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Question 461Question →

A nurse is monitoring a client who is receiving a transfusion of packed red blood cells. Ten minutes into the transfusion, the client reports sudden lower back pain, chills, and shortness of breath. Arrange the following nursing actions in the correct priority sequence.

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Answer

The correct sequence of actions for a suspected acute hemolytic transfusion reaction is to first stop the transfusion, then maintain intravenous access with new tubing and normal saline, assess the client's vital signs, notify the healthcare provider and blood bank, and finally return the blood products to the blood bank for analysis.
When a client experiences symptoms of a severe transfusion reaction (such as lower back pain, which indicates an acute hemolytic reaction), the absolute first priority is to stop the offending agent. Immediately stopping the blood minimizes the volume of incompatible cells infused. The next step is to maintain a patent intravenous line for emergency medications; this must be done with entirely new tubing primed with normal saline so that the blood remaining in the old tubing is not flushed into the client. Next, the nurse performs a rapid assessment of vital signs and respiratory status to gather necessary clinical data. This data is then immediately communicated to the healthcare provider and blood bank. Finally, as a post-crisis procedural step, the blood bag and tubing are returned to the blood bank for serological testing and investigation.

Step-by-Step Solution

1
Stop the blood transfusion immediately.
Further entry of the incompatible blood product into the client's circulation is halted.
This is the absolute highest priority to prevent the acute hemolytic reaction from worsening and causing severe physiological harm.
2
Replace the blood tubing with a new set and initiate an infusion of 0.9% sodium chloride.
A patent intravenous line is maintained without pushing remaining blood into the client.
Intravenous access is required for emergency medications. New tubing is essential because flushing the old tubing would administer the remaining incompatible blood.
3
Assess the client's vital signs and oxygen saturation.
Current hemodynamic and respiratory data are obtained.
The provider will need baseline post-reaction vital signs to prescribe appropriate life-saving interventions.
4
Notify the healthcare provider and the blood bank.
The medical team is alerted and emergency protocols are initiated.
The provider must be informed of the assessment findings to direct medical care, and the blood bank must stop any further dispensations from that donor batch.
5
Return the remaining blood product and attached tubing to the blood bank.
Evidence is preserved for serological investigation.
Laboratory analysis of the blood and tubing determines the precise cause of the reaction and confirms if a mismatch occurred.

Key Concept

Nursing Priority Management of Acute Hemolytic Transfusion Reactions
Question 462Question →

During morning rounds, the nurse reviews the electronic health record for a client with a long-standing history of severe chronic obstructive pulmonary disease (COPD). The client is currently resting comfortably while receiving oxygen therapy at 2 L/min via a nasal cannula. The most recent arterial blood gas analysis reveals a pH of 7.36, a PaCO2 of 58 mm Hg, a PaO2 of 62 mm Hg, and a bicarbonate (HCO3-) level of 32 mEq/L. Which of the following actions should the nurse implement based on this data?

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Answer: Document the findings as they reflect an expected, fully compensated respiratory acidosis.

Answer

The nurse should document the findings because they represent a fully compensated respiratory acidosis, which is the expected physiological baseline for a client with severe, chronic COPD.
The arterial blood gas values indicate a fully compensated respiratory acidosis. Because the pH is within the normal range (7.35-7.45) despite an elevated PaCO2, the kidneys have physiologically adapted and retained enough bicarbonate to compensate for chronic CO2 retention. This is the expected baseline for a client with severe COPD who is resting comfortably. Therefore, the nurse only needs to document the findings.

Step-by-Step Solution

1
Analyze the pH to determine the primary acid-base state.
The pH is 7.36, which is within the normal range (7.35-7.45) but leans slightly acidic.
Identifying the pH direction helps determine the primary disorder even when physiological compensation is present.
2
Evaluate the respiratory (PaCO2) and metabolic (HCO3-) parameters.
The PaCO2 is significantly elevated at 58 mm Hg (normal 35-45 mm Hg), and the HCO3- is elevated at 32 mEq/L (normal 22-26 mEq/L).
This confirms a primary respiratory acidosis with a metabolic compensatory response.
3
Assess the level of compensation.
Because the pH has successfully returned to the normal physiological range, the body has achieved full compensation.
Full compensation occurs when the secondary mechanism (kidneys retaining bicarbonate) successfully brings the pH back into normal limits to maintain homeostasis.
4
Correlate the findings with the client's clinical presentation and history.
The client has severe COPD and is resting comfortably. The PaO2 of 62 mm Hg is acceptable, and the compensated state is their chronic baseline. The correct action is to document the findings.
Intervening on chronic, fully compensated ABGs can cause severe harm, such as suppressing the hypoxic drive by administering excess oxygen.

Key Concept

In severe chronic obstructive pulmonary disease, physiological adaptation to chronic carbon dioxide retention leads to fully compensated respiratory acidosis, which serves as the client's expected baseline.
Question 463Question →

A client receiving an intravenous transfusion of packed red blood cells (PRBCs) suddenly reports severe lower back pain, chills, and shortness of breath. To reduce the risk of severe physiological complications from a suspected acute hemolytic transfusion reaction, arrange the following nursing actions in the correct priority sequence.

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Answer

The correct sequence is to first stop the transfusion, second disconnect the tubing and initiate normal saline with new tubing, third assess the client's vital signs and clinical status, fourth notify the healthcare provider and blood bank, and fifth collect required specimens and send the blood product to the laboratory.
The priority in any acute hemolytic transfusion reaction is to immediately stop the exposure to the incompatible antigen. Following this, maintaining a patent IV with normal saline via new tubing ensures emergency access without infusing the residual blood in the old tubing. Only after the client is protected from further harm and IV access is secured should the nurse perform a full assessment, notify the provider with the assessment findings, and finally handle the collection of laboratory specimens.

Step-by-Step Solution

1
Identify the signs of an acute hemolytic transfusion reaction.
The nurse recognizes lower back pain, chills, and shortness of breath as medical emergencies requiring immediate intervention.
Early recognition is crucial for initiating risk reduction measures and preventing severe renal or cardiopulmonary failure.
2
Prioritize immediate physical risk reduction interventions.
The nurse stops the transfusion and secures IV access with a normal saline infusion via new tubing.
Stopping the infusion prevents further antigen exposure, and a new saline line ensures patent access for emergency medications without flushing residual blood into the client.
3
Gather clinical data and escalate care to the interdisciplinary team.
The nurse assesses vital signs, notifies the provider and blood bank, and sends required specimens to the laboratory.
Assessment data guides the provider's emergency prescriptions, while laboratory analysis of the blood and urine confirms hemolysis and dictates further systemic treatments.

Key Concept

Nursing management of an acute hemolytic transfusion reaction to reduce the risk of systemic complications.

Alternative Method

While the physical steps follow a strict chronological protocol, cognitive delegation can occur simultaneously. If a second nurse or rapid response team member is present, the primary nurse can delegate notifying the provider and blood bank while continuing to independently manage the airway and IV access.
Estimated Time:1m 30s
Question 464Question →

A client is receiving care in the trauma step-down unit after sustaining a T4 complete spinal cord injury. When evaluating the client for potential hemodynamic complications, which assessment finding specifically indicates that the client is developing neurogenic shock rather than hemorrhagic shock?

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Answer: Apical heart rate of 52 beats per minute accompanied by warm, dry skin

Answer

The finding of an apical heart rate of 52 beats per minute accompanied by warm, dry skin indicates neurogenic shock.
Neurogenic shock results from the disruption of sympathetic pathways in the spinal cord (typically injuries above T6). This loss of sympathetic tone allows parasympathetic activity to dominate, causing significant bradycardia rather than the tachycardia seen in other shock states. Furthermore, the loss of vascular tone causes massive vasodilation, which pools blood in the periphery and makes the skin feel warm and dry, contrasting sharply with the cool, clammy skin caused by compensatory vasoconstriction in hemorrhagic shock.

Step-by-Step Solution

1
Analyze the pathophysiology of the specific injury.
A T4 spinal cord injury disrupts the sympathetic nervous system pathways, leaving the parasympathetic nervous system (vagus nerve) unopposed.
Understanding the neurological deficits is required to anticipate physiological adaptations and potential shock states.
2
Compare the clinical manifestations of neurogenic shock and hemorrhagic shock.
Neurogenic shock presents with bradycardia and vasodilation (warm, dry skin). Hemorrhagic shock presents with tachycardia and vasoconstriction (cool, clammy skin, narrowing pulse pressure).
Differentiating these shock states is essential because their underlying mechanisms and treatments are completely different.
3
Evaluate the options against the clinical features of neurogenic shock.
The option presenting bradycardia and warm, dry skin perfectly matches the distributive profile of neurogenic shock.
This confirms the correct physiological indicator for the specific complication.

Key Concept

Neurogenic shock is characterized by the loss of sympathetic vascular tone, resulting in massive vasodilation, hypotension, and bradycardia, differentiating it from hypovolemic or hemorrhagic shock which present with tachycardia and vasoconstriction.
Estimated Time:1m 15s
Question 465Question →

A nurse in the neurological intensive care unit is evaluating a client who sustained a complete T3 spinal cord injury two months ago. The client suddenly reports a severe, throbbing headache and blurred vision. The nurse observes pronounced flushing and diaphoresis on the client's face, neck, and upper chest, while the skin on the lower extremities is pale and cool. Vital signs reveal a blood pressure of 210/110 mmHg, a heart rate of 48 beats/min, and respirations of 22 breaths/min. Which immediate nursing actions are appropriate? Select all that apply.

Select all that apply

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Answer: Elevate the head of the bed to a high Fowler's position.; Assess the patency of the indwelling urinary catheter or palpate the bladder.; Loosen any constrictive clothing, tight compression stockings, or restrictive bedding.

Answer

The correct immediate actions are elevating the head of the bed to a high Fowler's position, assessing the patency of the urinary catheter, and loosening any constrictive clothing.
The client is experiencing autonomic dysreflexia, a life-threatening hypertensive emergency occurring in clients with spinal cord injuries at or above the T6 level. Immediate management focuses on lowering blood pressure and removing the noxious stimulus. Elevating the head of the bed to a high Fowler's position utilizes orthostasis to rapidly lower blood pressure. Because bladder distention is the most common trigger, assessing catheter patency or checking for urinary retention is a critical next step. Loosening constrictive clothing removes another common peripheral sensory trigger.

Step-by-Step Solution

1
Analyze the client's clinical presentation and history.
The client has a T3 spinal cord injury and presents with severe hypertension, bradycardia, headache, and diaphoresis above the injury level.
These are the classic hallmark signs of autonomic dysreflexia, a medical emergency triggered by a noxious stimulus below the level of the injury (typically T6 or higher).
2
Determine the priority physiological intervention to prevent immediate harm.
The priority is to immediately reduce the dangerously high blood pressure by utilizing orthostasis (elevating the head of the bed).
Severe hypertension in autonomic dysreflexia can quickly lead to a stroke or myocardial infarction if not managed instantly.
3
Identify interventions aimed at removing the underlying cause.
Assess the urinary system for distention or catheter blockages, check the bowel for impaction, and remove any tight clothing.
The hypertensive crisis will not resolve until the triggering noxious stimulus is identified and eliminated.

Key Concept

Management of Autonomic Dysreflexia in Spinal Cord Injury
Question 466Question →

A client with right-sided hemiparesis is receiving continuous enteral nutrition via a nasogastric tube. When organizing the client's daily care and hygiene, which interventions should the nurse include? Select all that apply.

Select all that apply

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Answer: Pause the enteral nutrition infusion prior to lowering the head of the bed for repositioning.; Elevate and support the right arm with pillows to prevent shoulder subluxation.; Incorporate passive range-of-motion exercises for the right-sided extremities during the bath.

Answer

The correct interventions include pausing the enteral infusion before lowering the bed, supporting the affected arm with pillows, and performing passive range-of-motion exercises on the affected extremities.
The correct interventions directly address the client's risks. Pausing continuous feeds before lowering the head of the bed is essential to prevent aspiration of stomach contents. Elevating and supporting the flaccid right arm with pillows prevents shoulder subluxation and dependent edema. Integrating passive range-of-motion exercises into daily care prevents joint contractures and maintains flexibility in the hemiparetic limbs.

Step-by-Step Solution

1
Analyze the client's current clinical status and risk factors.
The client has right-sided hemiparesis (mobility deficit, risk for subluxation and contractures) and receives continuous enteral feeding (risk for aspiration).
Identifying specific risks determines the necessary safety and comfort interventions.
2
Evaluate each intervention for safety, proper delegation, and correct physiological principles.
Pausing feeds prevents aspiration; supporting the arm prevents subluxation; ROM prevents contractures. Assessment cannot be delegated to UAP; avoiding the affected side completely is contraindicated; acute confusion is abnormal.
Nursing actions must align with evidence-based practice guidelines and scope of practice.

Key Concept

Basic care and comfort measures for clients with hemiparesis and enteral feedings focus on aspiration prevention, maintaining joint mobility, proper positioning, and safe delegation.
Question 467Question →

During morning rounds on the progressive cardiac care unit, a nurse evaluates a 68-year-old individual who sustained an anterior ST-segment elevation myocardial infarction 36 hours ago. The client is newly restless, diaphoretic, and reports a 'sense of impending doom.' Current vital signs include a blood pressure of 98/82 mm Hg, heart rate of 122 beats per minute, respiratory rate of 26 breaths per minute, and oxygen saturation of 93% on room air. The urinary catheter has drained 15 mL over the previous hour. Which intervention represents the highest priority?

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Answer: Alert the rapid response team and prepare to administer inotropic medications

Answer

The correct action is to alert the rapid response team and prepare to administer inotropic medications.
The clinical presentation—a narrowed pulse pressure of 16 mm Hg, tachycardia, severe oliguria, and restlessness following an anterior myocardial infarction—strongly indicates early cardiogenic shock. Because the left ventricle is failing as a pump, cardiac output drops significantly, activating compensatory mechanisms that cause vasoconstriction and tachycardia. The immediate priority is to activate the rapid response team to escalate care. The client will urgently need advanced interventions, such as inotropic medications or mechanical circulatory support, to improve contractility and tissue perfusion.

Step-by-Step Solution

1
Analyze the vital signs and clinical presentation to determine the client's physiological status.
The client presents with a significantly narrowed pulse pressure (98 - 82 = 16 mm Hg), tachycardia, tachypnea, oliguria (15 mL/hr), and altered mental status (restlessness).
Identifying abnormal trends and clustering assessment data is the critical first step in recognizing physiological deterioration.
2
Correlate the assessment findings with potential post-myocardial infarction complications.
The combination of these signs in a client who recently suffered an anterior wall myocardial infarction strongly indicates the onset of cardiogenic shock.
An anterior myocardial infarction causes extensive damage to the left ventricle, creating a high risk for severe pump failure and decreased cardiac output.
3
Determine the most appropriate immediate nursing intervention to address the complication.
The priority is to immediately escalate care by notifying the rapid response team and preparing for pharmacological support, such as inotropes, to improve myocardial contractility.
Cardiogenic shock is an unstable, life-threatening medical emergency that requires advanced hemodynamic interventions to restore adequate tissue perfusion.

Key Concept

Early recognition and urgent management of cardiogenic shock
Question 468Question →

A nurse is preparing to administer an intravenous (IV) push dose of phenytoin to a client. The client has a single peripheral IV line currently infusing 5% dextrose in water (D5W) continuously. Phenytoin is physically incompatible with D5W. The nurse has already verified the client's identity, checked the medication prescription, and donned clean gloves. Arrange the following steps in the correct chronological order to safely administer the medication.

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Answer

The correct sequence is to first stop the incompatible D5W infusion, clamp the tubing above the port, flush with normal saline to clear the line, administer the phenytoin, flush again with normal saline at the same slow rate, and finally unclamp and restart the D5W infusion.
When administering an IV push medication that is incompatible with the continuous IV fluid, the nurse must create a 'saline lock' environment within the active line. This requires stopping the pump, clamping the line to prevent backflow, and clearing the line with a compatible flush (normal saline) before the medication is introduced. After administration, the line must be flushed again with normal saline to clear the drug from the catheter before the incompatible continuous fluid is resumed. The post-flush must be given at the same rate as the medication to avoid speed shock from the drug remaining in the catheter's dead space.

Step-by-Step Solution

1
Stop the D5W continuous infusion.
The flow of the incompatible fluid is halted.
Prevents the incompatible solution from actively flowing into the line during the medication administration process.
2
Clamp the primary IV tubing above the lowest port.
The fluid pathway back to the IV bag is blocked.
Prevents the normal saline flush and the phenytoin from traveling retrogradely up the IV tubing.
3
Flush the IV line with 10 mL of 0.9% sodium chloride.
Residual D5W is cleared from the lower tubing and catheter.
Phenytoin is highly incompatible with dextrose and will precipitate (crystallize) if they mix, potentially causing an embolus.
4
Administer the IV push phenytoin.
The medication is delivered to the client safely.
The line is now clear and filled with compatible normal saline, allowing safe administration.
5
Flush the line again with 10 mL of 0.9% sodium chloride at the same rate as the medication.
Residual phenytoin is cleared from the catheter into the bloodstream.
Flushing at the same slow rate ensures the remaining medication in the dead space is not rapidly pushed into the client, preventing speed shock.
6
Unclamp the tubing and restart the D5W infusion.
The client's prescribed continuous fluid therapy is resumed.
The medication administration is complete and the line is cleared, allowing safe resumption of the primary fluid.

Key Concept

Safe administration of an IV push medication through a continuous infusion of an incompatible solution using the flush-administer-flush technique.
Question 469Question →

Four hours following an extensive bowel resection, a client reports severe thirst and exhibits new-onset restlessness. The nurse reviews the client's current clinical data:

ParameterCurrent ValuePreoperative Baseline
Blood Pressure104/76104/76 mm Hg134/82134/82 mm Hg
Heart Rate118118 beats/min7676 beats/min
Respiratory Rate2828 breaths/min1414 breaths/min
Oxygen Saturation96%96\% on room air98%98\% on room air

Recent arterial blood gas (ABG) results show a pH of 7.487.48, PaCO 2_2 of 3030 mm Hg, and HCO 3−_3^- of 2323 mEq/L.

Which of the following is the priority nursing action?

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Answer: Examine the surgical dressing and palpate the abdomen for rigidity or distension.

Answer

The priority action is to examine the surgical dressing and palpate the abdomen for rigidity or distension.
The client's presentation of restlessness, severe thirst, tachycardia, and a narrowing pulse pressure are hallmark signs of the compensatory stage of hypovolemic shock, likely due to internal hemorrhage following major abdominal surgery. The respiratory alkalosis is a compensatory response to sympathetic stimulation and poor tissue perfusion. The highest priority is to assess the source of the suspected bleeding by examining the surgical dressing and abdomen.

Step-by-Step Solution

1
Analyze the vital signs and clinical presentation.
The client exhibits tachycardia (118118 bpm), tachypnea (2828 breaths/min), a narrowing pulse pressure (from 5252 mm Hg to 2828 mm Hg), restlessness, and severe thirst.
Recognizing deviations from baseline is essential to identify early physiological deterioration.
2
Interpret the arterial blood gas (ABG) results.
The elevated pH (7.487.48) and low PaCO 2_2 (3030 mm Hg) with a normal HCO 3−_3^- (2323 mEq/L) indicate uncompensated respiratory alkalosis.
Understanding the acid-base balance helps determine if the respiratory changes are primary or a compensatory mechanism.
3
Synthesize the data to identify the primary problem.
The overall clinical picture strongly indicates the compensatory stage of hypovolemic (hemorrhagic) shock. The respiratory alkalosis is a secondary compensatory mechanism driven by sympathetic nervous system activation and poor tissue perfusion.
Prioritization requires identifying the root cause of the instability (Circulation) rather than treating isolated symptoms.
4
Determine the priority nursing intervention.
The nurse must immediately assess the surgical site and abdomen for evidence of internal or external hemorrhage before initiating further interventions.
Targeted assessment of the suspected source of circulatory loss dictates the subsequent life-saving resuscitation efforts.

Key Concept

Early recognition of hypovolemic shock and prioritization of circulatory assessment over compensatory symptoms.

Alternative Method

Use the pulse pressure calculation to detect early shock. The baseline pulse pressure was 5252 mm Hg (134−82134-82) and has narrowed significantly to 2828 mm Hg (104−76104-76). A narrowing pulse pressure is one of the earliest signs of volume depletion, occurring before a profound drop in systolic blood pressure.
Estimated Time:1m 30s
Question 470Question →

A client who is experiencing recurrent seizures is prescribed a 1,000 mg intravenous (IV) loading dose of phenytoin. The client currently has a continuous primary IV infusion of 5% dextrose in water (D5W) running at 75 mL/hr through a peripheral catheter. What is the safest administration sequence for the nurse to implement?

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Answer: Dilute the medication in 0.9% sodium chloride, pause the primary fluids, flush the catheter with 0.9% sodium chloride, and administer the dose through an in-line filter.

Answer

The safest action is to dilute the phenytoin in 0.9% sodium chloride, pause the primary dextrose infusion, flush the IV line with 0.9% sodium chloride before and after administration, and use an in-line filter.
Phenytoin is highly incompatible with dextrose-containing solutions and will form a solid precipitate if mixed. To safely administer the loading dose, the nurse must dilute it only in 0.9% sodium chloride (normal saline), stop the primary D5W infusion, flush the IV catheter with normal saline before and after administration, and use an in-line filter to catch any potential microscopic crystallization. Additionally, the infusion rate must not exceed 50 mg/minute to prevent severe hypotension and cardiac arrhythmias.

Step-by-Step Solution

1
Determine the compatibility of phenytoin with the current continuous IV fluid (D5W).
Phenytoin is identified as strictly incompatible with dextrose solutions.
Mixing phenytoin with dextrose causes immediate precipitation and microscopic crystal formation, which can lead to life-threatening emboli.
2
Select the appropriate administration technique and diluent.
The nurse must stop the D5W infusion, flush the line with 0.9% sodium chloride, administer the medication through an in-line filter, and flush again with normal saline.
This sequence prevents any mixing of the medication with dextrose in the tubing, and the filter catches any potential particulate matter.
3
Verify the safe administration rate for the loading dose.
The maximum IV administration rate for phenytoin is 50 mg/minute.
Rapid administration of phenytoin can precipitate severe cardiovascular toxicity, including hypotension, bradycardia, and cardiac arrest.

Key Concept

Phenytoin IV administration requires strict compatibility checks (only compatible with normal saline), the use of an in-line filter, and adherence to a maximum infusion rate of 50 mg/minute to prevent precipitation and severe cardiovascular toxicity.
Question 471Question →

A clinical nurse is preparing to draw a blood specimen for a comprehensive metabolic panel (CMP) from an adult client's triple-lumen central venous access device (CVAD). The client currently has a continuous intravenous infusion of 0.9% sodium chloride with 20 mEq of potassium chloride infusing through the proximal lumen. To ensure accurate laboratory results and reduce the risk of infection, in what order should the nurse perform the following actions? Arrange the steps in the correct sequence.

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Answer

The correct sequence is: Pause the continuous intravenous infusion -> Scrub the needleless connector -> Aspirate 5 mL of blood to discard -> Withdraw the required volume of blood -> Flush the catheter lumen.
The correct sequence prioritizes analytical accuracy and infection control. First, pausing the infusion prevents drawing a diluted or contaminated sample. Scrubbing the hub is the primary defense against CLABSI. Discarding the initial 5 mL ensures the sample is pure whole blood, not the dwelling medication. Drawing the sample follows, and the procedure concludes with a thorough saline flush to clear the line and maintain patency.

Step-by-Step Solution

1
Pause the continuous intravenous infusion and wait at least one minute.
The active infusion is halted.
Prevents contamination of the blood sample with the infusing fluids, ensuring accurate lab results.
2
Scrub the needleless connector of the designated lumen with an antiseptic swab.
The connector is disinfected.
Reduces the risk of introducing pathogens into the bloodstream, preventing CLABSI.
3
Attach a syringe and aspirate 5 mL of blood to discard.
The clearance volume is removed.
Removes residual fluid and medication dwelling within the catheter lumen that would otherwise alter the laboratory specimen.
4
Attach a new syringe to withdraw the required volume of blood for the laboratory sample.
The pure blood specimen is collected.
Provides an uncontaminated, accurate representation of the client's systemic blood for the comprehensive metabolic panel.
5
Flush the catheter lumen with 10 to 20 mL of sterile 0.9% sodium chloride.
The lumen is cleared of residual blood.
Removes red blood cells from the catheter, maintains patency, and prevents thrombus formation.

Key Concept

Central Venous Access Device (CVAD) Blood Sampling Sequence
Question 472Question →

A nurse is creating a plan of care for an older adult client admitted with acute decompensated heart failure. The client has severe peripheral edema, is experiencing orthopnea, and has become restless, frequently picking at their continuous intravenous (IV) infusion line. Which of the following nursing interventions should be included in the client's basic care and comfort plan? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Maintain the head of the bed elevated at 45 to 60 degrees.; Apply a protective moisture barrier cream to the perineal area following routine hygiene care.; Implement non-pharmacological interventions such as reducing room noise and dimming the lights to address restlessness.

Answer

The correct interventions are maintaining the head of the bed elevated at 45 to 60 degrees, applying a protective moisture barrier cream to the perineal area, and implementing non-pharmacological interventions to reduce environmental stimuli.
The correct nursing actions prioritize respiratory function, skin integrity, and safe comfort measures. Elevating the head of the bed utilizes gravity to pull the diaphragm downward, expanding the lungs and relieving orthopnea. Protecting the skin with a barrier cream is a fundamental hygiene measure that prevents breakdown in edematous tissue. Utilizing environmental modifications, such as dimming lights, addresses restlessness safely without resorting to restrictive measures.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has acute decompensated heart failure, orthopnea, peripheral edema, and restlessness.
Understanding the pathophysiology guides safe positioning and comfort interventions.
2
Evaluate positioning options based on respiratory status.
Elevating the head of the bed is indicated to relieve orthopnea; a flat position is contraindicated.
Supine positioning increases preload, worsening pulmonary edema.
3
Assess hygiene and skin care needs.
Applying moisture barrier cream is appropriate to protect edematous, vulnerable skin.
Basic care includes maintaining skin integrity and preventing breakdown.
4
Review safety, delegation, and restraint protocols for the restless client.
Initial assessment cannot be delegated. Restraints are inappropriate as an initial intervention; non-pharmacological soothing measures should be used first.
Nursing practice requires adherence to legal scope of practice and the principle of least restrictive interventions.

Key Concept

Basic Care and Comfort in Acute Decompensated Heart Failure
Question 473Question →

A nurse is evaluating a client who is receiving continuous intravenous fluid therapy for severe acute pancreatitis. Which assessment findings indicate the client is developing early hypovolemic shock? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Urine output of 25 mL over the past hour; Heart rate increases from 86 to 118 beats per minute; Client becomes increasingly restless and agitated

Answer

The assessment findings indicating early hypovolemic shock are the decreased urine output, the increased heart rate, and the new onset of restlessness and agitation.
In early (compensatory) hypovolemic shock, the sympathetic nervous system stimulates an increase in heart rate to maintain cardiac output. Blood is shunted away from non-vital organs, leading to decreased renal perfusion and oliguria (typically less than 30 mL/hr). Additionally, early decreases in cerebral perfusion initially manifest as subtle neurological changes, such as restlessness, agitation, or anxiety. Blood pressure is typically maintained during this phase.

Step-by-Step Solution

1
Analyze the pathophysiology of severe acute pancreatitis.
Recognize that massive fluid shifts into the peritoneal cavity and systemic inflammation can cause profound intravascular volume depletion.
To identify the client's specific risk for developing hypovolemic shock.
2
Identify compensatory mechanisms associated with early shock.
The sympathetic nervous system activates, causing tachycardia, peripheral vasoconstriction, and decreased renal perfusion to maintain core blood pressure.
To distinguish early physiological responses from late decompensatory failure.
3
Evaluate the given assessment findings against early shock indicators.
Tachycardia, oliguria (less than 30 mL/hr), and altered mentation are classical early signs. Hypotension and acidosis are late signs, while warm skin indicates a different shock etiology.
To select the options that correctly match the early compensatory phase of hypovolemia.

Key Concept

Early Indicators of Hypovolemic Shock
Question 474Question →

A nurse is developing a plan of care for an adult client who returned to the surgical unit 4 hours ago following a left-sided pneumonectomy for a pulmonary malignancy. Which intervention is essential to include to reduce the risk of severe physiological complications?

Show answer & explanation

Answer: Maintain the client in a supine position or side-lying on the left side.

Answer

Maintain the client in a supine position or side-lying on the left (operative) side.
Following a pneumonectomy, the client must be positioned supine or on the operative side (in this case, the left side). This positioning ensures that the remaining functional lung on the non-operative side is uncompressed and can fully expand for optimal gas exchange. Additionally, keeping the operative side down allows serous fluid to accumulate naturally in the empty hemithorax, which helps prevent a dangerous mediastinal shift by stabilizing the pressure in the chest cavity.

Step-by-Step Solution

1
Analyze the client's surgical procedure.
The client underwent a left-sided pneumonectomy, meaning the entire left lung was removed.
Understanding the anatomical changes is critical for anticipating post-operative physiological vulnerabilities.
2
Evaluate the physiological impact of positioning on the remaining lung.
Positioning on the non-operative (right) side will compress the only functional lung due to gravity, while positioning on the operative (left) side allows the functional lung to fully expand.
Maximum ventilation of the single remaining lung is essential to prevent hypoxia and respiratory failure.
3
Select the intervention that prioritizes airway and breathing risk reduction.
Maintaining the client supine or on the left side is the safest positioning strategy.
This specific positioning actively prevents respiratory decompensation and allows fluid to stabilize the empty pleural space, preventing mediastinal shift.

Key Concept

Post-pneumonectomy positioning requires the client to be placed supine or on the operative side to promote full expansion of the remaining functional lung and to prevent a mediastinal shift.
Estimated Time:1m 30s
Question 475Question →

A nurse is caring for a mechanically ventilated client who requires continuous sedation. The healthcare provider prescribes a propofol infusion at 20 mcg/kg/min20 \text{ mcg/kg/min}. The client weighs 176 lbs176 \text{ lbs}. The medication is supplied as 10 mg/mL10 \text{ mg/mL}. At what rate in mL/hr\text{mL/hr} should the nurse set the intravenous pump? (Record your answer to the nearest tenth.)

Show answer & explanation

Answer: 9.6

Answer

9.6
To determine the correct rate, the nurse must execute a sequential calculation: convert weight to kilograms (80 kg80 \text{ kg}), find the dose per minute (1,600 mcg/min1,600 \text{ mcg/min}), convert to the dose per hour (96,000 mcg/hr96,000 \text{ mcg/hr}), translate micrograms to milligrams (96 mg/hr96 \text{ mg/hr}), and finally divide by the concentration (10 mg/mL10 \text{ mg/mL}) to arrive at the correct pump rate of 9.6 mL/hr9.6 \text{ mL/hr}.

Step-by-Step Solution

1
Convert the client's weight from pounds to kilograms.
176 lbs÷2.2 lbs/kg=80 kg176 \text{ lbs} \div 2.2 \text{ lbs/kg} = 80 \text{ kg}
The prescription is weight-based, requiring the client's mass in kilograms.
2
Calculate the total required dose per minute.
20 mcg/kg/min×80 kg=1600 mcg/min20 \text{ mcg/kg/min} \times 80 \text{ kg} = 1600 \text{ mcg/min}
Multiplying the ordered dose by the client's weight determines the specific dose needed each minute.
3
Convert the dose per minute to the dose per hour.
1600 mcg/min×60 min/hr=96,000 mcg/hr1600 \text{ mcg/min} \times 60 \text{ min/hr} = 96,000 \text{ mcg/hr}
Intravenous pumps run in hourly rates (mL/hr), so the minute-based dose must be converted to an hourly dose.
4
Convert the hourly dose from micrograms to milligrams.
96,000 mcg/hr÷1000 mcg/mg=96 mg/hr96,000 \text{ mcg/hr} \div 1000 \text{ mcg/mg} = 96 \text{ mg/hr}
The supplied medication concentration is provided in milligrams, meaning the desired dose must match this unit.
5
Calculate the final infusion rate in mL/hr.
96 mg/hr÷10 mg/mL=9.6 mL/hr96 \text{ mg/hr} \div 10 \text{ mg/mL} = 9.6 \text{ mL/hr}
Dividing the desired hourly dose by the available concentration yields the volumetric rate to program into the IV pump.

Key Concept

Weight-based Intravenous Continuous Infusion Calculations
Question 476Question →

A nurse is caring for a client with a complete T4 spinal cord injury who suddenly reports a severe, pounding headache. The nurse notes facial flushing, profuse diaphoresis above the nipple line, and a blood pressure of 214/118214/118 mm Hg. Arrange the following nursing interventions in the correct order of clinical priority.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence of actions for managing autonomic dysreflexia is to first elevate the head of the bed, then loosen restrictive clothing, assess the bladder and catheter, evaluate for bowel impaction, and finally administer an antihypertensive medication.
Autonomic dysreflexia is a medical emergency in clients with spinal cord injuries at or above T6. The uninhibited sympathetic response below the level of injury causes severe vasoconstriction and hypertension. The absolute first priority is to lower the blood pressure immediately by elevating the head of the bed to induce orthostatic pooling. Next, the nurse must systematically identify and remove the noxious stimuli causing the reaction. External stimuli (tight clothing) are addressed first as they are quickest to resolve. Then, internal stimuli are assessed in order of frequency: bladder issues (most common) followed by bowel issues (second most common). Pharmacological interventions are reserved for situations where identifying and resolving the stimulus is ineffective or the blood pressure remains dangerously high.

Step-by-Step Solution

1
Elevate the head of the bed to a high Fowler's position.
Immediate mechanical reduction in systemic blood pressure.
Taking advantage of orthostatic pooling of blood in the lower extremities helps rapidly lower systemic blood pressure to prevent a hypertensive stroke, which is the immediate life threat.
2
Loosen any restrictive clothing, tight abdominal binders, or anti-embolism stockings.
Elimination of potential external noxious stimuli.
External pressure can trigger the exaggerated sympathetic nervous system response. Removing this pressure is rapid and non-invasive.
3
Palpate the bladder for distention and check the indwelling urinary catheter for kinks.
Identification and relief of the primary internal trigger.
A distended bladder is the most common cause of autonomic dysreflexia; emptying the bladder or removing a kink rapidly eliminates the primary stimulus.
4
Evaluate the rectum for fecal impaction after applying a topical anesthetic ointment.
Identification of secondary internal triggers.
Bowel impaction is the second most common cause. A topical anesthetic must be applied prior to the digital rectal exam to prevent further stimulation of the autonomic reflex during the procedure.
5
Administer a prescribed rapid-acting intravenous antihypertensive medication.
Pharmacological control of severe hypertension.
If identifying and removing the physical triggers does not resolve the crisis, or if the triggers cannot be immediately found, medical management is required to lower the blood pressure safely.

Key Concept

Management of autonomic dysreflexia prioritizes immediate blood pressure reduction through physical positioning, followed by the systematic elimination of noxious stimuli, before resorting to pharmacological intervention.
Question 477Question →

A nurse is caring for an adult client with end-stage cirrhosis who recently underwent an ultrasound-guided bedside paracentesis with the removal of 4.5 liters4.5 \text{ liters} of ascitic fluid. Prior to the procedure, the client's vital signs were blood pressure 126/82 mmHg126/82 \text{ mmHg} and heart rate 86 bpm86 \text{ bpm}.

Thirty minutes post-procedure, the client reports feeling slightly dizzy. The current assessment reveals the following data:

ParameterCurrent Value
Blood Pressure92/74 mmHg92/74 \text{ mmHg}
Heart Rate118 bpm118 \text{ bpm}
Respiratory Rate20 breaths/min20 \text{ breaths/min}
SpO2SpO_296%96\% on room air
Arterial pHpH7.327.32
PaCO2PaCO_231 mmHg31 \text{ mmHg}
HCO3−HCO_3^-15 mEq/L15 \text{ mEq/L}

Which action should the nurse take next to reduce the risk of severe physiological compromise?

Show answer & explanation

Answer: Initiate the prescribed intravenous infusion of 25% human albumin.

Answer

The correct action is to initiate the prescribed intravenous infusion of 25% human albumin to prevent paracentesis-induced circulatory dysfunction.
The removal of a large volume of ascitic fluid rapidly decreases intra-abdominal pressure, leading to splanchnic vasodilation and a massive shift of intravascular fluid into the peritoneal space. This phenomenon, known as paracentesis-induced circulatory dysfunction (PICD), causes severe hypovolemia. The client's narrowing pulse pressure (92−74=18 mmHg92 - 74 = 18 \text{ mmHg}) and tachycardia (118 bpm118 \text{ bpm}) are classic early compensatory signs of hypovolemic shock. Administering a hypertonic colloid, such as 25% human albumin, increases intravascular oncotic pressure, pulling fluid back into the vascular space and effectively mitigating the risk of cardiovascular collapse.

Step-by-Step Solution

1
Analyze the vital sign changes from baseline.
The blood pressure has dropped significantly to 92/74 mmHg92/74 \text{ mmHg}, the pulse pressure has narrowed to 18 mmHg18 \text{ mmHg} (92−74=1892 - 74 = 18), and the heart rate has increased to 118 bpm118 \text{ bpm}.
Recognizing early hemodynamic trends is essential for detecting the onset of compensatory hypovolemic shock.
2
Interpret the arterial blood gas (ABG) values.
The ABG indicates a metabolic acidosis (pHpH 7.327.32, HCO3−HCO_3^- 1515) with partial respiratory compensation (PaCO2PaCO_2 3131), not a respiratory acidosis.
Accurate ABG interpretation prevents implementing inappropriate interventions, such as attempting to correct a nonexistent respiratory problem.
3
Evaluate the physiological impact of large-volume fluid removal.
The rapid removal of 4.5 liters4.5 \text{ liters} of fluid drastically decreases intra-abdominal pressure, causing splanchnic vasodilation and a massive intravascular fluid shift.
Understanding the fluid dynamics of a large-volume paracentesis highlights the immediate risk for profound hypovolemia.
4
Select the priority risk-reduction intervention.
Administering a hypertonic colloid, such as 25% human albumin, is selected to restore intravascular volume.
Albumin provides the necessary oncotic pressure to pull fluid back into the vascular space, stabilizing hemodynamics and preventing cardiovascular collapse.

Key Concept

Paracentesis-Induced Circulatory Dysfunction (PICD)
Question 478Question →

A nurse is preparing to initiate a continuous intravenous (IV) infusion of regular insulin for a client experiencing diabetic ketoacidosis (DKA). The pharmacy has provided a prepared bag containing 100 units of regular insulin mixed in 100 mL of 0.9% sodium chloride. Which of the following actions must the nurse take when setting up the primary IV tubing for this infusion?

Show answer & explanation

Answer: Prime the IV tubing with the insulin solution and discard approximately 50 mL of the fluid before connecting it to the client.

Answer

The nurse must prime the intravenous tubing with the insulin solution and discard approximately 50 mL of the fluid before connecting it to the client.
Insulin molecules readily adsorb (bind) to the inner plastic lining of standard polyvinyl chloride (PVC) intravenous tubing. If the tubing is not primed and saturated with the insulin solution prior to connection, the client will receive a significantly lower dose of insulin than prescribed during the crucial initial hours of therapy. Discarding approximately 20 to 50 mL of the primed fluid ensures the tubing's binding sites are completely saturated, allowing for immediate and accurate dose delivery to the client.

Step-by-Step Solution

1
Identify the unique pharmacological properties of regular insulin when administered via a continuous intravenous infusion.
Regular insulin molecules naturally adsorb (bind) to the inner plastic lining of standard polyvinyl chloride (PVC) intravenous tubing.
Understanding this physical interaction is essential to prevent severe under-dosing during the critical initial hours of diabetic ketoacidosis treatment.
2
Determine the required nursing intervention to counteract insulin adsorption to the tubing.
The nurse must prime the tubing with the prepared insulin solution and allow 20 to 50 mL of the fluid to run through and be discarded.
This process fully saturates the binding sites on the PVC tubing, ensuring that the concentration of insulin reaching the client immediately matches the prescribed dose.
3
Evaluate the alternative interventions for safety and adherence to parenteral therapy protocols.
Avoid shaking the bag (which denatures proteins), do not use an unnecessary in-line filter, and never piggyback an insulin drip into a rapidly infusing fluid bolus.
Eliminating unsafe practices guarantees that the high-alert medication is administered correctly without risking cardiovascular collapse or hypoglycemia.

Key Concept

Intravenous Insulin Adsorption and Tubing Saturation
Question 479Question →

A 7272-year-old client with advanced emphysema is admitted to the progressive care unit with acute respiratory failure. The client is receiving noninvasive positive pressure ventilation (NIPPV). During the reassessment, the nurse notes copious, thick pulmonary secretions, extreme agitation, and a respiratory rate of 3232 breaths/minute. The most recent arterial blood gas (ABG) analysis reveals a pH of 7.257.25, PaCO2\text{PaCO}_2 of 7474 mmHg, HCO3−\text{HCO}_3^- of 3232 mEq/L, and PaO2\text{PaO}_2 of 5454 mmHg. To mitigate the risk of impending physiological collapse, which action should the nurse implement?

Show answer & explanation

Answer: Discontinue the noninvasive positive pressure ventilation, initiate manual bag-valve-mask ventilation, and prepare for endotracheal intubation.

Answer

The nurse must discontinue the noninvasive positive pressure ventilation, begin manual bag-valve-mask ventilation, and prepare for immediate endotracheal intubation.
The correct action directly mitigates the highest risk to the client: imminent respiratory arrest. The combination of extreme agitation (a classic sign of severe hypoxia), copious secretions, and a drastically worsening ABG profile (pH 7.257.25, PaCO2\text{PaCO}_2 7474 mmHg) demonstrates that noninvasive positive pressure ventilation has failed. The client can no longer protect their airway, making immediate endotracheal intubation the only safe and effective intervention.

Step-by-Step Solution

1
Analyze the arterial blood gas (ABG) results.
The ABG reveals uncompensated respiratory acidosis (pH 7.257.25, PaCO2\text{PaCO}_2 7474 mmHg) and severe hypoxemia (PaO2\text{PaO}_2 5454 mmHg).
Accurate ABG interpretation is essential to determine the adequacy of the client's current ventilation and oxygenation status.
2
Evaluate the clinical signs and symptoms in conjunction with the NIPPV therapy.
The presence of copious secretions and extreme agitation are identified as absolute contraindications for continuing NIPPV.
NIPPV masks block the expulsion of thick secretions, increasing aspiration risk, while agitation signals profound tissue hypoxia and air hunger.
3
Determine the priority risk-reduction intervention.
The decision is made to abandon the failing NIPPV strategy and secure a definitive airway.
When noninvasive measures fail to reverse life-threatening respiratory acidosis and airway protection is compromised, immediate endotracheal intubation is required to prevent respiratory arrest.

Key Concept

Recognizing the failure of noninvasive positive pressure ventilation (NIPPV) and identifying indications for immediate endotracheal intubation.
Question 480Question →

While providing care for an elderly client admitted with community-acquired pneumonia, the nurse notes a sudden shift in the client's baseline mental status, characterized by agitation and confusion. An immediate assessment yields the following data: blood pressure 86/52 mm Hg, heart rate 118 beats/min, respiratory rate 26 breaths/min, and an oral temperature of 96.8°F (36.0°C). Which intervention must the nurse execute first?

Show answer & explanation

Answer: Notify the rapid response team and prepare to administer an isotonic fluid bolus.

Answer

The nurse must prioritize notifying the rapid response team and initiating an isotonic fluid bolus to treat impending septic shock.
The correct answer emphasizes immediate circulatory support. The client's clinical picture—hypotension, tachycardia, tachypnea, hypothermia, and a sudden change in mental status—indicates progression to septic shock. Because perfusion is severely compromised, the highest priority according to the ABC (Airway, Breathing, Circulation) framework is to notify the rapid response team and restore intravascular volume with isotonic crystalloid fluids.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client exhibits new-onset confusion, hypothermia (96.8°F / 36.0°C), tachycardia (118 beats/min), tachypnea (26 breaths/min), and severe hypotension (86/52 mm Hg).
Identifying abnormal assessment findings and recognizing acute deviations from the baseline is the foundational step in clinical reasoning.
2
Synthesize the findings to identify the underlying pathophysiological process.
The combination of these signs in an older adult with an existing infection strongly indicates systemic inflammatory response syndrome (SIRS) progressing to septic shock.
Older adults frequently present atypically with severe infections, often manifesting hypothermia and altered mental status rather than a traditional high fever.
3
Determine the priority nursing intervention based on the ABCs (Airway, Breathing, Circulation).
Circulatory collapse, evidenced by the severe hypotension and compensatory tachycardia, requires immediate life-saving intervention with fluid resuscitation.
Restoring intravascular volume is critical to reverse poor tissue perfusion and prevent irreversible multiorgan failure.

Key Concept

Early Recognition and Management of Septic Shock in Older Adults
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