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Question 681Question →

While responding to a pump occlusion alarm, a nurse discovers that a client's continuous enteral nutrition formula has been erroneously connected to the proximal port of a peripherally inserted central catheter (PICC) and is actively infusing. Arrange the following nursing actions in the priority order to mitigate this adverse event and prevent further injury. All options must be used.

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Answer

The correct sequence is to first stop the infusion pump, then disconnect the tubing, assess the client's cardiopulmonary and neurological status, notify the healthcare provider and rapid response team, and finally complete the facility incident report.
In the event of an active route administration error (a 'never event' such as infusing tube feeding into a central line), the absolute first priority is to stop the source of harm. Halting the pump immediately prevents further formula from entering the bloodstream. Disconnecting the tubing ensures no residual fluid enters via gravity. Only after the source of harm is secured should the nurse assess the client's physiological status, as this baseline data is crucial before notifying the healthcare provider and rapid response team. Completing the incident report is an administrative risk-management task that is always performed last, after the client's safety is secured.

Step-by-Step Solution

1
Stop the infusion pump delivering the enteral nutrition.
The active infusion of enteral formula into the central venous system is halted.
This immediately removes the source of harm and prevents further catastrophic intravascular exposure.
2
Disconnect the enteral administration set from the central venous catheter.
The enteral tubing is physically separated from the client's vascular access.
This prevents any residual formula from flowing into the client via gravity or accidental restarting of the pump.
3
Assess the client's vital signs, oxygen saturation, and level of consciousness.
Baseline physiological data regarding the client's current stability is obtained.
Assessment data is required to determine the severity of the reaction and to accurately inform the healthcare provider.
4
Notify the healthcare provider and activate the rapid response team.
Advanced medical personnel are alerted and mobilized to the bedside.
The client will likely require immediate medical interventions, such as blood cultures, broad-spectrum IV antibiotics, or resuscitation.
5
Complete a facility incident report detailing the misconnection.
The adverse event is formally documented for the institution's quality and safety department.
Reporting allows the facility to conduct a root-cause analysis to prevent future tubing misconnections, but it must never delay direct client care.

Key Concept

Priority Management of Route Administration Errors and Tubing Misconnections
Question 682Question →

The triage nurse in a busy adult emergency department is concurrently evaluating four walk-in clients. Based on the principles of prioritization and triage, arrange the clients in the order they must be medically evaluated, from highest priority (first) to lowest priority (last).

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Answer

The correct sequence is to first see the client with stridor and drooling, followed by the client with rectal bleeding and tachycardia, then the client with right lower quadrant pain, and finally the client with chronic pedal edema requesting a refill.
Effective prioritization in nursing requires a systematic approach, typically starting with the ABCs (Airway, Breathing, Circulation), followed by Maslow's Hierarchy of Needs, and distinguishing between acute (unexpected) and chronic (expected) problems. The client with stridor has a closing airway, making them the absolute highest priority. The client with rectal bleeding and tachycardia is experiencing circulatory compromise, making them second. The client with acute abdominal pain is stable but requires timely diagnosis, placing them third. The client with chronic pedal edema has expected findings for their diagnosis and is seeking routine care, making them the lowest priority.

Step-by-Step Solution

1
Identify any clients with immediate threats to Airway, Breathing, or Circulation.
The 28-year-old has stridor and drooling, indicating a severe airway obstruction (anaphylaxis). This client is Priority 1.
Without an open airway, breathing and circulation interventions will fail.
2
Evaluate the remaining clients for acute circulatory compromise or severe physiological instability.
The 62-year-old has large-volume rectal bleeding and a heart rate of 118 bpm, indicating active bleeding and compensatory tachycardia. This client is Priority 2.
Active hemorrhage poses an immediate threat to life through hypovolemic shock, falling under 'Circulation' in the ABC framework.
3
Differentiate between acute illnesses and chronic/expected findings among the remaining clients.
The 35-year-old has acute abdominal pain suggestive of appendicitis, while the 70-year-old has expected, chronic pedal edema from established heart failure.
Acute, sudden-onset conditions have higher triage acuity than chronic, long-standing alterations.
4
Sequence the final two clients based on acuity.
The 35-year-old client with appendicitis symptoms is Priority 3. The 70-year-old client seeking a medication refill is Priority 4.
The client with an acute surgical abdomen requires timely evaluation to prevent complications like rupture, whereas the stable chronic client can safely wait.

Key Concept

Establishing Priorities using the ABCs and Acute vs. Chronic Frameworks
Question 683Question →

An intensive care unit nurse is preparing to enter the negative-pressure isolation room of a client who has both active pulmonary tuberculosis and a heavily draining abdominal wound infected with methicillin-resistant *Staphylococcus aureus* (MRSA) that requires irrigation. Arrange the following steps for donning the required personal protective equipment (PPE) in the correct sequential order.

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Answer

The correct sequence is: Perform hand hygiene, put on the isolation gown, apply the N95 respirator, place the face shield, and finally don the gloves.
According to standardized infection control guidelines, the proper sequence for donning personal protective equipment (PPE) is: 1) Hand hygiene, 2) Gown, 3) Mask or respirator, 4) Goggles or face shield, and 5) Gloves. This specific sequence ensures that the equipment fits correctly and provides maximum protection. Hand hygiene prevents contamination of clean supplies. The gown goes on first to protect the torso and clothing. The N95 respirator is applied next, allowing the straps to sit securely against the head for a proper seal. The face shield is then placed over the respirator to protect against splashes. Finally, the gloves are donned last so they can be pulled up and over the cuffs of the isolation gown, ensuring there is no exposed skin at the wrists.

Step-by-Step Solution

1
Identify the required PPE based on the prescribed transmission-based precautions and planned procedure.
The nurse requires an isolation gown and gloves for contact precautions (MRSA), an N95 respirator for airborne precautions (tuberculosis), and a face shield for potential fluid splashes during wound irrigation.
Standard and transmission-based precautions dictate specific PPE to interrupt the chain of infection for specific pathogens.
2
Determine the initial step prior to handling any clean equipment.
Hand hygiene must be performed first.
This removes potential pathogens from the nurse's hands, preventing contamination of the clean PPE.
3
Sequence the remaining PPE items according to standardized infection control guidelines.
The correct order is gown, followed by the respirator, then the face shield, and lastly the gloves.
This standardized sequence ensures that each piece of equipment is secured properly without interfering with the others. The gown covers the body first. The respirator is applied next so its straps lie flat against the head for an optimal seal. The face shield goes over the respirator to protect the face and eyes. Finally, the gloves are applied so they can be pulled securely over the gown cuffs.

Key Concept

The correct Centers for Disease Control and Prevention (CDC) sequence for donning personal protective equipment is hand hygiene, gown, mask or respirator, goggles or face shield, and finally gloves.
Question 684Question →

Before providing morning care to a client with confirmed disseminated varicella-zoster virus, a nurse must don full personal protective equipment (PPE) for Airborne and Contact Precautions. Arrange the following actions for applying the required PPE in the correct chronological sequence.

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Answer

The correct sequence for donning PPE is: perform hand hygiene, don the isolation gown, apply the N95 respirator, don eye protection, and finally, put on gloves.
According to the Centers for Disease Control and Prevention (CDC) guidelines, the standard chronological order for donning full PPE is designed to minimize contamination of the equipment and ensure a proper fit. Hand hygiene must always be completed first. The gown is applied to protect the torso and clothing. Next, the respiratory protection (such as an N95 respirator) is secured and seal-checked. Eye protection is then added carefully without interfering with the mask's seal. Gloves are always applied last and extended over the gown cuffs to create a seamless barrier against contact pathogens.

Step-by-Step Solution

1
Perform hand hygiene.
Hands are decontaminated.
Prevents the transfer of microorganisms from the hands to the clean PPE.
2
Don the isolation gown.
Torso and arms are covered.
Provides the primary body barrier against contact transmission.
3
Apply the N95 respirator.
Respiratory tract is protected.
Essential for Airborne Precautions to filter out small airborne infectious particles.
4
Don eye protection (face shield or goggles).
Mucous membranes of the eyes are protected.
Placed over or around the respirator to avoid breaking the tight seal of the respirator mask.
5
Don clean gloves over the gown cuffs.
Hands and wrists are fully protected.
Ensures a continuous, uninterrupted barrier between the sleeves of the gown and the gloves.

Key Concept

Donning Sequence for Personal Protective Equipment (PPE)
Question 685Question →

A registered nurse (RN) is supervising an unlicensed assistive personnel (UAP) on a medical-surgical unit. The RN observes the UAP preparing to feed a client who has a history of dysphagia, but the client's bed is completely flat. Arrange the RN's actions in the priority order they should be performed, from first to last.

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Answer

The correct sequence is to first intervene to stop the feeding, then elevate the head of the bed, followed by educating the UAP in private, and finally documenting and reporting the incident.
According to the principles of safe delegation and supervision, the RN's primary responsibility is client safety. When an unsafe practice is observed, the RN must immediately intervene to stop the action, thereby preventing aspiration. Once the immediate threat is halted, the RN corrects the situation by elevating the bed. After the client is safe, the RN fulfills their supervisory role by educating the UAP on the rationale in a private setting. Finally, the RN documents the incident and reports it to management for ongoing performance evaluation and potential retraining.

Step-by-Step Solution

1
Identify the immediate threat to client safety.
The client is at high risk for aspiration because they are lying flat while being fed, which violates aspiration precautions.
Airway protection is the highest clinical priority.
2
Determine the sequence of intervention based on supervision guidelines.
The RN must move from immediate client protection to environmental correction, then to staff education, and finally to administrative documentation.
Effective supervision requires immediate correction of unsafe behavior to protect the client, followed by supportive education and proper reporting.

Key Concept

Assignment, Delegation and Supervision
Question 686Question →

A nurse is providing care for an older adult client. While attempting to get out of bed, the client suddenly reports feeling dizzy and lightheaded. Arrange the following nursing actions in the prioritized order of performance, from first to last.

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Answer

The correct sequence is to first secure the client's physical safety by returning them to a resting position, followed by assessing vital signs, providing education on adapting to age-related vascular changes, and finally documenting the event.
In any acute scenario involving sudden dizziness, immediate client safety is the top priority. Returning the dizzy client to a safe position prevents a fall. Once physical safety is secured, the nurse must assess the client's physiological status (vital signs) to evaluate the extent of orthostatic changes, which are common in the aging process due to decreased baroreceptor sensitivity and vascular elasticity. After the assessment, educating the client on how to adapt to these age-related changes helps prevent future incidents. Finally, documenting the event ensures accurate communication and continuity of care with the healthcare team.

Step-by-Step Solution

1
Ensure safety by returning the client to a seated or supine position.
The client is protected from a potential fall.
Immediate physical safety is always the first priority when an older adult experiences acute dizziness or lightheadedness upon standing.
2
Assess physiological status by measuring blood pressure and pulse.
The presence and severity of orthostatic hypotension are determined.
Assessment follows immediate safety to identify the physiological cause of the symptoms, such as the delayed baroreceptor response commonly seen in the aging process.
3
Educate the client about position changes.
The client understands how to accommodate circulatory changes and prevent future episodes.
Education is most effective and appropriate once the acute event has resolved and the client is physiologically stable.
4
Document the event and findings.
The healthcare team is informed through the medical record.
Documentation completes the nursing process and must accurately reflect the care provided and the client's response.

Key Concept

Prioritization of safety and assessment for older adults experiencing age-related orthostatic hypotension.
Question 687Question →

During a night shift, a client recovering from a complicated bowel resection becomes profoundly restless and starts forcefully pulling at their wound vacuum dressing and peripheral intravenous line. Sequence the following nursing actions from the initial priority intervention to the most restrictive emergency measure.

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Answer

The correct sequence of interventions progresses from physiological assessment to the least restrictive behavioral alternatives, followed by device concealment, emergency restraint application, and concluding with provider notification.
The standard of care for restraint application requires a stepwise approach starting with assessing and treating underlying causes (e.g., hypoxia, pain). If agitation persists, the nurse must exhaust least restrictive measures (diversion, device concealment) before initiating physical restraints. When restraints are applied in an emergency to prevent self-harm, the provider must be notified immediately for an evaluation and a time-limited order.

Step-by-Step Solution

1
Assess physiological factors.
Oxygenation, pain, and elimination needs are evaluated.
Correcting an underlying physiological issue like hypoxia may completely resolve the agitation without any need for restraints.
2
Attempt behavioral and cognitive alternatives.
Diversion and reorientation techniques are applied.
Standards of care require the implementation of the least restrictive behavioral interventions before escalating to physical restraints.
3
Modify the immediate environment to protect devices.
Lines and dressings are concealed using a stockinette or long sleeves.
Out-of-sight devices reduce the client's focus on them, providing a localized safety measure that does not restrict overall mobility.
4
Apply emergency physical restraints.
Soft wrist restraints are secured safely to the movable bed frame.
Immediate safety intervention is legally and ethically justified when non-restrictive measures fail and there is an imminent risk of self-harm.
5
Obtain medical authorization.
The provider is notified for an in-person evaluation and prescription.
Law and facility protocols require a time-limited provider prescription immediately following any emergency restraint application.

Key Concept

Restraint Escalation Protocol and Least Restrictive Alternatives
Estimated Time:1m 30s
Question 688Question →

A client with severe delirium is aggressively attempting to pull out their central venous catheter. After all non-pharmacological alternatives have been exhausted, the healthcare provider prescribes bilateral soft wrist restraints to prevent injury. Arrange the following nursing actions for initiating these restraints in the correct chronological order.

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Answer

The correct sequence begins with verifying the medical prescription, followed by explaining the procedure to the client and family. The nurse then pads the wrists to protect the skin, secures the restraints to the movable bed frame using a quick-release tie, and finally assesses the neurovascular status to ensure adequate circulation.
The correct procedural order ensures legal compliance and prioritizes physical safety. The nurse must first have legal authorization (verifying the order), followed by ethical communication (explaining to the client). Once application begins, the nurse protects the skin (padding), safely anchors the device (securing to movable frame), and finally verifies that the application did not cause unintended harm (neurovascular assessment).

Step-by-Step Solution

1
Verify the specific parameters of the healthcare provider's prescription.
Legal and medical authorization is confirmed.
Restraints cannot be applied without a clear medical order unless it is an immediate, life-threatening emergency.
2
Explain the rationale for the restraints to the client and family.
The client and family are informed of the safety intervention.
Providing education respects the client's rights and can help de-escalate anxiety.
3
Pad the client's wrists.
A protective barrier is established between the restraint and the skin.
Padding prevents friction, shear, and pressure injuries over bony prominences.
4
Secure the restraint ties to the movable portion of the bed frame using quick-release knots.
The restraints are safely anchored.
Tying to the movable frame prevents tension changes if the head of the bed is raised or lowered. Quick-release knots ensure rapid removal if an emergency occurs.
5
Assess the bilateral radial pulses, capillary refill, and skin temperature.
Adequate circulation and nerve function are verified.
Evaluating neurovascular status immediately after securing the restraints ensures they are not constricting blood flow.

Key Concept

Safe Restraint Application Sequence
Question 689Question →

A nurse is riding in a crowded hospital elevator when two clinicians enter and begin loudly discussing a specific client's surgical complications, mentioning the client by name. Arrange the following actions the nurse should take in the correct chronological sequence, from first to last.

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Answer

The correct sequence is to first stop the active breach, relocate to a private area, address the inappropriate behavior, report the incident to leadership, and finally document the event officially.
When responding to an active breach of confidentiality, the nurse uses the nursing process framework to prioritize actions. The immediate threat (public exposure of PHI) must be neutralized first by stopping the conversation. Administrative follow-up, such as private education, chain-of-command reporting, and documentation, should only occur after the environment is secure and the active breach has ceased.

Step-by-Step Solution

1
Intervene promptly to stop the active discussion of the client's information.
The ongoing exposure of Protected Health Information (PHI) is immediately halted.
In any privacy breach or safety scenario, the immediate priority is always to stop the active harm or exposure before taking administrative steps.
2
Relocate to a secure, private environment with the clinicians after exiting the elevator.
The conversation is moved away from bystanders.
Confronting colleagues about specific details of a privacy breach in a public space like an elevator could result in a scene or further accidental disclosure of patient details.
3
Discuss the specific confidentiality violation and HIPAA regulations with the involved individuals.
The clinicians are made aware of their inappropriate behavior in a professional manner.
Nurses have a responsibility to hold peers accountable and educate them on maintaining adherence to confidentiality regulations.
4
Report the privacy breach to the designated facility privacy officer or nursing supervisor.
Facility leadership is informed of the incidental disclosure.
Organizations must track breaches for regulatory compliance, risk mitigation, and potential mandatory reporting or patient notification.
5
Complete an objective facility incident report detailing the unauthorized disclosure event.
The event is formally and objectively documented in the facility's risk management system.
Written documentation provides an official record of the variance, which is required for institutional tracking and quality improvement.

Key Concept

Mitigation and Escalation of Active Privacy Breaches
Estimated Time:1m 30s
Question 690Question →

A catastrophic chemical leak at a nearby manufacturing plant has resulted in dozens of exposed workers who are currently self-transporting to the local community hospital. The triage nurse receives radio confirmation that these individuals have bypassed field decontamination. What is the correct chronological sequence of actions the nurse must take to manage this crisis? Arrange the following steps from first to last.

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Answer

The correct sequence is to first secure the facility (lockdown), protect the staff (don PPE), manage the casualty flow (route to warm zone), neutralize the threat (decontamination), and finally provide medical care (triage in the cold zone).
In a hazardous materials (HazMat) mass casualty incident, the overriding principle is to prevent secondary contamination. The nurse must first prioritize facility protection by initiating a lockdown; if the hospital is contaminated, it becomes non-operational. Next, healthcare personnel must don proper PPE to protect themselves before interacting with the hazard. Once protected, staff route the contaminated victims to the warm zone, preventing them from entering clean areas. In the warm zone, physical decontamination (clothing removal and water irrigation) takes place. Only after victims are thoroughly decontaminated can they be safely moved to the cold zone for medical triage and stabilization.

Step-by-Step Solution

1
Initiate the hospital's lockdown protocol.
The facility is secured against unauthorized entry.
Prevents panicked, contaminated victims from rushing into the clean emergency department, which would cause massive secondary contamination and shut down the hospital.
2
Don specialized chemical-resistant PPE.
Healthcare personnel are physically protected from the chemical agent.
Responders must ensure their own safety before entering the hazard area to manage contaminated casualties.
3
Route the incoming vehicles and pedestrians to the external warm zone.
Victims are directed away from clean areas and towards the decontamination corridor.
Controlling the flow of casualties prevents the chaotic spread of the contaminant.
4
Instruct the victims to remove all clothing and begin gross water decontamination.
The chemical agent is physically removed from the victims' bodies.
Clothing removal eliminates up to 90% of the contaminant, and water irrigation addresses the remainder, neutralizing the immediate threat.
5
Perform disaster triage and provide stabilizing care in the internal cold zone.
Victims receive appropriate medical prioritization and treatment.
Medical care can only be safely provided once the victim is thoroughly decontaminated and moved to the clean (cold) zone.

Key Concept

Disaster Response: Hazardous Materials (HazMat) Protocol
Question 691Question →

An ambulatory care nurse is evaluating a client in a crowded clinic reception area. The client reports a persistent cough for four weeks, recent episodes of coughing up blood, and drenching night sweats. Arrange the following nursing actions in the correct priority sequence from first to last.

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Answer

The correct sequence prioritizes public safety through immediate source control (masking the client), followed by environmental isolation, provider protection (N95), diagnostic testing, and finally, client education.
In any triage setting, infection control follows a strict hierarchy of safety: protect the masses (source control via client masking), isolate the threat (move to negative-pressure room), protect the individual worker (don N95), perform clinical interventions (sputum collection), and finally address psychosocial/educational needs.

Step-by-Step Solution

1
Identify the transmission risk based on the clinical presentation.
Recognize symptoms (hemoptysis, night sweats, prolonged cough) as highly suspicious for active pulmonary tuberculosis, requiring Airborne Precautions.
Accurate pathogen identification drives the correct selection of infection control protocols.
2
Prioritize source control.
Provide the client with a standard surgical mask.
Placing a standard mask on the infectious source immediately stops the spread of droplet nuclei into the crowded reception area.
3
Establish environmental isolation.
Move the client to a negative-pressure airborne infection isolation room (AIIR).
Removing the client from the public area minimizes exposure risk to other waiting clients and unprotected staff.
4
Protect the healthcare worker.
The nurse dons a fit-tested N95 respirator.
Before entering the AIIR for prolonged contact or assessment, the nurse must protect themselves from airborne transmission.
5
Perform high-risk clinical tasks safely.
Collect the sputum sample for acid-fast bacilli (AFB).
Aerosol-generating procedures or tasks that induce coughing must be done in a controlled environment while wearing an N95 respirator.
6
Provide nursing education.
Explain the isolation protocols to the client.
Education is essential for compliance but must be sequenced after all acute safety and containment measures are established.

Key Concept

Airborne transmission prevention relies on immediate source control followed by environmental isolation.
Question 692Question →

A nurse answers a telephone call at the unit desk from an individual requesting a medical update on an adult client. Arrange the following actions the nurse should take in the correct sequence to ensure client confidentiality and information security.

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Answer

The correct sequence is to first identify the caller, then check the authorized contact list in the EHR, next authenticate the caller using the privacy code, then disclose the information, and finally document the interaction.
Ensuring confidentiality over the telephone requires a systematic approach. The nurse must first identify the caller (name/relationship), then verify authorization (checking the EHR for consent), followed by authentication (requesting the privacy code). Only after these security gates are passed can Protected Health Information (PHI) be disclosed. Finally, all disclosures must be documented to maintain an audit trail.

Step-by-Step Solution

1
Identify the caller.
The caller provides their name and relationship to the client.
Establishes who is requesting the information.
2
Check the EHR for authorization.
The nurse confirms the caller is on the approved contact list.
Ensures the client has granted permission for this specific individual to receive updates.
3
Authenticate with a privacy code.
The caller provides the correct alphanumeric code established upon admission.
Verifies that the person on the phone is actually the authorized individual.
4
Provide the medical update.
The nurse shares the requested clinical information.
Fulfills the request safely after security protocols are met.
5
Document the interaction.
A record of the disclosure is created in the client's chart.
Maintains a legal audit trail of who accessed the client's Protected Health Information (PHI).

Key Concept

Telephone Verification and HIPAA Compliance
Question 693Question →

An obstetrical client at 3838 weeks gestation is admitted to the unit in active labor. During a vaginal examination, the amniotic membranes spontaneously rupture. The nurse palpates a pulsating, rope-like structure descending through the cervical os, and the fetal monitor abruptly displays a prolonged deceleration to 6565 bpm. Arrange the following nursing interventions in the correct order of priority.

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Answer

The correct sequence of actions for a prolapsed umbilical cord prioritizes immediate relief of cord compression, followed by obtaining help, maternal repositioning, fetal oxygenation, and preparation for delivery.
The correct sequence of actions for a prolapsed umbilical cord prioritizes the immediate physiological needs of the fetus. The nurse must first manually elevate the presenting part to relieve cord compression and restore blood flow. Because the nurse cannot remove their hand, they must simultaneously or immediately after call for assistance. Next, maternal repositioning utilizes gravity to further offload pressure. Oxygen is then administered to maximize fetal oxygenation, and finally, preparations are made for definitive surgical delivery.

Step-by-Step Solution

1
Identify the obstetric emergency.
Recognition of an umbilical cord prolapse based on the pulsating structure and prolonged fetal heart rate deceleration.
Accurate rapid assessment dictates the subsequent immediate life-saving interventions.
2
Prioritize immediate relief of cord compression.
Applying upward pressure on the fetal presenting part.
The immediate threat to the fetus is asphyxia due to cord compression; offloading the pressure restores fetal blood flow and is the absolute first priority.
3
Activate the emergency response team.
Calling for assistance and notifying the provider.
The nurse must not leave the client or remove the examining hand, so help must be summoned to the room to assist with further interventions and prepare for surgery.
4
Implement adjunctive maternal positioning.
Placing the client in a knee-chest or extreme Trendelenburg position.
Gravity assists in shifting the fetus away from the maternal pelvis, further reducing compression on the umbilical cord.
5
Optimize fetal oxygenation.
Administering high-flow oxygen via a nonrebreather mask.
Maximizing maternal blood oxygen concentration helps increase the oxygen delivery to the compromised fetus.
6
Facilitate definitive treatment.
Preparing for an emergency cesarean birth.
A prolapsed umbilical cord is an acute obstetric emergency that almost always necessitates immediate surgical delivery to save the fetus.

Key Concept

Emergency Management of Umbilical Cord Prolapse
Question 694Question →

A nurse accidentally drops and shatters a large glass container of a concentrated chemical disinfectant in the utility room. The fumes are strong, and the liquid is spreading rapidly across the floor. Arrange the following actions in the correct sequence to ensure safety and properly manage the spill.

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Answer

The correct sequence for managing a hazardous chemical spill prioritizes immediate human safety, followed by information gathering, personal protection, and finally, containment and disposal.
When a hazardous chemical spill occurs, the primary goal is accident and injury prevention. The first action must always be to secure the safety of people by evacuating the immediate area and closing the door to prevent fumes from spreading to client care areas. Once the area is isolated, the nurse must consult the Safety Data Sheet (SDS) to understand the chemical's specific risks and determine the necessary personal protective equipment (PPE). Only after donning the required PPE should the nurse re-enter the area to contain the spill using a designated spill kit. Finally, the absorbed materials and broken glass must be disposed of in a specialized hazardous waste container, rather than regular trash, to maintain a safe environment.

Step-by-Step Solution

1
Evacuate all personnel from the utility room and close the door to isolate the hazard.
Personnel are removed from immediate danger, and fumes are contained.
The highest priority is protecting individuals from acute exposure to fumes and direct contact with the chemical.
2
Consult the facility's Safety Data Sheet (SDS) to determine the chemical properties and required precautions.
The nurse identifies the specific risks and required safety measures.
It is unsafe to attempt cleanup without knowing the exact chemical properties and the necessary protective equipment.
3
Don the specific personal protective equipment (PPE) recommended for this chemical.
The nurse is physically protected from the chemical's hazards.
PPE ensures the nurse does not sustain injury while managing the hazardous material.
4
Apply the absorbent materials from the facility's designated hazardous spill kit over the liquid.
The chemical spill is contained and absorbed.
Designated spill kits safely neutralize or absorb the chemical without creating further hazardous reactions.
5
Place the absorbed chemical and broken glass into a designated hazardous waste receptacle.
The hazard is completely removed from the environment.
Hazardous waste must be disposed of according to facility policy and environmental regulations to prevent secondary injuries.

Key Concept

Prioritization in hazardous materials management dictates that immediate life safety and isolation precede hazard identification, which in turn must precede cleanup efforts.
Question 695Question →

A glass laboratory tube shatters in a high-traffic clinical hallway, resulting in a significant blood spill. Arrange the following infection control actions in the correct chronological sequence. All options must be used.

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Answer

The correct sequence is to first restrict access to the area, then apply personal protective equipment, cover the spill with absorbent material, remove the material and glass with mechanical tongs, and finally apply a hospital-grade disinfectant.
Safe management of a biohazardous spill requires a systematic approach. The nurse must prioritize immediate environmental safety by restricting access. Next, the nurse protects themselves by donning PPE. The actual cleaning process requires a two-step method: first, removing the organic bioburden by absorbing and picking it up (using mechanical means to avoid sharps injury), and second, chemically disinfecting the pre-cleaned surface.

Step-by-Step Solution

1
Restrict access to the immediate perimeter.
Secures the environment from foot traffic.
Prevents cross-contamination and accidental sharps exposure while the nurse gathers necessary clean-up supplies.
2
Apply required personal protective equipment.
Protects the healthcare worker from exposure.
Standard precautions dictate that appropriate barrier protection must be worn before handling blood, body fluids, or contaminated sharps.
3
Cover the spill with absorbent material.
Contains the fluid and prevents splashing.
Organic material must be absorbed prior to disinfection because heavy bioburdens (like pooled blood) inhibit the efficacy of chemical cleaning agents.
4
Collect the saturated material and glass shards using mechanical tongs.
Removes the physical and biological hazard safely.
OSHA and standard guidelines mandate that broken glassware that may be contaminated must not be picked up directly with the hands.
5
Apply a hospital-grade disinfectant to the surface.
Destroys remaining microscopic pathogens.
Applying the disinfectant to a pre-cleaned surface and allowing the required contact time ensures complete decontamination.

Key Concept

Management of Biohazardous Spills (Standard Precautions)
Estimated Time:1m 30s
Question 696Question →

An older adult client with severe metabolic encephalopathy is persistently disrupting a continuous central venous infusion despite multiple documented less restrictive interventions. The healthcare provider has just prescribed bilateral soft wrist restraints. Arrange the nurse's subsequent actions in the correct chronological sequence of implementation.

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Answer

The correct sequence is to first verify the prescription, then educate the client and family, perform a baseline neurovascular assessment, apply the restraints with appropriate clearance, and finally secure the straps to a movable part of the bed.
The correct chronological sequence reflects fundamental nursing principles: validating legal authorization (verifying the order), prioritizing psychosocial needs and ethics (education), utilizing the nursing process (baseline assessment), and finally implementing the intervention safely (application and securing).

Step-by-Step Solution

1
Verify that the provider's prescription is current, time-limited, and specifies the clinical justification.
Ensures legal and clinical authorization for the procedure.
Medical-surgical restraints require a specific, non-PRN order prior to application, unless the situation is an immediate behavioral emergency.
2
Explain the rationale for the safety devices to the client and any present family members.
Promotes understanding and minimizes psychological distress.
Ethical nursing practice requires providing information and attempting to gain cooperation before initiating a restrictive physical intervention.
3
Perform a baseline assessment of the client's skin integrity and peripheral vascular status in both arms.
Establishes the pre-application circulatory and integumentary status.
A baseline is necessary to accurately evaluate the client for any subsequent neurovascular compromise during continuous monitoring.
4
Wrap the padded cuffs around the client's wrists, ensuring enough space to insert two fingers underneath.
Secures the client's wrists safely without compromising circulation.
Proper spacing prevents severe complications such as nerve damage, impaired tissue perfusion, or skin breakdown.
5
Tie the restraint straps to the movable portion of the bed frame utilizing a quick-release knot.
Anchors the restraints safely and securely.
Tying to the movable frame prevents injury when the bed position is adjusted, and a quick-release knot allows for immediate removal in case of a medical emergency (e.g., cardiac arrest or seizure).

Key Concept

The application of medical-surgical restraints follows a strict legal and procedural sequence prioritizing order verification, informed care, baseline assessment, and evidence-based safety techniques.
Question 697Question →

A nurse is preparing to administer an intermittent bolus enteral feeding via a percutaneous endoscopic gastrostomy (PEG) tube to a client. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence.

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Answer

The correct sequence is: Elevate the head of the bed, measure the gastric residual volume, flush the tube with water, administer the enteral formula by gravity, and finally flush the tube again before clamping.
Safe administration of enteral feedings follows a strict chronological order that prioritizes airway protection first (elevating the head of the bed), followed by assessing tolerance (checking residual volume), ensuring tube patency (pre-flush), delivering nutrition safely (gravity feeding), and maintaining equipment integrity (post-flush and clamp).

Step-by-Step Solution

1
Elevate the head of the bed to at least 30 to 45 degrees.
The client is placed in a safe, upright position.
Elevating the head of the bed is the most critical initial step to protect the airway and prevent aspiration of stomach contents into the lungs during the procedure.
2
Aspirate stomach contents to measure the gastric residual volume.
The amount of undigested formula in the stomach is quantified.
Measuring the residual volume assesses gastric emptying and tolerance of previous feedings, ensuring it is safe to administer the next bolus.
3
Flush the gastrostomy tube with 30 mL of water.
The tube is cleared of gastric contents.
Flushing verifies the patency of the tube and prevents occlusion before the thick enteral formula is introduced.
4
Allow the prescribed enteral formula to flow in by gravity.
The client receives the prescribed nutrition.
Administering the feeding by gravity simulates normal filling of the stomach, preventing nausea, cramping, and vomiting.
5
Flush the tube with 30 mL of water and clamp the device.
The tube is cleared of formula and safely secured.
A final flush removes residual formula that could curdle and occlude the tube over time, and clamping prevents leakage or air entry.

Key Concept

Enteral Nutrition Administration and Aspiration Prevention
Estimated Time:1m 30s
Question 698Question →

A nurse is caring for an older adult client who is experiencing acute postoperative confusion following a total hip arthroplasty. The client repeatedly attempts to climb out of bed unassisted, risking a severe fall and joint dislocation. Arrange the following nursing interventions in the correct order from the least restrictive to the most restrictive measure.

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Answer

The interventions should escalate sequentially from basic needs assessment (frequent rounding), to environmental modification (room relocation), to technological alerts (bed alarm), to intensive supervision (sitter), and finally to physical limitation (restraints).
Nursing standards of practice and regulatory guidelines require attempting and documenting the exhaustion of all least restrictive alternatives before utilizing physical restraints. The sequence correctly progresses from standard nursing care (frequent rounding) to environmental modifications (moving rooms), technological assistance (bed alarms), intensive human resource utilization (1:1 sitter), and finally culminating in the most restrictive measure (physical restraint).

Step-by-Step Solution

1
Address basic physiological needs through frequent rounding.
The root cause of the wandering behavior may be resolved.
Confused clients often attempt to get out of bed due to unexpressed needs, such as a full bladder or uncontrolled pain.
2
Relocate the client near the nurses' station.
The client is placed under closer passive surveillance.
Increased visibility allows nursing staff to intervene more rapidly if the client attempts to exit the bed unassisted.
3
Utilize a bed exit alarm.
Staff receive an immediate auditory alert if the client's weight shifts.
Alarms provide a reliable active warning system while keeping the client free of physical restraints.
4
Initiate continuous one-to-one observation.
The client receives constant supervision and immediate verbal redirection.
When environmental changes and alarms are insufficient, a dedicated sitter can provide constant safety monitoring before resorting to physical restraints.
5
Apply a physical restraint per healthcare provider prescription.
The client is physically prevented from exiting the bed.
Physical restraints are strictly a measure of last resort when all other non-restrictive alternatives have failed to prevent imminent, severe harm.

Key Concept

Prioritization of least restrictive interventions and alternatives before applying physical restraints in a client at high risk for falls.
Question 699Question →

While conducting hourly rounding on a medical-surgical unit, a nurse discovers that a client's central venous catheter (CVC) tubing has become disconnected at the hub. The client is suddenly grasping their chest, gasping for air, and exhibiting circumoral cyanosis. To prevent further catastrophic injury from a suspected air embolism, arrange the following immediate nursing actions in the correct priority sequence.

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Answer

The correct priority sequence is: Clamp the catheter, position the client in left lateral Trendelenburg, administer 100% oxygen, activate the rapid response team, and then obtain vital signs while remaining with the client.
In any sudden equipment failure leading to a life-threatening error (like a CVC disconnection), the absolute first priority is source control to halt the ongoing injury. Clamping the line stops the influx of air. Immediately after, the nurse must physically manipulate the existing hazard by placing the client in a left lateral Trendelenburg position; this uses gravity to trap the air in the right ventricle, preventing it from obstructing pulmonary blood flow. Once the mechanical threat is contained, the nurse treats the physiological effects by applying 100% oxygen, which combats hypoxia and helps dissolve the nitrogen-rich air bubble. Only after these immediate, independent, life-saving actions are complete should the nurse divert attention to activating the rapid response team and gathering comprehensive assessment data (vital signs).

Step-by-Step Solution

1
Clamp the central venous catheter.
Additional air is prevented from entering the client's bloodstream.
Air entry through an open central line can be rapid and fatal. Source control must always be the first step in injury mitigation.
2
Place the client in a left lateral Trendelenburg position.
The air embolus becomes trapped in the right ventricle.
Gravity causes the buoyant air to rise to the apex of the right ventricle, keeping it away from the pulmonary valve and preventing a complete blockage of pulmonary circulation.
3
Administer 100% oxygen via a non-rebreather mask.
Hypoxia is treated and the size of the air embolus is reduced.
A high concentration of oxygen creates a diffusion gradient that pulls nitrogen out of the air bubble, causing it to shrink while also treating tissue ischemia.
4
Activate the rapid response team.
Advanced medical assistance is summoned to the room.
An air embolism is a life-threatening emergency that requires a multidisciplinary response, but the nurse must perform immediate physical safeguards before leaving the bedside or reaching for a phone.
5
Obtain vital signs and monitor continuously.
Baseline data is collected for the arriving emergency team.
Ongoing assessment is crucial to detect hemodynamic collapse, but it takes secondary priority to the immediate mechanical and respiratory interventions.

Key Concept

Emergency management and injury prevention for a central line-associated air embolism.
Estimated Time:2m 0s
Question 700Question →

A nurse is preparing to administer a prescribed dose of intravenous (IV) ondansetron to a client who is recovering from a laparoscopic cholecystectomy and reporting nausea. The client has a peripheral saline lock in place on the right forearm. Arrange the following steps for administering the IV push medication in the correct sequence.

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Answer

The correct sequence for administering an IV push medication via a saline lock is to clean the port, flush with saline to check patency, administer the medication, flush again with saline to clear the line, and finally clamp the tubing.
The standard evidence-based protocol for administering an IV push medication into a peripheral saline lock is often remembered by the acronym SAS: Saline, Administer, Saline. First, the nurse must always maintain asepsis by cleaning the access port. Second, a normal saline flush is used to assess the patency of the intravenous site and ensure the fluid flows easily without causing swelling or pain. Third, the medication is pushed over the recommended time. Fourth, a second normal saline flush is administered to push the remaining medication in the extension tubing into the client's bloodstream. Finally, the tubing is clamped to maintain positive pressure and prevent blood reflux, which could cause a clot and subsequent loss of the IV access.

Step-by-Step Solution

1
Disinfect the injection port.
The port is aseptically prepared.
Reduces the risk of a peripheral line-associated bloodstream infection.
2
Flush the line with normal saline.
Line patency is verified.
Ensures the vein is viable and prevents extravasation or infiltration of the medication.
3
Administer the IV medication.
The therapeutic dose is delivered.
Treats the client's postoperative nausea safely.
4
Flush the line again with normal saline.
The tubing is cleared of medication.
Ensures the entire dose reaches the systemic circulation and prevents drug incompatibility if other medications are administered later.
5
Clamp the extension tubing.
The saline lock is secured.
Maintains positive pressure in the line to prevent blood from backing up and clotting inside the catheter.

Key Concept

Safe administration of intravenous push medications through a saline lock using the Saline-Administer-Saline (SAS) protocol.
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