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A nurse is caring for a client who is 3 days postoperative following an open exploratory laparotomy. The client coughs forcefully and reports a sudden "giving way" sensation in the abdomen. The nurse inspects the surgical site and observes that the incision has separated and a portion of the bowel is protruding. In what order should the nurse perform the following actions? Arrange the actions from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first call for assistance, then position the client to reduce abdominal tension, cover the wound to protect the bowel, assess vital signs, and finally prepare for surgery.

Wound evisceration is a surgical emergency. The nurse's immediate priority is to secure assistance without leaving the client. Next, the nurse must intervene to prevent further evisceration by placing the client in a low Fowler's position with flexed knees. Once positioned, the exposed viscera must be protected from drying and necrosis by covering them with sterile, saline-moistened dressings. After the bowel is protected, the nurse assesses for signs of shock by obtaining vital signs. Finally, the client is prepared for emergency surgical repair.

Step-by-Step Solution

Stay with the client and call for immediate assistance.

Assistance is secured without leaving the client unattended.

Wound evisceration is a medical emergency. The nurse must not leave the client alone but needs another staff member to notify the surgeon and bring sterile supplies.

Position the client in a low Fowler's position with the knees flexed.

Tension on the abdominal muscles and incision is minimized.

This positioning relaxes the abdominal muscles, preventing further protrusion of the abdominal contents while waiting for supplies.

Cover the exposed bowel with a sterile, saline-moistened dressing.

The protruding bowel is protected from drying and infection.

Exposed viscera can quickly become necrotic if allowed to dry. Covering them with sterile, moist dressings preserves tissue viability.

Obtain the client's vital signs.

A baseline is established to monitor for systemic complications.

Evisceration can lead to hypovolemic shock. Monitoring vital signs helps identify tachycardia, hypotension, and other signs of physiological deterioration.

Prepare the client for emergency surgery.

The client is readied for definitive surgical repair.

The only definitive treatment for wound evisceration is surgical closure. Preparing the client includes maintaining NPO status and ensuring patent IV access.

Key Concept

Management of Wound Evisceration

Question 722Question →

A client in the intensive care unit is receiving a continuous intravenous (IV) infusion of sodium bicarbonate to treat severe metabolic acidosis. During the infusion, the nurse observes that the client has developed muscle cramping and a positive Trousseau's sign. The healthcare provider prescribes a dose of calcium gluconate via intravenous piggyback (IVPB). The client currently has a single-lumen peripherally inserted central catheter (PICC) in the right arm. Which of the following actions is the most appropriate for the nurse to take?

Establish a new peripheral IV catheter in the opposite arm and administer the calcium gluconate through the new access.

Attach the calcium gluconate as a secondary infusion to the lowest Y-site on the active sodium bicarbonate line.

Withhold the calcium gluconate and prepare to draw an arterial blood gas (ABG) sample because the symptoms indicate the acidosis is resolving.

Program the IV pump to infuse the calcium gluconate rapidly over 3 minutes to immediately reverse the tetany.

Show answer & explanation

Answer: Establish a new peripheral IV catheter in the opposite arm and administer the calcium gluconate through the new access.

Answer

The nurse must establish a new peripheral IV catheter in the opposite arm and administer the calcium gluconate through the new access.

The correct action is to establish a new peripheral IV catheter. Sodium bicarbonate and calcium gluconate are highly incompatible. When mixed, they chemically react to form calcium carbonate, a solid precipitate that can cause fatal emboli. Because the client has a single-lumen PICC, a second venous access is required to safely administer the calcium without interrupting the critical bicarbonate infusion.

Step-by-Step Solution

Analyze the client's clinical symptoms and their relationship to the current intravenous therapy.

The client is exhibiting Trousseau's sign and muscle cramping, which are classic signs of acute hypocalcemia. This is a known complication of sodium bicarbonate administration, which increases blood pH (alkalosis) and causes calcium to bind tightly to albumin, lowering active ionized calcium levels.

Identifying the underlying physiological cause of the symptoms confirms the necessity and urgency of the calcium gluconate prescription.

Evaluate the compatibility of the continuous IV infusion with the newly prescribed piggyback medication.

Sodium bicarbonate and calcium gluconate are physically incompatible.

Mixing these two medications results in an immediate chemical reaction that forms calcium carbonate, a dangerous solid chalk-like precipitate.

Determine the safest method of administration given the client's current venous access.

The client only has a single-lumen PICC line. Administering both medications through this line would cause them to mix and precipitate.

Establishing a new peripheral IV access is required to safely administer the calcium gluconate without interrupting the critical continuous bicarbonate infusion or risking a fatal embolism from precipitation.

Key Concept

Intravenous medication compatibility and complications of acid-base correction

Question 723Question →

A nurse is evaluating a client who is two days postoperative following an exploratory laparotomy. The client suddenly reports a 'popping' sensation in the abdomen after a forceful cough. Upon inspection, the nurse observes that the surgical incision has separated and loops of bowel are protruding. In what order should the nurse perform the following interventions? (Arrange the actions from first to last)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence of interventions is: 1) stay with the client and call for help, 2) position the client in low-Fowler's with knees flexed, 3) cover the bowel with sterile saline dressings, 4) assess vital signs, and 5) prepare for emergency surgery.

Wound evisceration is a severe postoperative complication requiring immediate intervention. The sequence of actions is driven by the need to secure assistance, mechanically prevent further organ protrusion, protect the exposed tissues, monitor systemic perfusion, and definitively treat the complication in surgery.

Step-by-Step Solution

Recognize the evisceration, stay with the client, and call for help.

Assistance is secured without leaving the client in an unsafe, unmonitored state.

Evisceration is a life-threatening emergency requiring multiple simultaneous actions; the primary nurse must stay to stabilize the client.

Place the client in a low-Fowler's position with knees flexed.

Abdominal muscle tension is reduced.

Reducing intra-abdominal pressure prevents further protrusion of the bowel.

Cover the protruding organs with sterile, saline-moistened dressings.

The viscera are protected from drying and environmental contaminants.

Exposed bowel can quickly become necrotic or infected. Sterile saline maintains tissue viability.

Assess vital signs.

Baseline systemic status is established.

The client is at high risk for hypovolemic shock; monitoring blood pressure and heart rate guides further fluid resuscitation.

Prepare for immediate surgical intervention.

The client is readied for definitive treatment.

Surgical repair is the only definitive treatment for wound evisceration.

Key Concept

Management of Abdominal Wound Evisceration

Estimated Time:1m 30s

Question 724Question →

A nurse is managing the care of a client who is receiving a continuous intravenous (IV) infusion of unfractionated heparin for the treatment of a pulmonary embolism. Which of the following actions should the nurse take to ensure the safe administration and monitoring of this parenteral therapy? Select all that apply.

Select all that apply

Maintain the continuous heparin infusion on a programmable electronic IV pump.

Connect secondary IV intermittent infusions to the heparin line without consulting a compatibility reference.

Ensure that protamine sulfate is readily available on the nursing unit.

Calculate weight-based infusion rate adjustments using an estimated client weight provided by the family.

Monitor the client's activated partial thromboplastin time (aPTT) at regular prescribed intervals.

Interpret a sudden increase in resting heart rate and a narrowing pulse pressure as an expected response to the infusion.

Show answer & explanation

Answer: Maintain the continuous heparin infusion on a programmable electronic IV pump.; Ensure that protamine sulfate is readily available on the nursing unit.; Monitor the client's activated partial thromboplastin time (aPTT) at regular prescribed intervals.

Answer

The correct actions include maintaining the heparin on an electronic infusion pump, keeping protamine sulfate available, and monitoring aPTT levels.

Safe administration of a high-alert continuous heparin infusion requires strict control of the infusion rate via an electronic pump, serial monitoring of coagulation studies (aPTT) to guide titration, and immediate access to the specific reversal agent (protamine sulfate) in case of overdose or severe hemorrhage.

Step-by-Step Solution

Identify the high-alert status of the medication.

Unfractionated heparin is a high-alert anticoagulant with a narrow therapeutic index and a high risk for causing significant patient harm (hemorrhage) if administered incorrectly.

Recognizing the medication's risk level dictates the need for stringent parenteral safety protocols, including exact dosing and dedicated electronic pumps.

Evaluate parenteral administration requirements for continuous infusions.

Safe administration requires an exact measured weight in kilograms for dosing, the use of a programmable pump to prevent free-flow, and strict verification of IV compatibility before attaching secondary lines.

Medmath calculation errors based on estimated weights and IV incompatibilities are leading causes of preventable adverse events in parenteral therapy.

Determine appropriate ongoing clinical monitoring and emergency preparedness.

The nurse must monitor aPTT levels to titrate the infusion, keep the antidote (protamine sulfate) available, and assess for subtle signs of internal bleeding (such as tachycardia and narrowing pulse pressure).

Proactive monitoring ensures the therapy remains within the therapeutic range and allows for rapid intervention if life-threatening hemorrhage occurs.

Key Concept

Safe parenteral administration and monitoring of continuous high-alert anticoagulant therapy (heparin).

Question 725Question →

A client is admitted to the emergency department following blunt abdominal trauma from a motor vehicle collision. The nurse is closely monitoring the client for suspected internal hemorrhage. Which of the following assessment findings is the earliest physiological indicator that the client is developing hypovolemic shock?

A decrease in systolic blood pressure below 90 mm Hg

A reduction in urine output to less than 30 mL/hr

Mild tachycardia and a narrowing pulse pressure

Development of cool, mottled skin on the lower extremities

Show answer & explanation

Answer: Mild tachycardia and a narrowing pulse pressure

Answer

Mild tachycardia and a narrowing pulse pressure are the earliest indicators of hypovolemic shock.

In the early (compensatory) stage of hypovolemic shock, the body attempts to maintain cardiac output and vital organ perfusion. The sympathetic nervous system is stimulated, leading to an increased heart rate (mild tachycardia) and peripheral vasoconstriction. This vasoconstriction causes the diastolic blood pressure to rise while the systolic pressure may remain stable or slightly drop, resulting in a narrowing pulse pressure. These are the earliest detectable physiological shifts.

Step-by-Step Solution

Identify the client's clinical risk based on the scenario.

The client has blunt abdominal trauma and is at high risk for internal hemorrhage and subsequent hypovolemic shock.

Understanding the clinical risk guides the priority of physical assessments.

Recall the physiological progression of hypovolemic shock stages.

Shock progresses from the initial stage to the compensatory stage, followed by progressive and refractory stages.

Recognizing early versus late signs requires understanding how the body attempts to compensate for blood loss.

Determine the earliest signs associated with the compensatory stage.

The sympathetic nervous system activates immediately to maintain cardiac output, causing an increased heart rate (tachycardia) and peripheral vasoconstriction, which elevates diastolic blood pressure and narrows the pulse pressure.

These initial hemodynamic changes occur before overt signs like hypotension or altered end-organ perfusion.

Evaluate the other options to confirm they represent later stages.

Hypotension, oliguria, and mottled skin all represent progressive or late stages when compensatory mechanisms are failing.

Eliminating late signs confirms the correct early indicator.

Key Concept

Pathophysiology and early recognition of hypovolemic shock

Question 726Question →

A nurse is planning care for a client who was admitted to the intensive care unit $1$ hour ago following a left-sided pneumonectomy. Which of the following interventions should the nurse implement to minimize the risk of potential complications? Select all that apply.

Select all that apply

Turn the client onto the right, non-operative side every

2

hours to prevent dependent atelectasis.

Palpate the client's neck to assess for tracheal deviation.

Instruct the client to perform deep breathing exercises and use an incentive spirometer.

Maintain the head of the bed elevated in a semi-Fowler's position.

Administer intravenous sodium bicarbonate if the client's arterial blood gas shows a pH of

7.38

\text{PaCO}_2

42 \text{ mm Hg}

, and

\text{HCO}_3^-

24 \text{ mEq/L}

Auscultate the abdomen for bowel sounds prior to assessing the respiratory system to establish a baseline.

Show answer & explanation

Answer: Palpate the client's neck to assess for tracheal deviation.; Instruct the client to perform deep breathing exercises and use an incentive spirometer.; Maintain the head of the bed elevated in a semi-Fowler's position.

Answer

The correct interventions are palpating the neck for tracheal deviation, instructing the client to use an incentive spirometer, and maintaining the head of the bed in a semi-Fowler's position.

Following a pneumonectomy, the client has only one functioning lung, which must be protected and its expansion maximized. Elevating the head of the bed to a semi-Fowler's position utilizes gravity to pull abdominal organs downward, promoting optimal diaphragmatic excursion and ventilation. Deep breathing exercises and incentive spirometry are critical aggressive therapies to prevent atelectasis and pneumonia in the remaining lung. Palpating the neck for tracheal deviation is a vital assessment, as a shift away from midline indicates a life-threatening mediastinal shift or tension pneumothorax that requires immediate emergency intervention.

Step-by-Step Solution

Identify the client's surgical procedure and the associated physiological risks.

The client underwent a left-sided pneumonectomy (removal of the entire left lung), making them highly vulnerable to respiratory compromise, mediastinal shift, and fluid accumulation in the empty thoracic space.

Understanding the anatomical and physiological impact of the surgery guides immediate post-operative priorities.

Evaluate safe positioning requirements for a pneumonectomy client.

The client must be kept supine or positioned on the operative (left) side, with the head of the bed elevated in a semi-Fowler's position.

This specific positioning strategy allows the single remaining right lung to expand fully without being compressed by gravity or abdominal organs, ensuring adequate oxygenation.

Determine the highest priority physical assessments.

Airway and breathing are the immediate priorities. This includes checking for tracheal deviation and prioritizing respiratory auscultation over other body systems.

Tracheal deviation indicates a mediastinal shift, a life-threatening emergency requiring immediate intervention. The ABCs (Airway, Breathing, Circulation) dictate the sequence of care.

Key Concept

Post-pneumonectomy risk reduction involves prioritizing the expansion of the remaining lung, detecting life-threatening mediastinal shifts early, and strictly following the ABCs of assessment.

Question 727Question →

A nurse is caring for a client with a single-lumen peripheral intravenous (IV) catheter infusing $5\%$ dextrose in water (D5W) at $100\text{ mL/hr}$ . The healthcare provider prescribes a STAT dose of IV push haloperidol for severe agitation. The nurse consults a drug compatibility database and notes that haloperidol is physically incompatible with D5W. Which of the following actions should the nurse take to safely administer the medication?

Stop the D5W infusion, flush the IV line with

0.9\%

sodium chloride, administer the haloperidol slowly, flush again with

0.9\%

sodium chloride, and restart the D5W.

Pause the D5W infusion pump, administer the haloperidol directly into the lowest IV port, and immediately resume the D5W to flush the medication into the vein.

Rapidly administer the haloperidol over

15\text{ seconds}

into the Y-site port closest to the client to minimize contact time with the D5W fluid.

Dilute the haloperidol in a

10\text{ mL}

syringe of sterile water for injection and administer it slowly through the infusing D5W line.

Show answer & explanation

Answer: Stop the D5W infusion, flush the IV line with $0.9\%$ sodium chloride, administer the haloperidol slowly, flush again with $0.9\%$ sodium chloride, and restart the D5W.

Answer

Stop the D5W infusion, flush the IV line with 0.9% sodium chloride, administer the haloperidol slowly, flush again with 0.9% sodium chloride, and restart the D5W.

When an IV push medication is physically incompatible with a continuous IV fluid, the nurse must use the flush-medication-flush technique. The nurse stops the continuous infusion, flushes the line with a compatible fluid (usually

0.9\%

sodium chloride) to clear out the incompatible fluid, administers the medication at the prescribed rate, and then flushes again with the compatible fluid before resuming the original continuous infusion. This prevents dangerous precipitation inside the IV tubing and the client's vein.

Step-by-Step Solution

Identify the physical incompatibility between the prescribed IV push medication and the continuous IV fluid.

The nurse recognizes that haloperidol and D5W cannot mix in the IV tubing.

Mixing incompatible medications or fluids can cause crystallization or precipitation, which can obstruct the catheter or cause a fatal vascular embolism.

Stop the incompatible continuous infusion and flush the line with a compatible solution (typically 0.9% sodium chloride).

The D5W is cleared from the IV tubing.

Flushing creates a safe, fluid-free buffer zone in the tubing to prevent the two incompatible substances from coming into physical contact.

Administer the IV push medication slowly, followed by a second flush of the compatible solution at the same administration rate.

The medication safely reaches the systemic circulation without precipitating.

The post-administration flush ensures the medication is fully cleared from the line before the incompatible D5W infusion is restarted, preventing mixing.

Key Concept

Safe administration of incompatible IV push medications via the flush-medication-flush technique

Question 728Question →

While managing the care of a client with a severe traumatic brain injury and continuously elevated intracranial pressure (ICP), a nurse prepares to reposition the client. Which positioning strategy is indicated to mitigate the risk of further intracranial pressure elevation?

Maintain the bed's backrest at a

30

-degree angle with the client's cervical spine in a neutral, midline alignment.

Maintain the client in a completely flat, supine alignment to maximize cerebral arterial perfusion.

Flex the client's hips to a

90

-degree angle to promote lower extremity venous return.

Rotate the client's head sharply to one side to secure airway patency and prevent aspiration.

Show answer & explanation

Answer: Maintain the bed's backrest at a $30$ -degree angle with the client's cervical spine in a neutral, midline alignment.

Answer

The indicated positioning strategy is to maintain the bed's backrest at a 30-degree angle with the client's cervical spine in a neutral, midline alignment.

Maintaining the backrest at a

30

-degree angle with a neutral cervical spine alignment promotes optimal gravity-assisted venous drainage from the cranial vault through the jugular veins. This precise positioning strategy effectively reduces intracranial pressure without significantly compromising cerebral perfusion pressure.

Step-by-Step Solution

Identify the client's primary physiological risk.

The client has a traumatic brain injury complicated by continuously elevated intracranial pressure (ICP).

Recognizing the primary threat dictates which physiological mechanisms (like venous return) must be prioritized.

Determine the therapeutic goal of nursing positioning interventions for this condition.

The positioning strategy must promote venous drainage away from the brain to reduce fluid volume and pressure within the cranial vault, without severely compromising arterial blood supply.

ICP is highly sensitive to changes in cerebral blood volume; facilitating jugular venous outflow is a primary non-pharmacological method to lower this volume.

Evaluate the hemodynamic impact of each positioning option.

A 30-degree head elevation with midline neck alignment optimizes jugular venous outflow. Conversely, flat positioning, severe hip flexion, and extreme neck rotation physically impede venous return or increase intra-abdominal pressure, which would exacerbate the elevated ICP.

Ensuring the selected position actively supports the therapeutic goal prevents iatrogenic complications.

Key Concept

Positioning to Reduce Intracranial Pressure (ICP)

Question 729Question →

During continuous monitoring of an individual experiencing a severe asthma exacerbation, the nurse notes prominent accessory muscle use, diaphoresis, and a respiratory rate of $32$ breaths per minute. A recent assessment of lung sounds indicates a marked reduction in bilateral wheezing compared to baseline. The concurrent arterial blood gas (ABG) panel on room air yields a pH of $7.39$ , a $\text{PaCO}_2$ of $41\text{ mm Hg}$ , and a $\text{PaO}_2$ of $58\text{ mm Hg}$ . What is the priority nursing intervention in this scenario?

Activate the rapid response team and prepare for immediate airway management.

Continue the current nebulizer treatments as the acid-base balance is normalizing.

Lower the head of the bed to facilitate increased blood flow to the pulmonary vasculature.

Instruct the individual to take slow, deep breaths to correct the respiratory alkalosis.

Show answer & explanation

Answer: Activate the rapid response team and prepare for immediate airway management.

Answer

The priority action is to activate the rapid response team and prepare for immediate airway management due to signs of impending respiratory failure.

The client is exhibiting signs of impending respiratory failure. In early asthma attacks, hyperventilation causes respiratory alkalosis (low carbon dioxide, high pH). As the client fatigues, ventilation decreases, leading to a 'normalizing' carbon dioxide and pH level. This is known as a 'pseudonormal' ABG. Combined with diminished lung sounds (a 'silent chest') and hypoxemia, this indicates severe airway obstruction and muscle exhaustion requiring immediate mechanical ventilation.

Step-by-Step Solution

Analyze the physical assessment findings.

The client shows severe work of breathing (accessory muscle use, tachypnea) but a sudden decrease in wheezing.

A 'silent chest' or marked reduction in wheezing during an exacerbation implies that airflow is so severely restricted that wheezes can no longer be produced.

Interpret the arterial blood gas (ABG) results in the context of the physical assessment.

The pH (

7.39

) and

\text{PaCO}_2

(

41\text{ mm Hg}

) are within normal limits, while the

\text{PaO}_2

(

58\text{ mm Hg}

) indicates severe hypoxemia.

Early in an asthma attack, tachypnea causes hyperventilation and respiratory alkalosis (low

\text{PaCO}_2

). As the client fatigues, they can no longer blow off carbon dioxide, causing the

\text{PaCO}_2

to rise back to 'normal' levels before progressing to respiratory acidosis.

Determine the priority clinical intervention.

Immediate escalation of care and preparation for endotracheal intubation.

The combination of a 'pseudonormal' ABG and a silent chest is an ominous sign of extreme muscle fatigue and impending respiratory arrest, necessitating advanced airway support.

Key Concept

Interpretation of 'Pseudonormal' ABGs in Acute Asthma

Question 730Question →

A nurse is preparing to administer a prescribed intravenous (IV) push medication through a client's central venous catheter (CVC). The specific lumen to be used is currently capped and locked with a heparin solution. Place the following steps for administering the medication in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence follows the standard SASH protocol: Scrub the hub, flush with Saline (after aspirating), Administer the medication, flush with Saline again, and finally lock with Heparin.

The SASH (Saline, Administer, Saline, Heparin) method is the evidence-based standard of practice for administering medications through a capped central venous catheter. This sequence ensures infection control, confirms line patency, prevents drug incompatibilities, and maintains the line for future use.

Step-by-Step Solution

Scrub the needleless connector.

Disinfects the access point.

Prevents Central Line-Associated Bloodstream Infections (CLABSI).

Aspirate for blood and flush with normal saline.

Confirms placement and clears the heparin lock.

Ensures the catheter is in the vein and patent, and prevents incompatibility between heparin and the incoming medication.

Administer the IV push medication.

Delivers the prescribed therapy.

Provides the required pharmacological treatment at a safe, controlled rate.

Flush with normal saline at the medication's administration rate.

Clears the medication from the catheter.

Ensures the full dose reaches the patient without inadvertently bolusing the residual medication left in the line.

Instill the heparin flush solution.

Locks the catheter lumen.

Maintains catheter patency and prevents blood clots from forming while the line is capped.

Key Concept

Central Venous Catheter Medication Administration (SASH Protocol)

Question 731Question →

A client admitted with an acute upper gastrointestinal bleed is receiving an infusion of packed red blood cells (PRBCs) through a single-lumen peripheral intravenous catheter. The healthcare provider issues a stat prescription for intravenous pantoprazole to help control the bleeding. What is the most appropriate nursing action for administering the pantoprazole?

Initiate a second peripheral intravenous access site to administer the medication.

Attach the medication syringe to the lowest injection port on the blood administration set.

Pause the blood transfusion, flush the catheter with

0.9\%

sodium chloride, administer the medication, and resume the blood.

Delay the medication administration until the blood transfusion is complete to avoid interrupting the infusion.

Show answer & explanation

Answer: Initiate a second peripheral intravenous access site to administer the medication.

Answer

The most appropriate action is to initiate a second peripheral intravenous access site to administer the pantoprazole, as blood products require a strictly dedicated line.

Blood products must be administered through a dedicated intravenous line. Medications should never be added to blood bags or piggybacked into a blood administration set due to the high risk of cellular hemolysis, precipitation, and clotting. Because the pantoprazole is a stat order for an active bleed, it cannot be delayed. The only safe and timely action is to establish a new peripheral IV access.

Step-by-Step Solution

Analyze the current intravenous access and the continuous infusion.

The client has a single-lumen IV currently dedicated to packed red blood cells.

Identifying available access determines if a new medication can be safely administered.

Evaluate the compatibility of the prescribed medication with the current infusion.

Medications cannot be added to or piggybacked into a blood transfusion line.

Mixing medications with blood products can cause hemolysis, clotting, or altered drug efficacy.

Assess the urgency of the new prescription.

The pantoprazole is ordered 'stat' for an active gastrointestinal bleed.

Stat orders must be administered immediately and cannot wait for the blood transfusion to finish.

Determine the safest administration method.

A new peripheral IV line must be established.

This allows immediate administration of the stat medication without compromising the ongoing blood transfusion.

Key Concept

Medications must never be added to a blood product infusion line. A dedicated IV line is required for blood transfusions to prevent hemolysis and other life-threatening complications. Stat medications require immediate administration and warrant establishing new access if current access is unavailable.

Estimated Time:1m 0s

Question 732Question →

A nurse is caring for a client who is two days postoperative following a right total knee arthroplasty. The client suddenly reports sharp, pleuritic chest pain, severe shortness of breath, and a feeling of impending doom. The client appears diaphoretic and highly agitated. Arrange the following nursing actions in the priority order they should be performed. (Place the first action at the top and the last action at the bottom.)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct priority sequence is to first elevate the head of the bed, then apply oxygen, obtain vital signs, notify the rapid response team, and finally establish secondary intravenous access.

The correct sequence prioritizes immediate, non-invasive airway and breathing interventions (elevating the head of the bed and applying oxygen) because they take seconds to perform and immediately address the life-threatening hypoxia. Once the client's breathing is mechanically supported, the nurse must assess the client's physiological status (vital signs) to gather the necessary data before communicating with the rapid response team. Finally, preparing for advanced medical interventions (establishing IV access) is done once help is on the way.

Step-by-Step Solution

Recognize the clinical signs of a pulmonary embolism (sudden dyspnea, pleuritic pain, impending doom) as an acute respiratory emergency.

The client is identified as requiring immediate life-saving interventions.

Failure to act promptly on signs of acute respiratory compromise can lead to respiratory failure and cardiac arrest.

Elevate the head of the bed to a high-Fowler's position.

The diaphragm drops, allowing for maximal chest expansion.

This is the most rapid intervention to decrease the work of breathing and improve ventilation mechanics.

Apply high-flow supplemental oxygen.

Alveolar oxygen concentration rapidly increases.

This treats the severe hypoxemia caused by the ventilation-perfusion mismatch associated with a pulmonary embolus.

Obtain a complete set of vital signs, including oxygen saturation.

Baseline physiological and hemodynamic data is established.

This quantitative data is required to determine the severity of the compromise and to accurately report the client's status to the provider.

Notify the rapid response team and healthcare provider.

Advanced medical support and specialized orders are obtained.

The client requires diagnostic testing and medical interventions (such as anticoagulation) that require a provider's order.

Establish a secondary peripheral intravenous access line.

A dedicated venous line is available for emergency administration.

The client will likely require fluid resuscitation, vasopressors, or continuous anticoagulation infusions to manage the crisis.

Key Concept

In an acute respiratory emergency, nursing priorities follow the airway, breathing, circulation (ABC) framework and the nursing process: intervene immediately to support airway/breathing, assess to gather data, communicate findings, and prepare for advanced medical management.

Question 733Question →

A nurse receives the shift report on four clients admitted to a medical-surgical unit. Which client should the nurse assess first?

A client with chronic obstructive pulmonary disease (COPD) who has an arterial blood gas showing a pH of 7.36, a

PaCO_2

of 54 mm Hg, and an

HCO_3^-

of 30 mEq/L.

A client admitted with bacterial pneumonia who has a temperature of

101.4^\circ F

(

38.6^\circ C

) and reports coughing up rust-colored sputum.

A client who had a cardiac catheterization via the right femoral artery four hours ago, and now exhibits a blood pressure of 112/90 mm Hg, a heart rate of 114 bpm, and new-onset agitation.

A client with heart failure who has 1+ bilateral pitting edema in the lower extremities and a 2.2 lb (1 kg) weight gain over the past 24 hours.

Show answer & explanation

Answer: A client who had a cardiac catheterization via the right femoral artery four hours ago, and now exhibits a blood pressure of 112/90 mm Hg, a heart rate of 114 bpm, and new-onset agitation.

Answer

The client who had a cardiac catheterization four hours ago and is exhibiting a narrow pulse pressure, tachycardia, and new-onset agitation.

The correct client requires immediate assessment because they are demonstrating classic early signs of hypovolemic shock. Following an arterial puncture like a cardiac catheterization, patients are at high risk for hemorrhage, including retroperitoneal bleeding. While the systolic blood pressure (112 mm Hg) appears acceptable at first glance, the pulse pressure has narrowed significantly to 22 mm Hg (112 minus 90). The sympathetic nervous system causes vasoconstriction to maintain perfusion, leading to this narrow pulse pressure, alongside tachycardia (114 bpm) and early hypoxia to the brain causing agitation. Immediate intervention is required to prevent cardiovascular collapse.

Step-by-Step Solution

Analyze the clinical data for each client to distinguish between expected, chronic disease manifestations and acute, life-threatening changes.

The clients with COPD, pneumonia, and heart failure are all displaying symptoms that are expected or stable for their underlying pathophysiological processes.

Differentiating baseline pathology from acute deterioration is the foundational step in clinical prioritization.

Evaluate the specific vital signs and neurological status of the post-cardiac catheterization client.

The blood pressure of 112/90 mm Hg reveals a narrow pulse pressure of 22 mm Hg (normal is 30-50 mm Hg). Combined with a heart rate of 114 bpm and new agitation, this indicates a sympathetic nervous system response.

Early recognition of shock requires identifying subtle compensatory mechanisms, such as peripheral vasoconstriction (narrowing pulse pressure) and tachycardia, before a late drop in systolic blood pressure occurs.

Apply the Airway, Breathing, Circulation (ABC) prioritization framework.

The post-procedural client is experiencing an acute circulatory deficit, likely due to internal bleeding or hematoma formation at the femoral access site.

Acute circulatory compromise poses an immediate threat to life and must be addressed before stable respiratory or fluid balance issues.

Key Concept

Recognition of early shock and clinical prioritization

Question 734Question →

A nurse is caring for a pediatric client who weighs $22\text{ kg}$ . The healthcare provider has prescribed intravenous ceftriaxone $50\text{ mg/kg/day}$ divided into two equal doses. The pharmacy dispenses a ceftriaxone vial reconstituted to a concentration of $1\text{ g}$ per $10\text{ mL}$ . How many milliliters ( $\text{mL}$ ) should the nurse administer for a single dose? Record your answer to one decimal place.

Show answer & explanation

Answer: 5.5

Answer

5.5

The correct answer is

5.5\text{ mL}

. First, determine the daily dose:

22\text{ kg} \times 50\text{ mg/kg} = 1100\text{ mg/day}

. Next, divide this by 2 for the single dose:

1100\text{ mg} \div 2 = 550\text{ mg}

. The concentration is

1\text{ g} (1000\text{ mg})

10\text{ mL}

, which equals

100\text{ mg/mL}

. Finally,

550\text{ mg} \div 100\text{ mg/mL} = 5.5\text{ mL}

Step-by-Step Solution

Calculate the total daily dose based on the client's weight.

1100\text{ mg/day}

The prescription is given as a weight-based daily total (

50\text{ mg/kg/day}

Divide the total daily dose into the single administration dose.

550\text{ mg/dose}

The medication is to be divided into two equal doses per day.

Convert the supplied medication concentration into milligrams.

1000\text{ mg}

per

10\text{ mL}

, or

100\text{ mg/mL}

The vial is labeled in grams (

1\text{ g}

), but the calculated dose is in milligrams.

Calculate the final liquid volume to administer.

5.5\text{ mL}

To find the exact volume of the reconstituted liquid that contains the

550\text{ mg}

single dose.

Key Concept

Weight-based pediatric medication dosage and liquid concentration calculation.

Estimated Time:2m 0s

Question 735Question →

A client is receiving a continuous intravenous heparin infusion for a deep vein thrombosis. The nurse suspects the client may be experiencing covert internal bleeding leading to early hypovolemic shock. Which clinical manifestations support this physiological adaptation? (Select all that apply)

Select all that apply

Blood pressure alters from 128/74 mm Hg to 116/88 mm Hg

Resting heart rate increases from 78 to 114 beats per minute

Arterial blood gas reveals a PaCO2 of 52 mm Hg

Skin over the extremities is warm and flushed

Hourly urine output drops to 18 mL

Show answer & explanation

Answer: Blood pressure alters from 128/74 mm Hg to 116/88 mm Hg; Resting heart rate increases from 78 to 114 beats per minute; Hourly urine output drops to 18 mL

Answer

The assessment findings that indicate early hypovolemic shock are the narrowing pulse pressure, increased heart rate, and decreased urine output.

The correct manifestations demonstrate the body's compensatory mechanisms during early volume loss. As intravascular volume drops, the sympathetic nervous system triggers tachycardia to maintain cardiac output. It also causes peripheral vasoconstriction, which raises the diastolic blood pressure and narrows the pulse pressure. Additionally, decreased renal perfusion stimulates the renin-angiotensin-aldosterone system (RAAS), resulting in decreased urine output (oliguria) to conserve fluid.

Step-by-Step Solution

Identify the primary physiological risk for the client.

The client is on a continuous heparin infusion, placing them at high risk for hemorrhage and subsequent hypovolemic shock.

Recognizing the risk helps focus the assessment on signs of volume depletion and physiological compensation.

Analyze the provided vital sign trends for compensatory cardiovascular mechanisms.

The heart rate increases significantly, and the pulse pressure narrows (diastolic pressure rises while systolic pressure drops slightly).

The sympathetic nervous system activates immediately to maintain mean arterial pressure by increasing the heart rate and vasoconstricting peripheral vessels.

Evaluate systemic organ perfusion markers.

The urine output has dropped below the minimum expected 30 mL/hr.

The body shunts blood away from the kidneys to protect the brain and heart, triggering the RAAS pathway to retain sodium and water.

Differentiate these findings from other etiologies and late-stage decompensation.

Warm/flushed skin and hypercapnia (elevated PaCO2) are rejected.

Warm skin indicates vasodilation (seen in early sepsis), and an elevated PaCO2 indicates hypoventilation, whereas early hypovolemic shock causes cool/clammy skin and hyperventilation (low PaCO2).

Key Concept

Early physiological adaptation to hypovolemic shock involves sympathetic nervous system activation, leading to compensatory tachycardia, peripheral vasoconstriction (narrowing pulse pressure, cool skin), and fluid conservation (oliguria).

Question 736Question →

During the afternoon clinical rounds, the nurse evaluates a client recently admitted with severe acute pancreatitis. The nurse reviews the latest diagnostic data and physical assessment findings. Which specific observations indicate the onset of physiological decompensation requiring immediate medical intervention? Select all that apply.

Select all that apply

Carpopedal spasm observed during the inflation of a sphygmomanometer cuff.

Arterial blood gas results demonstrating a

\text{pH}

7.28

\text{PaCO}_2

31 \text{ mmHg}

, and

\text{HCO}_3^-

15 \text{ mEq/L}

Auscultation of new-onset fine crackles in the bilateral lung bases with an oxygen saturation of

91\%

The client assumes a side-lying, fetal position with knees drawn up to the abdomen.

Serum amylase and lipase laboratory values reported as three times the upper limit of normal.

A calculated mean arterial pressure (MAP) of

76 \text{ mmHg}

with a capillary refill time of

2 \text{ seconds}

Show answer & explanation

Answer: Carpopedal spasm observed during the inflation of a sphygmomanometer cuff.; Arterial blood gas results demonstrating a $\text{pH}$ of $7.28$ , $\text{PaCO}_2$ of $31 \text{ mmHg}$ , and $\text{HCO}_3^-$ of $15 \text{ mEq/L}$ .; Auscultation of new-onset fine crackles in the bilateral lung bases with an oxygen saturation of $91\%$ .

Answer

The findings requiring immediate intervention are the carpopedal spasm, the metabolic acidosis on the arterial blood gas, and the new-onset lung crackles with declining oxygen saturation.

Acute pancreatitis can precipitate severe systemic complications due to the release of activated pancreatic enzymes and inflammatory mediators into the bloodstream. These circulating toxins cause alveolar-capillary permeability changes resulting in ARDS (evidenced by crackles and hypoxemia), widespread vascular permeability resulting in hypoperfusion and metabolic acidosis (evidenced by the low pH and HCO3), and fat saponification leading to severe hypocalcemia (evidenced by Trousseau's sign). All three indicate multi-organ failure and require immediate life-saving intervention.

Step-by-Step Solution

Analyze the carpopedal spasm during blood pressure measurement.

Identified as a positive Trousseau's sign.

Indicates severe hypocalcemia due to fat necrosis, posing an immediate risk for tetany, seizures, or cardiac dysrhythmias.

Interpret the arterial blood gas values.

Identified metabolic acidosis (low pH, low HCO3) with partial respiratory compensation (low PaCO2).

Indicates poor tissue perfusion or lactic acidosis, which are early signs of shock requiring aggressive fluid resuscitation.

Evaluate the respiratory findings.

Identified potential Acute Respiratory Distress Syndrome (ARDS).

Pancreatic enzymes circulating systemically can injure alveolar-capillary membranes, leading to fluid shifts into the lungs (crackles) and hypoxemia.

Differentiate expected disease presentation from life-threatening complications.

Excluded elevated amylase/lipase, fetal positioning, and normal hemodynamic parameters.

These findings are expected baseline parameters or normal regulatory responses, not immediate physiological threats.

Key Concept

Systemic complications of acute pancreatitis

Question 737Question →

During a routine shift, a nurse is assigned to a client who requires both nutritional support and antimicrobial therapy. The client currently has total parenteral nutrition (TPN) infusing continuously via a dedicated port of a multi-lumen central venous catheter. A new order is placed for an intermittent infusion of intravenous azithromycin. What is the safest method for the nurse to deliver the newly prescribed medication?

Establish a separate peripheral venous access site specifically for the antibiotic infusion.

Attach the antibiotic as a secondary piggyback line to the active total parenteral nutrition tubing.

Temporarily halt the nutritional infusion, flush the central line port with sterile saline, administer the drug, and then restart the nutrition.

Inject the prescribed dose of the antibiotic directly into the total parenteral nutrition bag before hanging a new one.

Show answer & explanation

Answer: Establish a separate peripheral venous access site specifically for the antibiotic infusion.

Answer

The safest method is to establish a separate peripheral venous access site for the antibiotic infusion.

Total parenteral nutrition (TPN) must always be administered through a dedicated intravenous line. Because of its complex composition (high dextrose, amino acids, electrolytes, and sometimes lipids), it has a very high risk of chemical incompatibility and precipitation when mixed with other medications. Furthermore, the line should not be accessed or manipulated unnecessarily due to the high risk of central line-associated bloodstream infections. Establishing a separate peripheral IV is the only safe way to administer the intermittent antibiotic without compromising the TPN.

Step-by-Step Solution

Analyze the client's current intravenous therapy setup.

The client has a continuous TPN infusion running through a dedicated port of a multi-lumen central line.

Understanding the current access is necessary to determine where a new medication can be safely administered.

Recall the pharmacological guidelines regarding Total Parenteral Nutrition.

TPN requires a strictly dedicated line and cannot be mixed with or interrupted by other medications.

TPN contains a complex mixture of high-concentration dextrose, amino acids, and electrolytes that easily precipitates when mixed with other drugs. Furthermore, interrupting it causes sudden hypoglycemia.

Select the intervention that allows for the antibiotic to be given without violating TPN safety rules.

Establishing a separate peripheral intravenous site is identified as the correct action.

A separate line ensures the antibiotic is delivered on schedule while maintaining the chemical integrity and continuity of the TPN infusion.

Key Concept

Total Parenteral Nutrition (TPN) Safety and Dedicated IV Lines

Question 738Question →

A client with hepatic cirrhosis has just returned to the medical-surgical unit following a percutaneous liver biopsy. The client is awake, alert, and reports mild tenderness at the biopsy site. To reduce the risk of the most significant immediate complication, which action is the priority for the nurse to implement?

Assist the client into a right lateral position with a small rolled towel under the puncture site.

Place the client in a semi-Fowler's position to facilitate lung expansion and prevent atelectasis.

Palpate the client's abdomen deeply to assess for the early development of a retroperitoneal hematoma.

Delegate the initial and subsequent 15-minute vital sign monitoring to the unlicensed assistive personnel.

Show answer & explanation

Answer: Assist the client into a right lateral position with a small rolled towel under the puncture site.

Answer

Assist the client into a right lateral position with a small rolled towel under the puncture site.

The liver is a highly vascular organ, and a percutaneous biopsy carries a significant risk of internal hemorrhage. This risk is amplified in clients with hepatic cirrhosis who frequently suffer from coagulopathies. Assisting the client into a right lateral (side-lying) position with a towel or pillow under the puncture site utilizes the client's own body weight to apply direct, continuous pressure to the liver capsule. This mechanical compression promotes hemostasis, prevents hematoma formation, and reduces the risk of life-threatening bleeding.

Step-by-Step Solution

Identify the procedure performed and its major associated physiological risks.

The client underwent a percutaneous liver biopsy, which carries a severe risk of hemorrhage due to the liver's high vascularity and the client's cirrhosis-induced coagulopathy.

Understanding the most dangerous post-procedure risk determines the immediate nursing priorities.

Determine the most effective physical intervention to mitigate the bleeding risk.

Applying direct pressure to the biopsy site encourages hemostasis and prevents blood from leaking into the abdominal cavity.

Mechanical compression is a primary physiological mechanism for arresting bleeding from a puncture wound.

Select the specific nursing action that achieves optimal site compression.

Positioning the client on their right side (right lateral decubitus) with a towel underneath uses the client's body weight to press the liver against the chest wall.

This is the evidence-based standard of care for immediate post-liver biopsy risk reduction.

Key Concept

Post-Procedure Risk Reduction: Liver Biopsy Positioning and Hemostasis

Question 739Question →

A nurse is caring for a client who was admitted 12 hours ago with a pelvic fracture following a fall. The client is currently restless, frequently shifting in bed, and repeatedly asking for something to drink. The most recent vital signs reveal a blood pressure of 114/82 mm Hg, a heart rate of 118 beats/minute, and a respiratory rate of 24 breaths/minute. The client's admission heart rate was 84 beats/minute. Which of the following actions should the nurse take first?

Perform a focused assessment of peripheral perfusion and inspect for internal bleeding.

Administer the prescribed as-needed intravenous opioid analgesic.

Provide a small cup of clear liquids to alleviate the client's thirst.

Instruct the client to take slow, deep breaths to decrease the heart rate.

Show answer & explanation

Answer: Perform a focused assessment of peripheral perfusion and inspect for internal bleeding.

Answer

The correct action is to perform a focused assessment of peripheral perfusion and inspect for internal bleeding.

The correct answer focuses on further assessing for internal bleeding because the client is exhibiting classic early signs of hypovolemic shock. Pelvic fractures are highly vascular and prone to significant retroperitoneal bleeding. The body compensates for early blood loss by activating the sympathetic nervous system, leading to tachycardia, tachypnea, restlessness (due to mild cerebral hypoxia), and thirst. The blood pressure often remains normal in the early compensatory stage. The nurse must immediately perform a focused assessment of perfusion (such as capillary refill and skin temperature) and inspect for signs of bleeding before notifying the provider.

Step-by-Step Solution

Analyze the clinical cues presented by the client.

The client has a pelvic fracture, increasing tachycardia (84 to 118 beats/minute), tachypnea, restlessness, and intense thirst.

Identifying abnormal trends in vital signs and behavior is the first step in clinical judgment.

Correlate the cues to the underlying pathophysiology.

Pelvic fractures carry a high risk of massive internal hemorrhage. The identified cues are classic early compensatory signs of hypovolemic shock, even though the blood pressure remains within a normal range.

Understanding how the body compensates for blood loss allows the nurse to anticipate complications before severe hypotension occurs.

Determine the priority nursing action based on the assessment.

Before notifying the healthcare provider or implementing interventions, the nurse must gather targeted assessment data regarding tissue perfusion and potential bleeding.

The nursing process dictates that assessment must occur before intervention when a new, potentially life-threatening complication is suspected.

Key Concept

Early recognition of hypovolemic shock in high-risk trauma clients

Question 740Question →

Ten minutes after the initiation of an intravenous (IV) piperacillin-tazobactam infusion, a client develops audible inspiratory stridor, restlessness, and lightheadedness. The client's heart rate is $128\text{ bpm}$ and blood pressure is $84/50\text{ mmHg}$ . Which of the following priority actions should the nurse implement? Select all that apply.

Select all that apply

Stop the piperacillin-tazobactam infusion and disconnect the current intravenous tubing.

Prepare to administer prescribed intramuscular epinephrine.

Initiate a rapid infusion of

0.9\%

sodium chloride using new intravenous tubing.

Administer an intravenous normal saline flush through the primary tubing to maintain line patency.

Position the client upright with their legs dangling over the edge of the bed.

Complete a comprehensive respiratory assessment before calling the rapid response team.

Show answer & explanation

Answer: Stop the piperacillin-tazobactam infusion and disconnect the current intravenous tubing.; Prepare to administer prescribed intramuscular epinephrine.; Initiate a rapid infusion of $0.9\%$ sodium chloride using new intravenous tubing.

Answer

The correct actions are to stop the infusion and disconnect the tubing, prepare intramuscular epinephrine, and initiate a rapid infusion of 0.9% sodium chloride using new tubing.

Anaphylaxis is a severe, life-threatening hypersensitivity reaction. The immediate priority is to stop the offending agent and disconnect the tubing to prevent any more medication from entering the client. Intramuscular epinephrine is the primary pharmacological treatment to reverse bronchoconstriction (stridor) and cardiovascular collapse. Additionally, rapid infusion of isotonic crystalloids (like

0.9\%

sodium chloride) through entirely new IV tubing is required to expand intravascular volume and correct profound hypotension.

Step-by-Step Solution

Identify the client's clinical presentation.

The client is exhibiting stridor, tachycardia, and severe hypotension (

84/50\text{ mmHg}

These are hallmark signs of anaphylactic shock, a life-threatening allergic reaction to the IV antibiotic.

Determine the immediate priority regarding the IV medication.

Stop the piperacillin-tazobactam infusion and disconnect the tubing completely.

Halting the administration of the allergen is the most critical first step to prevent further physiological deterioration.

Identify indicated pharmacological and hemodynamic interventions.

Prepare intramuscular epinephrine and administer IV fluids through new, uncontaminated tubing.

Epinephrine is required to reverse airway edema and cardiovascular collapse, while IV fluids treat the profound hypotension caused by massive vasodilation.

Key Concept

Anaphylaxis Management in Parenteral Therapy

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