-acting glycemic control.
Required to prevent rebound ketoacidosis when transitioning off the intravenous insulin infusion.

Key Concept

Prioritization in Diabetic Ketoacidosis (DKA) Resuscitation
Question 434Question →

A nurse case manager is coordinating the discharge of a 10-year-old client who was newly diagnosed with type 1 diabetes mellitus. The client has a pre-existing severe autism spectrum disorder with significant sensory sensitivities. The transition to home requires extensive coordination among the interdisciplinary team. Arrange the nurse's collaborative actions in the most appropriate chronological sequence from first to last.

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Answer

The correct sequence follows the nursing process: assess the client's specific needs, clarify the medical regimen with the provider, collaborate with the interdisciplinary team to design an adapted plan, implement the education with the family, and finally coordinate the community handoff.
The sequence correctly applies the nursing process to interdisciplinary care coordination. First, the nurse must assess the client's unique behavioral needs and the family's baseline knowledge. Second, the nurse clarifies the exact medical orders with the endocrinologist to know what must be taught. Third, the nurse collaborates with the dietitian and behavioral therapist to adapt those medical requirements into a specialized teaching plan. Fourth, the team implements this education with the family. Finally, once the family is prepared and discharge is imminent, the nurse conducts a handoff with the school nurse to ensure community safety.

Step-by-Step Solution

1
Evaluate the client's specific sensory sensitivities and the parents' baseline understanding of diabetes management.
The nurse identifies the client's learning barriers and the parents' knowledge deficits.
Assessment is the foundational first step of the nursing process and must precede any planning or intervention.
2
Clarify the target glycemic parameters and final home insulin prescription with the pediatric endocrinologist.
The exact medical requirements for discharge are established.
Before an interdisciplinary teaching plan can be created, the nurse must verify the precise medical regimen prescribed by the provider.
3
Partner with the behavioral therapist and registered dietitian to develop a customized, sensory-friendly dietary teaching plan.
An individualized, interdisciplinary care and education plan is created.
The nurse collaborates with specialized team members to adapt the medical requirements into a teaching format that accommodates the client's autism.
4
Implement the tailored diabetes management education sessions with the client and parents.
The family receives the necessary training to safely manage the condition at home.
Implementation (teaching) occurs after the customized plan has been fully developed by the team.
5
Coordinate a structured handoff with the school nurse to review the individualized emergency hypoglycemia protocol.
Continuity of care is established in the community setting.
Handoff to community resources is the final step in the discharge process, ensuring safety once the client returns to their normal environment.

Key Concept

Interdisciplinary care coordination requires applying the nursing process to complex discharge planning: assessing unique client needs, establishing medical parameters, collaborating on a customized plan, implementing family education, and ensuring safe community handoff.
Question 435Question →

While caring for a postoperative client on the surgical unit, a nurse notes a significant change in the client's condition and calls the covering physician. Organize the nurse's communication statements into the correct sequence based on the standard SBAR interdisciplinary communication tool.

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Answer

The correct sequence is: Situation, Background, Assessment, and Recommendation.
The SBAR framework is a standardized communication tool used to share critical information accurately and efficiently among interprofessional team members. It stands for Situation (what is happening right now), Background (what led to this situation), Assessment (what the nurse thinks the problem is based on findings), and Recommendation (what action needs to be taken). The correct order follows this logical progression to ensure patient safety and effective collaboration.

Step-by-Step Solution

1
Identify the 'Situation' statement.
The statement introducing the nurse, the client in bed 4, and the immediate severe abdominal pain.
SBAR begins by clearly stating the immediate problem and identifying the parties involved.
2
Identify the 'Background' statement.
The statement detailing the recent open cholecystectomy and previous stable status.
After stating the problem, the nurse provides the clinical context and history necessary to understand the situation.
3
Identify the 'Assessment' statement.
The statement describing the rigid abdomen, tachycardia, and absent bowel sounds.
The nurse then provides current vital signs and physical assessment findings to support clinical reasoning.
4
Identify the 'Recommendation' statement.
The statement requesting the physician to come evaluate the client right away.
The communication concludes with a specific request or suggested action to resolve the situation.

Key Concept

SBAR Communication Framework
Question 436Question →

A pregnant client is admitted to the labor and delivery unit for a scheduled elective cesarean birth. The client signed the surgical consent form in the provider's office last week. As the nurse prepares to administer a prescribed preoperative oral antacid, the client states, 'I've changed my mind. I am not having surgery and want to try delivering naturally.' Arrange the following nursing actions in the correct priority sequence. (Place the first action at the top and the last action at the bottom.)

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Answer

The correct sequence is to first withhold the medication, then explore the client's concerns, contact the obstetrician, maintain ongoing monitoring, and finally document the event.
When a client revokes informed consent, the nurse's immediate priority is to stop any interventions related to the procedure to respect client autonomy. Second, the nurse should use therapeutic communication to explore the client's underlying concerns. Third, the nurse must notify the healthcare provider, as it is the provider's legal responsibility to discuss the medical risks of refusal and alternative options. Fourth, while awaiting the provider, the nurse must continue standard monitoring to ensure maternal and fetal safety. Finally, all actions, verbatim client statements, and provider notifications must be thoroughly documented in the legal medical record.

Step-by-Step Solution

1
Withhold the preoperative medication and cease all surgical preparations.
The surgical preparation is safely halted.
Proceeding with preoperative medications after a client revokes consent violates their autonomy and constitutes battery.
2
Explore the client's concerns and reasons for changing the birth plan.
The nurse understands the client's perspective and reasons for refusal.
Therapeutic communication helps assess the client's concerns and gathers essential context before notifying the provider.
3
Contact the obstetrician to report that the client is withdrawing surgical consent.
The healthcare provider is alerted to the revoked consent.
It is the provider's legal responsibility to discuss the risks of refusal and alternative medical options with the client.
4
Maintain ongoing maternal and fetal monitoring while awaiting the provider.
Maternal and fetal safety are ensured.
Physiological monitoring remains a continuous priority while waiting for the provider to arrive and evaluate the client.
5
Document the client's verbatim statements and the provider notification in the medical record.
An accurate legal record of the event is created.
Thorough documentation of the revoked consent and the chain of communication must be recorded after immediate client needs are met.

Key Concept

A competent client has the right to revoke informed consent at any time prior to a procedure. The nurse's role is to halt the procedure, assess the client's concerns, notify the healthcare provider, ensure ongoing safety, and thoroughly document the event.
Question 437Question →

A neonatal intensive care unit (NICU) nurse is providing an interdepartmental SBAR (Situation, Background, Assessment, Recommendation) handoff report to a pediatric rehabilitation nurse. The client is a 6-month-old infant transitioning to the rehabilitation unit for complex care management. Arrange the nurse's communication statements in the correct chronological sequence according to the SBAR protocol.

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Answer

The correct sequence follows the SBAR protocol: Situation (identifying the client and reason for transfer), Background (medical history and recent procedures), Assessment (current clinical status and active concerns), and Recommendation (actionable requests for the receiving interdisciplinary team).
The SBAR communication model requires a chronological and logical flow of information. It begins with the Situation (who is calling and why), followed by the Background (relevant medical history and past procedures). Once context is established, the nurse provides the Assessment (current objective data and clinical impressions), and concludes with the Recommendation (actionable requests and necessary interdisciplinary referrals). This sequence prevents vital clinical details from being overlooked during complex interdepartmental transfers.

Step-by-Step Solution

1
Identify the 'Situation' statement.
Select the statement beginning with 'This is Nurse Martinez...'
The Situation component must immediately establish who is calling, the client's identity, and the exact purpose of the communication.
2
Identify the 'Background' statement.
Select the statement beginning with 'He was born prematurely...'
The Background provides essential historical context, including the admitting diagnosis and past interventions that inform current care.
3
Identify the 'Assessment' statement.
Select the statement beginning with 'His vital signs are currently stable...'
The Assessment details the most current objective data and the nurse's clinical appraisal of active issues.
4
Identify the 'Recommendation' statement.
Select the statement beginning with 'Upon his arrival...'
The Recommendation clearly states what the caller is requesting from the receiver, specifically detailing the required interdisciplinary evaluations.

Key Concept

The SBAR protocol provides a standardized framework for interprofessional communication. Accurate categorization of clinical data ensures safe and comprehensive transitions of care, particularly for clients with complex multisystem needs.
Question 438Question →

Following the shift handoff report on a medical-surgical unit, a registered nurse must determine the sequence of client assessments. Arrange the following clients from highest priority (first) to lowest priority (last).

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Answer

The correct prioritization sequence is: 1) the client with sudden chest pain and shortness of breath, 2) the client with symptomatic hypoglycemia, 3) the post-operative client requesting pain medication, and 4) the stable client waiting for discharge instructions.
Prioritization of care is determined by assessing the acuity and stability of each client. The most critical framework is Airway, Breathing, and Circulation (ABC). The client with DVT and sudden chest pain/shortness of breath has a life-threatening breathing issue (suspected pulmonary embolism) and must be seen first. The client with symptomatic hypoglycemia has an urgent circulation/metabolic need and is seen second. The post-operative client with pain has an acute but stable need and is seen third. The client requiring discharge teaching is completely stable and represents the lowest priority.

Step-by-Step Solution

1
Identify the client with the most critical airway, breathing, or circulation (ABC) compromise.
The client with a deep vein thrombosis reporting sudden chest pain and shortness of breath.
Sudden chest pain and shortness of breath in a client with a DVT strongly indicates a pulmonary embolism, which is a life-threatening airway and breathing emergency.
2
Identify the client with the next most urgent physiological need.
The client with symptomatic hypoglycemia (blood glucose 58 mg/dL).
Hypoglycemia is an acute metabolic emergency that can rapidly lead to neurologic damage if left untreated, but it follows ABC priorities.
3
Prioritize remaining clients based on acute versus non-acute needs.
The post-operative client requesting pain medication is prioritized next.
Acute pain requires timely intervention for comfort and recovery, placing it ahead of routine tasks.
4
Assign the lowest priority to stable clients with routine or expected needs.
The client waiting for discharge instructions.
Discharge teaching is important but routine, and the client is clinically stable, making them the lowest priority among the group.

Key Concept

Prioritization frameworks such as Airway-Breathing-Circulation (ABC), Maslow's Hierarchy of Needs, and acute versus chronic condition principles are used to determine the sequence of client care.
Question 439Question →

A registered nurse is receiving shift report for four assigned clients on a medical-surgical unit. In what order should the nurse assess these clients? Arrange the clients from highest priority (to be seen first) to lowest priority (to be seen last).

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Answer

The correct order is: the client with asthma exacerbation (highest priority), followed by the client with heart failure, then the postoperative client requesting pain medication, and finally the client preparing for discharge (lowest priority).
Prioritization in nursing follows the Airway-Breathing-Circulation (ABC) framework and the principle of addressing unstable, acute problems before stable, chronic ones. The client with new-onset wheezing has an acute breathing compromise and must be assessed first. The client with heart failure and new swelling has a circulation issue and is assessed second. The postoperative client requesting pain medication has a non-life-threatening physiological need and is assessed third. The stable client requiring discharge teaching is assessed last.

Step-by-Step Solution

1
Identify any clients with acute, life-threatening airway, breathing, or circulation (ABC) issues.
The client with new-onset wheezing has an acute breathing issue and is identified as the highest priority.
Airway and breathing problems can rapidly lead to deterioration and must be addressed immediately.
2
Evaluate the remaining clients for other systemic physiological concerns.
The client with heart failure has increased lower extremity swelling, indicating a circulation issue.
Circulatory issues are the next priority in the ABC framework after airway and breathing have been addressed.
3
Assess the remaining clients for non-life-threatening physiological needs, such as pain.
The postoperative client requesting pain medication is physiologically stable but experiencing discomfort.
Pain management is a high priority for comfort but is secondary to cardiopulmonary stability.
4
Identify clients requiring routine, stable care such as education or discharge preparation.
The client requiring discharge teaching is stable and ready to transition home.
Routine teaching is the lowest priority and can be safely delayed until acute needs of other clients are met.

Key Concept

Airway-Breathing-Circulation (ABC) framework and acute versus stable prioritization
Question 440Question →

A nurse is caring for a client recovering from an ischemic stroke who develops a wet, gurgling voice and coughing while taking sips of water. The nurse contacts the healthcare provider using the SBAR (Situation, Background, Assessment, Recommendation) communication tool. Arrange the nurse's statements in the correct sequence to structure this interprofessional handoff.

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Answer

The correct sequence follows the standard SBAR protocol: Situation, Background, Assessment, and Recommendation.
The SBAR framework is a standardized communication tool used to facilitate clear, concise, and structured information exchange between interdisciplinary team members. The correct order requires stating the Situation (current problem) first, followed by the Background (clinical context), then the Assessment (nurse's findings and impression), and finally the Recommendation (requested action, such as an SLP consult).

Step-by-Step Solution

1
Identify the Situation (S)
Select the statement describing the immediate problem: 'I am calling about the client in Room 402 who is experiencing new-onset coughing...'
The first step in interprofessional communication is to quickly identify the patient and state the immediate reason for the contact.
2
Identify the Background (B)
Select the statement providing context: 'The client was admitted three days ago with a left hemispheric ischemic stroke...'
Once the provider knows the problem, they need brief, pertinent historical data to frame their clinical judgment.
3
Identify the Assessment (A)
Select the statement with clinical findings and impression: 'The client's oxygen saturation has dropped... I am concerned about potential aspiration.'
The nurse provides objective data and shares their clinical impression of what is occurring.
4
Identify the Recommendation (R)
Select the statement requesting action: 'I have made the client NPO. Could you prescribe an urgent speech-language pathology (SLP) swallow evaluation?'
The final step is to clearly state what intervention is needed from the provider or other interdisciplinary team members.

Key Concept

SBAR Communication in Interdisciplinary Collaboration
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