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Question 701Question →

A registered nurse is preparing to exit the negative-pressure isolation room of a client diagnosed with disseminated varicella-zoster. The nurse is currently wearing a gown, an N95 respirator, a face shield, and gloves. Arrange the following steps for safely removing the personal protective equipment (PPE) and exiting the room in the correct chronological sequence.

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Answer

The correct sequence is: remove gloves, remove face shield, remove gown, exit the room, remove the N95 respirator, and finally perform hand hygiene.
The correct sequence for doffing PPE follows the core infection control principle of removing the most contaminated items first while maintaining continuous respiratory protection until safely outside an airborne isolation environment. The standard alphabetical mnemonic for doffing (Gloves, Goggles, Gown, Mask) dictates removing gloves first, followed by eyewear, then the gown. Crucially, for airborne pathogens, the nurse must exit the room before removing the N95 respirator, concluding the entire process with thorough hand hygiene.

Step-by-Step Solution

1
Remove gloves.
Hands are freed from the most contaminated component of the PPE.
Gloves harbor the highest concentration of contact pathogens and must be removed before touching the head or neck.
2
Remove the face shield.
Eye protection is safely discarded without contaminating the hands.
The back straps are considered clean, preventing cross-contamination from the contaminated front shield.
3
Remove the gown.
The gown is bundled inside-out and discarded in the designated room receptacle.
Rolling the gown inside-out prevents pathogens from transferring to the nurse's uniform.
4
Exit the client's room.
The nurse is securely in the hallway or anteroom.
Airborne pathogens (varicella-zoster) require maintaining a respiratory seal until safely outside the negative-pressure area.
5
Remove the N95 respirator.
The respirator is safely discarded outside the infectious environment.
Removing the bottom strap first prevents the mask from pivoting and contaminating the chest.
6
Perform hand hygiene.
Hands are completely decontaminated.
This guarantees that any accidental contamination during the doffing procedure is neutralized.

Key Concept

PPE Doffing Sequence for Airborne and Contact Precautions
Question 702Question →

A nurse is educating a client who is 24 hours postpartum about the expected progression of vaginal discharge. Arrange the types of lochia in the chronological order they occur, from immediately after delivery to the final stage of healing.

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Answer

The correct sequence of postpartum vaginal discharge is Lochia rubra, followed by Lochia serosa, and finally Lochia alba.
Following delivery, the uterus sheds its lining resulting in vaginal discharge known as lochia. The correct chronological sequence reflects the normal healing of the placental site: rubra (dark red, days 1-3), serosa (pink/brown, days 4-10), and alba (yellow/white, day 10 up to 6 weeks).

Step-by-Step Solution

1
Identify the immediate postpartum period (days 1-3).
Lochia rubra is the first discharge.
Fresh bleeding from the placental site is initially dark or bright red.
2
Identify the intermediate postpartum period (days 4-10).
Lochia serosa is the second discharge.
As active bleeding slows, the discharge transitions to a pinkish-brown color, containing old blood and serum.
3
Identify the late postpartum period (day 10 to 6 weeks).
Lochia alba is the final discharge.
The placental site continues to heal, producing a yellowish-white discharge composed of white blood cells and healing tissue.

Key Concept

Postpartum physiological adaptations: Progression of Lochia
Estimated Time:45s
Question 703Question →

The nurse is preparing to safely transfer a client with right-sided hemiparesis from the bed to a wheelchair. In which 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 prioritizes safe environmental setup (placing the chair on the strong side and locking brakes), patient preparation (sitting the client up and applying the transfer belt), and safe physical execution (pivoting on the strong leg and reaching for armrests).
A safe transfer sequence must follow a logical progression that maximizes client safety, utilizes their functional abilities, and minimizes nursing injury. The environment must be prepared first by placing the wheelchair on the unaffected (left) side and locking all brakes. Once the environment is secure, the client is assisted to a seated position to stabilize hemodynamics before the transfer belt is applied. Finally, the physical transfer is executed by having the client bear weight on their strong leg, pivot, and secure themselves using the armrests before sitting.

Step-by-Step Solution

1
Position the wheelchair on the unaffected side.
The wheelchair is placed on the client's left side at a 45-degree angle.
Transferring toward the strong side ensures the client can support their own weight during the pivot.
2
Secure the equipment.
The bed and wheelchair brakes are locked.
Locking all wheels is a mandatory safety measure to prevent the equipment from rolling away.
3
Mobilize the client to a seated position.
The client sits on the edge of the bed with feet flat on the floor.
Sitting and dangling allows the cardiovascular system to adapt, preventing dizziness upon standing.
4
Apply the transfer belt.
The transfer belt is fastened snugly around the client's waist.
Applying the belt while the client is seated upright ensures a proper fit and provides a safe point of contact for the nurse.
5
Execute the standing pivot.
The client bears weight on the left leg and pivots toward the chair.
The strong leg acts as the pivot point, compensating for the right-sided weakness.
6
Lower the client into the wheelchair.
The client reaches for the armrests and sits down securely.
Feeling the armrests behind them ensures spatial awareness and prevents the client from missing the seat.

Key Concept

Safe Client Transfer Techniques and Mobility Assistance
Question 704Question →

A nurse is preparing to administer an intermittent intravenous (IV) antibiotic via a secondary line (piggyback) to a client who is currently receiving a continuous primary IV fluid infusion. Arrange the following steps for setting up and initiating the secondary infusion in the correct chronological order.

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Answer

The correct procedural sequence is: 1) Close the roller clamp on the secondary tubing, 2) Spike the secondary medication bag, 3) Prime the secondary tubing, 4) Scrub the uppermost Y-site port on the primary line, and 5) Attach the tubing and lower the primary fluid bag.
Safe initiation of an IV piggyback requires preparing the equipment before breaking into the patient's existing line. The nurse must first secure the clamp to prevent fluid loss, spike the bag, and prime the air from the line. Once the secondary set is fully prepared, the nurse cleanses the patient's primary line to maintain sterility, connects the secondary line, and manipulates the physical height of the bags to ensure the medication infuses correctly via gravity.

Step-by-Step Solution

1
Close the roller clamp on the secondary tubing.
The tubing is occluded.
Prevents the premature loss of medication when the bag is punctured.
2
Spike the secondary medication bag.
The bag is connected to the administration set.
Establishes a closed pathway for the medication.
3
Prime the secondary tubing with the medication.
Air is removed from the tubing.
Prevents air embolisms from entering the client's vascular system.
4
Cleanse the primary line's uppermost Y-site port.
The access point is sterilized.
Maintains strict asepsis before breaching the primary closed IV system.
5
Connect the lines and lower the primary IV bag using a hanger.
The secondary system is fully integrated.
Lowering the primary bag utilizes gravity, ensuring the higher secondary bag infuses first.

Key Concept

Safe administration and procedural sequencing of secondary intravenous (IV piggyback) medications.
Question 705Question →

A client is admitted to the intensive care unit with confirmed avian influenza (H5N1) and requires airborne, contact, and eye precautions. A staff nurse is preparing to enter the negative-pressure room to perform an assessment. In what order should the nurse apply the necessary personal protective equipment (PPE)? Arrange the actions in the correct sequence from first to last.

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Answer

The correct sequence for donning personal protective equipment is: hand hygiene, isolation gown, N95 respirator, face shield or goggles, and finally gloves.
According to standard infection control protocols established by the Centers for Disease Control and Prevention (CDC), the sequence for donning PPE is strictly organized to ensure all barriers are properly placed and secured. Hand hygiene must always occur first. The gown is applied to protect the torso and arms. The respirator is applied next so its straps can secure directly to the head. Eye protection follows, resting securely on the face. Finally, gloves are applied last so they can be stretched entirely over the cuffs of the gown, ensuring a continuous barrier.

Step-by-Step Solution

1
Perform hand hygiene using an alcohol-based hand rub or soap and water.
Hands are free of transient flora.
Reduces baseline pathogens and prevents contamination of clean PPE.
2
Put on a fluid-resistant isolation gown and fasten all ties securely.
The torso and clothing are protected.
Provides the primary body barrier and must go on before gloves.
3
Apply a NIOSH-approved N95 respirator and perform a user seal check.
The respiratory tract is protected.
Must be secured to the face and head before any eye protection is placed over it to guarantee a tight seal.
4
Place a face shield or goggles over the face and eyes.
Mucous membranes of the eyes are protected.
Sits securely on top of the respirator straps to prevent interference with the respirator's fit.
5
Don clean, nonsterile gloves and extend them over the cuffs of the gown.
Hands and wrists are protected.
Applying gloves last allows the nurse to pull them over the gown cuffs, securing the wrists and leaving no skin exposed.

Key Concept

The Centers for Disease Control and Prevention (CDC) dictates a strict chronological sequence for donning personal protective equipment (PPE) to maximize effectiveness and minimize self-contamination: hand hygiene, gown, mask or respirator, goggles or face shield, and then gloves.
Question 706Question →

A nurse is preparing to perform Leopold maneuvers on a pregnant client to determine fetal presentation, lie, and position. After ensuring the client has emptied her bladder and is positioned comfortably with her knees slightly flexed, in what chronological order should the nurse perform the steps of this assessment?

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Answer

The correct sequence for Leopold maneuvers is: 1) Palpate the uterine fundus, 2) Palpate the lateral aspects of the abdomen, 3) Grasp the lower uterine segment above the symphysis pubis, and 4) Face the client's feet to palpate the bilateral lower abdomen.
Leopold maneuvers must be performed in a specific, systematic four-step sequence to accurately determine fetal presentation, lie, position, and attitude. The assessment progresses logically from the top of the uterus (fundus) down to the lower segment, mapping out the large fetal parts before turning to assess the detailed flexion of the fetal head in the pelvis.

Step-by-Step Solution

1
Identify the first maneuver (Fundal Grip).
The nurse palpates the upper abdomen (fundus).
This initial step systematically determines if the fetus is in a longitudinal or transverse lie by identifying what part is at the top of the uterus.
2
Identify the second maneuver (Umbilical Grip).
The nurse palpates the sides of the abdomen.
Once the lie is established, the nurse must locate the fetal back versus the extremities (small parts) to determine the exact position.
3
Identify the third maneuver (Pawlik's Grip).
The nurse grasps the lower uterine segment above the pubic bone.
This confirms the presenting part found in the first step and assesses whether it has descended and engaged into the pelvic inlet.
4
Identify the fourth maneuver (Pelvic Grip).
The nurse turns to face the client's feet and palpates the lower abdomen bilaterally.
This final step identifies the cephalic prominence to determine the fetal attitude (flexion or extension of the head), which is only possible after establishing the other parameters.

Key Concept

Leopold Maneuvers Sequencing
Estimated Time:1m 0s
Question 707Question →

A nurse is preparing to draw a blood specimen from a client's multi-lumen central venous catheter (CVC). A continuous intravenous infusion of 0.9% sodium chloride is currently running through a different lumen of the catheter. Arrange the following steps in the correct chronological order to obtain the blood sample safely and prevent laboratory result contamination.

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Answer

The correct sequence is to first pause the active infusion, then scrub the hub, verify patency and discard the dead space fluid, draw the actual sample, and finally flush the line and restart the infusion.
The correct sequence ensures patient safety, prevents central line-associated bloodstream infections (CLABSI), and guarantees the integrity of the laboratory specimen. Pausing other infusions is the critical first step to prevent hemodilution. Aseptic technique (scrubbing the hub) must precede any line access. A discard sample is necessary to remove the fluid sitting in the catheter's dead space before obtaining the actual diagnostic sample. Finally, the line must be flushed to prevent clotting, and the paused infusion must be restarted.

Step-by-Step Solution

1
Pause the continuous intravenous infusion on the other lumen for at least 1 to 2 minutes.
The flow of intravenous fluids into the central circulation is temporarily halted.
This prevents hemodilution and ensures the drawn blood sample is not contaminated by the infusing fluids.
2
Scrub the needleless connector of the designated sampling lumen with an antiseptic swab.
The entry point for the syringe is disinfected.
Strict asepsis prevents the introduction of pathogens into the client's central bloodstream, preventing infection.
3
Flush the sampling lumen to verify patency, then withdraw and discard 5 to 10 mL of blood.
The catheter is confirmed to be patent, and the dead space is cleared of residual fluids.
Discarding the initial blood volume ensures that the subsequent sample consists of pure circulating blood rather than flush solution or residual fluids.
4
Attach a new sterile syringe and withdraw the required volume of blood for the laboratory specimen.
An uncontaminated diagnostic sample is successfully collected.
Using a fresh syringe ensures the actual specimen is accurately obtained for laboratory analysis.
5
Flush the sampling lumen with 10 to 20 mL of 0.9% sodium chloride and restart the paused infusion.
The catheter lumen is cleared of residual blood, and the client's continuous therapy is resumed.
A thorough flush prevents fibrin buildup and catheter occlusion, while restarting the infusion ensures therapeutic continuity.

Key Concept

Central Venous Catheter (CVC) Blood Specimen Collection (Discard Method)
Question 708Question →

A charge nurse at a medical center receives a telephone call from an individual claiming that an explosive device has been placed in the facility. Arrange the following actions the nurse should take in the correct chronological sequence. All options must be used.

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Answer

The correct sequence for managing a telephone bomb threat is to first keep the caller on the line, quietly signal a colleague to notify security, record the exact wording of the threat, conduct a visual sweep of the immediate area, and finally prepare the unit while awaiting further directives.
The standard protocol for a telephone bomb threat dictates that the receiver must first try to keep the caller engaged to gather information. Simultaneously, they should signal a coworker to activate the emergency response. Documenting the specific details occurs continuously but is finalized as the primary data collection phase. After the call concludes, the immediate environment is visually swept for obvious threats. Finally, the unit must wait for incident command to determine if evacuation is safe and necessary.

Step-by-Step Solution

1
Keep the caller on the telephone as long as possible to gather details and listen to background noises.
The connection is maintained, allowing for maximum intelligence gathering.
The caller is the primary source of information. Prolonging the call increases the chances of identifying background noises, caller demographics, or the exact location of the device.
2
Quietly signal a colleague to contact hospital security and activate the emergency operations plan.
Security and administration are alerted while the call is still active.
Early activation of the facility's emergency response is critical. Using a colleague prevents the nurse from having to disconnect the call to seek help.
3
Record the exact wording of the threat, the characteristics of the caller's voice, and any specified detonation times.
Crucial evidence is preserved accurately.
Human memory is fallible under stress. Documenting the caller's precise phrasing, accent, state of mind, and specific threats provides essential evidence for law enforcement.
4
Conduct a visual sweep of the nursing station and surrounding client areas for suspicious or out-of-place objects.
The immediate clinical environment is assessed for localized threats.
Once the initial threat communication is managed, staff must check their own area for immediate danger. Suspicious items should be reported but never touched.
5
Prepare clients and staff for possible evacuation while awaiting directives from the incident commander.
The unit is ready to mobilize safely if required.
Self-evacuating during a bomb threat is dangerous because the device may be located along evacuation routes. The unit must wait for clearance from the incident command center.

Key Concept

During a bomb threat, the primary nursing priorities are maintaining communication to gather intelligence, discreetly activating the emergency response, preserving evidence, assessing the immediate area, and preventing premature evacuation that could endanger clients.
Question 709Question →

A nurse is preparing to transfer a client with right-sided hemiparesis from the bed to a wheelchair. To prevent falls and ensure client safety, arrange the following nursing actions in the correct sequence.

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Answer

The correct sequence prioritizes environmental preparation and securing equipment, followed by client physiological preparation, applying safety devices, and executing the physical transfer.
To ensure client safety and prevent falls during a transfer, the nurse must follow a systematic approach. First, the environment must be prepared by positioning the wheelchair optimally on the client's strong (unaffected) side. Next, the equipment must be secured by locking all wheels. Once the environment is safe, the nurse prepares the client by assisting them to sit on the edge of the bed, allowing time to assess for dizziness or orthostatic hypotension. After the client is stable, a transfer belt is applied to provide a secure handhold. Finally, the physical transfer is executed by having the client bear weight on their strong leg and pivot into the wheelchair.

Step-by-Step Solution

1
Position the wheelchair at a 45-degree angle to the bed on the client's left side.
The equipment is placed in the optimal location for a safe transfer.
The wheelchair must be placed on the client's unaffected (strong) side before proceeding so the client can bear weight appropriately.
2
Engage the wheel locks on both the hospital bed and the wheelchair.
The environment is completely secured.
Locking the wheels prevents the bed or chair from rolling away while the client is attempting to stand or pivot, effectively preventing falls.
3
Assist the client to sit on the edge of the bed and allow their legs to dangle for a few minutes.
The client is upright and hemodynamically stable.
Allowing the client to dangle helps prevent orthostatic hypotension and dizziness, which are major risk factors for falls during transfers.
4
Fasten a transfer belt securely around the client's waist.
A safety device is applied to the client.
The transfer belt provides an ergonomic and secure way for the nurse to support the client in case their weak side gives out.
5
Instruct the client to bear weight on their left leg and pivot into the wheelchair.
The client safely completes the transfer to the wheelchair.
Bearing weight on the unaffected (left) side ensures stability during the physical movement from the bed to the chair.

Key Concept

Safe client transfer techniques and fall prevention.
Question 710Question →

A client arrives unannounced at a community health clinic after being heavily splashed with organophosphate pesticides at a local agricultural site. The client is exhibiting excessive salivation, diaphoresis, and severe muscle twitching. Arrange the following emergency response actions in the correct sequential order from first to last.

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Answer

The correct sequence prioritizes responder safety, facility containment, gross physical decontamination, thorough skin decontamination, and finally medical treatment.
In any hazardous materials (hazmat) emergency, the absolute first priority is the safety of the responders. Therefore, donning PPE is the initial action. Next, the facility must be protected by isolating the client in an external or designated decontamination area. Decontamination then proceeds in a specific sequence: removing clothing first (which eliminates the bulk of the contaminant) followed by washing with copious amounts of water and soap. Only after the client is completely decontaminated is it safe for healthcare personnel to provide direct medical interventions, such as administering antidotes.

Step-by-Step Solution

1
Prioritize responder safety.
The nurse dons appropriate PPE.
Healthcare workers must protect themselves first to avoid becoming secondary casualties.
2
Secure the facility.
The client is directed to an outdoor or isolated decontamination area.
This prevents the chemical from spreading inside the clinic and exposing others.
3
Perform gross decontamination.
Contaminated clothing is removed.
Clothing traps the chemical; removing it eliminates the majority of the exposure source.
4
Perform thorough skin decontamination.
The client is washed with copious amounts of soap and water.
Washing removes residual chemicals from the skin, halting further systemic absorption.
5
Initiate medical treatment.
The nurse administers the prescribed antidote.
Once the client is safe to handle without risk of secondary exposure, life-saving medical interventions can begin.

Key Concept

Chemical Exposure Emergency Response and Decontamination Sequence
Question 711Question →

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 chills and lower back pain. In what order should the nurse perform the following actions to minimize the client's risk of further injury? Arrange the steps from first to last.

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Answer

The correct sequence is: Stop the transfusion, initiate a normal saline infusion with new tubing, assess vital signs, notify the provider and blood bank, and return the blood bag to the blood bank.
When a client exhibits signs of a blood transfusion reaction (such as sudden chills and lower back pain), the immediate priority is to stop the transfusion to prevent further exposure. Next, the nurse must maintain IV access by infusing normal saline through completely new tubing (to avoid flushing residual blood from the old tubing into the client). With safety measures in place, the nurse then assesses the client's vital signs and respiratory status to determine clinical stability. Following the assessment, the healthcare provider and blood bank are notified so that emergency treatments can be ordered. Finally, the blood bag and tubing are returned to the blood bank for testing.

Step-by-Step Solution

1
Identify the complication.
The client's chills and lower back pain indicate a potential acute hemolytic transfusion reaction.
Recognizing the signs of a severe reaction is necessary to initiate emergency risk reduction measures.
2
Determine the most critical immediate intervention.
The nurse must stop the blood transfusion first.
Halting the infusion of the offending agent immediately minimizes the amount of incompatible blood the client receives, directly reducing physiological risk.
3
Determine the subsequent sequence of actions to maintain safety and report the event.
The nurse changes the IV tubing to run normal saline, then assesses vital signs, notifies the provider, and sends the blood back.
New tubing prevents infusing residual blood. Vital signs guide further medical interventions ordered by the provider. Returning the blood allows for necessary laboratory analysis.

Key Concept

Blood Transfusion Reaction Protocol
Question 712Question →

A nurse is performing a 1-hour postpartum assessment on a client who had a spontaneous vaginal delivery. The nurse notes heavy vaginal bleeding, and the uterine fundus is palpated as soft, boggy, and displaced to the right of the umbilicus. Arrange the following nursing actions in the correct priority sequence from first to last.

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Answer

The correct priority sequence is to first massage the uterine fundus, then assist the client to empty her bladder, administer a prescribed uterotonic medication, notify the healthcare provider, and finally document the findings.
In the setting of a boggy and deviated fundus, the nurse must prioritize immediate physiological stabilization. The first action is always to perform fundal massage to stimulate contraction and slow active hemorrhage. Next, the underlying cause of the deviation (a distended bladder) must be addressed by assisting the client to void or catheterizing. If these non-pharmacological measures are insufficient, administering a prescribed uterotonic is the next logical step to ensure sustained contraction. Escalation to the healthcare provider follows if the client remains unstable, and documentation is completed once the clinical emergency is managed.

Step-by-Step Solution

1
Massage the uterine fundus.
Stimulates the uterine muscle fibers to contract.
The most common cause of postpartum hemorrhage is uterine atony. Direct physical stimulation through massage is the most immediate and effective way to initiate contraction and slow bleeding.
2
Assist the client to empty her bladder.
Allows the uterus to return to its midline position and contract fully.
A fundus displaced to the right indicates a distended bladder. A full bladder physically prevents the uterus from contracting, contributing to ongoing atony.
3
Administer a prescribed as-needed uterotonic medication.
Provides pharmacological support for uterine contraction.
If mechanical stimulation and bladder emptying are insufficient to maintain uterine tone, medications are necessary to control the bleeding.
4
Notify the healthcare provider.
Escalates the level of care.
If the client's bleeding is not controlled by standard nursing interventions, medical evaluation is required for potential surgical or advanced medical management.
5
Document the assessment findings and interventions.
Creates a legal and medical record of the event.
Accurate documentation ensures continuity of care but is a lower priority than direct client stabilization.

Key Concept

Management of Postpartum Hemorrhage and Uterine Atony
Question 713Question →

A nurse is preparing to collect a blood specimen for a comprehensive metabolic panel (CMP) from a patient's multi-lumen central venous catheter (CVC). The patient is currently receiving continuous total parenteral nutrition (TPN) through the distal lumen, and the nurse plans to use the proximal lumen for the blood draw. Arrange the following actions in the correct sequential order to ensure accurate laboratory results and maintain catheter patency.

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Answer

The correct sequence is: Pause the TPN infusion, scrub the hub, flush and withdraw the waste sample, draw the required specimen, flush the line vigorously, and finally restart the TPN infusion.
Accurate blood sampling from a multi-lumen central venous catheter requires a strict aseptic and procedural sequence to prevent diagnostic contamination and line occlusion. Pausing continuous infusions (like TPN) prevents false lab alterations. Scrubbing the hub ensures asepsis. Wasting the initial blood clears the catheter dead space. Drawing the sample provides the clean specimen. Vigorously flushing clears viscous red blood cells to prevent clotting. Finally, restarting the TPN ensures therapeutic continuity.

Step-by-Step Solution

1
Pause continuous infusions
TPN is temporarily stopped
Prevents artificial elevation of lab values (e.g., severe hyperglycemia in the sample) due to contamination from the infusing solution.
2
Scrub the hub
Needleless connector is disinfected
Reduces the risk of Central Line-Associated Bloodstream Infections (CLABSI).
3
Flush and discard waste
Catheter dead space is cleared
Removes residual flush fluid and medication that would otherwise dilute or contaminate the diagnostic sample.
4
Draw required specimen
Pure blood sample is obtained
Provides the laboratory with an accurate, systemic blood sample for the CMP.
5
Flush with pulsatile technique
Blood is completely cleared from the lumen
Creates turbulence to prevent fibrin buildup, clotting, and long-term catheter occlusion.
6
Restart infusions
TPN therapy resumes
Ensures the patient continues to receive their prescribed, necessary parenteral nutrition without prolonged interruption.

Key Concept

Central Venous Catheter Blood Draw and Parenteral Nutrition Management
Estimated Time:2m 0s
Question 714Question →

A medical-surgical nurse discovers that a client with a history of hypertension mistakenly received another client's prescribed dose of oral metoprolol. Arrange the following nursing actions in the correct sequence from highest to lowest priority.

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Answer

The correct sequence is to first assess the client's vital signs, then notify the healthcare provider, implement any new orders, inform the client of the error, and finally complete the internal incident report.
In the event of a medication error, the absolute first priority is patient safety, which requires immediate physical assessment (vital signs). Armed with this data, the nurse contacts the healthcare provider to report the error and receive corrective orders. Those orders are then implemented. Once the client's safety is managed, ethical disclosure to the client occurs. Finally, an incident report is filed for the facility's risk management protocols, making it the lowest priority.

Step-by-Step Solution

1
Assess the client's apical heart rate and blood pressure.
Establishes the client's baseline physiological status.
The nurse must immediately determine if the client is experiencing adverse clinical effects from the unintended beta-blocker, such as severe bradycardia or hypotension.
2
Notify the primary healthcare provider of the incorrect medication administration.
Informs the provider of the error alongside the client's current vital signs.
The provider needs accurate, current assessment data to make informed decisions about necessary medical interventions.
3
Implement any newly prescribed corrective interventions or monitoring.
Provides immediate medical treatment or heightened surveillance.
Prompt execution of the provider's new orders (such as initiating continuous cardiac monitoring or administering an antidote) is critical to mitigate the effects of the error.
4
Disclose the occurrence of the medication error to the client.
Fulfills ethical and legal obligations for transparency in patient care.
After physiological safety is secured, the nurse (often in collaboration with the provider or charge nurse) must honestly inform the client about the error.
5
Submit an objective variance report to the risk management department.
Documents the error for institutional quality improvement purposes.
Filing an incident report helps the facility identify systemic flaws to prevent future errors, but this administrative task should never delay direct patient care.

Key Concept

Nursing priorities following a medication error follow a strict sequence: Assessment, Provider Notification, Corrective Intervention, Client Disclosure, and Administrative Documentation.
Question 715Question →

A nurse is instructing a client with left-sided hemiparesis on how to safely descend stairs using a quad cane. The client holds the cane in the right hand. In what order should the nurse instruct the client to perform the following actions to step down?

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Answer

The correct sequence for descending stairs with a cane is to first stabilize weight on the strong leg, lower the cane, move the weak leg down to the cane, shift weight to the cane and weak leg, and finally bring the strong leg down to join them.
The correct sequence follows the standard principle of 'down with the bad' for descending stairs with an assistive device. The sequence prioritizes stability by shifting weight to the strong side and moving the cane first to establish a new base of support. The affected (weak) leg is then lowered while the unaffected (strong) leg remains safely on the upper step to bear the body weight. Only after the weight is safely distributed between the cane and the affected leg on the lower step does the unaffected leg step down. This sequence minimizes the risk of the weak leg buckling under the full body weight.

Step-by-Step Solution

1
Shift body weight entirely to the unaffected right leg.
The body is stabilized, allowing movement of the cane and affected leg.
Ensures a secure base of support before initiating the transfer of assistive devices.
2
Advance the quad cane down to the next step.
The cane is securely positioned on the lower level.
Provides a wide base of support on the new level before any vulnerable movement occurs.
3
Lower the affected left leg down to the step with the cane.
The weak leg is safely moved to the lower step.
The weak leg is moved while maximum support is provided by the strong leg (above) and the cane (below).
4
Transfer body weight to the cane and the affected left leg.
The strong leg is freed to move.
The weight must be shifted forward and down onto the established supports to allow the final step.
5
Step down with the unaffected right leg to the same lower step.
Both feet and the cane are now secure on the lower step.
Completes the descent of one step while minimizing the time the weak leg bears independent weight.

Key Concept

Safe stair descent using a cane ('Down with the bad' principle)
Estimated Time:1m 30s
Question 716Question →

A healthcare provider is preparing to enter the negative-pressure isolation room of a client with suspected severe acute respiratory syndrome (SARS). The client requires airborne and contact precautions, along with standard precautions and eye protection. Arrange the following steps for donning personal protective equipment (PPE) in the correct chronological sequence according to Centers for Disease Control and Prevention (CDC) guidelines.

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Answer

The correct sequence is: perform hand hygiene, put on the isolation gown, apply the N95 respirator, place the eye protection, and finally don the gloves.
The correct sequence (Hand hygiene, Gown, Respirator, Eye protection, Gloves) strictly follows established CDC infection control guidelines designed to ensure healthcare worker safety, maintain the integrity of the PPE barrier, and prevent contamination.

Step-by-Step Solution

1
Determine the starting action required for any aseptic or clean procedural protocol.
Perform hand hygiene.
Hands must be clean before touching and applying clean PPE to prevent transfer of pathogens.
2
Sequence the primary body coverage layer.
Put on the isolation gown.
The gown covers the torso and arms, creating the primary barrier that other items will overlap.
3
Sequence the respiratory and facial protection.
Apply the N95 respirator first, followed by eye protection.
The respirator must secure tightly to the face for an effective seal; applying eye protection first would disrupt the respirator straps and seal.
4
Determine the final step to secure the extremity barrier.
Don gloves and pull them over the gown cuffs.
Applying gloves last allows them to overlap the gown cuffs, creating a seamless seal at the wrists.

Key Concept

The CDC standardized sequence for donning PPE is: Hand Hygiene -> Gown -> Mask/Respirator -> Goggles/Face Shield -> Gloves. This sequence maximizes barrier efficacy and prevents contamination of the equipment.
Estimated Time:1m 15s
Question 717Question →

A nurse is continuously monitoring a client who is receiving an intravenous infusion of doxorubicin, a known vesicant, via a peripheral catheter. The client suddenly reports severe burning pain at the insertion site, and the nurse observes localized swelling and erythema. To reduce the risk of severe tissue necrosis, in what order should the nurse perform the following interventions?

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Answer

The correct sequence is to first stop the infusion, then disconnect the IV tubing, aspirate residual medication from the catheter, remove the IV catheter, and finally elevate the extremity and apply a cold compress.
The sequence follows the standard oncology protocol for vesicant extravasation: immediately stop the infusion to prevent further harm, disconnect the line, leave the cannula in place temporarily to aspirate residual drug from the subcutaneous pocket, remove the cannula, and apply appropriate thermal therapy (cold for doxorubicin) to localize the drug.

Step-by-Step Solution

1
Stop the vesicant infusion immediately.
Halts further exposure of the subcutaneous tissue to the cytotoxic agent.
The priority in any extravasation event is to mitigate further physiological harm by stopping the source.
2
Disconnect the IV tubing from the catheter.
Separates the primary medication bag and tubing from the client.
Prevents accidental delivery of additional medication remaining in the administration set.
3
Attach a syringe and aspirate blood/medication from the hub.
Extracts residual doxorubicin from the catheter and the immediate subcutaneous pocket.
Reduces the total vesicant volume in the localized tissue, which directly reduces the extent of subsequent necrosis.
4
Remove the peripheral IV catheter.
Discontinues the compromised access site.
The cannula is removed only after aspiration to prevent tracking the vesicant upward through the tissue layers upon removal.
5
Elevate the extremity and apply a cold compress.
Causes local vasoconstriction.
Cold therapy localizes the doxorubicin (an anthracycline) and reduces cellular uptake, containing tissue damage.

Key Concept

Management of Vesicant Extravasation to Reduce Tissue Necrosis Risk
Question 718Question →

A nurse is preparing to obtain a sterile urine specimen for culture and sensitivity from a client who has a continuous indwelling urinary catheter. Arrange the following steps in the correct order to minimize the risk of infection and ensure an accurate sample.

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Answer

The correct sequence is: Clamp the drainage tubing, cleanse the aspiration port, attach a syringe to aspirate urine, transfer the urine to a sterile container, and finally unclamp the drainage tubing.
To obtain a sterile urine specimen from a closed indwelling catheter system, the nurse must first clamp the tubing below the port to allow fresh urine to collect. Next, the port must be cleansed with an antiseptic to maintain sterility. The nurse then uses a sterile syringe to aspirate the urine, transfers it to a sterile container, and finally unclamps the tubing to allow continuous drainage to resume.

Step-by-Step Solution

1
Clamp the drainage tubing below the aspiration port
Fresh urine accumulates in the tubing above the clamp.
Urine in the drainage bag is not sterile and may have been sitting for hours. Clamping ensures a fresh sample is collected from the bladder.
2
Cleanse the aspiration port with an antiseptic wipe
The surface of the port is disinfected.
This prevents the introduction of microorganisms from the port surface into the closed drainage system.
3
Attach a sterile syringe and withdraw the urine sample
A sterile sample of fresh urine is obtained.
Using a sterile syringe maintains the sterility of both the closed catheter system and the urine specimen.
4
Transfer the urine into a sterile specimen container
The sample is secured for laboratory transport.
A sterile container is required for a culture and sensitivity test to accurately identify any urinary pathogens.
5
Unclamp the drainage tubing
Continuous urinary drainage is restored.
Failing to unclamp the tubing can cause bladder distention, discomfort, and potentially harmful retrograde flow of urine.

Key Concept

Maintaining a sterile closed drainage system when obtaining a urine culture from an indwelling catheter reduces the risk of catheter-associated urinary tract infections (CAUTI) and ensures diagnostic accuracy.
Question 719Question →

A client receiving a transfusion of packed red blood cells (PRBCs) suddenly reports severe lower back pain, chills, and shortness of breath. Suspecting an acute hemolytic transfusion reaction, the nurse must intervene immediately. Arrange the following nursing actions in the correct chronological sequence.

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Answer

The correct chronological sequence is to first stop the transfusion, then maintain IV access with normal saline using new tubing, assess the client's current status, notify the healthcare provider and blood bank, and finally return the blood products for analysis.
In the event of a transfusion reaction, the absolute highest priority is to stop the offending agent (the blood product). Second, IV access must be maintained for emergency interventions, but this MUST be done with completely new tubing to avoid flushing residual blood into the client. Once the client is protected from further immediate harm, the nurse assesses vital signs and cardiopulmonary status to provide accurate data to the healthcare provider. With assessment findings ready, the provider and blood bank are notified. Finally, the remaining blood product and tubing are sent to the laboratory for investigation.

Step-by-Step Solution

1
Stop the blood transfusion immediately.
The client receives no further incompatible or reactive blood product.
Halting the infusion is the most critical initial action to minimize the severity of a hemolytic or allergic reaction.
2
Disconnect the blood administration set and maintain IV access with 0.9% sodium chloride through new IV tubing.
A patent intravenous line is secured for administering emergency medications.
Flushing the existing tubing would force more incompatible blood into the client; therefore, a completely new fluid administration set must be attached to the catheter hub.
3
Assess the client's vital signs and cardiopulmonary status.
The nurse obtains essential clinical data reflecting the severity of the transfusion reaction.
Immediate assessment provides the baseline data necessary for the healthcare provider to prescribe targeted emergency interventions.
4
Notify the healthcare provider and the blood bank.
The medical team is alerted, and emergency medical orders are obtained.
The provider needs the assessment data to order necessary treatments (e.g., vasopressors, antihistamines, fluids), and the blood bank must initiate their formal investigation.
5
Return the blood bag, tubing, and labels to the blood bank.
The blood bank receives the physical evidence of the transfusion.
Laboratory analysis of the returned product helps determine the definitive cause of the adverse reaction.

Key Concept

Nursing Management of Acute Transfusion Reactions
Question 720Question →

A nurse is preparing to withdraw a prescribed intravenous medication from a glass ampule. Place the steps for this procedure in the correct chronological order.

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Answer

The correct chronological sequence is: tap the ampule to clear the neck, wrap the neck with a protective barrier, snap the neck away from the body, withdraw the medication using a filter needle, and finally replace the filter needle with an appropriate administration device.
Safe medication preparation from an ampule requires a strict procedural sequence to prevent injury and contamination. The medication must first be tapped down into the base to prevent dosage loss. The nurse must then protect their hands with a barrier before snapping the neck away from the body to prevent cuts. Finally, a filter needle is strictly required to prevent microscopic glass shards from being drawn into the syringe, and this filter needle must be replaced before the medication can be safely administered to the client.

Step-by-Step Solution

1
Ensure all medication is in the bottom of the ampule by tapping the top.
Medication is cleared from the top chamber.
Prevents spilling and losing a portion of the prescribed dose when the top is snapped off.
2
Wrap the neck of the ampule with a gauze pad and snap it away from the body.
The ampule is opened safely.
Protects the nurse's hands from cuts and ensures flying glass fragments are directed away.
3
Withdraw the medication using a filter needle attached to the syringe.
Medication is drawn into the syringe.
The filter prevents any microscopic glass shards created during the breaking process from entering the syringe.
4
Change the needle before administration.
The syringe is safely prepared for client injection.
A filter needle is intended only for withdrawing from glass ampules and must be replaced to prevent tissue injury or injecting trapped glass.

Key Concept

Safe medication preparation and withdrawal from a glass ampule
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