Examkin

All practice questions

3881 questions

All types3,881Multiple choice1,926Multiple select908Numeric119Matching66Ordering862
Question 601Question →

A 54-year-old client with a mechanical bowel obstruction has been receiving continuous nasogastric suctioning for the past 48 hours. During the morning assessment, the client reports numbness around the mouth and exhibits frequent muscle twitching in the extremities. Arterial blood gas results reveal a pHpH of 7.54, PaCO2PaCO_2 of 40 mm Hg, and HCO3−HCO_3^- of 34 mEq/L. Which action is the priority for the nurse to implement to reduce the client's risk for severe physiological complications?

Show answer & explanation

Answer: Notify the healthcare provider of the clinical findings and anticipate an order for a serum electrolyte panel

Answer

The correct action is to notify the healthcare provider and anticipate orders for a serum electrolyte panel to address the client's metabolic alkalosis and suspected hypocalcemia.
The correct answer directly addresses the root cause of the client's deterioration. The client is experiencing uncompensated metabolic alkalosis due to continuous gastric acid loss from the nasogastric tube. Alkalosis causes calcium to bind more tightly to protein, reducing ionized calcium levels and resulting in hypocalcemia (manifested by perioral numbness and muscle twitching). Requesting a serum electrolyte panel is critical to confirm the deficits and safely guide the necessary intravenous replacement therapy, thereby reducing the risk of life-threatening complications like cardiac arrhythmias or tetany.

Step-by-Step Solution

1
Analyze the arterial blood gas (ABG) results.
The elevated pHpH (7.54) indicates alkalosis, and the elevated HCO3−HCO_3^- (34 mEq/L) with a normal PaCO2PaCO_2 indicates uncompensated metabolic alkalosis.
Identifying the specific acid-base imbalance is necessary to determine the physiological root cause of the client's symptoms.
2
Correlate the ABG findings with the client's clinical history and current symptoms.
Prolonged nasogastric suctioning removes hydrochloric acid from the stomach, causing metabolic alkalosis. Alkalosis decreases the amount of ionized calcium in the blood, leading to symptomatic hypocalcemia (perioral numbness and muscle twitching).
Connecting diagnostic data to physical assessment findings differentiates expected conditions from impending severe complications like tetany or seizures.
3
Determine the priority nursing intervention based on the assessment.
The nurse must immediately notify the healthcare provider to obtain serum electrolyte levels (especially calcium and potassium) to initiate targeted replacement therapy.
Electrolyte derangements of this severity are life-threatening and require collaborative medical intervention to prevent cardiac arrhythmias or respiratory arrest from tetany.

Key Concept

Metabolic Alkalosis and Associated Hypocalcemia
Question 602Question →

A nurse is evaluating a client who is 4 hours post-operative following an open cholecystectomy. The client is receiving continuous intravenous fluids and pain management via a morphine patient-controlled analgesia (PCA) pump. Which of the following assessment findings indicate the client is experiencing an acute physiological deterioration requiring immediate intervention? Select all that apply.

Select all that apply

Show answer & explanation

Answer: A narrowing pulse pressure with a current blood pressure of 100/82 mm Hg; A cumulative urine output of 25 mL over the past two hours; An arterial blood gas analysis showing a pH of 7.27, a PaCO2 of 60 mm Hg, and an HCO3 of 24 mEq/L

Answer

The findings requiring immediate intervention are a narrowing pulse pressure (100/82 mm Hg), a cumulative urine output of 25 mL over two hours, and an arterial blood gas showing uncompensated respiratory acidosis (pH 7.27, PaCO2 60 mm Hg).
The correct findings all represent acute, life-threatening physiological deterioration. A narrowing pulse pressure and severe oliguria (<30 mL/hr) are classic early indicators of compensatory hypovolemic or hemorrhagic shock, demanding rapid fluid resuscitation or surgical intervention. An ABG with a pH of 7.27 and PaCO2 of 60 mm Hg demonstrates acute uncompensated respiratory acidosis, directly resulting from hypoventilation caused by the morphine PCA pump, necessitating immediate airway management.

Step-by-Step Solution

1
Analyze the client's postoperative context and current therapies.
The client had abdominal surgery (risk for bleeding/fluid shifts) and is on a morphine PCA (risk for respiratory depression).
Identifying the client's specific risks guides the interpretation of assessment data.
2
Evaluate the vital signs and urine output for indications of shock.
The pulse pressure of 18 mm Hg (100 - 82) is critically narrow. The urine output of 12.5 mL/hr is well below the minimum 30 mL/hr threshold.
Narrowing pulse pressure and oliguria are early compensatory signs of hypovolemic or hemorrhagic shock resulting from decreased cardiac output.
3
Interpret the arterial blood gas (ABG) results.
A pH of 7.27 (acidemia) and PaCO2 of 60 mm Hg (hypercapnia) with normal HCO3 indicate acute, uncompensated respiratory acidosis.
This confirms opioid-induced respiratory depression from the PCA pump, a life-threatening emergency.
4
Differentiate expected postoperative findings from acute deterioration.
Hypoactive bowel sounds, normal ABG values (pH 7.37), and a resting heart rate of 74 bpm are expected or stable findings.
Prioritization requires distinguishing between normal recovery processes and physiological decline.

Key Concept

Early recognition of hypovolemic shock (narrowing pulse pressure, oliguria) and respiratory depression (respiratory acidosis) in the postoperative period is critical for preventing irreversible physiological compromise.
Question 603Question →

A client's morning laboratory results reveal a serum potassium level of 2.62.6 mEq/L. The healthcare provider prescribes 4040 mEq of intravenous potassium chloride (KCl) in 100100 mL of 0.9%0.9\% sodium chloride to be infused over 11 hour. The client has a continuous infusion of 5%5\% dextrose in water running at 5050 mL/hr through a 2020-gauge peripheral catheter in the left hand. Which of the following actions should the nurse take?

Show answer & explanation

Answer: Contact the healthcare provider to question the prescribed infusion rate and route.

Answer

Contact the healthcare provider to question the prescribed infusion rate and route.
The correct action is to contact the healthcare provider to question the prescribed infusion rate and route. Intravenous potassium chloride (KCl) is a high-alert medication with strict administration guidelines. The maximum recommended rate for IV potassium administration through a peripheral line is typically 10 mEq/hr to prevent severe vein irritation and life-threatening cardiac arrhythmias. An order for 40 mEq over 1 hour is dangerously fast. Such high doses generally require a central venous catheter, an infusion pump, and continuous cardiac monitoring. Therefore, the nurse must withhold the medication and clarify the unsafe prescription.

Step-by-Step Solution

1
Evaluate the prescribed medication, dose, route, and rate.
The prescription is for 40 mEq of potassium chloride to be given intravenously over 1 hour via a peripheral line.
Nurses must verify the safety of all medication orders before administration.
2
Compare the prescription against safety standards for intravenous potassium.
The maximum safe rate for peripheral IV potassium is generally 10 mEq/hr. A central venous catheter is required for higher concentrations, and rates rarely exceed 20 mEq/hr without intensive care cardiac monitoring.
Rapid infusion of potassium can cause fatal arrhythmias and severe venous irritation.
3
Determine the priority nursing action.
The prescription is unsafe. The nurse must not administer the medication and must contact the prescriber.
The nurse has a legal and ethical duty to refuse to administer an unsafe order and to seek immediate clarification.

Key Concept

Safe administration of intravenous potassium chloride
Question 604Question →

A nurse is caring for a client admitted with acute pancreatitis. Over the last 4 hours, the client has become increasingly restless. The nurse assesses the current vital signs: temperature 37.6°C (99.7°F), heart rate 122 bpm, respiratory rate 26 breaths/min, and blood pressure 108/86 mmHg. The client's baseline blood pressure upon admission was 128/74 mmHg. The client's capillary refill is 4 seconds, and peripheral pulses are faint. Which of the following physiological adaptations best explains this client's current clinical presentation?

Show answer & explanation

Answer: Sympathetic nervous system activation causing peripheral vasoconstriction in response to severe intravascular fluid shifts.

Answer

The client's presentation is best explained by sympathetic nervous system activation causing peripheral vasoconstriction in response to intravascular fluid shifts.
In acute pancreatitis, fluid shifts rapidly into the interstitial spaces (third-spacing), causing profound hypovolemia. The body adapts by activating the sympathetic nervous system (the fight-or-flight response). Epinephrine and norepinephrine are released, causing intense peripheral vasoconstriction to shunt blood to vital organs. This vasoconstriction raises the systemic vascular resistance and the diastolic blood pressure, resulting in a narrowed pulse pressure (108 - 86 = 22 mmHg). It also causes faint peripheral pulses and delayed capillary refill. The maintained systolic blood pressure and restlessness (indicating brain perfusion is maintained but marginally compromised) confirm the client is actively in the compensatory stage of shock.

Step-by-Step Solution

1
Analyze the client's vital sign trends and physical assessment findings.
The client has tachycardia (122 bpm), tachypnea (26 breaths/min), a narrowed pulse pressure (22 mmHg compared to baseline 54 mmHg), delayed capillary refill (4 seconds), faint pulses, and restlessness.
Identifying abnormal parameters and calculating the pulse pressure is the first step in recognizing clinical deterioration.
2
Correlate the findings with the pathophysiology of acute pancreatitis.
Acute pancreatitis causes massive inflammatory third-spacing of fluid into the peritoneal cavity, leading to severe hypovolemia.
Understanding the underlying disease process explains the trigger for the systemic physiological changes.
3
Determine the stage and type of shock based on the physiological response.
The body compensates for hypovolemia by activating the sympathetic nervous system. This causes intense peripheral vasoconstriction (increasing diastolic BP, narrowing pulse pressure, delaying capillary refill) to maintain core perfusion.
A narrowed pulse pressure and signs of poor peripheral perfusion with a relatively maintained systolic blood pressure are classic hallmarks of the compensatory stage of shock.

Key Concept

Compensatory Stage of Hypovolemic Shock
Question 605Question →

A nurse is preparing to administer a prescribed intravenous (IV) push medication to a client. The medication is incompatible with the client's continuous primary IV fluid infusion. The client has a single peripheral IV line. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first pause the incompatible infusion, scrub the injection port, flush the line with normal saline, administer the IV push medication, flush again with normal saline at the medication rate, and finally restart the primary infusion.
When administering an IV push medication that is incompatible with a continuous IV infusion, the nurse must ensure the two fluids do not mix. This is achieved by first pausing the primary infusion, cleaning the port, and flushing the line with a compatible fluid (usually 10 mL of 0.9% sodium chloride) before the medication is introduced. The medication is then administered over the recommended time. A second flush is required to ensure the full dose reaches the client, which must be administered at the same rate as the medication so the remaining drug is not pushed in too quickly. Finally, the primary infusion is restarted.

Step-by-Step Solution

1
Pause the incompatible primary continuous IV fluid infusion.
The flow of the incompatible fluid is stopped.
Prevents mixing of the incompatible fluid and the IV push medication within the IV tubing, which could cause precipitation.
2
Scrub the injection port closest to the client.
The injection port is disinfected.
Reduces the risk of introducing pathogens into the client's bloodstream.
3
Flush the IV line with normal saline.
The incompatible fluid is cleared from the tubing.
Ensures the tubing is clear of the incompatible fluid before the medication is introduced.
4
Administer the IV push medication.
The medication is delivered to the client.
Provides the prescribed pharmacological therapy.
5
Flush the IV line again with normal saline at the same rate as the medication.
The remaining medication is cleared from the tubing and delivered to the client.
Ensures the client receives the full dose of the medication. Flushing at the medication rate prevents a sudden bolus of the drug.
6
Restart the primary continuous IV fluid infusion.
The primary fluid infusion is resumed.
Maintains the prescribed fluid therapy after the medication administration is complete.

Key Concept

Administration of an IV push medication through an incompatible continuous IV infusion requires pausing the primary fluid and performing careful flushing before and after to prevent mixing and precipitation.
Question 606Question →

An adult client is receiving a transfusion of packed red blood cells (PRBCs) through a peripheral intravenous catheter for symptomatic anemia. Approximately 1515 minutes after the transfusion begins, the client reports sudden lower back pain, chills, and severe shortness of breath. The nurse observes that the client's urine in the bedside drainage bag has turned a dark, reddish-brown color. Which of the following is the most appropriate initial nursing action?

Show answer & explanation

Answer: Stop the blood transfusion immediately and maintain intravenous access with normal saline using new tubing.

Answer

The nurse must immediately stop the blood transfusion and maintain intravenous access with normal saline using completely new tubing.
The client is exhibiting the hallmark signs of an acute hemolytic transfusion reaction (lower back pain, hemoglobinuria, chills, dyspnea). This is a life-threatening medical emergency typically caused by ABO incompatibility. The absolute first priority is to stop the transfusion to prevent further exposure to the incompatible blood. The nurse must then maintain the intravenous line with normal saline using entirely new tubing, because flushing the existing blood tubing would force more incompatible red blood cells into the client's circulation.

Step-by-Step Solution

1
Analyze the client's clinical presentation and symptom onset.
The client developed sudden lower back pain, chills, dyspnea, and hemoglobinuria (dark urine) within 1515 minutes of starting a PRBC transfusion.
Recognizing classic signs of a life-threatening acute hemolytic transfusion reaction is the first critical step in clinical judgment.
2
Determine the highest priority nursing intervention.
The most critical action is to stop the infusion of the incompatible blood product immediately.
Continuing the transfusion, even at a slower rate, will introduce more incompatible cells, rapidly worsening systemic inflammatory response, renal failure, and potential cardiovascular collapse.
3
Identify the proper procedure for maintaining venous access after stopping the transfusion.
Disconnect the blood tubing at the intravenous hub and connect new tubing primed with 0.9%0.9\% normal saline.
Flushing the existing tubing would push the remaining incompatible blood into the client's systemic circulation. New tubing ensures only safe saline is administered to keep the vein open for emergency medications.

Key Concept

Management of Acute Hemolytic Transfusion Reactions
Estimated Time:1m 15s
Question 607Question →

A client with new-onset atrial fibrillation is prescribed a continuous intravenous (IV) infusion of amiodarone at a rate of 11 mg/min. The pharmacy dispenses an IV bag containing 900900 mg of amiodarone in 500500 mL of 5%5\% dextrose in water (D5WD_5W). At what rate, in mL/hr, should the nurse program the IV infusion pump? (Record your answer to the nearest tenth).

Show answer & explanation

Answer: 33.3

Answer

33.3
To determine the correct IV pump setting, the nurse must first convert the 11 mg/min prescription to an hourly dose (6060 mg/hr). Then, by dividing the desired hourly dose by the total amount of medication in the bag (900900 mg) and multiplying by the total volume (500500 mL), the nurse calculates the required flow rate of 33.333...33.333... mL/hr. Rounding to the nearest tenth gives the final programmed rate of 33.333.3 mL/hr.

Step-by-Step Solution

1
Convert the prescribed dose from per minute to per hour.
6060 mg/hr
IV infusion pumps are programmed to deliver fluids in mL/hr, so the prescribed medication dose must first be standardized to an hourly rate.
2
Calculate the required volume to deliver the hourly dose based on the supplied concentration.
33.333...33.333... mL/hr
Using the desired over have formula multiplied by volume: (Desired Dose / Have) x Volume. So, (60/900)×500=33.333...(60 / 900) \times 500 = 33.333...
3
Round the final calculated rate to the nearest tenth.
33.333.3 mL/hr
The question explicitly specifies to record the final answer rounded to the nearest tenth.

Key Concept

Intravenous medication dosage calculation and infusion pump programming
Estimated Time:1m 30s
Question 608Question →

A young adult is brought to the emergency department experiencing sustained, continuous tonic-clonic seizures. The healthcare provider prescribes a loading dose of intravenous phenytoin. The patient currently has a peripheral venous catheter with a continuous infusion of 5% dextrose in water (D5W) running at 75 mL/hr. Which nursing action is essential for the safe administration of this prescribed medication?

Show answer & explanation

Answer: Flush the intravenous catheter with 0.9% sodium chloride immediately before and after the medication is given.

Answer

Flush the intravenous catheter with 0.9% sodium chloride immediately before and after the medication is given.
Phenytoin is compatible only with 0.9% sodium chloride (normal saline). Because the primary infusion is 5% dextrose in water, the nurse must adequately flush the line with normal saline before and after administration to prevent drug precipitation and ensure safe delivery.

Step-by-Step Solution

1
Identify the prescribed medication and the current continuous intravenous fluid.
The medication is phenytoin, and the continuous fluid is 5% dextrose in water (D5W).
Establishing the baseline therapy is required to evaluate compatibility.
2
Recall the compatibility profile for intravenous phenytoin.
Phenytoin is only compatible with 0.9% sodium chloride (normal saline) and will crystallize in dextrose solutions.
Preventing drug precipitation in the intravenous line is a critical safety measure.
3
Determine the appropriate intervention to safely administer the medication.
The line must be thoroughly flushed with 0.9% sodium chloride before and after the phenytoin is administered.
Flushing clears the line of the incompatible dextrose solution, preventing adverse reactions or catheter occlusion.

Key Concept

Intravenous phenytoin is incompatible with dextrose solutions and requires a 0.9% sodium chloride flush before and after administration.
Question 609Question →

An adult client is receiving continuous intravenous fluid replacement for massive gastrointestinal losses secondary to a high-output enterocutaneous fistula. When evaluating the client's hemodynamic status, which assessment findings indicate the development of early, compensatory hypovolemic shock? Select all that apply.

Select all that apply

Show answer & explanation

Answer: A progressive narrowing of the pulse pressure; Heart rate increasing from 82 to 114 beats per minute; New-onset restlessness and apprehension

Answer

The correct findings are a progressive narrowing of the pulse pressure, an increasing heart rate, and new-onset restlessness.
During the compensatory stage of hypovolemic shock, the body's sympathetic nervous system activates to maintain cardiac output and vital organ perfusion. This neurohormonal response results in an increased heart rate (tachycardia) and peripheral vasoconstriction. The vasoconstriction elevates the diastolic blood pressure, leading to a narrowed pulse pressure. Additionally, subtle decreases in cerebral oxygenation manifest early as behavioral changes, such as restlessness, anxiety, or apprehension.

Step-by-Step Solution

1
Analyze the client's clinical scenario.
The client has massive GI fluid losses, placing them at high risk for hypovolemic shock.
Identifying the etiology (volume loss) helps anticipate the specific compensatory physiological responses.
2
Recall the physiological changes in the compensatory stage of shock.
The body activates the sympathetic nervous system, releasing epinephrine and norepinephrine to maintain cardiac output and blood pressure.
This sympathetic response drives the early clinical manifestations.
3
Evaluate each option against known compensatory mechanisms.
Tachycardia, narrowed pulse pressure (due to vasoconstriction), and restlessness (due to mild cerebral hypoxia) are all classic early signs.
Matching expected pathophysiology to assessment findings ensures accurate clinical judgment.
4
Identify and exclude incorrect findings that contradict early hypovolemic shock.
High PaCO2 (respiratory acidosis), warm/flushed skin, and normal urine output are excluded.
These indicate either different types of shock (septic), later stages of failure, or a lack of distress.

Key Concept

Early Physiological Signs of Compensatory Hypovolemic Shock
Question 610Question →

A client with a documented history of severe chronic obstructive pulmonary disease (COPD) presents to the emergency department with acute confusion and worsening dyspnea. Initial room air arterial blood gas (ABG) values are pH 7.28, PaCO2 66 mm Hg, HCO3 31 mEq/L, and PaO2 52 mm Hg. The healthcare provider prescribes supplemental oxygen at 4 L/min via nasal cannula. One hour later, which of the following repeat ABG results most strongly indicates a life-threatening complication directly caused by the prescribed therapy?

Show answer & explanation

Answer: pH 7.19, PaCO2 84 mm Hg, HCO3 32 mEq/L, PaO2 96 mm Hg

Answer

The ABG showing pH 7.19, PaCO2 84 mm Hg, HCO3 32 mEq/L, and PaO2 96 mm Hg.
In clients with severe COPD who chronically retain carbon dioxide, administering excessive supplemental oxygen (resulting here in a PaO2 of 96 mm Hg) can lead to oxygen-induced hypercapnia. This occurs due to a worsening ventilation-perfusion (V/Q) mismatch and the Haldane effect. The resulting acute spike in PaCO2 (from 66 to 84 mm Hg) causes a sharp drop in pH (from 7.28 to 7.19), leading to life-threatening acute respiratory acidosis and potential CO2 narcosis.

Step-by-Step Solution

1
Analyze the client's baseline and underlying condition.
The client has severe COPD with baseline hypercapnia (PaCO2 66) and metabolic compensation (HCO3 31).
Understanding baseline pathophysiology is essential to evaluate the response to clinical interventions.
2
Identify the primary risks of the prescribed intervention.
Providing oxygen at 4 L/min to a severe COPD client risks hyper-oxygenation, which can worsen ventilation-perfusion mismatch and reduce the respiratory drive (Haldane effect).
Oxygen therapy in severe COPD must be carefully titrated, typically aiming for a PaO2 of 60-70 mm Hg or SpO2 88-92%.
3
Evaluate the options for signs of this specific respiratory complication.
The option with an abnormally high PaO2 (96 mm Hg), rapidly rising PaCO2 (84 mm Hg), and dropping pH (7.19) perfectly mirrors oxygen-induced hypercapnia.
This confirms that excessive oxygen has severely compromised the client's ventilation, leading to life-threatening acute-on-chronic respiratory acidosis.

Key Concept

Oxygen-induced hypercapnia in Chronic Obstructive Pulmonary Disease (COPD)
Question 611Question →

A nurse is assessing a client who sustained blunt abdominal trauma in a motor vehicle collision 2 hours ago. The nurse suspects the client is developing early compensatory hypovolemic shock due to internal bleeding. Which of the following assessment findings support this clinical judgment? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Heart rate steadily increasing from 82 to 112 beats/minute.; Pulse pressure narrowing from 45 mm Hg to 28 mm Hg.; The client becoming increasingly restless and anxious.

Answer

The correct findings that indicate early compensatory hypovolemic shock are a steadily increasing heart rate, a narrowing pulse pressure, and increasing restlessness or anxiety.
In the early (compensatory) stage of hypovolemic shock, the body attempts to maintain adequate tissue perfusion and cardiac output. The sympathetic nervous system stimulates an increase in heart rate (tachycardia). Peripheral vasoconstriction increases diastolic blood pressure, leading to a narrowing pulse pressure even while systolic pressure remains relatively stable. Additionally, early slight decreases in cerebral oxygenation manifest as restlessness, apprehension, or anxiety.

Step-by-Step Solution

1
Analyze the pathophysiology of early (compensatory) hypovolemic shock.
The sympathetic nervous system triggers vasoconstriction and increases the heart rate to maintain cardiac output and tissue perfusion despite fluid loss.
Understanding the body's compensatory mechanisms is essential to identifying early clinical manifestations.
2
Evaluate the provided vital sign trends for signs of compensation.
Mild tachycardia and a narrowing pulse pressure (due to elevated diastolic pressure from vasoconstriction) are classic early indicators before the systolic blood pressure drops.
Systolic hypotension is a late sign; detecting subtle early trends prevents progression to irreversible shock.
3
Evaluate neurological and respiratory changes associated with early shock.
Decreased cerebral perfusion leads to early restlessness and anxiety. Compensatory tachypnea typically causes respiratory alkalosis.
Neurological changes are often the very first observable sign of decreased oxygen delivery.
4
Differentiate between shock types based on skin presentation.
Cool, clammy skin is expected in hypovolemic shock due to vasoconstriction, whereas warm, flushed skin is characteristic of early septic or neurogenic shock.
Ensures the findings align specifically with hypovolemia rather than vasodilation.

Key Concept

Recognition of the subtle, early compensatory signs of hypovolemic shock, including mild tachycardia, narrowing pulse pressure, and altered mentation, prior to the onset of profound hypotension.
Question 612Question →

A nurse is monitoring an adult client who is receiving a unit of packed red blood cells (PRBCs). Fifteen minutes into the infusion, the client suddenly reports severe lower back pain, chills, and shortness of breath. To reduce the risk of severe physiological complications, arrange the following nursing actions in the correct priority sequence. (Arrange the first action at the top and the final action at the bottom).

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: 1) Stop the blood transfusion immediately, 2) Disconnect the blood tubing and initiate normal saline using new intravenous tubing, 3) Assess the client's vital signs and respiratory status, 4) Notify the healthcare provider and the blood bank of the suspected reaction, 5) Return the blood bag, attached administration set, and labels to the blood bank.
In the event of a suspected severe transfusion reaction, the priority is to stop the source of the injury. Therefore, stopping the transfusion is the absolute first action. Secondly, intravenous access must be maintained for emergency resuscitation, requiring normal saline to be infused through entirely new tubing to prevent flushing remaining blood into the client. Thirdly, a rapid physiological assessment of vital signs provides necessary data about the severity of the reaction (e.g., hypotension, hypoxia). Fourth, the healthcare provider and blood bank are notified, utilizing the gathered assessment data to receive medical orders. Finally, returning the blood bag and tubing to the blood bank is completed for diagnostic analysis after the client is stabilized.

Step-by-Step Solution

1
Identify the clinical signs of a severe transfusion reaction.
The client's lower back pain, chills, and shortness of breath indicate a potential acute hemolytic transfusion reaction.
Early recognition of a transfusion reaction dictates immediate emergency intervention to prevent morbidity or mortality.
2
Determine the first priority to reduce further risk to the client.
Stopping the transfusion immediately is prioritized above all other actions.
Halting the infusion prevents any additional incompatible red blood cells from entering the client's circulation, thereby limiting the severity of the reaction.
3
Establish the next immediate physical intervention to preserve safety.
Maintaining a patent intravenous line with normal saline using new tubing is the second step.
A patent line is critical for administering emergency fluids or medications. Flushing with the existing blood tubing would incorrectly push more incompatible blood into the client.
4
Prioritize the remaining assessment, communication, and procedural tasks.
Assessment of vital signs precedes notifying the provider, followed by returning the equipment to the blood bank.
The provider needs current vital signs to prescribe appropriate emergency orders. Returning the blood bag is a necessary administrative and diagnostic step but has the lowest immediate physiological priority.

Key Concept

Management of Acute Hemolytic Transfusion Reactions
Question 613Question →

A client is brought to the emergency department unresponsive with a respiratory rate of 6 breaths per minute. Initial arterial blood gas (ABG) analysis reveals a pH of 7.25, PaCO2 of 65 mm Hg, and HCO3 of 24 mEq/L. If this acid-base imbalance continues, which compensatory physiological mechanism will the client's body utilize?

Show answer & explanation

Answer: Increased renal reabsorption of bicarbonate and excretion of hydrogen ions

Answer

The client's body will compensate through increased renal reabsorption of bicarbonate and excretion of hydrogen ions.
The client is in uncompensated respiratory acidosis, caused by severe hypoventilation and carbon dioxide retention. Because the respiratory system is the source of the problem, it cannot compensate. Instead, the physiological adaptation relies on the renal system. Over hours to days, the kidneys will compensate by increasing the reabsorption of bicarbonate (base) into the bloodstream and excreting excess hydrogen ions (acid) into the urine, which helps restore the blood pH toward normal.

Step-by-Step Solution

1
Analyze the initial ABG values to determine the primary acid-base imbalance.
pH is 7.25 (acidosis), PaCO2 is 65 mm Hg (acidosis), and HCO3 is 24 mEq/L (normal). The primary imbalance is uncompensated respiratory acidosis.
Identifying the primary disturbance is required to determine which organ system will initiate compensation.
2
Determine the cause of the imbalance based on the clinical presentation.
The respiratory rate is 6 breaths per minute, indicating severe hypoventilation causing carbon dioxide retention.
Understanding the source of the problem confirms that the respiratory system cannot fix the imbalance itself.
3
Identify the correct compensatory mechanism for the primary imbalance.
Because the lungs are failing to ventilate adequately, the kidneys must compensate by adjusting acid and base elimination.
The renal system compensates for respiratory acidosis by retaining bicarbonate (to increase buffering capacity) and excreting excess hydrogen ions in the urine.

Key Concept

Acid-Base Compensation Mechanisms
Question 614Question →

A nurse is caring for a critically ill client who has a double-lumen central venous catheter (CVC). The client is receiving a continuous intravenous (IV) infusion of norepinephrine through the distal lumen for hemodynamic support. The healthcare provider prescribes a scheduled dose of IV push furosemide and an intermittent IV infusion of piperacillin-tazobactam. Which of the following actions should the nurse take? (Select all that apply.)

Select all that apply

Show answer & explanation

Answer: Scrub the needleless connector hub of the proximal lumen with an appropriate antiseptic friction rub for at least 1515 seconds prior to access.; Administer the intermittent piperacillin-tazobactam infusion through the proximal lumen using an electronic infusion pump.; Flush the proximal lumen with a 0.9%0.9\% sodium chloride solution before and after administering the IV push furosemide.

Answer

The safe and appropriate actions include scrubbing the needleless connector hub for at least 1515 seconds prior to access, administering the antibiotic through the unused proximal lumen, and flushing the lumen with 0.9%0.9\% sodium chloride before and after IV push administration.
Safe parenteral therapy through a multi-lumen CVC requires maintaining the continuity of life-sustaining infusions, utilizing strict aseptic technique during access, and ensuring line patency. Separate lumens exit at different points in the vein, allowing for the simultaneous administration of incompatible or critical medications without interruption or precipitation.

Step-by-Step Solution

1
Identify the critical nature of the continuous infusion.
Norepinephrine is a life-sustaining vasoactive drip.
Interrupting a vasopressor can cause rapid hemodynamic collapse, so the distal lumen must remain dedicated to this infusion.
2
Determine the safe route for the new intermittent medications.
The unused proximal lumen of the double-lumen CVC will be utilized.
Multi-lumen catheters have separate internal channels that exit at different points in the vein, allowing incompatible medications to be administered simultaneously without mixing inside the catheter.
3
Apply standard central line infection prevention and maintenance protocols.
Scrub the hub for at least 1515 seconds and perform routine saline flushes.
Scrubbing the hub prevents CLABSI, while flushing before and after IV push medications confirms patency and clears the line of residual drug.
4
Evaluate delegation and dosage safety principles.
Assessments cannot be delegated, and exact weight must be used for dosing.
RNs retain responsibility for all clinical assessments, and estimated weights are unsafe for titrating critical care drips.

Key Concept

Management of Multi-Lumen Central Venous Catheters and High-Alert Medications
Question 615Question →

During the immediate post-operative period, a nurse evaluates a 48-year-old client who underwent a total thyroidectomy 4 hours ago. The client reports a subjective feeling of "tightness and fullness" in the neck, accompanied by mild tingling around the mouth. Current vital signs reveal a blood pressure of 135/85 mmHg, a heart rate of 110 bpm, a respiratory rate of 22 breaths/min, and an oxygen saturation of 96% on room air. Which action should the nurse take FIRST to mitigate the risk of severe physiological decompensation?

Show answer & explanation

Answer: Inspect the incisional dressing and the tissues behind the client's neck for excessive bleeding.

Answer

The correct action is to inspect the incisional dressing and the tissues behind the client's neck for excessive bleeding.
After a thyroidectomy, a subjective feeling of neck fullness or tightness, especially when accompanied by tachycardia, is a hallmark early sign of an expanding hematoma. Because the surgical site is directly adjacent to the trachea, a hematoma can rapidly compress the trachea and cause a complete airway obstruction. The nurse must prioritize Airway, Breathing, and Circulation (ABCs). Inspecting the dressing and the dependent area behind the neck (where blood often pools) is the immediate priority to identify this life-threatening complication before proceeding to other assessments.

Step-by-Step Solution

1
Analyze the client's reported symptoms and vital signs.
The client is exhibiting two distinct complication indicators: neck fullness/tightness with tachycardia (potential hematoma) and perioral tingling (potential hypocalcemia).
Identifying the pathophysiological meaning behind clinical cues is the first step in clinical judgment.
2
Apply the ABCs (Airway, Breathing, Circulation) framework for prioritization.
Neck fullness indicates an expanding hematoma, which is an immediate threat to the airway (tracheal compression). Tingling indicates hypocalcemia, which is a neurological/circulatory issue that typically progresses slower than a compromised airway.
When multiple complications arise simultaneously, the nurse must prioritize interventions that address the most immediate threat to life.
3
Determine the priority nursing intervention.
Assessing the source of the airway threat by inspecting for hemorrhage must precede assessing or treating the electrolyte imbalance.
Failing to promptly identify and report an expanding hematoma post-thyroidectomy can lead to complete airway obstruction and respiratory arrest.

Key Concept

Post-operative Complication Prioritization (Airway/Hemorrhage vs. Electrolyte Imbalance)
Question 616Question →

An older adult client with a 3-day history of severe, persistent vomiting is admitted to the medical unit. The client appears lethargic, and the nurse notes a respiratory rate of 10 breaths per minute. Arterial blood gas (ABG) results reveal a pH of 7.50, PaCO2 of 54 mm Hg, and HCO3- of 38 mEq/L. Which of the following physiological adaptations best explains this client's respiratory pattern?

Show answer & explanation

Answer: A compensatory decrease in alveolar ventilation designed to retain carbon dioxide and lower blood pH

Answer

The correct response describes a compensatory decrease in alveolar ventilation designed to retain carbon dioxide and lower the blood pH.
The correct answer accurately links the clinical findings to the underlying physiological process. Severe vomiting causes a loss of gastric acid, resulting in metabolic alkalosis (indicated by the pH of 7.50 and HCO3- of 38 mEq/L). The body's natural physiological adaptation to metabolic alkalosis is respiratory compensation. The respiratory center decreases the rate and depth of breathing (hypoventilation, seen here as 10 breaths per minute) to retain carbon dioxide. This retained carbon dioxide forms carbonic acid in the blood (reflected by the elevated PaCO2 of 54 mm Hg), which helps to lower the pH back toward the normal range.

Step-by-Step Solution

1
Analyze the ABG results to determine the primary acid-base imbalance.
pH is 7.50 (alkalosis). HCO3- is 38 mEq/L (alkalosis). PaCO2 is 54 mm Hg (acidosis).
Matching the pH direction with the abnormal values identifies the primary disorder as metabolic alkalosis.
2
Correlate the primary disorder with the client's clinical history.
Severe vomiting causes significant loss of gastric acid (hydrochloric acid), leading directly to metabolic alkalosis.
Connecting the lab values to the etiology confirms the diagnosis of primary metabolic alkalosis.
3
Evaluate the body's compensatory mechanisms for this specific imbalance.
The respiratory system compensates for metabolic alkalosis by retaining acid (PaCO2) to lower the pH toward the normal range.
The body attempts to restore the 20:1 ratio of bicarbonate to carbonic acid.
4
Identify the physical manifestation of this respiratory compensation.
To retain PaCO2, the respiratory center decreases the rate and depth of breathing (hypoventilation), resulting in the observed respiratory rate of 10 breaths per minute.
This confirms that the slow respiratory rate is a deliberate physiological adaptation, not a sign of respiratory failure.

Key Concept

Acid-Base Imbalances and Compensatory Mechanisms
Question 617Question →

A client arrives at the medical-surgical unit for continuous monitoring following a diagnostic lumbar puncture performed 30 minutes ago. Which nursing interventions should be implemented to reduce the risk of physiological complications? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Maintain the client in a flat, supine position for the duration prescribed by the healthcare provider.; Inspect the puncture site dressing for clear, halo-like drainage or frank blood.; Encourage the client to increase oral fluid intake, unless medically contraindicated.

Answer

The correct interventions are maintaining the client in a flat, supine position, inspecting the puncture site for drainage or bleeding, and encouraging oral fluid intake.
Following a lumbar puncture, nursing care prioritizes the prevention of a cerebrospinal fluid (CSF) leak, which leads to a severe spinal headache. Maintaining a flat, supine position minimizes pressure at the dural puncture site, allowing it to seal. Encouraging oral fluids accelerates the body's natural replacement of the withdrawn CSF. Frequent inspection of the dressing for a 'halo' sign (a clear ring surrounding a blood spot, indicating CSF) or frank blood ensures early identification of complications requiring provider intervention.

Step-by-Step Solution

1
Identify the primary physiological risks associated with a lumbar puncture.
The main risks include cerebrospinal fluid (CSF) leakage, post-dural puncture spinal headache, and bleeding/hematoma formation.
Understanding the specific complications of the procedure dictates the preventative nursing care required.
2
Select interventions that directly mitigate the identified risks.
Keeping the client flat reduces dural pressure (preventing CSF leak), fluids help replace CSF, and checking the dressing ensures early detection of bleeding or leakage.
These evidence-based actions actively reduce the risk of the most common post-procedural complications.
3
Evaluate and eliminate contraindicated actions.
Elevating the head increases CSF leak risk; ignoring vital sign changes misses early shock; giving opioids before assessment masks neurological decline.
Recognizing unsafe practices is essential for maintaining a safe care environment and preventing iatrogenic injury.

Key Concept

Post-procedure care for a lumbar puncture focuses on preventing cerebrospinal fluid leakage and spinal headaches through strict supine positioning and hydration, alongside vigilant monitoring for neurological changes or bleeding.
Estimated Time:1m 30s
Question 618Question →

A nurse is caring for a client receiving mechanical ventilation for acute respiratory distress syndrome (ARDS). The client's most recent arterial blood gas (ABG) analysis reveals the following:

ParameterValueReference Range
pH7.287.287.35−7.457.35 - 7.45
PaCO2\text{PaCO}_258 mm Hg58\text{ mm Hg}35−45 mm Hg35 - 45\text{ mm Hg}
HCO3−\text{HCO}_3^-24 mEq/L24\text{ mEq/L}22−26 mEq/L22 - 26\text{ mEq/L}
PaO2\text{PaO}_252 mm Hg52\text{ mm Hg}80−100 mm Hg80 - 100\text{ mm Hg}

The client is currently receiving a fraction of inspired oxygen (FiO2\text{FiO}_2) of 0.600.60. Which of the following nursing actions are appropriate? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Assess the endotracheal tube for patency and suction if indicated; Anticipate an order to increase the ventilator's respiratory rate; Prepare to assist with placing the client in a prone position

Answer

The appropriate actions include assessing the endotracheal tube for patency, anticipating an increase in the ventilator's respiratory rate, and preparing to place the client in a prone position.
The client is experiencing uncompensated respiratory acidosis coupled with severe hypoxemia, which is characteristic of worsening ARDS. Interventions must focus on improving ventilation and oxygenation. Assessing and suctioning the endotracheal tube ensures the airway is clear of secretions that could block gas exchange. Anticipating an increase in the respiratory rate is correct because a higher minute ventilation will help the client eliminate excess carbon dioxide, thereby increasing the pH. Preparing the client for a prone position is a critical, evidence-based intervention for ARDS that shifts blood flow to better-ventilated anterior alveoli, significantly improving oxygenation.

Step-by-Step Solution

1
Analyze the arterial blood gas results to determine the primary acid-base imbalance.
The low pH (7.287.28) indicates acidemia. The elevated PaCO2\text{PaCO}_2 (58 mm Hg58\text{ mm Hg}) with a normal HCO3−\text{HCO}_3^- (24 mEq/L24\text{ mEq/L}) indicates uncompensated respiratory acidosis.
Correct interpretation of ABGs is required to identify that the client is hypoventilating and retaining carbon dioxide.
2
Evaluate the client's oxygenation status.
The PaO2\text{PaO}_2 is 52 mm Hg52\text{ mm Hg} despite an FiO2\text{FiO}_2 of 0.600.60. This indicates severe hypoxemia and a significant intrapulmonary shunt typical of ARDS.
Identifying severe hypoxemia dictates the need for interventions that improve oxygenation, such as positioning changes.
3
Select interventions that address both the respiratory acidosis and the severe hypoxemia.
Increasing the ventilator rate blows off CO2\text{CO}_2. Suctioning the endotracheal tube removes obstructions. Prone positioning improves oxygenation in ARDS.
Nursing care must directly target the physiological abnormalities revealed by the assessment data.

Key Concept

Management of uncompensated respiratory acidosis and severe hypoxemia in Acute Respiratory Distress Syndrome (ARDS)
Question 619Question →

A nurse is monitoring an adult client who is receiving intravenous antibiotics for acute pyelonephritis. Which assessment finding provides the earliest clinical indication that the client is developing septic shock?

Show answer & explanation

Answer: Warm, flushed skin and a widening pulse pressure

Answer

Warm, flushed skin and a widening pulse pressure
Septic shock initially presents in a hyperdynamic ('warm') phase characterized by massive peripheral vasodilation induced by systemic inflammation. This physiological adaptation attempts to maintain cardiac output, resulting in warm, flushed skin and a widening pulse pressure. Recognizing this early phase is critical for immediate intervention before the client progresses to decompensated 'cold' shock.

Step-by-Step Solution

1
Identify the primary clinical risk for a client with severe pyelonephritis.
The client is at high risk for gram-negative sepsis and subsequent septic shock.
Severe bacterial infections can trigger a systemic inflammatory response.
2
Differentiate the pathophysiology of early septic shock from other forms of shock.
Unlike hypovolemic or cardiogenic shock (which cause immediate vasoconstriction), early septic shock is distributive and causes massive peripheral vasodilation.
Endotoxins trigger the release of vasoactive mediators, compromising vascular tone.
3
Determine the corresponding clinical signs of this early vasodilatory phase.
The vasodilation creates a hyperdynamic state, manifesting clinically as warm, flushed skin, bounding pulses, and a widening pulse pressure.
These are the earliest indicators before cardiovascular failure leads to profound hypotension and cold extremities.

Key Concept

Early indicators of distributive (septic) shock
Question 620Question →

A nurse is assessing a client who returned to the medical-surgical unit 45 minutes ago following a therapeutic thoracentesis for a large right-sided pleural effusion. During the procedure, 1,200 mL of fluid was removed. Which assessment finding is the most critical indicator that the client is developing a severe physiological complication requiring immediate intervention?

Show answer & explanation

Answer: Sudden onset of tachypnea, absent breath sounds on the right side, and a tracheal deviation toward the left

Answer

The sudden onset of tachypnea, absent breath sounds on the right side, and a tracheal deviation toward the left.
The correct answer highlights sudden tachypnea, absent breath sounds on the right side, and a tracheal deviation toward the left. These are classic, late-stage clinical manifestations of a tension pneumothorax, a severe and life-threatening complication that can occur after a thoracentesis if the visceral pleura is punctured. The tracheal deviation away from the affected side indicates a critical pressure buildup in the pleural space, requiring emergent needle decompression or chest tube placement to prevent cardiovascular collapse.

Step-by-Step Solution

1
Analyze the clinical scenario and the recent procedure.
The client is 45 minutes post-thoracentesis with a large volume (1,200 mL) of fluid removed.
Large volume fluid removal during a thoracentesis places the client at a high risk for complications such as pneumothorax, hemothorax, or re-expansion pulmonary edema.
2
Evaluate each assessment finding to differentiate between expected post-procedural symptoms and critical physiological decompensation.
Mild respiratory alkalosis, positional preferences to avoid lying flat, and moderate localized pain are identified as expected or non-emergent findings.
Recognizing normal compensatory mechanisms and expected procedural discomfort prevents the nurse from misallocating emergency resources.
3
Identify the finding that represents an immediate threat to airway, breathing, or circulation (ABCs).
Tachypnea, unilaterally absent breath sounds, and tracheal deviation are identified as an acute emergency.
These are classic clinical manifestations of a tension pneumothorax, a life-threatening complication that requires rapid provider notification and intervention.

Key Concept

Monitoring for and identifying early signs of post-thoracentesis complications, specifically tension pneumothorax, to reduce client risk.
PreviousPage 31 / 195Next
All practice questions — NCLEX-RN | Examkin