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Question 641Question →

A client is admitted to the intensive care unit with severe diabetic ketoacidosis (DKA). The client is lethargic, exhibiting Kussmaul respirations, and has a blood glucose level of 520 mg/dL (28.9 mmol/L). The healthcare provider has entered multiple initial prescriptions. In what order should the nurse perform the following actions? Arrange the interventions in the correct clinical sequence from first to last.

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Answer

The correct sequence for managing severe DKA is: 1) Initiate 0.9% sodium chloride, 2) Evaluate serum potassium level, 3) Start a continuous IV regular insulin infusion, 4) Add 5% dextrose to IV fluids when glucose drops to 250 mg/dL, and 5) Administer the first subcutaneous insulin dose before stopping the IV insulin.
The management of Diabetic Ketoacidosis (DKA) follows a strict, evidence-based sequence designed to stabilize the client and prevent life-threatening complications. The absolute immediate priority is fluid resuscitation with isotonic saline (0.9% NaCl) to restore intravascular volume and tissue perfusion resulting from severe osmotic diuresis. Second, before administering any insulin, the serum potassium level must be evaluated. Insulin administration causes an intracellular shift of potassium, which can lead to profound hypokalemia and fatal cardiac arrhythmias. Third, once a safe potassium level is verified, a continuous IV infusion of regular insulin is initiated to steadily correct the hyperglycemia and resolve the metabolic acidosis. Fourth, as the blood glucose level decreases to approximately 250 mg/dL (13.9 mmol/L), 5% dextrose is added to the IV fluid regimen to prevent a rapid drop in glucose, which could precipitate hypoglycemia and cerebral edema. Finally, once the ketoacidosis has resolved (evidenced by a normalized anion gap), the client is transitioned to a subcutaneous insulin regimen. The first subcutaneous dose must be administered prior to discontinuing the IV insulin to provide overlapping coverage and prevent a rebound into ketoacidosis.

Step-by-Step Solution

1
Restore intravascular volume.
Initiate a rapid intravenous infusion of 0.9% sodium chloride.
Fluid resuscitation is the immediate first priority in DKA to reverse severe dehydration caused by osmotic diuresis and to improve tissue perfusion.
2
Assess electrolyte status.
Evaluate the client's initial serum potassium laboratory result.
It is critical to verify the potassium level before giving insulin, as insulin therapy causes an intracellular shift of potassium, potentially leading to severe hypokalemia.
3
Correct hyperglycemia and acidosis.
Start a continuous intravenous infusion of regular insulin.
After fluid resuscitation has begun and potassium is confirmed to be in a safe range, IV insulin is administered to lower glucose levels and stop ketone production.
4
Prevent hypoglycemia and cerebral edema.
Add 5% dextrose to the intravenous fluids when blood glucose decreases to 250 mg/dL (13.9 mmol/L).
As blood glucose drops closer to normal, adding dextrose prevents a rapid fluid shift into the brain cells (cerebral edema) and avoids inducing hypoglycemia.
5
Transition to maintenance therapy.
Administer the first dose of subcutaneous insulin before discontinuing the intravenous insulin infusion.
Providing a subcutaneous insulin dose while the IV insulin is still running ensures continuous insulin coverage, preventing a rebound into ketoacidosis.

Key Concept

Diabetic Ketoacidosis (DKA) Acute Management Sequence
Question 642Question →

A primary care clinic nurse is applying an evidence-based behavioral intervention framework to promote smoking cessation for a young adult client during a routine wellness visit. In what chronological order should the nurse implement these interventions? Arrange the nursing actions from first to last.

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Answer

The correct sequence for implementing the tobacco cessation framework is to document tobacco use, deliver a personalized message to quit, evaluate the client's readiness to make a quit attempt, provide behavioral counseling and therapies, and finally schedule a follow-up evaluation.
The 5 A's model is a robust, evidence-based clinical framework for addressing tobacco dependence, which is a cornerstone of health promotion and disease prevention. The correct sequence closely mirrors the standard nursing process. It begins with initial assessment and screening (Ask), progresses to a clear diagnosis and health communication (Advise), evaluates the client's readiness to learn or change (Assess), implements targeted interventions such as structured counseling and medication (Assist), and concludes with evaluation and ongoing support (Arrange). Attempting these steps out of chronological order, such as providing a quit plan to a client who has not yet demonstrated a willingness to quit, fundamentally reduces the efficacy of the health promotion intervention.

Step-by-Step Solution

1
Systematically document the client's current tobacco use status during the initial vital signs and intake assessment.
The nurse successfully identifies the client as a current tobacco user.
Before any health promotion teaching can begin, the nurse must screen and identify the risk factor.
2
Deliver a clear, strong, and personalized message urging the client to quit smoking to prevent future health complications.
The client receives and understands the direct medical recommendation to cease tobacco use.
Direct, personalized advice from a healthcare professional significantly increases long-term quit rates.
3
Determine the client's readiness and willingness to make a formal quit attempt within the next thirty days.
The nurse comprehensively evaluates the client's motivation and current stage of behavioral change.
Interventions must be tailored to the client's current willingness to change; pushing a detailed plan on a resistant client is ineffective.
4
Provide practical behavioral counseling and collaborate with the healthcare provider to recommend appropriate nicotine replacement therapy.
The client receives a concrete quit plan, coping strategies, and appropriate pharmacological support.
Once clinical readiness is established, providing tangible support and resources maximizes the chances of a successful quit attempt.
5
Schedule a follow-up telephone call or clinic evaluation to occur within the first week after the established quit date.
A supportive accountability system is formalized for the critical early days of cessation.
Relapse risk is highest in the first few days following cessation. Timely follow-up provides accountability and allows for rapid adjustment of the plan.

Key Concept

The 5 A's Behavioral Intervention Framework for Smoking Cessation
Question 643Question →

A nurse finds a conscious client who has diabetes mellitus profusely sweating and reporting tremors and palpitations. Arrange the following nursing actions in the priority order they should be performed.

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Answer

First, check the blood glucose level. Second, administer 15 grams of a fast-acting carbohydrate. Third, wait 15 minutes. Fourth, recheck the blood glucose level. Finally, provide a snack containing protein and a complex carbohydrate.
The sequence follows the standard '15-15 rule' for hypoglycemia management. The nursing process dictates assessment first (checking the blood glucose) to confirm the condition. Once confirmed, immediate treatment with a fast-acting carbohydrate is provided. The nurse must wait 15 minutes for absorption before rechecking the glucose level. Finally, a complex carbohydrate and protein snack is given to maintain blood glucose stability and prevent a secondary drop.

Step-by-Step Solution

1
Assess the client's current glycemic status.
The capillary blood glucose level is checked.
Symptoms of hypoglycemia can mimic other acute conditions. Assessment must precede intervention to confirm the diagnosis.
2
Administer immediate treatment for hypoglycemia.
15 grams of a fast-acting carbohydrate is given.
A simple carbohydrate rapidly absorbs into the bloodstream to quickly elevate the blood glucose level.
3
Allow time for the intervention to work.
The nurse waits 15 minutes.
It takes approximately 15 minutes for the simple carbohydrate to take effect and accurately reflect in the blood.
4
Evaluate the effectiveness of the intervention.
The capillary blood glucose level is rechecked.
The nurse must verify that the blood glucose has risen above 70 mg/dL (3.9 mmol/L). If it has not, the previous treatment steps are repeated.
5
Prevent recurrence of hypoglycemia.
A snack with protein and a complex carbohydrate is provided.
Simple carbohydrates have a short duration of action. Protein and complex carbohydrates provide sustained glucose release to prevent a subsequent drop.

Key Concept

Management of acute hypoglycemia using the 15-15 rule
Question 644Question →

An adult client is brought to the emergency department by friends after consuming large amounts of alcohol over the past few days. The client is lethargic, exhibits severe ataxia, and has slurred speech. The healthcare provider has prescribed several interventions. Order the nursing actions from first to last to ensure safe and effective care.

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Answer

The correct sequence is: 1) Evaluate airway and respiratory status, 2) Perform a capillary blood glucose test, 3) Establish peripheral IV access, 4) Administer intravenous thiamine, and 5) Initiate the dextrose fluid infusion.
The priority of care for an intoxicated, lethargic client begins with the ABCs. Airway and respiratory status must be evaluated first due to the risk of respiratory depression. Next, a bedside capillary blood glucose test is essential because alcohol intoxication can cause severe hypoglycemia, which mimics worsening neurological decline. Following assessment, the nurse establishes IV access to deliver treatments. Crucially, intravenous thiamine must be administered before any dextrose-containing fluids to prevent the precipitation of Wernicke's encephalopathy, a severe neurological complication caused by thiamine depletion during glucose metabolism.

Step-by-Step Solution

1
Evaluate the client's airway patency and respiratory status.
Ensures the client has adequate oxygenation and ventilation.
Lethargic clients with acute alcohol intoxication are at high risk for respiratory depression and airway compromise, making this the highest priority.
2
Perform a bedside capillary blood glucose test.
Identifies if the client is experiencing hypoglycemia.
Alcohol severely impairs the liver's ability to produce glucose. Hypoglycemia mimics worsening intoxication and requires immediate detection.
3
Establish peripheral intravenous (IV) access.
Provides a direct route for medications and fluids.
Venous access is necessary before prescribed emergency medications and intravenous hydration can be administered.
4
Administer the prescribed dose of intravenous thiamine.
Replenishes essential vitamin B1 levels.
Thiamine must be given prior to any glucose load in clients with chronic alcohol use to prevent Wernicke's encephalopathy.
5
Initiate the prescribed infusion of dextrose-containing intravenous fluids.
Corrects dehydration and low blood sugar.
Administered safely only after thiamine has been supplied, treating the underlying metabolic and fluid deficits without risking brain injury.

Key Concept

In clients with severe alcohol intoxication or chronic use, intravenous thiamine must be administered before or simultaneously with intravenous glucose to prevent Wernicke's encephalopathy.
Question 645Question →

A nurse is teaching a client who has a non-weight-bearing cast on the right lower extremity how to ascend stairs using crutches. Arrange the following actions in the correct chronological order.

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Answer

To ascend stairs with crutches while non-weight-bearing, the client places weight on the crutches, steps up with the unaffected leg, shifts weight to the unaffected leg, and finally brings the crutches and affected leg up to the stair tread.
When ascending stairs using a three-point gait with crutches (non-weight-bearing), the standard safe practice follows the phrase 'up with the good.' The client must start from a stable tripod position, bear weight on the crutches, and step up with the unaffected (strong) leg first. Once the unaffected leg is planted on the stair tread, the client shifts their weight onto that leg. This securely allows the client to lift the crutches and the affected leg simultaneously to the same step, maintaining a non-weight-bearing status on the injured extremity.

Step-by-Step Solution

1
Place weight on crutches.
The unaffected leg is freed to move.
Establishing a solid base of support is required before initiating upward movement.
2
Advance the unaffected leg to the stair tread.
The strong leg is now positioned on the higher level.
The unaffected leg must lead when going up stairs ('up with the good') to lift the body's weight safely.
3
Shift body weight to the unaffected leg.
The crutches and the affected leg are no longer bearing weight.
Weight must be transferred to the elevated strong leg so the crutches can be lifted.
4
Bring the crutches and affected leg up to the step.
The client is fully positioned on the new stair tread.
This completes the movement sequence safely without placing any weight on the injured leg.

Key Concept

Mobility and Assistive Devices: Ascending Stairs with Crutches
Question 646Question →

A nurse is caring for a client who is receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes after the transfusion begins, the client reports sudden lower back pain, chills, and shortness of breath. In which order should the nurse perform the following actions? Arrange the actions from first to last.

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Answer

Stop the transfusion, initiate normal saline with new tubing, assess the client, notify the provider and blood bank, and return the blood product to the blood bank.
The absolute priority when a transfusion reaction is suspected is to prevent further exposure to the blood product, maintain venous access, assess the client, and obtain medical intervention. Stopping the transfusion immediately is always the first step, followed by maintaining the intravenous line with 0.9% sodium chloride through entirely new tubing to prevent infusing residual blood. Next, assessing the client provides critical baseline data for the healthcare provider. Notifying the provider and blood bank allows for rapid emergency interventions. Finally, returning the blood bag and tubing allows the facility to analyze the cause of the reaction.

Step-by-Step Solution

1
Stop the blood transfusion immediately.
Further entry of incompatible blood into the client's circulation is halted.
This is the most critical first step to minimize the severity of the physiological reaction.
2
Disconnect the blood tubing and initiate an infusion of 0.9% sodium chloride using new tubing.
A patent intravenous line is maintained with a neutral fluid.
Intravenous access is critical for administering emergency medications. New tubing must be used so that the blood remaining in the old tubing is not flushed into the client.
3
Assess the client's vital signs and respiratory status.
Baseline data regarding the client's physiological decompensation is gathered.
The nurse needs current, accurate assessment data to communicate the severity of the reaction to the provider.
4
Notify the healthcare provider and the facility blood bank.
The medical team is alerted and emergency orders can be obtained.
The provider will need to prescribe interventions based on the assessment, and the blood bank must initiate their transfusion reaction protocol.
5
Return the blood bag and administration set to the blood bank.
The implicated blood product is secured for laboratory analysis.
The blood bank needs the bag, the remaining blood, and the tubing to test for crossmatching errors or bacterial contamination.

Key Concept

Management of a suspected hemolytic blood transfusion reaction.
Estimated Time:1m 0s
Question 647Question →

A nurse is teaching a client with a left tibial fracture, who is prescribed non-weight-bearing status on the left leg, how to safely stand up from a seated position in a chair using axillary crutches. Arrange the following instructional steps in the correct chronological order.

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Answer

The correct sequence is: slide forward to the edge of the chair, place both crutches in the hand on the affected side, grasp the armrest with the unaffected hand, push up to a standing position, and finally establish a tripod stance.
When assisting a non-weight-bearing client to stand with crutches, safety and balance depend on proper leverage. The client must first move to the edge of the chair to align their center of gravity over their base of support. By placing both crutches in the hand on the affected side, the strong, unaffected arm is left free to grasp the solid chair armrest. The client then pushes up using the strong arm and strong leg, ensuring no weight is placed on the affected side. Only after achieving a stable standing position should the client move one crutch to the other hand to create the tripod stance for safe ambulation.

Step-by-Step Solution

1
Analyze the biomechanical requirements for standing from a seated position with one non-weight-bearing extremity.
The client needs to maximize leverage using their strong limbs while protecting the injured leg.
Understanding the core goal ensures each procedural step contributes to safety, stability, and adherence to weight-bearing restrictions.
2
Determine the initial positioning of the client in the chair.
The first essential step is sliding forward to the edge of the chair.
This brings the center of mass closer to the base of support, facilitating upward momentum without straining.
3
Identify the correct placement of the assistive devices and hands before attempting to stand.
Both crutches should be placed in the hand on the affected side, and the unaffected hand should grasp the armrest.
This configuration leaves the strong, unaffected arm free to push off the solid armrest, providing maximum upward leverage.
4
Sequence the remaining actions to achieve a safe, upright position.
The client pushes up using the armrest and strong leg, and only then transfers one crutch to the other side.
Establishing the tripod stance can only safely occur once the client is fully upright and balanced on the strong leg; attempting this while seated is unstable.

Key Concept

Assistive Devices and Safe Client Transfers
Question 648Question →

A nurse is preparing to administer a prescribed intravenous (IV) push medication through a client's peripheral saline lock. Place the following steps in the correct chronological order for safe administration.

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Answer

The correct sequence is to assess the IV site, scrub the connector port, flush with saline to check patency, administer the medication, and flush with saline again to clear the line.
The correct sequence for administering an IV push medication through an intermittent device is known as the SAS method (Saline, Administer, Saline), preceded by critical safety and hygiene assessments. The nurse must first assess the site for complications. Next, the hub must be scrubbed for infection control. A pre-flush of normal saline follows to ensure the line is patent and ready. The medication is then administered at the correct rate. Finally, a post-flush of normal saline is administered at the same rate as the medication to clear the line and ensure the full dose is delivered.

Step-by-Step Solution

1
Assess the peripheral IV insertion site for any signs of complications.
The nurse confirms the IV site is free of redness, swelling, pain, or leakage.
Administering medication into a compromised or infiltrated IV site can cause severe tissue damage (extravasation) or fail to deliver the drug systemically.
2
Scrub the needleless connector port of the saline lock with an antimicrobial swab.
The entry point is disinfected.
Rigorous scrubbing of the hub prevents the introduction of microorganisms directly into the client's bloodstream.
3
Attach a syringe and flush the catheter with 0.9% sodium chloride to confirm patency.
The line flushes easily without resistance or patient discomfort.
This confirms the line is patent and clears any existing fluid that might be incompatible with the new medication.
4
Inject the prescribed medication at the recommended rate.
The medication is delivered safely into the bloodstream.
Therapeutic delivery of the drug requires adhering to safe push rates to avoid toxicity or speed shock.
5
Flush the catheter again with 0.9% sodium chloride at the same rate the medication was administered.
The medication is cleared from the tubing and the lock is maintained.
The final flush ensures the entire dose reaches the central circulation and prevents medication from lingering in the catheter, which could cause occlusion.

Key Concept

Safe administration of IV push medications via a peripheral saline lock utilizing the SAS (Saline-Administer-Saline) method.
Estimated Time:1m 0s
Question 649Question →

A clinic nurse is utilizing the '5 R's' motivational intervention for a client who currently smokes but is not ready to quit. Arrange the nursing actions in the correct chronological sequence according to this evidence-based model.

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Answer

The correct chronological sequence follows the '5 R's' model: determining Relevance, identifying Risks, recognizing Rewards, exploring Roadblocks, and utilizing Repetition.
The '5 R's' model is an evidence-based intervention designed to motivate clients who are unwilling to quit smoking at the current time. The correct sequence begins by establishing personal Relevance to build therapeutic rapport. Next, the nurse explores the Risks of continued smoking, followed immediately by the Rewards of quitting, which balances the negative and positive aspects of behavior change. The nurse then helps identify Roadblocks (barriers) to success. Finally, Repetition ensures the intervention is consistently applied during future interactions to capture any changes in the client's readiness.

Step-by-Step Solution

1
Determine Relevance
The nurse asks the client why quitting is personally relevant.
Establishing a personal connection and relevance is the foundation of motivational interviewing and must occur before discussing general risks.
2
Identify Risks
The nurse asks the client to list negative consequences of smoking.
Once personal relevance is established, the client is guided to articulate the negative impacts of their current lifestyle choice.
3
Recognize Rewards
The nurse asks the client to state the benefits of quitting.
Discussing rewards immediately after risks helps balance the conversation and emphasizes the positive aspects of behavior change.
4
Explore Roadblocks
The nurse helps the client identify barriers to quitting.
After establishing why the client should quit, the nurse must assess what practical or psychological barriers are standing in the way.
5
Utilize Repetition
The nurse repeats the motivational intervention.
Behavioral change takes time; repeating the intervention at each visit reinforces the message and continuously assesses for shifts in readiness.

Key Concept

5 R's Motivational Intervention for Smoking Cessation
Estimated Time:1m 30s
Question 650Question →

A nurse is monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs). Fifteen minutes into the transfusion, the client reports sudden lower back pain, chills, and shortness of breath. Arrange the following nursing actions in the correct order of priority, from first to last.

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Answer

1. Stop the blood transfusion immediately. 2. Disconnect the blood tubing and initiate normal saline with new IV tubing. 3. Assess the client's vital signs and respiratory status. 4. Notify the healthcare provider and the blood bank.
The priority in any acute hemolytic transfusion reaction is to immediately stop the infusion of the incompatible blood product to minimize physiological harm. After stopping the transfusion, the nurse must maintain a patent intravenous line using normal saline and completely new tubing to ensure emergency medications can be given without pushing residual blood into the client. Once the source is removed and access is secured, the nurse performs a rapid assessment of vital signs and respiratory status to determine the severity of the reaction. Finally, the nurse notifies the healthcare provider to obtain treatment prescriptions and the blood bank to initiate a formal transfusion reaction investigation.

Step-by-Step Solution

1
Identify the clinical signs of an acute hemolytic transfusion reaction.
The client's lower back pain, chills, and shortness of breath indicate a life-threatening reaction.
Recognizing a severe reaction dictates immediate and prioritized nursing interventions.
2
Determine the most critical first action.
Stop the blood transfusion.
Preventing further exposure to the incompatible blood product is the highest priority to minimize harm.
3
Determine the next priority for maintaining vascular access.
Initiate normal saline with new tubing.
A patent IV line is required for emergency interventions, and new tubing prevents residual blood from entering the circulation.
4
Determine the next action for client safety.
Assess vital signs and respiratory status.
The nurse must gather current, objective hemodynamic and respiratory data to communicate to the provider.
5
Determine the final administrative and collaborative action.
Notify the healthcare provider and blood bank.
Medical orders are needed to treat the physiological response, and the blood bank must investigate the root cause of the reaction.

Key Concept

Prioritization in Acute Transfusion Reactions
Question 651Question →

A critical care nurse is removing a non-tunneled central venous catheter (CVC) from a client's right subclavian vein. Immediately after the catheter is withdrawn, the client gasps, reports sudden severe chest pain, and becomes pale and tachycardic. Suspecting a venous air embolism, arrange the following actions in the exact priority sequence the nurse must perform them to reduce the risk of fatal cardiopulmonary collapse.

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Answer

The correct priority sequence is to first occlude the insertion site, position the client in the left lateral Trendelenburg position, administer high-flow oxygen, activate the rapid response team, and finally prepare for cardiopulmonary resuscitation.
The physiological principle of managing a venous air embolism requires immediately stopping the source of the air leak, trapping the embolus to prevent pulmonary obstruction, treating the resulting hypoxemia, and then securing advanced medical help.

Step-by-Step Solution

1
Occlude the catheter insertion site immediately with a sterile, occlusive dressing.
Stops further air entry into the venous system.
Atmospheric pressure is higher than intrathoracic venous pressure during inspiration, drawing air in. Occlusion is the fastest way to stop the leak.
2
Reposition the client into the left lateral Trendelenburg position.
Traps the air embolus in the right side of the heart.
Durant's maneuver utilizes gravity to keep the buoyant air bubble in the right ventricular apex, preventing it from entering the pulmonary outflow tract.
3
Administer 100% high-flow oxygen via a non-rebreather face mask.
Treats hypoxemia and reduces the size of the air embolus.
High-concentration oxygen creates a diffusion gradient that accelerates the reabsorption of nitrogen (the primary component of room air) from the bubble.
4
Activate the hospital's emergency rapid response team.
Mobilizes advanced medical support.
The client requires immediate medical evaluation and potential advanced interventions such as right atrial aspiration or intubation.
5
Initiate continuous hemodynamic monitoring and prepare for cardiopulmonary resuscitation.
Ensures readiness for cardiac arrest.
Venous air embolism can rapidly evolve into obstructive shock and cardiopulmonary arrest, necessitating immediate advanced life support.

Key Concept

Management of Venous Air Embolism
Question 652Question →

A community health nurse is preparing to conduct an initial health screening and risk assessment for a 45-year-old client who recently immigrated and has limited English proficiency. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence from first to last.

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Answer

The correct sequence follows the nursing process: first, establish communication; second, collect subjective data; third, collect objective data; fourth, analyze the data to identify risks; and finally, implement targeted education.
The correct sequence for conducting a health screening strictly adheres to the nursing process (ADPIE) while prioritizing foundational communication. First, obtaining a medical interpreter ensures that the client is fully informed and can provide accurate information. Second, gathering subjective data allows the nurse to understand the client's background and specific concerns. Third, collecting objective data completes the comprehensive assessment phase. Fourth, analyzing the combined subjective and objective data enables the nurse to identify specific health risks (diagnosis). Finally, the nurse implements targeted interventions by providing culturally appropriate education based on those clearly identified risks.

Step-by-Step Solution

1
Obtain a professional medical interpreter to establish communication and explain the screening process.
Effective and legally appropriate communication is established.
A therapeutic relationship and informed consent are prerequisites for any assessment, requiring accurate communication as the immediate priority.
2
Elicit a comprehensive subjective health history, including past illnesses and immunization status.
Subjective baseline data is gathered.
The formal assessment phase begins with gathering subjective information directly from the client, which helps direct the focus of the physical examination.
3
Perform an objective physical assessment, including measuring vital signs and body mass index.
Objective baseline data is obtained.
Physical examination follows the health history to complete the comprehensive data collection phase.
4
Analyze the collected assessment data to identify specific risk factors for chronic and communicable diseases.
Client-specific health risks are diagnosed.
This step corresponds to the analysis phase of the nursing process, which must occur after all data is collected but before planning or implementing care.
5
Implement culturally appropriate client education regarding targeted primary and secondary disease prevention strategies.
Preventative strategies are initiated.
Implementation of client teaching must be tailored to the specific risks identified during the prior analysis phase.

Key Concept

Application of the nursing process in health screening and risk assessment
Question 653Question →

A 78-year-old client residing in a skilled nursing facility suddenly develops acute confusion, agitation, and new-onset urinary incontinence. The nurse enters the client's room and observes the client attempting to climb over the bed rails. In what order should the nurse prioritize the following actions? (Arrange the actions from highest to lowest priority.)

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Answer

1. Implement immediate safety measures
2. Obtain vital signs
3. Perform focused neurological assessment
4. Assess for potential localized triggers
5. Communicate findings to the provider
In older adults, acute changes such as confusion and incontinence often indicate an underlying pathology rather than normal aging. The nurse must prioritize care using the nursing process and safety frameworks. Immediate physical safety is the highest priority for an agitated client attempting to leave the bed. Following safety, assessing physiological stability (vital signs and oxygenation) is the next priority to rule out life-threatening causes of delirium like hypoxia. Once stable, a focused neurological assessment quantifies the acute change, followed by assessing for localized triggers (such as urinary issues). Finally, with all assessment data gathered, the nurse is fully prepared to notify the provider.

Step-by-Step Solution

1
Ensure immediate physical safety
The client is prevented from falling or sustaining injury.
When a client is acutely agitated and attempting an unsafe action, immediate physical safety intervention precedes all assessments.
2
Assess physiological stability via vital signs
Oxygenation and systemic hemodynamic status are evaluated.
Hypoxia or severe vital sign instability must be identified and corrected immediately, as they are primary physiological threats and common causes of delirium in older adults.
3
Conduct a focused neurological evaluation
The nurse determines the severity and nature of the cognitive change.
Understanding the specific neurological deficits helps confirm acute delirium versus an expected chronic cognitive baseline.
4
Investigate potential localized triggers
The nurse checks for common sources of infection or discomfort, such as the urinary tract.
Older adults frequently present atypically (e.g., sudden delirium and incontinence) when experiencing a UTI. Gathering this data is crucial before calling the provider.
5
Notify the healthcare provider
The provider is informed of the comprehensive assessment.
The nurse must have complete safety, vital sign, and assessment data ready before using SBAR to request diagnostic orders or medical treatments.

Key Concept

Prioritization of Care for Acute Delirium in Older Adults
Question 654Question →

An 85-year-old client residing in a long-term care facility suddenly exhibits severe agitation, disorientation, and disorganized thinking. The unlicensed assistive personnel reports that the client was completely alert, oriented, and calm earlier in the shift. In what order should the nurse perform the following assessment actions to evaluate this acute change? Arrange the steps from first (highest) priority to last (lowest) priority.

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Answer

The correct priority order is to first assess ABCs and vital signs, followed by a rapid neurological assessment, checking blood glucose and infection signs, reviewing the medication record, and finally contacting the family for baseline cognitive history.
The correct sequence follows the airway, breathing, circulation (ABC) prioritizing framework, moving from immediate life-threatening physiological needs to focused physical assessments, and finally to historical data collection. Acute confusion in an older adult is considered delirium until proven otherwise and requires urgent investigation for underlying hypoxia, stroke, infection, or medication toxicity.

Step-by-Step Solution

1
Assess airway, breathing, circulation, and vital signs including pulse oximetry.
Physiological stability is confirmed or immediate interventions are initiated.
Hypoxia or hemodynamic instability are critical, immediate life-threats that commonly present as acute confusion in older adults.
2
Perform a rapid neurological evaluation.
Focal neurological deficits (e.g., signs of a stroke) are ruled out or identified.
Acute cerebrovascular events require immediate, time-sensitive medical interventions and must be evaluated immediately after basic life support parameters.
3
Obtain capillary blood glucose and evaluate for signs of systemic infection (e.g., UTI, pneumonia).
Metabolic and infectious causes of delirium are identified.
Older adults often present with acute confusion as the primary or sole atypical symptom of an infection or metabolic imbalance.
4
Review the client's medication administration record (MAR).
Potential iatrogenic causes of confusion are identified.
Age-related physiological changes increase susceptibility to adverse drug events, making medication toxicity a frequent cause of acute mental status changes.
5
Interview family or caregivers to confirm baseline cognitive status.
The nurse establishes the exact symptom onset and differentiates acute delirium from chronic dementia.
Gathering collateral history provides essential context, but it is secondary to stabilizing and physically assessing the acutely changing client.

Key Concept

Prioritization of acute delirium assessment in the aging population
Question 655Question →

An adult client receiving volume-controlled mechanical ventilation suddenly exhibits profound clinical deterioration. The ventilator triggers continuous high peak airway pressure alarms. Simultaneously, the cardiac monitor displays a heart rate of 142142 beats per minute, and the arterial line shows a precipitous blood pressure drop to 68/38 mmHg68/38 \text{ mmHg}. Arrange the following emergency nursing actions in the correct chronological sequence for managing this acute crisis.

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Answer

The correct chronological sequence is to first detach the client from the ventilator and manually ventilate, then assess the lung fields for signs of tension pneumothorax. This is followed by preparing for immediate needle decompression, assembling a chest drainage unit for definitive treatment, and finally obtaining a post-procedure chest radiograph.
When a mechanically ventilated client develops sudden high peak airway pressures accompanied by hemodynamic collapse (tachycardia and severe hypotension), a tension pneumothorax causing obstructive shock must be suspected immediately. The evidence-based DOPE mnemonic (Displacement, Obstruction, Pneumothorax, Equipment) guides the initial approach. The absolute first action is to disconnect the ventilator and manually ventilate using a bag-valve-mask with 100%100\% oxygen. This safely removes equipment malfunction as a variable, halts forced barotrauma, and allows the nurse to feel for severe resistance (stiff compliance). Second, the nurse rapidly assesses for asymmetric breath sounds and tracheal deviation to clinically confirm the complication. Third, once tension pneumothorax is identified, the priority shifts to assisting with immediate, life-saving needle decompression to relieve intrapleural pressure and restore cardiac output. Fourth, a chest tube drainage unit is prepared for definitive, continuous evacuation of the pleural space. Finally, diagnostic imaging is obtained to evaluate the effectiveness of the interventions and verify correct tube placement.

Step-by-Step Solution

1
Detach the endotracheal tube from the mechanical ventilator and manually ventilate.
Halts continuous positive pressure from the machine and allows the nurse to manually assess lung compliance.
Continuing mechanical ventilation in the presence of a tension pneumothorax exacerbates intrathoracic pressure and obstructive shock.
2
Auscultate bilateral lung fields and assess tracheal deviation.
Identifies absent breath sounds on one side and a trachea shifted away from the affected side.
Confirms the clinical suspicion of a tension pneumothorax before initiating invasive emergency procedures.
3
Delegate alerting the provider and prepare a 1414-gauge catheter.
Ensures the life-saving equipment is immediately ready for the provider to perform a needle thoracostomy.
Needle decompression is the most rapid way to vent trapped pleural air and restore cardiac output in a crashing client.
4
Assemble a closed water-seal chest drainage unit.
Prepares the equipment needed for chest tube insertion.
Needle decompression is a temporary measure; a chest tube is the definitive treatment for a pneumothorax.
5
Coordinate a portable chest radiograph.
Provides visual confirmation of lung re-expansion and correct tube placement.
Post-procedure evaluation is necessary to ensure the interventions were successful and no further complications exist.

Key Concept

Prioritization of Respiratory Emergencies and Obstructive Shock Management
Question 656Question →

A client receiving an intravenous infusion of vincristine reports severe pain and burning at the peripheral intravenous site. The nurse observes swelling and blanching around the insertion site. Arrange the following nursing actions in the correct sequence.

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Answer

The correct sequence for managing a vincristine extravasation is to first stop the infusion, then aspirate the residual drug, remove the intravenous catheter, administer the subcutaneous antidote (hyaluronidase), and finally apply a warm compress and elevate the affected extremity.
Managing a vesicant extravasation requires a prioritized, protocol-driven approach to minimize severe tissue necrosis. The infusion must be stopped immediately as the absolute first action to halt further exposure. Leaving the catheter in place temporarily allows the nurse to aspirate any residual drug from the catheter and the immediate subcutaneous pocket. Once aspirated, the catheter is removed. For vinca alkaloids like vincristine, the specific antidote (hyaluronidase) is injected subcutaneously around the site to break down connective tissue. Finally, warm compresses are applied—a unique requirement for vinca alkaloids—to induce vasodilation, which helps disperse the drug systemically and reduces local tissue damage. Elevation helps to reduce edema.

Step-by-Step Solution

1
Identify the primary emergency intervention.
The infusion must be stopped immediately.
Vincristine is a vesicant. Halting the infusion is the most critical first step to prevent further extravasation into the tissue.
2
Determine the sequence for local catheter management.
Aspirate residual medication before removing the catheter.
Aspiration removes drug remaining in the catheter lumen and immediate tissue. Removing the catheter first would leave this toxic volume in the subcutaneous tissue.
3
Remove the access device.
The peripheral intravenous catheter is discontinued.
The catheter is no longer viable and must be removed to allow for the administration of the subcutaneous antidote.
4
Administer the specific pharmacologic antidote.
Inject hyaluronidase subcutaneously around the extravasation site.
Hyaluronidase breaks down hyaluronic acid in connective tissue, allowing the extravasated vincristine to disperse and be absorbed rapidly, minimizing local necrosis.
5
Apply appropriate thermal and positional therapy.
Apply a warm compress and elevate the extremity.
Unlike most vesicants which require cold compresses to localize the drug, vinca alkaloids uniquely require warm compresses to induce vasodilation and further disperse the drug. Elevation helps reduce local edema.

Key Concept

Vesicant Extravasation Management (Vinca Alkaloids)
Question 657Question →

A nurse is monitoring a client who is receiving a transfusion of packed red blood cells. Ten minutes after the transfusion begins, the client reports sudden chills, severe lower back pain, and shortness of breath. Arrange the following nursing actions in the correct priority order to manage this situation from first to last.

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Answer

The correct sequence is to first stop the transfusion to prevent further exposure, then maintain IV access with new tubing and normal saline, followed by a rapid assessment of the client. After mitigating immediate threats, the nurse notifies the provider and blood bank, and finally returns the equipment for diagnostic investigation.
In a suspected acute hemolytic transfusion reaction, the most critical risk reduction action is to remove the offending agent by stopping the transfusion immediately. Next, patent IV access must be maintained with completely new tubing and normal saline to prevent flushing residual blood into the client and to allow for emergency medication administration. Only after securing safety and access should the nurse assess the client's current status to report accurate findings to the provider. Finally, the remaining blood products are sent to the blood bank for mandatory analysis.

Step-by-Step Solution

1
Stop the blood transfusion.
The infusion of incompatible blood is halted.
This is the primary risk reduction strategy to prevent further antigen-antibody reactions and organ damage.
2
Change the IV tubing and initiate normal saline.
Patent venous access is secured without flushing more blood into the client.
Vascular access is required for emergency resuscitation, but the existing tubing contains incompatible blood that must not be infused.
3
Assess the client.
Baseline data on the severity of the reaction is obtained.
The nurse needs current vital signs, oxygen saturation, and respiratory status to report to the provider.
4
Notify the healthcare provider and blood bank.
Medical interventions are prescribed and facility protocols are activated.
Collaborative care is necessary to treat the systemic reaction and begin the root-cause analysis.
5
Return the blood bag and tubing to the laboratory.
Evidence is preserved for typing and cross-matching analysis.
The laboratory must test the remaining product to identify the specific incompatibility that caused the reaction.

Key Concept

Management of Acute Hemolytic Transfusion Reactions
Question 658Question →

A nurse is caring for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache, and the nurse notes profound facial flushing and diaphoresis above the level of the injury. The client's current blood pressure is 218/114 mm Hg. Arrange the following nursing interventions in the priority order they should be performed, from first to last.

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Answer

The priority sequence is to first elevate the head of the bed, followed by loosening constrictive clothing, assessing for the noxious stimulus, administering antihypertensives if the condition persists, and finally documenting the event.
In autonomic dysreflexia, the immediate goal is to lower the blood pressure to prevent a stroke while simultaneously hunting for the trigger. Elevating the head of the bed achieves the fastest drop in blood pressure. Once positioned safely, the nurse systematically removes triggers from least invasive (clothing) to most common (bladder/bowel). Medications are reserved for when removing triggers fails to resolve the severe hypertension.

Step-by-Step Solution

1
Recognize the signs of autonomic dysreflexia.
Identify the medical emergency requiring immediate blood pressure reduction.
A T4 spinal cord injury combined with sudden extreme hypertension, headache, and diaphoresis indicates this life-threatening syndrome.
2
Position the client upright.
Blood pressure begins to lower.
Gravity promotes venous pooling in the lower extremities, reducing venous return and subsequently providing an immediate, non-pharmacological reduction in blood pressure.
3
Eliminate sensory triggers.
Noxious stimuli are removed.
Loosening tight clothing and draining the bladder directly address the root causes triggering the exaggerated sympathetic nervous system response.
4
Administer medications and document.
Blood pressure normalizes and the care record is updated.
Persistent hypertension requires pharmacological management, followed by accurate legal and clinical documentation once the crisis is resolved.

Key Concept

Management of autonomic dysreflexia in spinal cord injuries
Question 659Question →

A nurse in an ophthalmology clinic is teaching an older adult client how to independently administer prescribed glaucoma eye drops at home. Arrange the steps of this self-care procedure in the correct chronological sequence.

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Answer

The correct chronological sequence for self-administering eye drops is: wash hands, tilt head back, form a pocket with the lower eyelid, instill the drop into the conjunctival sac, and finally close the eye while applying pressure to the inner canthus.
Safe and effective self-administration of eye drops requires a precise sequence to ensure sterility, proper placement, and local absorption. The client must first wash their hands to prevent infection. Next, tilting the head back and pulling the lower eyelid down creates a pocket in the conjunctival sac, which is less sensitive than the cornea. Instilling the drop into this sac without touching the dropper to the eye maintains sterility. Finally, applying pressure to the inner canthus (nasolacrimal occlusion) minimizes systemic absorption of the medication, which is particularly important for glaucoma medications.

Step-by-Step Solution

1
Wash hands with soap and water and remove the medication cap.
Hands are clean and the medication is ready for use.
Prevents the introduction of infectious agents into the eye.
2
Tilt the head back slightly and gaze upward.
The eye is positioned optimally.
Minimizes the blink reflex and allows gravity to assist in drop placement.
3
Gently pull the lower eyelid downward.
A small pocket is formed in the lower conjunctival sac.
Provides a safe reservoir for the medication, avoiding the highly sensitive cornea.
4
Instill the medication into the conjunctival sac.
Medication is delivered without contamination.
Ensures proper dosing while maintaining the sterility of the dropper tip.
5
Close the eye and apply pressure to the inner corner.
Medication is retained locally in the eye.
Nasolacrimal occlusion prevents systemic absorption of the medication.

Key Concept

Self-Administration of Ophthalmic Medications
Estimated Time:1m 0s
Question 660Question →

A nurse is preparing to transfer a client who has left-sided hemiparesis from the bed to a wheelchair. In which order should the nurse perform the following actions? (Arrange the steps from first to last.)

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Answer

The correct sequence begins with positioning the wheelchair on the strong (right) side, followed by assisting the client to sit and applying a gait belt. The nurse then braces the weak (left) knee, helps the client stand and pivot on the strong (right) foot, and finally has the client grasp the armrest with the strong (right) hand before sitting.
When transferring a client with unilateral weakness (hemiparesis), the nurse must optimize the client's remaining strength and ensure safety. The sequence begins with environmental setup: placing the wheelchair on the unaffected (right) side so the client can lead the transfer with their strong side. Locking the brakes is mandatory. Next, the client is assisted to sit (to stabilize hemodynamics) and a gait belt is applied for safety. The nurse then stands directly in front, grasping the belt and crucially bracing the weak (left) knee to prevent it from collapsing. The client is assisted to stand and pivot on their strong (right) leg. Finally, the client uses their strong (right) arm to reach back for the armrest, ensuring a safe, controlled descent into the chair.

Step-by-Step Solution

1
Position the wheelchair on the client's right side and ensure the brakes are locked.
The environment is prepared for a safe transfer toward the client's strong side.
Placing the chair on the unaffected side allows the client to pivot safely on their strong leg without crossing the weak leg.
2
Assist the client to a sitting position on the edge of the bed and apply a transfer belt.
The client is physiologically stabilized and the nurse has a secure method to support them.
Dangling prevents orthostatic hypotension, and the transfer belt ensures the nurse can safely guide the client's center of gravity.
3
Stand facing the client, grasp the transfer belt, and brace the client's left knee.
The nurse provides critical physical support to the hemiparetic extremity.
Bracing the weak left knee with the nurse's knee prevents it from buckling during weight-bearing.
4
Assist the client to stand and instruct them to pivot on the right foot.
The client moves safely from the bed toward the wheelchair.
The strong right leg must bear the majority of the weight to ensure a safe, balanced pivot maneuver.
5
Instruct the client to reach back and grasp the wheelchair armrest with the right hand.
The client is safely and securely seated in the wheelchair.
Reaching with the unaffected arm provides stability, widens the base of support, and guides the client's descent into the seat.

Key Concept

Safe client transfer and positioning for a client with hemiparesis
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