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A charge nurse is observing a newly licensed nurse care for a 24-year-old client admitted with diabetic ketoacidosis (DKA). The client is lethargic and exhibiting deep, rapid respirations at 32 breaths/minute. Arterial blood gas (ABG) results indicate a pH of 7.23, $PaCO_2$ of 26 mm Hg, and $HCO_3^-$ of 14 mEq/L. Which action by the newly licensed nurse requires immediate intervention by the charge nurse?

Coaching the client to breathe into a paper bag to decrease the respiratory rate.

Initiating a rapid intravenous infusion of

0.9\%

sodium chloride as prescribed.

Preparing a continuous intravenous infusion of regular insulin to lower blood glucose.

Withholding prescribed intravenous potassium chloride until the client produces urine.

Show answer & explanation

Answer: Coaching the client to breathe into a paper bag to decrease the respiratory rate.

Answer

Coaching the client to breathe into a paper bag to decrease the respiratory rate.

The newly licensed nurse is attempting to treat the client's rapid breathing as if it were a panic attack (hyperventilation syndrome). However, in diabetic ketoacidosis, deep and rapid breathing (Kussmaul respirations) is a vital compensatory mechanism. The lungs are exhaling large amounts of

CO_2

(which acts as an acid in the blood) to help bring the acidic pH back toward normal. Having the client breathe into a paper bag forces them to rebreathe

CO_2

, defeating the compensatory mechanism and causing the blood pH to drop further, which can lead to cardiovascular collapse and death. The charge nurse must intervene immediately.

Step-by-Step Solution

Analyze the client's clinical presentation and Arterial Blood Gas (ABG) results.

The low pH of 7.23 and low

HCO_3^-

of 14 mEq/L indicate metabolic acidosis. The

PaCO_2

of 26 mm Hg is lower than the normal range, indicating a respiratory compensation effort.

Identifying the primary acid-base imbalance is necessary to determine the physiological state and the appropriateness of clinical interventions.

Evaluate the client's respiratory pattern in relation to the ABG values.

The deep, rapid breathing at 32 breaths/minute represents Kussmaul respirations.

The lungs are naturally attempting to compensate for the severe metabolic acidosis by blowing off excess carbon dioxide (an acid) to raise the blood pH.

Assess each nursing action to determine if it reduces risk or causes harm.

Using a paper bag would cause the client to rebreathe carbon dioxide, which disrupts the compensatory mechanism and worsens the acidosis. The other actions (administering fluids, insulin, and verifying urine before potassium) are standard, correct interventions for DKA.

The charge nurse must intervene only when a delegated or observed action places the client at significant risk for physiological deterioration.

Key Concept

Compensatory mechanisms in metabolic acidosis (Kussmaul respirations)

Question 582Question →

A nurse is preparing to administer intravenous (IV) potassium chloride (KCl) $40\text{ mEq}$ in $250\text{ mL}$ of $0.9\%$ sodium chloride to a client with a serum potassium level of $2.6\text{ mEq/L}$ . The client is currently receiving a continuous IV infusion of pantoprazole through a single peripheral IV line. Which of the following actions by the nurse are appropriate? Select all that apply.

Select all that apply

Verify that the client's urine output has been at least

30\text{ mL/hr}

before initiating the infusion.

Administer the medication as an undiluted IV push over

3

5\text{ minutes}

to quickly stabilize the cardiac rhythm.

Assess the peripheral IV insertion site for signs of phlebitis or infiltration hourly during the infusion.

Program the electronic infusion pump to deliver the potassium chloride at a rate of

40\text{ mEq/hr}

Check a drug reference guide to confirm the compatibility of potassium chloride with pantoprazole at the Y-site.

Temporarily stop the pantoprazole, manually flush the line with

3\text{ mL}

of sterile water, and connect the potassium infusion.

Show answer & explanation

Answer: Verify that the client's urine output has been at least $30\text{ mL/hr}$ before initiating the infusion.; Assess the peripheral IV insertion site for signs of phlebitis or infiltration hourly during the infusion.; Check a drug reference guide to confirm the compatibility of potassium chloride with pantoprazole at the Y-site.

Answer

The appropriate actions are verifying adequate urine output, assessing the IV site hourly for infiltration, and checking Y-site compatibility with the concurrent pantoprazole infusion.

Safe administration of intravenous potassium chloride requires confirming adequate renal function (urine output

> 30\text{ mL/hr}

) to prevent accumulation, meticulously assessing the peripheral IV site due to the drug's vesicant properties, and verifying Y-site compatibility with any continuous infusions to prevent dangerous crystallization in the tubing.

Step-by-Step Solution

Evaluate the prescribed medication (potassium chloride) for strict safety parameters and administration routes.

Identify that potassium chloride must be diluted, infused slowly via a pump (max

10\text{ mEq/hr}

peripherally), and never given IV push.

Rapid administration of potassium causes fatal cardiac dysrhythmias.

Assess the client's physiological readiness to receive the medication.

Determine that urine output must be at least

30\text{ mL/hr}

Potassium is primarily excreted by the kidneys; oliguria or anuria can lead to toxic accumulation.

Analyze the method of delivery and concurrently infusing medications.

Identify that Y-site compatibility with pantoprazole must be verified, and the peripheral site must be monitored hourly.

Mixing incompatible drugs causes precipitation, and potassium is a vesicant that can cause severe tissue necrosis if it infiltrates.

Key Concept

High-alert parenteral medication safety principles, specifically focusing on intravenous potassium administration, compatibility, and organ function assessment.

Question 583Question →

A nurse is evaluating a client who underwent a percutaneous coronary intervention (PCI) via the right femoral artery 2 hours ago. Which of the following assessment findings require immediate intervention? Select all that apply.

Select all that apply

The client reports a new, sudden onset of right-sided flank pain.

The client's heart rate has increased steadily from 78 to 112 beats per minute over the last hour.

The client is resting in bed with the head of the bed elevated to a 60-degree angle.

The client's current blood pressure is 118/76 mm Hg, compared to a pre-procedure baseline of 124/80 mm Hg.

The client's most recent arterial blood gas analysis reveals a pH of 7.42, PaCO2 of 38 mm Hg, and HCO3 of 24 mEq/L.

The client's right pedal pulse is palpable and equal in amplitude to the left pedal pulse.

Show answer & explanation

Answer: The client reports a new, sudden onset of right-sided flank pain.; The client's heart rate has increased steadily from 78 to 112 beats per minute over the last hour.; The client is resting in bed with the head of the bed elevated to a 60-degree angle.

Answer

The findings requiring immediate intervention include the new onset of right-sided flank pain, a steadily increasing heart rate, and the head of the bed being elevated to a 60-degree angle.

The correct options identify significant risks and complications associated with femoral artery access. Sudden flank pain is a classic indicator of retroperitoneal hemorrhage. A steadily increasing heart rate is an early compensatory sign of hypovolemic shock. Elevating the head of the bed to 60 degrees is a contraindicated position because severe hip flexion can dislodge the clot at the femoral insertion site, leading to acute bleeding.

Step-by-Step Solution

Analyze the procedure and approach.

The client underwent a percutaneous coronary intervention via the right femoral artery.

Identifying the procedure highlights the specific risks: femoral access carries a high risk of bleeding, hematoma, retroperitoneal hemorrhage, and arterial occlusion.

Evaluate each option for signs of complications or procedural risks.

Flank pain indicates internal bleeding. Tachycardia indicates early shock. A bed elevated to 60 degrees creates hip flexion that risks dislodging the clot.

Differentiating between expected post-procedure findings and actual physiological decompensation is essential for risk reduction.

Differentiate abnormal findings from normal post-procedure data.

Slightly lower blood pressure, normal ABG values, and palpable pedal pulses are normal, expected findings that do not require intervention.

Recognizing normal parameters prevents unnecessary interventions and improper prioritization.

Key Concept

Post-Cardiac Catheterization Complication Monitoring

Question 584Question →

An emergency department nurse is continuously monitoring a client who sustained severe blunt abdominal trauma. The client's baseline vital signs upon arrival were blood pressure 124/76 mm Hg, heart rate 82/min, and respiratory rate 16/min. Which of the following subsequent assessment findings should the nurse identify as the earliest clinical indicator of hemorrhagic shock?

Blood pressure of 118/88 mm Hg and a heart rate of 98/min

Blood pressure of 86/52 mm Hg and a heart rate of 124/min

Arterial blood gas results demonstrating uncompensated metabolic acidosis

Presence of cold, mottled extremities with barely palpable pedal pulses

Show answer & explanation

Answer: Blood pressure of 118/88 mm Hg and a heart rate of 98/min

Answer

Blood pressure of 118/88 mm Hg and a heart rate of 98/min

In the early (compensatory) stage of hemorrhagic shock, the sympathetic nervous system is activated in response to decreased circulating volume. This triggers the release of catecholamines, causing peripheral vasoconstriction and an increased heart rate. The vasoconstriction disproportionately elevates the diastolic blood pressure, leading to a narrowed pulse pressure (the difference between systolic and diastolic pressure). Identifying this subtle trend (e.g., pulse pressure narrowing from 48 to 30 mm Hg) allows the nurse to intervene before the client decompensates.

Step-by-Step Solution

Analyze the baseline vital signs provided in the scenario.

Baseline: BP 124/76 (Pulse Pressure = 48 mm Hg), HR 82/min. The client has abdominal trauma, placing them at high risk for internal hemorrhage.

Establishing a baseline is essential to identify subtle trending changes that indicate physiological decompensation.

Recall the pathophysiology of the early (compensatory) stage of shock.

The body activates the sympathetic nervous system, releasing epinephrine and norepinephrine. This causes vasoconstriction and an increased heart rate to maintain perfusion to vital organs.

Understanding compensatory mechanisms helps differentiate early signs from late signs of shock.

Evaluate the clinical manifestations of sympathetic activation on vital signs.

Vasoconstriction primarily increases diastolic blood pressure, while systolic remains relatively stable, resulting in a narrowed pulse pressure. Mild tachycardia also occurs concurrently.

A narrowing pulse pressure and increasing heart rate are the most reliable early indicators of volume loss before frank hypotension occurs.

Compare the options against the timeline of shock progression.

Hypotension, metabolic acidosis, and mottled skin are all signs of progressive or irreversible shock where compensation has already failed.

The question specifically asks for the earliest clinical indicator, making the narrowed pulse pressure the correct choice.

Key Concept

Early recognition of compensatory shock through narrowed pulse pressure and tachycardia

Question 585Question →

A nurse is caring for an older adult client who recently experienced a cerebrovascular accident (stroke), resulting in right-sided hemiparesis and dysphagia. Which of the following basic care and comfort interventions should the nurse implement? Select all that apply.

Select all that apply

Position the client in a high-Fowler's position during and for at least 30 minutes after meals.

Place food directly onto the unaffected left side of the client's mouth.

Instruct the client to tilt their head backward when initiating a swallow.

Check the affected side of the client's mouth for pocketed food after eating.

Reassure the family that mild, frequent coughing while eating is a normal age-related change.

Keep the client positioned primarily on their affected right side while resting to prevent pressure on the healthy side.

Show answer & explanation

Answer: Position the client in a high-Fowler's position during and for at least 30 minutes after meals.; Place food directly onto the unaffected left side of the client's mouth.; Check the affected side of the client's mouth for pocketed food after eating.

Answer

The correct interventions are placing the client in a high-Fowler's position, placing food on the unaffected left side, and checking the affected side for pocketed food.

The appropriate interventions directly address the client's right-sided weakness and swallowing difficulties. Sitting up at 90 degrees utilizes gravity for safe swallowing. Placing food on the unaffected (left) side uses the functional muscles for chewing. Checking the affected side for pocketed food prevents silent or delayed aspiration of hidden food particles.

Step-by-Step Solution

Analyze the client's condition and physiological deficits.

The client has right-sided hemiparesis (weakness/paralysis) and dysphagia (difficulty swallowing) following a stroke.

Understanding the deficits is crucial for identifying interventions that promote comfort, nutrition, and safety.

Evaluate the nutritional and feeding safety interventions.

High-Fowler's positioning, placing food on the strong side, and checking for pocketed food all safely manage the dysphagia and hemiparesis.

These actions utilize gravity, compensate for weakness, and prevent aspiration pneumonia, aligning with best practices for basic care.

Evaluate the distractors related to positioning and aging.

Tilting the head back, assuming coughing is normal, and resting on the paralyzed side are identified as unsafe practices.

These distractors represent common misconceptions regarding airway protection, geriatric physiology, and skin integrity.

Key Concept

Basic care, comfort, and safety interventions for clients with hemiparesis and dysphagia include aspiration precautions (high-Fowler's, chin-tuck, checking for pocketing) and pressure injury prevention.

Question 586Question →

A multidisciplinary team is preparing to remove a pleural chest tube from a client whose lung has fully re-expanded. As the nurse assisting with the procedure, arrange the following actions in the correct chronological sequence to minimize the risk of complications. All options must be used.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct chronological sequence is to premedicate the client, instruct them to perform the Valsalva maneuver during removal, apply an occlusive dressing immediately, perform a clinical respiratory assessment, and finally obtain a verifying radiograph.

The primary goal during chest tube removal is preventing air from re-entering the pleural space while minimizing client discomfort. Analgesia is administered first to allow the medication to take effect. During the actual removal, the Valsalva maneuver (bearing down) ensures positive intrathoracic pressure, pushing air outward rather than pulling it in. The moment the tube exits, an occlusive petroleum dressing is applied to seal the tract. Only after the insertion site is physically secured does the nurse assess clinical respiratory status, which is then followed by a radiograph for definitive confirmation of lung expansion.

Step-by-Step Solution

Administer analgesia.

Client pain is proactively managed prior to the procedure.

Promotes comfort and compliance during an otherwise painful extraction.

Instruct the Valsalva maneuver.

Intrathoracic pressure increases.

Prevents atmospheric air from being drawn into the pleural cavity as the tube exits the chest wall.

Apply the occlusive dressing.

The insertion stoma is hermetically sealed.

Maintains negative intrathoracic pressure and guards against a secondary pneumothorax.

Auscultate lung sounds.

Immediate clinical status is verified.

Rapidly identifies any acute physiological decompensation, respiratory distress, or absent breath sounds immediately post-removal.

Facilitate a chest radiograph.

Lung expansion is objectively confirmed.

Radiographic imaging serves as the definitive diagnostic proof to rule out a new pneumothorax or hemothorax.

Key Concept

Safety Protocols for Chest Tube Removal

Question 587Question →

An adult client admitted with severe diabetic ketoacidosis (DKA) is prescribed a continuous intravenous (IV) infusion of regular insulin. When initiating and managing this high-alert parenteral therapy, which actions should the nurse include in the plan of care? (Select all that apply.)

Select all that apply

Prime the intravenous tubing with

50\text{ mL}

of the insulin solution and discard the fluid before connecting the line to the client.

Anticipate adding an intravenous fluid containing 5% dextrose once the client's blood glucose level decreases to

250\text{ mg/dL}

Monitor the client frequently for the development of new-onset muscle weakness and cardiac dysrhythmias.

Discontinue the continuous insulin infusion immediately once the client's blood glucose level reaches

150\text{ mg/dL}

to prevent hypoglycemia.

Add prescribed long-acting insulin glargine directly into the continuous regular insulin intravenous bag to establish basal glycemic control.

Regulate the continuous insulin infusion using a manual gravity drip with a microdrip chamber to ensure steady administration.

Show answer & explanation

Answer: Prime the intravenous tubing with $50\text{ mL}$ of the insulin solution and discard the fluid before connecting the line to the client.; Anticipate adding an intravenous fluid containing 5% dextrose once the client's blood glucose level decreases to $250\text{ mg/dL}$ .; Monitor the client frequently for the development of new-onset muscle weakness and cardiac dysrhythmias.

Answer

The correct actions are priming the tubing with 50 mL of the insulin solution, adding a dextrose-containing IV fluid when blood glucose reaches 250 mg/dL, and monitoring for signs of hypokalemia.

Safe administration of continuous intravenous insulin requires addressing the drug's tendency to bind to PVC tubing by wasting a priming volume. Clinically, the nurse must anticipate the profound intracellular shift of potassium caused by insulin, necessitating vigilant monitoring for hypokalemia (dysrhythmias, muscle weakness). Furthermore, DKA protocols mandate the addition of 5% dextrose to IV fluids when blood glucose reaches 250 mg/dL to prevent hypoglycemia while allowing the insulin drip to continue until the acidotic state is fully resolved.

Step-by-Step Solution

Analyze the pharmacological properties of intravenous regular insulin in the context of IV administration.

Regular insulin adsorbs to PVC plastic. To ensure the client receives the correct dose, the IV tubing must be primed with insulin solution (typically 20-50 mL) to saturate binding sites before the tubing is connected to the client.

Failure to prime with the insulin solution results in the client receiving a lower-than-prescribed dose initially.

Determine the physiological effects of continuous IV insulin on serum electrolytes.

Insulin promotes the intracellular shift of potassium, lowering serum potassium levels. The nurse must monitor for hypokalemia, which presents with muscle weakness and cardiac dysrhythmias.

Hypokalemia is a life-threatening complication of DKA treatment.

Evaluate the protocol for blood glucose management during DKA resolution.

When blood glucose drops to approximately 250 mg/dL, the primary goal shifts from rapidly lowering glucose to clearing ketones and closing the anion gap. Dextrose must be added to the IV fluids.

Adding dextrose allows the continuous insulin infusion to remain running without causing severe hypoglycemia.

Identify contraindicated actions related to insulin infusions.

Insulin infusions should never be stopped abruptly without subcutaneous coverage, glargine cannot be given IV or mixed, and gravity drips are unsafe for high-alert medications.

These actions compromise patient safety through rebound acidosis, incompatibility reactions, and inaccurate dosing.

Key Concept

Pharmacological management of Diabetic Ketoacidosis (DKA) and IV insulin safety

Question 588Question →

A nurse is assessing a client who is 4 hours post-operative following an exploratory laparotomy. The nurse is monitoring for complications. Which of the following assessment findings should the nurse identify as early indicators of developing hypovolemic shock? Select all that apply.

Select all that apply

New-onset restlessness and mild agitation.

Blood pressure reading of 118/92 mm Hg, compared to a baseline of 130/80 mm Hg.

Peripheral pulses palpated as +3 (bounding).

Skin that is warm and flushed to the touch.

Urine output totaling 40 mL in the surgical catheter drainage bag over the past 2 hours.

Incisional pain rated as 7 on a 0 to 10 scale during repositioning.

Show answer & explanation

Answer: New-onset restlessness and mild agitation.; Blood pressure reading of 118/92 mm Hg, compared to a baseline of 130/80 mm Hg.; Urine output totaling 40 mL in the surgical catheter drainage bag over the past 2 hours.

Answer

The early indicators of developing hypovolemic shock are new-onset restlessness and mild agitation, a narrowing pulse pressure (blood pressure changing from 130/80 to 118/92 mm Hg), and oliguria (urine output of 40 mL over 2 hours).

Early hypovolemic shock is characterized by compensatory mechanisms aimed at maintaining cardiac output and vital organ perfusion. The sympathetic nervous system activates, causing peripheral vasoconstriction (which narrows the pulse pressure) and shunting blood away from non-vital organs like the kidneys, resulting in oliguria. Mild cerebral hypoxia manifests as restlessness and agitation.

Step-by-Step Solution

Analyze the clinical scenario

The client is 4 hours post-exploratory laparotomy and is at high risk for hemorrhage and fluid volume deficit.

Identifying the primary risk factor helps anticipate potential complications.

Evaluate vital signs for compensatory mechanisms

The blood pressure shows a narrowed pulse pressure (from 50 mm Hg to 26 mm Hg), which is a classic early sign of compensatory vasoconstriction.

The sympathetic nervous system acts to maintain mean arterial pressure despite volume loss by increasing peripheral vascular resistance.

Assess organ perfusion indicators

Restlessness indicates mild cerebral hypoxia, and a urine output of 20 mL/hr indicates decreased renal perfusion.

The brain and kidneys are highly sensitive to decreases in cardiac output, making them excellent early indicators of shock.

Differentiate expected findings and other shock states

Bounding pulses and warm skin are incorrect for hypovolemia, and localized pain is an expected post-surgical finding.

Hypovolemia causes weak pulses and cool skin; localized pain does not indicate systemic hemodynamic instability.

Key Concept

Early Recognition of Hypovolemic Shock

Question 589Question →

A nurse in the emergency department evaluates a client who sustained a complete spinal cord injury at the T6 level in a traumatic incident 2 hours ago. During the assessment, the nurse notes the client's abdomen is firm, distended, and dull to percussion. The client's current vital signs are:

Blood pressure: 84/48 mm Hg
Heart rate: 128 bpm
Respiratory rate: 24/min

Based on the clinical presentation, which physiological complication should the nurse identify?

Hypovolemic shock, as indicated by the compensatory tachycardia and abdominal findings.

Neurogenic shock, resulting from an acute loss of sympathetic vascular tone below the injury.

Autonomic dysreflexia, triggered by a noxious visceral stimulus from the distended abdomen.

Spinal shock, leading to a temporary loss of systemic autonomic and motor reflexes.

Show answer & explanation

Answer: Hypovolemic shock, as indicated by the compensatory tachycardia and abdominal findings.

Answer

The correct answer is hypovolemic shock, as indicated by the compensatory tachycardia and abdominal findings.

The client's clinical presentation of hypotension combined with significant tachycardia (128 bpm) and a firm, distended abdomen strongly indicates acute blood loss (hypovolemic/hemorrhagic shock). In a T6 spinal cord injury, the sympathetic cardioaccelerator fibers (T1-T4) remain intact, allowing the heart to mount a compensatory tachycardia in response to the decreasing intravascular volume.

Step-by-Step Solution

Analyze the client's vital signs and physical assessment findings.

The client is hypotensive (84/48 mm Hg) and tachycardic (128 bpm) with a firm, distended abdomen that is dull to percussion.

Identifying the specific hemodynamic profile is necessary to differentiate between various types of shock in a trauma patient.

Evaluate the findings in the context of a T6 spinal cord injury.

The tachycardia indicates an intact sympathetic cardioaccelerator response (T1-T4) to hypovolemia, while the abdominal findings suggest active intra-abdominal bleeding.

Patients with acute spinal cord injuries are at risk for multiple concurrent complications. Recognizing that neurogenic shock typically causes bradycardia helps rule it out, shifting the focus to a hemorrhagic source.

Key Concept

Differentiating shock states in spinal cord injury based on hemodynamic profiles

Question 590Question →

A nurse is preparing to administer a prescribed oral medication to a client who has a nasogastric (NG) tube connected to low intermittent wall suction. The medication has been appropriately crushed and dissolved in sterile water. Arrange the following nursing actions in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first pause suction and verify placement, flush for patency, administer the medication, flush to clear the line, and finally clamp the tube to allow for absorption.

Safe administration of enteral medications requires a systematic approach. The nurse must first ensure safety by pausing suction and verifying placement. Once verified, flushing ensures patency, followed by gravity administration of the medication, and a subsequent flush to clear the line. Finally, clamping the tube prevents the medication from being immediately suctioned out, allowing for gastric absorption.

Step-by-Step Solution

Disconnect suction and verify placement.

The suction is paused and the tube is confirmed to be in the stomach.

Ensures the medication will not be aspirated into the lungs.

Flush with 30 mL of water.

The tube is cleared of any residual stomach contents.

Confirms tube patency and clears the path for the medication.

Administer the medication via gravity.

The dissolved medication enters the stomach.

Gravity administration prevents excessive pressure that could damage the tube.

Flush with 15 to 30 mL of water.

Residual medication is cleared from the tube.

Ensures the full dose reaches the stomach and prevents the tube from clogging.

Clamp the tube for at least 30 minutes.

The tube remains closed and disconnected from suction.

Allows adequate time for the medication to be absorbed through the gastric mucosa.

Key Concept

Enteral Medication Administration Principles

Question 591Question →

A nurse is assessing a client who is 4 hours postoperative following a partial hepatectomy. Which of the following assessment findings should the nurse identify as early indicators of developing hypovolemic shock? Select all that apply.

Select all that apply

New-onset restlessness and mild agitation

Arterial blood gas results demonstrating uncompensated respiratory acidosis

A narrowing pulse pressure

Warm, flushed skin in the distal extremities

Respiratory rate increasing from 14 to 26 breaths per minute

A steady decline in resting heart rate

Show answer & explanation

Answer: New-onset restlessness and mild agitation; A narrowing pulse pressure; Respiratory rate increasing from 14 to 26 breaths per minute

Answer

The correct early indicators of hypovolemic shock are new-onset restlessness and mild agitation, a narrowing pulse pressure, and an increasing respiratory rate.

In the early, compensatory stage of hypovolemic shock, the body's primary goal is to maintain cardiac output and tissue perfusion. The sympathetic nervous system triggers an increase in heart rate and respiratory rate. Peripheral vasoconstriction occurs, which increases the diastolic blood pressure, leading to a narrower pulse pressure. Despite these compensations, subtle decreases in cerebral oxygenation manifest early as behavioral changes, including restlessness, anxiety, or mild agitation.

Step-by-Step Solution

Identify the stage and type of shock described in the scenario.

The scenario requires identifying the early (compensatory) stage of hypovolemic shock, typically caused by hemorrhage following major abdominal surgery.

Recognizing the specific stage of shock is critical because assessment findings change drastically as shock progresses from compensatory to progressive, and ultimately to irreversible stages.

Analyze physiological responses in the compensatory stage of hypovolemic shock.

The body activates the sympathetic nervous system and the renin-angiotensin-aldosterone system. This leads to tachycardia, tachypnea, peripheral vasoconstriction, and shunting of blood to vital organs.

Understanding the underlying pathophysiology explains the expected vital signs and physical assessment findings.

Evaluate each option against the compensatory mechanisms.

Restlessness (decreased cerebral perfusion), narrowing pulse pressure (vasoconstriction raising diastolic pressure), and tachypnea (compensatory oxygen demand) align with early shock. Acidosis, warm skin, and bradycardia do not.

This process eliminates distractors that represent different types of shock (e.g., septic shock) or later stages of physiological decompensation.

Key Concept

Compensatory mechanisms and early clinical manifestations of hypovolemic shock

Question 592Question →

A client with a severe soft tissue infection is receiving a newly prescribed intravenous antibiotic. Ten minutes after the infusion begins, the client becomes visibly anxious and states, "My throat feels very tight." Which of the following additional assessment findings would indicate the client is developing anaphylactic shock? Select all that apply.

Select all that apply

Diffuse urticaria and generalized pruritus

Expiratory wheezing and tachypnea

Tachycardia with a weak, thready pulse

Sudden elevation in systolic blood pressure

Arterial blood gas results demonstrating respiratory alkalosis

Show answer & explanation

Answer: Diffuse urticaria and generalized pruritus; Expiratory wheezing and tachypnea; Tachycardia with a weak, thready pulse

Answer

The correct findings indicating anaphylactic shock are diffuse urticaria and generalized pruritus, expiratory wheezing and tachypnea, and tachycardia with a weak, thready pulse.

Anaphylactic shock is a severe, systemic hypersensitivity reaction characterized by massive release of histamine and other chemical mediators. This leads to increased capillary permeability causing cutaneous reactions like urticaria and pruritus. It also causes profound smooth muscle contraction in the airways, resulting in bronchospasm, wheezing, and tachypnea. Finally, systemic vasodilation causes a rapid drop in blood pressure, prompting a compensatory tachycardia with a weak, thready pulse due to decreased cardiac output.

Step-by-Step Solution

Analyze the client's presentation and recognize the medical emergency.

The client's acute anxiety and report of throat tightness shortly after starting a new IV medication highly suggest an allergic reaction progressing to anaphylaxis.

Identifying the underlying pathophysiology is essential for anticipating related systemic manifestations.

Evaluate each assessment finding against the pathophysiology of anaphylactic shock.

Anaphylaxis involves massive histamine release, leading to increased capillary permeability (urticaria), smooth muscle contraction (bronchospasm and wheezing), and massive vasodilation (compensatory tachycardia).

Matching clinical signs to the disease process isolates the correct manifestations.

Identify the incorrect assessment findings.

Elevated blood pressure and respiratory alkalosis contradict the hemodynamics and respiratory compromise typical of anaphylaxis.

Anaphylactic shock causes severe hypotension and respiratory acidosis due to airway obstruction.

Key Concept

Pathophysiology and clinical manifestations of anaphylactic shock

Question 593Question →

A nurse is caring for a client with a severe intra-abdominal infection who has received $3\text{ L}$ of $0.9\%$ sodium chloride intravenously over the past $2$ hours. The client is lethargic, and the nurse notes the following assessment findings:

Assessment	Finding
Blood pressure	$78/40\text{ mm Hg}$
Heart rate	$128\text{ beats/min}$
Respiratory rate	$28\text{ breaths/min}$
Urine output	$10\text{ mL/hr}$
Arterial Blood Gas	$pH = 7.25$ , $PaCO_2 = 30\text{ mm Hg}$ , $HCO_3^- = 14\text{ mEq/L}$

Based on these findings, which of the following actions is the nurse's priority?

Administer intravenous sodium bicarbonate to reverse the severe acidemia.

Elevate the head of the bed to

90^\circ

to assist with the increased respiratory rate.

Initiate a prescribed continuous intravenous infusion of norepinephrine.

Request a stat prescription for a portable chest x-ray to determine the cause of tachypnea.

Show answer & explanation

Answer: Initiate a prescribed continuous intravenous infusion of norepinephrine.

Answer

The priority 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 (Mean Arterial Pressure

< 65\text{ mm Hg}

) and oliguria despite receiving a massive fluid bolus of

3\text{ L}

. The ABG reveals a metabolic acidosis, which in this context is lactic acidosis secondary to systemic hypoperfusion. The compensatory mechanism for this is tachypnea (blowing off

CO_2

). The absolute highest priority is to restore vascular tone and vital organ perfusion by initiating a vasopressor such as norepinephrine.

Step-by-Step Solution

Evaluate the client's hemodynamic status and response to initial fluid resuscitation.

The blood pressure remains critically low (

78/40\text{ mm Hg}

, resulting in a Mean Arterial Pressure of approximately

52\text{ mm Hg}

) despite the administration of a massive

3\text{ L}

isotonic fluid bolus.

This identifies that the client has progressed to fluid-refractory septic shock and requires immediate escalation of cardiovascular support.

Analyze the arterial blood gas (ABG) results in the context of the clinical picture.

The ABG shows a partially compensated metabolic acidosis (

pH

7.25

HCO_3^-

14\text{ mEq/L}

) with compensatory hyperventilation (

RR

28

PaCO_2

30\text{ mm Hg}

This confirms that the acid-base imbalance is driven by lactic acid accumulation from poor tissue perfusion (anaerobic metabolism), rather than a primary respiratory issue.

Determine the highest priority intervention using ABCs and survival priorities.

Administering a vasopressor (norepinephrine) is identified as the immediate life-saving action.

Restoring systemic vascular resistance and mean arterial pressure is essential to perfuse vital organs, halt the ischemic cascade, and resolve the underlying cause of the lactic acidosis.

Key Concept

Management of fluid-refractory septic shock and recognition of secondary lactic acidosis.

Question 594Question →

A nurse is planning care for a client who is 8 hours post-operative following a right total hip arthroplasty utilizing a posterior approach. Which of the following nursing interventions should the nurse implement to reduce the client's risk for postoperative complications? Select all that apply.

Select all that apply

Place an abduction wedge between the client's legs while the client is resting in bed.

Elevate the head of the bed to 90 degrees when the client is eating meals.

Assess the pedal pulses, capillary refill, and sensation of the right lower extremity.

Delegate the evaluation of the surgical dressing for active bleeding to the unlicensed assistive personnel (UAP).

Apply bilateral sequential compression devices (SCDs) as prescribed.

Place a pillow directly under the client's right knee to alleviate joint tension.

Show answer & explanation

Answer: Place an abduction wedge between the client's legs while the client is resting in bed.; Assess the pedal pulses, capillary refill, and sensation of the right lower extremity.; Apply bilateral sequential compression devices (SCDs) as prescribed.

Answer

The correct interventions are placing an abduction wedge between the client's legs, assessing the neurovascular status of the right lower extremity, and applying bilateral sequential compression devices.

Following a posterior approach total hip arthroplasty, the client is at high risk for joint dislocation, deep vein thrombosis (DVT), and neurovascular compromise. Nursing interventions to reduce these risks include using an abduction wedge to prevent hip adduction, applying sequential compression devices to promote venous return, and frequently performing targeted neurovascular assessments to detect early signs of impaired tissue perfusion or nerve damage.

Step-by-Step Solution

Identify the surgical procedure and its associated risks.

The client had a posterior approach total hip arthroplasty. Major risks include hip dislocation, venous thromboembolism (DVT/PE), and neurovascular compromise.

Understanding the specific risks associated with the posterior approach is necessary to determine appropriate preventative interventions.

Evaluate the positioning options for hip dislocation risk.

Abduction wedges prevent adduction (a risk factor), so they are correct. Elevating the head of the bed to 90 degrees causes extreme hip flexion (another risk factor), so it is incorrect.

Following a posterior approach, patients must avoid hip flexion greater than 90 degrees, adduction, and internal rotation.

Evaluate the remaining interventions for safety and complication prevention.

Neurovascular assessments and SCD application actively prevent or detect complications. Delegating dressing evaluation and placing a pillow under the knee introduce new risks (missed hemorrhage and DVT, respectively).

Nursing care must focus on proactive monitoring and avoiding practices that impede circulation or violate scope of practice.

Key Concept

Postoperative Risk Reduction: Total Hip Arthroplasty

Question 595Question →

A client admitted with cardiogenic shock requires hemodynamic support. The healthcare provider orders a continuous intravenous infusion of dobutamine at a rate of $5\text{ mcg/kg/min}$ . The client's current weight is $82\text{ kg}$ . The pharmacy dispenses a premixed bag containing $500\text{ mg}$ of dobutamine in $250\text{ mL}$ of $5\%$ dextrose in water ( $D_5W$ ).

At what rate, in $\text{mL/hr}$ , should the nurse program the infusion pump? Record your answer as a number with one decimal place.

Show answer & explanation

Answer: 12.3

Answer

12.3

The correct infusion rate is calculated by determining the total weight-based dose per minute, converting it to an hourly dose, aligning the units with the supplied medication, and dividing by the concentration of the IV bag. This sequential mathematical process accurately results in an infusion pump setting of 12.3 mL/hr.

Step-by-Step Solution

Determine the total dose of dobutamine required per minute.

82\text{ kg} \times 5\text{ mcg/kg/min} = 410\text{ mcg/min}

The prescribed dose is weight-based, so the client's total weight in kilograms must be multiplied by the ordered rate.

Convert the per-minute dose to an hourly dose.

410\text{ mcg/min} \times 60\text{ min/hr} = 24,600\text{ mcg/hr}

Intravenous infusion pumps are programmed in milliliters per hour, requiring the medication dose to be calculated over a 60-minute period.

Convert the hourly dose from micrograms (mcg) to milligrams (mg).

24,600\text{ mcg} \div 1000\text{ mcg/mg} = 24.6\text{ mg/hr}

The supplied medication is measured in milligrams, so the requested dose must be converted to align with the available supply.

Determine the concentration of the supplied dobutamine.

500\text{ mg} \div 250\text{ mL} = 2\text{ mg/mL}

Calculating the milligrams of medication per single milliliter of fluid simplifies the final volume calculation.

Calculate the required infusion pump rate.

24.6\text{ mg/hr} \div 2\text{ mg/mL} = 12.3\text{ mL/hr}

Dividing the required hourly dose by the concentration of the IV solution yields the final volume to infuse per hour.

Key Concept

Weight-Based Intravenous Dosing and Pump Rate Calculation

Question 596Question →

A nurse in the emergency department is caring for a client who is admitted with severe diabetic ketoacidosis (DKA). The client is lethargic, has a blood glucose of $680\text{ mg/dL}$ ( $37.7\text{ mmol/L}$ ), and an arterial pH of $7.12$ . Arrange the following collaborative and nursing interventions in the correct chronological order of implementation.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

1. Administer a rapid infusion of 0.9% sodium chloride; 2. Verify the initial serum potassium level; 3. Initiate an IV infusion of regular insulin; 4. Add 5% dextrose to the fluids; 5. Administer the first dose of subcutaneous insulin.

The evidence-based sequence for DKA management is: 1) restore intravascular volume with isotonic normal saline, 2) check potassium to ensure it is safe to administer insulin, 3) administer continuous IV regular insulin to stop ketogenesis, 4) add dextrose to the IV fluids when the blood glucose reaches 250 mg/dL to prevent hypoglycemia, and 5) transition to subcutaneous insulin once the anion gap is closed.

Step-by-Step Solution

Address the primary life threat: severe dehydration and hypovolemia.

Intravenous 0.9% sodium chloride is administered rapidly.

Patients with severe DKA can lose up to 10% of their body weight in fluids due to osmotic diuresis. Restoring perfusion is the absolute first step.

Assess electrolyte status prior to starting hormonal therapy.

The serum potassium level is verified.

Insulin shifts potassium into cells. If the patient is already hypokalemic, administering insulin could cause a fatal cardiac arrhythmia. Potassium must be known and, if necessary, replaced first.

Treat the underlying pathophysiology (ketogenesis).

A continuous intravenous infusion of regular insulin is initiated.

Insulin stops the breakdown of fats, halting ketone production and gradually lowering blood glucose.

Prevent complications of rapid glucose lowering.

5% dextrose is added to the intravenous fluids when blood glucose reaches approximately 250 mg/dL.

Adding dextrose prevents hypoglycemia while allowing the insulin drip to continue running in order to fully close the anion gap. It also prevents cerebral edema from rapid osmotic shifts.

Transition to maintenance therapy.

Subcutaneous insulin is administered.

Once the ketoacidosis resolves (the anion gap closes), the patient is transitioned to subcutaneous insulin prior to stopping the IV drip to prevent DKA recurrence.

Key Concept

Prioritization in Diabetic Ketoacidosis (DKA) Management

Estimated Time:2m 0s

Question 597Question →

During morning rounds, a nurse assesses a client who sustained a transmural anterior myocardial infarction 48 hours ago. The client is suddenly restless, exhibiting a cough with frothy, pink-tinged sputum. Current vital signs show a heart rate of $122\text{ beats/min}$ , blood pressure of $92/74\text{ mmHg}$ , and a respiratory rate of $30\text{ breaths/min}$ . An arterial blood gas (ABG) analysis on room air reveals a pH of $7.49$ , $PaCO_2$ of $29\text{ mmHg}$ , $PaO_2$ of $62\text{ mmHg}$ , and $HCO_3^-$ of $22\text{ mEq/L}$ . Based on this clinical picture, which intervention is the priority?

Apply supplemental oxygen via a non-rebreather mask and prepare to administer a prescribed intravenous loop diuretic.

Coach the client to decrease their respiratory rate to normalize the arterial carbon dioxide level.

Initiate a rapid intravenous infusion of an isotonic crystalloid to treat the signs of impending shock.

Place the client in a supine position with the lower extremities elevated to improve systemic blood pressure.

Show answer & explanation

Answer: Apply supplemental oxygen via a non-rebreather mask and prepare to administer a prescribed intravenous loop diuretic.

Answer

Apply supplemental oxygen via a non-rebreather mask and prepare to administer a prescribed intravenous loop diuretic.

The client is exhibiting classic signs of acute cardiogenic pulmonary edema (pink frothy sputum, hypoxia) and impending cardiogenic shock (hypotension, tachycardia) secondary to left ventricular failure from the recent anterior myocardial infarction. The severe hypoxemia (

PaO_2

62\text{ mmHg}

) is driving the compensatory tachypnea, resulting in respiratory alkalosis. The immediate life-saving interventions require aggressively improving oxygenation via a non-rebreather mask and reducing the fluid volume (preload) burdening the failing heart by administering a loop diuretic.

Step-by-Step Solution

Analyze the client's symptoms and vital signs.

The client presents with restlessness, pink frothy sputum, tachycardia, hypotension with a narrow pulse pressure, and severe tachypnea.

Identifying the clinical pattern is the first step to diagnosing an acute, life-threatening complication post-myocardial infarction.

Interpret the arterial blood gas (ABG) results.

The ABG shows uncompensated respiratory alkalosis (pH

7.49

PaCO_2

29\text{ mmHg}

) driven entirely by severe hypoxemia (

PaO_2

62\text{ mmHg}

Understanding the acid-base imbalance reveals that the hyperventilation is a critical compensatory mechanism for poor oxygenation, not an anxiety response.

Synthesize the findings to determine the primary pathophysiology.

The combination of an anterior myocardial infarction history, pink frothy sputum, hypoxemia, and hemodynamic instability indicates acute cardiogenic pulmonary edema progressing to cardiogenic shock.

Connecting the cardiac history with current respiratory and hemodynamic compromise points directly to severe left ventricular failure.

Select the highest priority intervention based on the diagnosis.

The priority is to simultaneously improve systemic oxygenation and reduce cardiac preload.

Supplemental oxygen treats the life-threatening hypoxemia, while a loop diuretic decreases the fluid overload in the pulmonary capillaries.

Key Concept

Cardiogenic Pulmonary Edema and Early Cardiogenic Shock Recognition

Question 598Question →

A nurse is caring for an adult client admitted with acute decompensated heart failure. The healthcare provider prescribes $80$ mg of furosemide to be administered intravenously (IV) push. The medication is available in a vial labeled $10$ mg/mL. The client currently has a continuous peripheral IV infusion of $5\%$ dextrose in water (D5W) running at $50$ mL/hr. Which of the following is the safest and most appropriate nursing action for administering this medication?

Draw up

8

mL of the medication and administer it rapidly over

30

60

seconds to ensure immediate diuresis.

Stop the D5W continuous infusion completely before administration, as furosemide and D5W are incompatible at the Y-site.

Draw up

8

mL of the medication and administer it continuously over a minimum of

4

minutes.

Withhold the medication and assess the client's baseline urine output for one hour before determining if the full dose is necessary.

Show answer & explanation

Answer: Draw up $8$ mL of the medication and administer it continuously over a minimum of $4$ minutes.

Answer

The nurse should draw up

8

mL of the medication and administer it continuously over a minimum of

4

minutes.

Furosemide is a potent loop diuretic. When administered intravenously, the maximum safe rate of administration is generally

20

mg per minute to prevent ototoxicity (which can manifest as tinnitus or permanent hearing loss). For a prescribed dose of

80

mg, the nurse must divide the dose by the maximum rate (

80

mg /

20

mg/min), determining that the push must take a minimum of

4

minutes. The volume calculation is straightforward:

80

mg divided by the concentration of

10

mg/mL equals

8

mL.

Step-by-Step Solution

Calculate the volume of medication to withdraw from the vial.

The nurse needs

8

mL of furosemide.

Using the formula: (Desired Dose / Available Concentration) = Volume.

80

mg /

10

mg/mL =

8

mL.

Determine the maximum safe rate of intravenous administration.

The maximum safe administration rate for IV furosemide is

20

mg per minute.

Administering loop diuretics too rapidly significantly increases the risk of ototoxicity (tinnitus and hearing loss).

Calculate the minimum time required to push the medication.

The medication must be administered over at least

4

minutes.

Dividing the total dose by the maximum rate per minute:

80

mg /

20

mg/min =

4

minutes.

Key Concept

Safe administration of intravenous push loop diuretics

Question 599Question →

During rounding, a nurse evaluates a client who underwent an open abdominal surgery 10 hours ago. The client reports mild nausea and generalized weakness. The nurse compares the current vital signs to the assessment obtained four hours prior:

Parameter	4 Hours Ago	Current
Heart Rate	78 beats/min	114 beats/min
Blood Pressure	126/74 mm Hg	108/84 mm Hg
Respiratory Rate	16 breaths/min	24 breaths/min
Temperature	98.6°F (37°C)	98.2°F (36.8°C)

Based on these clinical findings, what is the priority nursing action?

Inspect the surgical dressing and closed-suction drains for sanguineous output.

Administer the prescribed as-needed antiemetic medication to relieve the client's nausea.

Request a prescription for an arterial blood gas analysis to evaluate the tachypnea.

Apply supplemental oxygen via nasal cannula to address the increased respiratory rate.

Show answer & explanation

Answer: Inspect the surgical dressing and closed-suction drains for sanguineous output.

Answer

The priority action is to inspect the surgical dressing and drains for excessive sanguineous drainage to assess for postoperative hemorrhage.

The correct action directly addresses the most critical potential complication. The client's pulse pressure narrowed from 52 mm Hg (126 - 74) to 24 mm Hg (108 - 84), accompanied by tachycardia and tachypnea. This triad indicates the compensatory stage of hypovolemic shock. Direct assessment of the surgical site for hemorrhage is the immediate priority.

Step-by-Step Solution

Analyze the vital sign trends over the four-hour period.

The heart rate increased significantly (tachycardia), the respiratory rate increased (tachypnea), and the blood pressure demonstrates a narrowing pulse pressure (systolic decreased while diastolic increased).

Comparing current data to baseline is essential to detect clinical deterioration.

Correlate the vital sign changes with the client's postoperative status.

A narrowing pulse pressure combined with tachycardia in a postoperative client strongly suggests compensatory hypovolemic shock due to internal or external bleeding.

During early blood loss, the sympathetic nervous system triggers vasoconstriction, raising diastolic pressure, while decreased stroke volume lowers systolic pressure.

Determine the priority nursing intervention based on the clinical picture.

The nurse must immediately assess the surgical site and any drains to confirm or rule out active hemorrhage before initiating other symptomatic treatments.

Identifying the source of bleeding is required to implement definitive, life-saving interventions.

Key Concept

Early recognition of hypovolemic shock using pulse pressure trends

Question 600Question →

A nurse is managing the care of a client receiving total parenteral nutrition (TPN) via a peripherally inserted central catheter (PICC). Which of the following nursing actions are appropriate? Select all that apply.

Select all that apply

Change the TPN infusion tubing and filter every 24 hours.

Assess the client's capillary blood glucose every 4 to 6 hours.

Keep a bag of 10% dextrose in water (D10W) available in case the TPN solution bag becomes empty.

Administer prescribed intravenous push (IVP) medications through the same lumen as the TPN infusion.

Increase the infusion rate to catch up if the volume delivered falls behind the prescribed schedule.

Delegate the routine assessment of the central line insertion site to the unlicensed assistive personnel (UAP).

Show answer & explanation

Answer: Change the TPN infusion tubing and filter every 24 hours.; Assess the client's capillary blood glucose every 4 to 6 hours.; Keep a bag of 10% dextrose in water (D10W) available in case the TPN solution bag becomes empty.

Answer

The appropriate actions are changing the tubing/filter every 24 hours, monitoring blood glucose every 4 to 6 hours, and keeping a bag of D10W available.

The correct actions reflect safe total parenteral nutrition (TPN) administration principles. Because TPN is rich in glucose and nutrients, the infusion tubing and filter must be replaced every 24 hours to prevent bacterial growth. The continuous high dextrose concentration requires capillary blood glucose monitoring every 4 to 6 hours to detect and manage hyperglycemia. Additionally, if the TPN bag becomes empty before a replacement is available, immediately infusing 10% dextrose in water (D10W) at the exact same rate prevents life-threatening rebound hypoglycemia.

Step-by-Step Solution

Identify the therapy being administered and its associated physiological risks.

The client is receiving total parenteral nutrition (TPN), which is hypertonic, rich in glucose and nutrients, and must be administered via a central line.

Understanding the composition of TPN helps anticipate potential complications such as systemic infection, severe hyperglycemia, and rebound hypoglycemia.

Evaluate each nursing action against TPN safety protocols and central venous catheter care standards.

Changing the tubing every 24 hours limits bacterial colonization. Monitoring blood glucose every 4 to 6 hours detects hyperglycemia early. Hanging D10W if TPN runs out prevents sudden hypoglycemia.

These interventions directly mitigate the known risks associated with continuous high-dextrose parenteral infusions.

Identify contraindicated actions that violate pharmacological safety and delegation principles.

Giving medications through a dedicated TPN line, speeding up the IV rate, and delegating site assessments to a UAP are unsafe clinical practices.

TPN requires a dedicated line to avoid drug crystallization. Rate alterations cause dangerous glycemic shifts, and UAPs lack the scope of practice to perform physiological assessments.

Key Concept

Total Parenteral Nutrition (TPN) Administration and Safety

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