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Question 441Question →

An emergency department nurse is preparing to manage a newly admitted client experiencing diabetic ketoacidosis. The treatment plan includes initiating a continuous intravenous infusion of regular insulin. Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.

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Answer: Flush the intravenous tubing with 50 mL of the prepared regular insulin solution prior to attaching it to the client; Add 5% dextrose to the intravenous hydration fluids when the client's blood glucose level drops to 250 mg/dL (13.9 mmol/L); Assess the client's capillary blood glucose levels every hour while the continuous insulin infusion is active

Answer

The correct actions include flushing the intravenous tubing with the insulin solution prior to connection, adding 5% dextrose to fluids when blood glucose reaches 250 mg/dL (13.9 mmol/L), and monitoring capillary blood glucose levels every hour.
Intravenous regular insulin adheres to the inner lining of standard polyvinyl chloride (PVC) tubing. Flushing the tubing with 20 to 50 mL of the insulin solution saturates these binding sites, guaranteeing that the client receives the prescribed concentration. As blood glucose levels decline during treatment and approach 250 mg/dL (13.9 mmol/L), the nurse must add a dextrose source (such as 5% dextrose) to the intravenous fluids. This step prevents a rapid drop in serum osmolality and avoids hypoglycemia, which can trigger cerebral edema. Furthermore, continuous insulin infusions mandate strict monitoring; hourly capillary blood glucose checks are required to safely titrate the infusion based on established protocols.

Step-by-Step Solution

1
Identify the primary physiological and pharmacological risks associated with continuous regular insulin infusions for diabetic ketoacidosis.
The main risks include rapidly developing hypoglycemia, hypokalemia, and dosing errors due to drug adherence to tubing or incorrect weight estimates.
Understanding the pharmacodynamics of intravenous insulin is essential for safe administration and anticipating complications.
2
Evaluate the options related to preparation and safe administration.
Flushing the tubing saturates binding sites, ensuring accurate dosing. Using the current actual weight is required for high-alert medication dosing, invalidating the use of old or estimated weights. IV compatibility must always be checked.
Insulin adsorbs to PVC tubing, which can result in under-dosing if not properly primed. Incompatible medications can precipitate or alter drug efficacy.
3
Evaluate the options related to monitoring and concurrent fluid therapies.
Hourly blood glucose checks are the standard of care. Adding dextrose when glucose reaches 250 mg/dL (13.9 mmol/L) prevents hypoglycemia. Checking the baseline potassium before starting insulin is mandatory.
Frequent monitoring and proactive fluid adjustments stabilize the client's metabolic state without causing dangerous shifts in glucose or electrolytes.

Key Concept

Safe administration and continuous monitoring of intravenous regular insulin therapy.
Question 442Question →

A nurse is evaluating a client who was brought to the clinic experiencing a severe panic attack. The client has a respiratory rate of 34 breaths per minute and reports tingling in the fingers and lightheadedness. Based on this clinical presentation, which acid-base imbalance should the nurse anticipate?

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Answer: Respiratory alkalosis

Answer

Respiratory alkalosis
The correct answer is respiratory alkalosis. During a severe panic attack, a client typically hyperventilates. This rapid breathing causes the body to exhale excessive amounts of carbon dioxide (CO2). Because CO2 acts as an acid in the bloodstream, blowing off too much of it decreases the body's carbonic acid levels, causing the blood pH to rise above 7.45 and leading directly to respiratory alkalosis.

Step-by-Step Solution

1
Identify the primary physiological mechanism occurring in the client.
The client is hyperventilating (respiratory rate of 34 breaths per minute) due to a panic attack.
Recognizing the underlying physiological change is the first step in identifying the resulting acid-base imbalance.
2
Determine the effect of hyperventilation on carbon dioxide (CO2) levels.
Rapid, deep breathing causes excessive elimination of CO2 from the lungs.
CO2 acts as an acid in the blood. When breathing rate increases, the body "blows off" this acid.
3
Correlate the loss of CO2 to the correct acid-base imbalance.
The significant loss of CO2 decreases blood acidity, raising the pH and causing an alkalotic state of respiratory origin.
Since the origin of the imbalance is the respiratory system's excessive removal of CO2, the condition is respiratory alkalosis.

Key Concept

Acid-Base Imbalances: Respiratory Alkalosis
Question 443Question →

A nurse is managing the care of a client admitted to the intensive care unit with severe diabetic ketoacidosis (DKA). The client's initial blood glucose is 680 mg/dL (37.7 mmol/L), pH is 7.15, and blood pressure is 88/54 mm Hg. Arrange the following nursing interventions in the correct sequence of execution from first to last.

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Answer

The correct sequence is: fluid resuscitation, potassium evaluation, insulin infusion initiation, addition of dextrose to fluids, and transition to subcutaneous insulin.
In diabetic ketoacidosis, severe osmotic diuresis leads to profound dehydration and potential hypovolemic shock. Therefore, the absolute first priority is fluid resuscitation with isotonic saline to restore perfusion. Once fluids are running, the nurse must ensure the serum potassium is greater than 3.3 mEq/L before giving insulin, as insulin drives potassium back into the cells and can trigger lethal hypokalemia. Following potassium verification, a continuous regular insulin infusion is started to halt ketone production and resolve the acidosis. As the blood glucose falls to around 200-250 mg/dL (11.1-13.9 mmol/L), 5% dextrose is added to the IV fluids to prevent hypoglycemia and cerebral edema while the insulin continues to clear the remaining ketones. Finally, once the acidosis has completely resolved and the client can tolerate oral intake, a transition to subcutaneous insulin is initiated before stopping the IV insulin.

Step-by-Step Solution

1
Prioritize fluid resuscitation by administering 0.9% sodium chloride.
Intravascular volume is expanded, and blood pressure stabilizes.
Severe dehydration and hypovolemic shock are the most immediate life-threatening complications of the osmotic diuresis caused by DKA.
2
Assess the serum potassium level.
The nurse confirms the potassium is at a safe baseline level.
Insulin administration drives potassium into the intracellular space, which can cause severe hypokalemia and lethal arrhythmias if the baseline level is not adequate.
3
Initiate the continuous regular insulin infusion.
Blood glucose levels begin to steadily decline and ketogenesis is inhibited.
Insulin is required to correct the underlying metabolic acidosis by stopping the breakdown of fats into ketones.
4
Add 5% dextrose to the intravenous fluids once blood glucose reaches approximately 200-250 mg/dL (11.1-13.9 mmol/L).
The blood glucose decline is stabilized while insulin administration continues.
Dextrose prevents a rapid drop in blood glucose, which can lead to life-threatening cerebral edema and hypoglycemia, while allowing the insulin drip to continue clearing ketones.
5
Administer subcutaneous insulin.
The client is prepared for the discontinuation of the intravenous insulin infusion.
Transitioning to subcutaneous insulin occurs when the anion gap closes and the acidosis is resolved, providing basal glycemic control before the IV drip is turned off.

Key Concept

The physiological stabilization sequence for diabetic ketoacidosis requires treating hypovolemia first, then securing safe electrolyte levels before reversing the acidosis with insulin.
Question 444Question →

A client is receiving care 4 hours after a right-sided pneumonectomy. The nurse notes the client has become increasingly restless. Current vital signs include a blood pressure of 138/86 mm Hg, heart rate of 118/min, and respiratory rate of 28/min. Arterial blood gas (ABG) analysis reveals a pH of 7.28, PaCO2 of 56 mm Hg, HCO3 of 24 mEq/L, and PaO2 of 64 mm Hg. Which intervention should the nurse implement immediately to reduce the risk of further physiological deterioration?

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Answer: Place the client in a right lateral position and ensure the head of the bed is elevated

Answer

Place the client in a right lateral position and ensure the head of the bed is elevated.
Following a pneumonectomy (complete removal of a lung), the standard of care to reduce the risk of respiratory compromise is to position the client on their operative side (in this scenario, the right side) or flat on their back. This critical positioning strategy ensures that the remaining functioning lung (the left lung) is positioned uppermost. This prevents the weight of the heart and mediastinal structures from compressing the healthy lung, thereby maximizing its ability to expand and participate in gas exchange. Elevating the head of the bed further facilitates diaphragmatic excursion to help resolve the client's acute respiratory acidosis and hypoxemia.

Step-by-Step Solution

1
Interpret the client's vital signs and Arterial Blood Gas (ABG) results.
The ABGs show a low pH (7.28), elevated PaCO2 (56), normal HCO3 (24), and low PaO2 (64). This indicates uncompensated respiratory acidosis with hypoxemia.
Accurate ABG interpretation is required to identify the precise physiological decompensation occurring (respiratory failure).
2
Analyze the specific surgical procedure (right-sided pneumonectomy) and its implications for risk reduction.
A pneumonectomy involves the removal of an entire lung. The right lung is absent, meaning the client is entirely dependent on the left lung for gas exchange.
Surgical context dictates which nursing interventions are safe or strictly contraindicated to prevent life-threatening complications.
3
Determine the priority intervention to optimize gas exchange and reduce risk.
The client must be positioned on their operative side (right side) or supine, with the head of the bed elevated.
Placing the client on the operative side ensures the fluid-filled empty space remains dependent, allowing the remaining 'good' lung (left lung) to remain uppermost. This maximizes its expansion and improves ventilation to correct the respiratory acidosis.

Key Concept

Post-Pneumonectomy Positioning and ABG Analysis
Question 445Question →

A nurse on a medical-surgical unit is evaluating a client with end-stage renal disease who was admitted after missing multiple scheduled hemodialysis sessions. The client appears lethargic and exhibits deep, rapid respirations. Based on this clinical presentation, which of the following arterial blood gas (ABG) results is most expected?

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Answer: pH=7.28\text{pH} = 7.28, PaCO2=30 mm Hg\text{PaCO}_2 = 30 \text{ mm Hg}, HCO3−=15 mEq/L\text{HCO}_3^- = 15 \text{ mEq/L}

Answer

The expected arterial blood gas result is pH=7.28\text{pH} = 7.28, PaCO2=30 mm Hg\text{PaCO}_2 = 30 \text{ mm Hg}, and HCO3−=15 mEq/L\text{HCO}_3^- = 15 \text{ mEq/L}.
Missing scheduled hemodialysis leads to an accumulation of metabolic waste products and acids, resulting in metabolic acidosis (characterized by a low pH and a low HCO3−\text{HCO}_3^-). In response to the acidic environment, the central chemoreceptors stimulate the respiratory center, causing the client to increase the depth and rate of respirations (Kussmaul respirations). This compensatory hyperventilation expels excess carbon dioxide (CO2\text{CO}_2), which lowers the PaCO2\text{PaCO}_2. The correct ABG reflects this exact physiological state: an acidemic pH (7.28), a low bicarbonate indicating the metabolic source (15 mEq/L), and a compensatory decrease in carbon dioxide (30 mm Hg).

Step-by-Step Solution

1
Identify the primary acid-base disturbance.
Missed hemodialysis causes retention of uremic waste and metabolic acids, leading to metabolic acidosis (decreased pH and decreased HCO3-).
The kidneys are unable to excrete hydrogen ions or regenerate bicarbonate.
2
Analyze the physical assessment findings.
The client is exhibiting deep, rapid respirations, known as Kussmaul respirations.
This is a classic symptom of severe metabolic acidosis.
3
Determine the physiological consequence of the symptoms.
Hyperventilation effectively blows off carbon dioxide (CO2), lowering the PaCO2 in the blood.
The respiratory system is attempting to compensate for the metabolic acidosis by inducing a mild respiratory alkalosis.
4
Select the matching ABG values.
The correct ABG must show low pH (< 7.35), low HCO3- (< 22 mEq/L), and low PaCO2 (< 35 mm Hg).
These values collectively indicate metabolic acidosis with partial respiratory compensation.

Key Concept

Clients with acute renal failure or missed dialysis develop high anion gap metabolic acidosis; the body compensates by hyperventilating (Kussmaul respirations) to lower PaCO2.
Question 446Question →

A nurse is caring for a client diagnosed with Guillain-Barré syndrome who reports increasing difficulty swallowing and generalized weakness. The client is restless, has shallow respirations at 28 breaths/min, and an arterial blood gas (ABG) reveals: pH=7.29\text{pH} = 7.29, PaCO2=58 mm Hg\text{PaCO}_2 = 58 \text{ mm Hg}, HCO3−=24 mEq/L\text{HCO}_3^- = 24 \text{ mEq/L}, and PaO2=62 mm Hg\text{PaO}_2 = 62 \text{ mm Hg}. Based on these findings, which of the following is the priority nursing action?

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Answer: Prepare the client for immediate endotracheal intubation and mechanical ventilation.

Answer

Prepare the client for immediate endotracheal intubation and mechanical ventilation.
The ABG results demonstrate uncompensated acute respiratory acidosis (pH<7.35\text{pH} < 7.35 and PaCO2>45 mm Hg\text{PaCO}_2 > 45 \text{ mm Hg}). In a client with Guillain-Barré syndrome, this hypercapnia, combined with shallow breathing and difficulty swallowing, signifies severe neuromuscular paralysis extending to the diaphragm and bulbar muscles. The client is rapidly losing the physical ability to ventilate. Immediate intubation and mechanical ventilation are required to secure the airway, provide adequate ventilation, and prevent respiratory arrest.

Step-by-Step Solution

1
Analyze the arterial blood gas (ABG) values.
The results show a pH\text{pH} of 7.29 (acidosis), a PaCO2\text{PaCO}_2 of 58 mm Hg (respiratory origin), a normal HCO3−\text{HCO}_3^-, and a PaO2\text{PaO}_2 of 62 mm Hg (hypoxemia).
Accurate interpretation of ABGs is required to identify uncompensated acute respiratory acidosis and hypoxemia.
2
Correlate the ABG findings with the pathophysiology of Guillain-Barré syndrome.
The syndrome causes ascending neuromuscular paralysis. Shallow breathing, dysphagia, and elevated carbon dioxide indicate that paralysis has severely affected the bulbar and diaphragmatic muscles.
Understanding the disease process explains why the respiratory failure is occurring (pump failure due to muscle weakness).
3
Determine the most appropriate life-saving intervention.
The client is losing the physical ability to ventilate independently and requires an artificial airway and mechanical ventilation.
Prioritization must focus on ABCs (Airway and Breathing). Since the client cannot physically breathe effectively, mechanical support is the only viable solution.

Key Concept

Management of acute respiratory failure in neuromuscular disorders
Question 447Question →

A nurse is preparing to administer a unit of packed red blood cells (PRBCs) to an adult client with symptomatic anemia. Arrange the following actions in the correct chronological order that the nurse should perform them, from first action to last action.

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Answer

The correct sequence is: prime the tubing with normal saline, verify the blood product with a second nurse, obtain baseline vital signs, initiate the transfusion slowly, and remain with the client for the first 15 minutes.
Safe administration of packed red blood cells requires strict adherence to a standardized sequence to prevent fatal errors and manage adverse reactions. The equipment must first be primed with normal saline, the only compatible fluid. Next, mandatory bedside verification by two nurses ensures the right blood goes to the right client. Baseline vitals must then be obtained immediately before starting the flow. The infusion is initiated slowly to limit exposure in case of an error, and the nurse must remain with the client for the first 15 minutes when acute, life-threatening reactions are most likely to occur.

Step-by-Step Solution

1
Prime the Y-type blood administration set with 0.9% sodium chloride.
The IV line is prepared, purged of air, and flushed with a compatible solution.
Normal saline is the only fluid compatible with blood products. Priming first prevents hemolysis and ensures the line is ready for the blood.
2
Verify the blood product and client identity with a second registered nurse at the bedside.
The correct blood component is confirmed for the correct client.
This is a critical safety standard to prevent fatal ABO incompatibility errors.
3
Obtain and document the client's baseline vital signs.
A pre-transfusion physiological baseline is established.
Accurate vital signs taken immediately before starting allow the nurse to identify subtle changes that indicate an adverse transfusion reaction.
4
Spike the blood bag and initiate the transfusion at a slow rate.
The blood begins infusing into the client.
Starting slowly limits the amount of incompatible blood received if an acute reaction occurs, minimizing potential harm.
5
Remain with the client for the first 15 minutes of the transfusion.
The client is closely observed during the highest-risk period.
Severe, life-threatening transfusion reactions typically manifest within the first 15 minutes or first 50 mL of the infusion.

Key Concept

Blood Product Administration Sequence and Safety
Estimated Time:1m 30s
Question 448Question →

While assessing a client who is 4 hours postoperative following an exploratory laparotomy, the nurse suspects the onset of hypovolemic shock. Which of the following clinical findings are considered early compensatory manifestations of this condition? Select all that apply.

Select all that apply

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Answer: Narrowed pulse pressure; Restlessness and apprehension; Heart rate of 118 beats/minute

Answer

The early compensatory manifestations of hypovolemic shock include narrowed pulse pressure, restlessness and apprehension, and tachycardia (e.g., heart rate of 118 beats/minute).
During the early compensatory stage of hypovolemic shock, the body activates the sympathetic nervous system to maintain perfusion. This physiological adaptation causes an increase in heart rate (tachycardia) to boost cardiac output, peripheral vasoconstriction which raises diastolic blood pressure (leading to a narrowed pulse pressure), and mild cerebral hypoxia which manifests clinically as restlessness, apprehension, or anxiety.

Step-by-Step Solution

1
Analyze the client's postoperative status and the physiological risk.
The client is at risk for hypovolemic shock due to potential surgical blood loss or fluid shifts following a laparotomy.
Identifying the etiology of potential shock helps anticipate the expected physiological response.
2
Differentiate between the stages of shock (compensatory versus progressive/decompensated).
The compensatory stage relies on sympathetic nervous system activation to maintain cardiac output and vital organ perfusion.
The question specifically asks for early compensatory manifestations, requiring the exclusion of late findings.
3
Evaluate each assessment finding against the physiological changes of the compensatory stage.
Tachycardia, narrowing pulse pressure, and neurological changes (restlessness) are compensatory. Hypotension is a late sign, and warm skin is atypical for hypovolemic shock.
Accurate identification of early signs allows for prompt, life-saving interventions before irreversible tissue damage occurs.

Key Concept

Early recognition of the compensatory stage of hypovolemic shock
Question 449Question →

A client who recently underwent a large bowel resection is recovering in the surgical unit. The nurse is actively monitoring the client for postoperative complications, specifically fluid volume deficit. Which of the following assessment findings is the earliest indicator that the client is developing hypovolemic shock?

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Answer: Unexplained restlessness and an increasing resting heart rate

Answer

Unexplained restlessness and an increasing resting heart rate
In the early (compensatory) stage of hypovolemic shock, the body activates the sympathetic nervous system to maintain cardiac output and tissue perfusion. This physiological adaptation leads to mild tachycardia and causes mild cerebral hypoxia, which presents as unexplained restlessness, apprehension, or anxiety. These are typically the first detectable signs of clinical deterioration, occurring well before blood pressure drops.

Step-by-Step Solution

1
Recall the physiological stages of shock (initial, compensatory, progressive, refractory).
Early shock triggers compensatory mechanisms to maintain cardiac output.
Understanding the timeline of physiological responses is necessary to identify early versus late signs.
2
Identify the effects of the compensatory stage on the body.
The sympathetic nervous system activates, leading to an increased heart rate and subtle changes in mental status due to mild cerebral hypoxia.
These are the body's first attempts to preserve blood flow to vital organs.
3
Differentiate these early signs from late, decompensated signs of shock.
Hypotension, oliguria, and mottled skin occur when compensatory mechanisms begin to fail.
Selecting a late sign would delay critical interventions.

Key Concept

Early Indicators of Hypovolemic Shock
Estimated Time:1m 0s
Question 450Question →

An older adult client is admitted to the surgical recovery unit immediately following a left eye cataract extraction with intraocular lens implantation. The client reports a mild 'scratchy' sensation in the operated eye and asks the nurse for help getting comfortable. Which nursing intervention regarding positioning and comfort is most appropriate?

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Answer: Elevate the head of the bed to 30 degrees and assist the client to rest in a supine position or on the right side.

Answer

The nurse should elevate the head of the bed to 30 degrees and position the client supine or on their right (non-operative) side.
After cataract surgery, nursing care focuses on preventing an increase in intraocular pressure (IOP) and protecting the surgical site. Elevating the head of the bed to 30 degrees (Semi-Fowler's position) promotes venous drainage from the head, which helps keep IOP low. The client should be positioned either supine or on the non-operative side (the right side, in this scenario) to prevent direct pressure on the operated left eye. The reported 'scratchy' sensation is a normal, expected finding postoperatively and does not indicate a complication that requires deviation from these standard positioning protocols.

Step-by-Step Solution

1
Analyze the procedure and the client's symptoms.
The client had left eye cataract surgery and is experiencing a normal postoperative 'scratchy' sensation.
Understanding the surgical site and expected postoperative findings dictates the appropriate comfort and safety interventions.
2
Identify the primary postoperative goals for cataract extraction.
The main goals are to prevent an increase in intraocular pressure (IOP) and protect the surgical site from trauma or direct physical pressure.
Increased IOP or direct pressure can cause hemorrhage, suture rupture, or intraocular lens displacement.
3
Evaluate the positioning options based on these physiological goals.
Elevating the head of the bed to 30 degrees promotes venous drainage (lowering IOP). Lying on the non-operative right side or back successfully avoids pressure on the left eye.
These positions are anatomically and physiologically optimal for recovery, unlike lying flat or on the operative side.
4
Assess the delegation aspect in the remaining distractors.
Delegating the assessment of the eye to a UAP is unsafe and outside their scope of practice.
Only registered nurses have the training and licensure to perform clinical assessments of surgical sites.

Key Concept

Post-Cataract Surgery Positioning and Care
Estimated Time:1m 0s
Question 451Question →

A nurse is monitoring a client who is 3 hours post-operative following a radical nephrectomy. Which of the following assessment findings should the nurse identify as early (compensatory) indicators of hemorrhagic shock? Select all that apply.

Select all that apply

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Answer: Pulse pressure narrowing from 45 mm Hg to 25 mm Hg; Sudden onset of mild restlessness and anxiety; Apical heart rate increasing from 76 to 112 beats per minute

Answer

The early compensatory indicators of hemorrhagic shock are a narrowing pulse pressure, a sudden onset of mild restlessness and anxiety, and an increasing apical heart rate.
In the early (compensatory) stage of hemorrhagic shock, the sympathetic nervous system is activated to maintain vital organ perfusion. This causes peripheral vasoconstriction, which raises the diastolic blood pressure, leading to a narrowing pulse pressure. The heart rate increases (tachycardia) to sustain cardiac output. Additionally, mild cerebral hypoxia and sympathetic stimulation manifest early as sudden restlessness, anxiety, or apprehension.

Step-by-Step Solution

1
Analyze the client's clinical context.
The client is 3 hours post-operative for a major abdominal surgery, placing them at high risk for acute internal blood loss and subsequent hypovolemic (hemorrhagic) shock.
Identifying the specific risk profile helps anticipate the physiological signs associated with fluid volume deficit.
2
Recall the pathophysiology of the early (compensatory) stage of shock.
The body activates the sympathetic nervous system to maintain cardiac output and blood pressure. This causes vasoconstriction, tachycardia, and the shunting of blood away from non-vital peripheral tissues toward vital organs.
Understanding the body's compensatory mechanisms is necessary to distinguish early signs from late signs of shock.
3
Evaluate each assessment finding against the expected compensatory responses.
Tachycardia, a narrowing pulse pressure (due to increased diastolic blood pressure from vasoconstriction), and altered mental status (from mild cerebral hypoxia) perfectly match the early stage. Hypotension is a late sign, and warm skin indicates vasodilation, not vasoconstriction.
This elimination process systematically isolates the correct indicators of early hemorrhagic shock.

Key Concept

Early (Compensatory) Signs of Hemorrhagic Shock
Estimated Time:1m 30s
Question 452Question →

A nurse is evaluating the arterial blood gas (ABG) results of a client who has severely depressed respirations following a suspected opioid overdose. The nurse determines the client is experiencing uncompensated respiratory acidosis. Which of the following ABG values would confirm this specific finding? Select all that apply.

Select all that apply

Show answer & explanation

Answer: pH 7.31; PaCO2 58 mm Hg; HCO3- 23 mEq/L

Answer

The values that confirm uncompensated respiratory acidosis are a pH of 7.31, PaCO2 of 58 mm Hg, and HCO3- of 23 mEq/L.
Uncompensated respiratory acidosis is characterized by a low pH (less than 7.35) and an elevated PaCO2 (greater than 45 mm Hg) due to inadequate ventilation. The bicarbonate (HCO3-) remains within the normal range (22 to 26 mEq/L) because the kidneys have not yet initiated a compensatory response.

Step-by-Step Solution

1
Analyze the pH to determine if the client is acidotic or alkalotic.
A pH less than 7.35 indicates acidosis. The value of 7.31 confirms acidemia.
Identifying the primary acid-base imbalance is the first step in ABG interpretation.
2
Evaluate the PaCO2 to determine if the cause is respiratory.
A PaCO2 greater than 45 mm Hg indicates a respiratory cause for the acidosis. The value of 58 mm Hg confirms hypercapnia.
Elevated carbon dioxide levels indicate hypoventilation, which drives respiratory acidosis.
3
Assess the HCO3- to determine the level of compensation.
An HCO3- within the normal range of 22 to 26 mEq/L indicates that no metabolic compensation has occurred yet. The value of 23 mEq/L confirms an uncompensated state.
In acute respiratory acidosis, it takes days for the kidneys to retain enough bicarbonate to compensate for the elevated CO2.

Key Concept

Uncompensated Respiratory Acidosis
Question 453Question →

A client admitted with rapid atrial fibrillation is receiving a continuous intravenous (IV) infusion of diltiazem through a single-lumen peripheral catheter. The healthcare provider prescribes a scheduled dose of IV pantoprazole for stress ulcer prophylaxis. The nurse checks a drug reference guide and notes that pantoprazole is chemically incompatible with diltiazem. Which action is the most appropriate for the nurse to take?

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Answer: Initiate a second peripheral intravenous catheter to administer the pantoprazole.

Answer

The most appropriate action is to initiate a second peripheral intravenous catheter to administer the pantoprazole.
Diltiazem is a critical, continuous cardiac medication used to control heart rate. It should not be paused for the administration of a routine or secondary medication. Because it is chemically incompatible with pantoprazole, the two cannot be infused through the same line simultaneously. Therefore, the safest and most appropriate nursing action is to establish a second peripheral IV line to administer the pantoprazole, ensuring both therapies are delivered safely and without interruption.

Step-by-Step Solution

1
Identify the prescribed medications and verify their compatibility.
Diltiazem and pantoprazole are chemically incompatible.
Mixing incompatible medications in the same IV line can lead to precipitate formation, posing a severe embolic risk to the client.
2
Evaluate the clinical purpose and nature of the primary continuous infusion.
Diltiazem is a critical cardiac medication used for rate control in rapid atrial fibrillation.
Interrupting a continuous vasoactive or antiarrhythmic drip can rapidly lead to hemodynamic instability or a return of the rapid ventricular response.
3
Determine the safest administration route that satisfies both medication requirements.
A second, dedicated IV line must be established.
This ensures the critical continuous cardiac medication is not paused, while safely allowing the administration of the incompatible secondary medication.

Key Concept

Management of Intravenous Incompatibilities and Continuous Cardiac Infusions
Question 454Question →

A medical-surgical nurse is developing a plan of care for a client who is 2 hours postoperative following a subtotal thyroidectomy. Which of the following interventions should the nurse include to reduce the risk of physiological complications? (Select all that apply.)

Select all that apply

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Answer: Maintain the client in a semi-Fowler's position with the head and neck supported in neutral alignment; Assess the anterior surgical dressing and palpate the posterior neck for occult bleeding; Ensure intravenous calcium gluconate is immediately available on the surgical unit

Answer

The correct actions are maintaining a semi-Fowler's position with neutral neck alignment, assessing the anterior dressing and posterior neck for bleeding, and ensuring intravenous calcium gluconate is available.
Following a thyroidectomy, clients are at high risk for airway compromise, hemorrhage, and hypocalcemia. Maintaining a semi-Fowler's position minimizes neck edema, assessing the posterior neck detects occult bleeding, and having calcium gluconate available prepares the team for potential parathyroid gland damage.

Step-by-Step Solution

1
Identify the surgical procedure and the timeframe.
The client is 2 hours postoperative following a subtotal thyroidectomy.
Understanding the procedure and timing helps anticipate immediate postoperative risks.
2
Determine the major risks associated with this surgery.
Primary risks include airway obstruction from edema, occult hemorrhage, and hypocalcemia due to accidental parathyroid gland damage.
Risk reduction potential relies on recognizing these specific threats early.
3
Evaluate each intervention against the identified risks.
Semi-Fowler's position reduces edema; checking the posterior neck detects hidden bleeding; and having calcium gluconate ready addresses potential hypocalcemia.
These specific actions directly mitigate the highest-priority physiological risks.

Key Concept

Reduction of Risk Potential: Postoperative Care and Complication Prevention
Question 455Question →

A client with severe chronic obstructive pulmonary disease (COPD) and right-sided heart failure (cor pulmonale) is receiving treatment for acute respiratory distress and massive lower extremity edema. The client requires assistance with all activities of daily living. Which nursing actions appropriately address the client's basic care and comfort needs? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Provide frequent, small meals that are high in calories and easy to chew; Suspend the client's heels off the bed by placing a supportive cushion under the calves; Offer oral hygiene with a soft toothbrush and non-alcohol-based mouthwash every few hours

Answer

The correct interventions are providing frequent small meals, suspending the heels off the bed, and offering regular oral hygiene.
Providing small, high-calorie meals reduces the energy required for eating and digestion, which is crucial for clients with severe respiratory distress. Suspending the heels relieves pressure on edematous, vulnerable tissues, preventing pressure injuries. Frequent oral hygiene with non-alcohol-based products keeps mucous membranes moist and comfortable, especially for clients breathing through their mouths or receiving oxygen therapy.

Step-by-Step Solution

1
Analyze the client's physiological needs related to severe COPD, cor pulmonale, and peripheral edema.
The client requires energy conservation, pressure relief for edematous extremities, and mucous membrane care.
Systemic fluid overload and respiratory distress significantly increase metabolic demands and the risk of skin breakdown.
2
Evaluate each intervention against basic care standards and safety protocols for this specific condition.
Nutritional support via small meals, pressure relief via heel suspension, and regular oral care are identified as safe and effective.
These actions directly promote comfort and hygiene without compromising respiratory or circulatory function.
3
Identify contraindicated actions in the remaining options.
Popliteal pressure, delegating assessments, and ignoring neurological changes are recognized as unsafe practices.
These actions violate positioning guidelines, delegation rules, and pathophysiology principles.

Key Concept

Basic care and comfort for clients with severe cardiopulmonary compromise involves energy conservation, skin integrity maintenance, and recognizing acute physiological changes over normal aging.
Question 456Question →

A nurse is preparing to administer an initial prescribed dose of intravenous amphotericin B deoxycholate 50 mg50\text{ mg} in 500 mL500\text{ mL} of 5%5\% dextrose in water (D5W) to a client with a severe systemic fungal infection. The medication is scheduled to infuse over 4 hours. The client currently has a single peripheral intravenous (IV) catheter with a continuous infusion of 0.9%0.9\% sodium chloride running at 75 mL/hr75\text{ mL/hr}. Which sequence of actions is the safest and most appropriate for the nurse to implement?

Show answer & explanation

Answer: Pause the 0.9%0.9\% sodium chloride infusion, flush the IV catheter with D5W, administer the amphotericin B at 125 mL/hr125\text{ mL/hr}, and flush again with D5W before restarting the saline.

Answer

The nurse must pause the 0.9%0.9\% sodium chloride infusion, flush the line with D5W, infuse the amphotericin B at 125 mL/hr125\text{ mL/hr}, and flush again with D5W before resuming the saline.
Amphotericin B deoxycholate is highly incompatible with saline solutions and will form a precipitate if mixed. Because the client has only one IV site, the continuous saline infusion must be paused, and the line must be thoroughly flushed with 5%5\% dextrose in water (D5W) prior to and following the medication administration. The correct infusion rate is calculated by dividing the total volume (500 mL500\text{ mL}) by the total time (4 hours4\text{ hours}), resulting in 125 mL/hr125\text{ mL/hr}.

Step-by-Step Solution

1
Identify the IV compatibility of the prescribed medication.
Amphotericin B deoxycholate is incompatible with 0.9%0.9\% sodium chloride and must be mixed and flushed exclusively with 5%5\% dextrose in water (D5W).
Mixing amphotericin B with saline causes precipitation, which can lead to catheter occlusion or an embolism.
2
Determine the appropriate line management strategy for a single IV access.
The continuous saline infusion must be paused, and the IV line must be completely cleared of saline by flushing with D5W before and after the amphotericin B infusion.
This ensures the incompatible solutions do not meet within the catheter lumen.
3
Calculate the correct infusion pump rate in mL/hr.
Divide the total volume (500 mL500\text{ mL}) by the prescribed infusion time (4 hours4\text{ hours}) to yield a rate of 125 mL/hr125\text{ mL/hr}.
Infusion pumps are programmed based on fluid volume over time, not medication dosage over time.

Key Concept

Amphotericin B IV Compatibility and Safe Administration
Question 457Question →

A client is admitted to the intensive care unit with severe sepsis secondary to a perforated viscus. The nurse has just completed administering a prescribed initial intravenous fluid bolus of 30 mL/kg of 0.9% sodium chloride. A subsequent reassessment reveals a blood pressure of 82/46 mmHg, a heart rate of 126 beats/minute, a respiratory rate of 28 breaths/minute, and a urine output of 15 mL over the past hour. Arterial blood gas results demonstrate a pH of 7.27, PaCO2PaCO_2 of 30 mmHg, PaO2PaO_2 of 82 mmHg, and HCO3−HCO_3^- of 14 mEq/L. Based on these findings, which of the following is the priority nursing action?

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Answer: Initiate a prescribed continuous intravenous infusion of norepinephrine.

Answer

The correct action is to initiate a prescribed continuous intravenous infusion of norepinephrine.
The client is exhibiting signs of fluid-refractory septic shock, evidenced by profound hypotension that persists after standard initial fluid resuscitation (30 mL/kg bolus). In this phase of shock, the profound systemic vasodilation must be counteracted with a vasopressor. Norepinephrine is the first-line vasopressor used to increase systemic vascular resistance, restore a mean arterial pressure of at least 65 mmHg, and improve tissue perfusion to reverse the ongoing lactic acidosis.

Step-by-Step Solution

1
Analyze the hemodynamic response to the initial fluid resuscitation.
The client's blood pressure remains critically low (82/46 mmHg) despite receiving the standard 30 mL/kg fluid bolus.
This identifies the transition from fluid-responsive shock to fluid-refractory vasodilatory shock.
2
Interpret the arterial blood gas values in the context of the client's vital signs.
The ABG shows partially compensated metabolic acidosis (low pH, low HCO3−HCO_3^-) with a compensatory respiratory alkalosis (tachypnea leading to low PaCO2PaCO_2). The PaO2PaO_2 is adequate.
This confirms that the tachypnea is a compensatory mechanism for lactic acidosis caused by hypoperfusion, rather than acute respiratory failure.
3
Determine the highest priority clinical intervention based on current guidelines.
Vasopressor support (norepinephrine) must be initiated immediately.
In fluid-refractory septic shock, vasopressors are the primary intervention to increase mean arterial pressure, restore organ perfusion, and halt the progression of lactic acidosis.

Key Concept

Fluid-Refractory Septic Shock and Hemodynamic Support
Question 458Question →

A critical care nurse is managing a client with symptomatic bradycardia who is unresponsive to standard atropine therapy. The client weighs 187 lbs187\text{ lbs}. The healthcare provider prescribes a continuous IV infusion of dopamine at 4 mcg/kg/min4\text{ mcg/kg/min}. The pharmacy supplies a premixed bag containing 250 mg250\text{ mg} of dopamine in 500 mL500\text{ mL} of 5%5\% dextrose in water (D5W). What is the correct infusion pump setting in mL/hr\text{mL/hr}? Record your answer using one decimal place.

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Answer: 40.8

Answer

40.8
To find the correct pump setting in mL/hr, you must first convert the client's weight to kilograms (187 / 2.2 = 85 kg), multiply by the prescribed mcg/kg/min dosage to find the total mcg/min (85 * 4 = 340 mcg/min), and multiply by 60 to find the total mcg/hr (20,400 mcg/hr). Finally, divide this hourly requirement by the solution's concentration (500 mcg/mL) to get 40.8 mL/hr.

Step-by-Step Solution

1
Convert the client's weight from pounds to kilograms.
187 lbs÷2.2=85 kg187\text{ lbs} \div 2.2 = 85\text{ kg}
The dopamine dosage is prescribed based on the client's weight in kilograms.
2
Calculate the required medication dose per minute.
85 kg×4 mcg/kg/min=340 mcg/min85\text{ kg} \times 4\text{ mcg/kg/min} = 340\text{ mcg/min}
This establishes the total amount of dopamine the client must receive each minute.
3
Convert the per-minute dose to an hourly dose.
340 mcg/min×60 min/hr=20,400 mcg/hr340\text{ mcg/min} \times 60\text{ min/hr} = 20,400\text{ mcg/hr}
Infusion pumps are programmed to deliver volume on an hourly basis (mL/hr).
4
Determine the concentration of the dopamine solution in mcg/mL.
250 mg=250,000 mcg250\text{ mg} = 250,000\text{ mcg}; 250,000 mcg÷500 mL=500 mcg/mL250,000\text{ mcg} \div 500\text{ mL} = 500\text{ mcg/mL}
Converting milligrams to micrograms matches the prescribed dose unit, allowing calculation of the exact fluid volume per mL.
5
Calculate the final infusion pump rate.
20,400 mcg/hr÷500 mcg/mL=40.8 mL/hr20,400\text{ mcg/hr} \div 500\text{ mcg/mL} = 40.8\text{ mL/hr}
Dividing the total hourly medication requirement by the concentration yields the fluid volume needed per hour.

Key Concept

Weight-based continuous IV infusion calculation
Question 459Question →

A client with chronic kidney disease presents to the emergency department reporting profound muscle weakness and palpitations. The continuous cardiac monitor displays tall, peaked T waves and a widened QRS complex. Laboratory results show a serum potassium level of 7.2 mEq/L (7.2 mmol/L). The arterial blood gas (ABG) analysis reveals: pH 7.27, PaCO2 36 mmHg, PaO2 92 mmHg, and HCO3- 16 mEq/L. To immediately reduce the risk of a fatal ventricular dysrhythmia, which prescribed action should the nurse take first?

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Answer: Administer intravenous calcium gluconate.

Answer

The correct action is to administer intravenous calcium gluconate.
The correct action is to administer intravenous calcium gluconate. Severe hyperkalemia (potassium > 7.0 mEq/L) combined with classic ECG changes (peaked T waves, widened QRS complex) indicates impending cardiac arrest. Calcium gluconate acts immediately (within 1 to 3 minutes) to antagonize the cardiotoxicity of potassium. It raises the threshold potential of the myocardial cells, stabilizing the membrane and preventing lethal ventricular dysrhythmias. While it does not lower the serum potassium level, it is the absolute first-line priority to reduce the immediate risk of a fatal physiological complication.

Step-by-Step Solution

1
Analyze the client's clinical presentation, laboratory results, and continuous ECG findings.
The client has severe hyperkalemia (7.2 mEq/L) accompanied by characteristic, life-threatening ECG changes (peaked T waves, widened QRS) and uncompensated metabolic acidosis.
Synthesizing the objective data identifies the most immediate life-threatening condition, which is cardiac toxicity from severe hyperkalemia.
2
Evaluate the physiological mechanism and onset time of the available prescribed interventions.
Calcium gluconate works within minutes to stabilize the myocardium; insulin with dextrose and sodium bicarbonate take 15 to 30 minutes to shift potassium.
Prioritization in an emergency requires selecting the intervention that addresses the most immediate physiological threat (ventricular fibrillation) in the fastest possible time.
3
Select the intervention that provides immediate risk reduction for the fatal complication.
Intravenous calcium gluconate is identified as the absolute highest priority action.
It immediately raises the cardiac threshold potential, protecting the heart from lethal dysrhythmias while other, slower potassium-lowering treatments take effect.

Key Concept

Prioritization of interventions to reduce the risk of life-threatening cardiac complications in severe hyperkalemia.
Estimated Time:1m 30s
Question 460Question →

A nurse is caring for a client who has a central venous catheter. While the nurse is changing the injection caps, the client suddenly becomes extremely restless, gasps for air, and reports severe chest pain. The nurse suspects a venous air embolism. In what order should the nurse perform the following actions? Arrange the items from first to last.

Drag items to arrange them in the correct order

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Answer

The correct sequence of actions is to first clamp the catheter, then place the client in a left lateral Trendelenburg position, administer high-concentration oxygen, activate the rapid response team, and finally assess the client's vital signs.
When a venous air embolism is suspected during central line care, the nurse must act rapidly to prevent cardiopulmonary collapse. The immediate priority is to stop further air from entering the circulation by clamping the catheter. Next, the client must be placed in a left lateral Trendelenburg position (Durant's maneuver) to trap the air bubble in the apex of the right ventricle, preventing it from migrating into the pulmonary arterial system. Administering 100% oxygen helps correct hypoxia and speeds the reabsorption of nitrogen gas from the bubble. Once these immediate life-saving physical interventions are complete, the nurse activates the rapid response team to obtain advanced medical support, followed by continuous assessment of vital signs to monitor for hemodynamic deterioration.

Step-by-Step Solution

1
Clamp the central venous catheter immediately.
Further air entry into the venous system is stopped.
In any crisis, stopping the immediate cause of harm takes absolute precedence.
2
Place the client in a left lateral Trendelenburg position.
The client is positioned on their left side with their head lower than their feet.
This traps the air in the right ventricle, preventing it from entering and obstructing the pulmonary circulation.
3
Administer 100% oxygen via a non-rebreather mask.
The client receives maximal oxygen concentration.
Treats ischemia caused by the embolism and accelerates the reabsorption of nitrogen from the air bubble.
4
Activate the rapid response team.
Advanced medical providers are notified.
The client requires critical care interventions that exceed the scope of independent nursing practice.
5
Assess the client's vital signs and continuous pulse oximetry.
Baseline data post-intervention is established.
Monitors for signs of cardiovascular collapse and evaluates the effectiveness of the initial interventions.

Key Concept

Emergency Management of Venous Air Embolism
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