Examkin

All practice questions

862 questions

All types3,881Multiple choice1,926Multiple select908Numeric119Matching66Ordering862
Question 721Question →

During bedside rounds, a rapid response team nurse evaluates a client with sepsis-induced encephalopathy. The client is severely agitated and continuously pulling at their central venous catheter and indwelling urinary catheter. Place the following safety interventions in the correct sequence of escalation, starting from the first priority action to the measure of last resort.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence of escalating safety interventions begins with assessing for physiological causes, followed by implementing basic environmental modifications, concealing the medical devices, assigning a continuous bedside observer, and finally, obtaining a prescription for physical restraints as a last resort.
The standard of care for managing an agitated client who is at risk of dislodging medical devices mandates a stepwise escalation from the least restrictive to the most restrictive interventions. The process begins with assessing and treating underlying physiological causes. If agitation persists, the nurse implements environmental modifications and attempts to remove visual triggers by concealing the devices. If these measures fail, a continuous bedside sitter is employed to redirect the client. Finally, if all less restrictive alternatives have been exhausted and the client remains at risk of self-harm, the nurse must obtain a provider's prescription to apply physical restraints.

Step-by-Step Solution

1
Determine the priority action according to the nursing process.
Assessment is the initial step.
Nurses must first identify and treat any reversible physiological causes of the client's agitation, such as hypoxia or pain.
2
Identify the least restrictive non-pharmacological intervention.
Environmental modifications are prioritized next.
Creating a calm environment with minimal sensory overload is a foundational, non-restrictive safety measure.
3
Select the next least restrictive alternative for a client pulling at tubes.
Device concealment is the next logical step.
Hiding lines and catheters under clothing or stockinettes removes the visual stimulus without restricting the client's movement.
4
Determine the appropriate intervention when environmental and visual modifications fail.
Assigning a one-to-one bedside observer is required.
Direct continuous supervision maintains client safety and redirects behavior without the need for physical restraints.
5
Identify the measure of last resort.
Obtaining a provider prescription for physical restraints is the final step.
Restraints are legally and ethically the most restrictive option and are only permissible when all less restrictive alternatives have been exhausted.

Key Concept

Prioritization of Restraint Alternatives
Question 722Question →

An intensive care nurse is managing an intubated client who is severely agitated and attempting to remove the endotracheal tube. After less restrictive measures have failed, the nurse initiates the application of bilateral soft wrist restraints. Arrange the following nursing actions in the correct chronological order from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: obtaining staff assistance, applying the restraints to the movable bed frame, assessing neurovascular status, contacting the healthcare provider for a prescription, and documenting the event.
In a behavioral emergency where a client poses an immediate risk to themselves (such as pulling out an endotracheal tube), the nurse's first priority is securing the client safely with the help of other staff. Once help is present, the restraints are applied correctly to the movable portion of the bed frame to prevent injury during bed adjustments. Immediately following application, the nurse must perform a neurovascular assessment to ensure circulation is not compromised. After the client is physically safe and stable, the nurse contacts the healthcare provider to obtain the required prescription, and finally documents the entire event.

Step-by-Step Solution

1
Call for assistance from other healthcare personnel.
Adequate staff is present to safely manage the client.
Attempting to restrain an agitated client alone can result in injury to both the nurse and the client.
2
Secure the restraint straps to the movable part of the bed frame.
Restraints are applied safely without risking tension during bed movement.
Tying restraints to the movable frame ensures they will not tighten or pull inappropriately if the bed's position is changed.
3
Evaluate peripheral pulses, capillary refill, and skin temperature.
Neurovascular status is confirmed as intact.
Immediate assessment ensures the applied restraints are not compromising distal blood flow or causing nerve damage.
4
Contact the primary healthcare provider to obtain the restraint prescription.
Legal and facility protocols for emergency restraint use are initiated.
In a behavioral emergency, restraints can be applied for immediate safety, but the provider must be notified promptly (usually within 1 hour) to evaluate the client and provide an order.
5
Document the interventions, client behaviors, and neurovascular assessments in the medical record.
The emergency event is properly recorded.
Accurate and timely documentation provides a legal record of the emergency, the alternative interventions attempted, and the client's condition.

Key Concept

Emergency application of physical restraints and priority sequencing
Question 723Question →

A nurse is caring for a client with an acute exacerbation of chronic obstructive pulmonary disease (COPD) who is experiencing severe hypoxia-induced restlessness. The client is persistently attempting to remove their continuous positive airway pressure (CPAP) mask and peripheral intravenous (IV) catheter. Arrange the following nursing actions in the correct sequence for managing this client's behavior, progressing from the initial nursing process step to the most restrictive intervention. All options must be used.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence begins with assessment, followed by verbal reorientation, camouflaging the lines, assigning a sitter, and finally applying physical restraints.
The safe use of restraints requires nurses to follow the principle of the least restrictive alternative. This means interventions must escalate sequentially. First, the nurse must assess for and treat underlying physiological causes of agitation, such as hypoxia. Next, the nurse should employ the least restrictive behavioral intervention, which is verbal reorientation. If unsuccessful, the nurse implements environmental modifications, such as camouflaging the medical devices to remove visual triggers. If the client continues to pull at lines, instituting continuous one-to-one observation (a sitter) provides safety without physical restriction. Finally, if all less restrictive measures fail and are documented as ineffective, the nurse may apply physical restraints as a last resort, provided there is a valid primary healthcare provider's prescription.

Step-by-Step Solution

1
Assess respiratory status and oxygen saturation.
Identifies whether the agitation is secondary to worsening hypoxia.
The nursing process always begins with assessment to rule out and treat life-threatening physiological causes before addressing behaviors.
2
Attempt verbal reorientation and explain the medical necessity of the equipment.
Provides cognitive support and may de-escalate the client's behavior.
Verbal intervention is the least restrictive behavioral approach.
3
Conceal the intravenous site and continuous positive airway pressure (CPAP) tubing.
Removes the visual trigger that prompts the client to pull at the devices.
Camouflage is a non-restrictive environmental modification that often effectively distracts the client.
4
Assign unlicensed assistive personnel for continuous one-to-one observation.
Ensures immediate bedside intervention if the client attempts to remove life-sustaining equipment.
Direct observation ensures safety without the use of physical force or restriction.
5
Apply prescribed bilateral soft wrist restraints.
Physically prevents the client from removing the CPAP mask and IV catheter.
Physical restraints are the most restrictive measure and are legally permitted only as a last resort when all other alternatives have failed.

Key Concept

Least Restrictive Environment and Escalation of Safety Interventions
Question 724Question →

A client is scheduled to receive a bolus enteral formula via an established nasogastric (NG) tube. Which sequence of actions must the nurse execute to safely deliver this nutritional support? Arrange the clinical steps in the correct chronological order from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The safe sequence is to first position the client upright, verify tube placement and residual volume, perform a pre-flush with water, administer the nutritional formula, and finally execute a post-flush while maintaining the upright position.
Safe enteral feeding requires a rigorous, systematic approach to prevent life-threatening pulmonary aspiration and mechanical tube complications. Elevating the head of the bed uses gravity to protect the airway and must be done first. Verifying placement and residual volume ensures the stomach can accommodate the feed safely without reflux. The pre-flush verifies tube patency, the feeding provides necessary nutrition, and the post-flush maintains tube hygiene while continued elevation protects against post-feeding aspiration.

Step-by-Step Solution

1
Elevate the head of the client's bed to a minimum of 30 degrees.
The client is placed in an upright position.
Gravity is the primary defense against aspiration. The airway must be protected before any manipulation of the gastric tube begins.
2
Aspirate the stomach contents to assess residual volume and confirm tube placement.
Tube placement is verified and gastric emptying is assessed.
Ensuring the tube hasn't migrated to the lungs and that the stomach isn't overly full prevents pulmonary aspiration of stomach contents.
3
Instill 30 mL of sterile water to flush the nasogastric tube.
The tube is cleared and patency is confirmed.
Flushing verifies that the tube is not kinked or clogged, preparing it for the thicker formula.
4
Administer the prescribed amount of the enteral nutritional formula.
The client receives the prescribed nutrition.
With safety checks complete, the bolus feeding can be infused securely.
5
Flush the tube with an additional 30 mL of water and maintain the elevated bed position.
The tube is cleared of formula and the client remains positioned safely.
The final flush prevents the formula from coagulating and occluding the tube, while continued elevation prevents post-feeding reflux and aspiration.

Key Concept

Enteral Tube Feeding Administration Safety
Estimated Time:1m 30s
Question 725Question →

The nurse is preparing a client for a bedside abdominal paracentesis. In what order should the nurse perform the following actions to ensure client safety and reduce the risk of complications? Arrange the actions in the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first verify informed consent, then instruct the client to void, followed by obtaining baseline data, and finally positioning the client upright.
The proper sequence prioritizes legal requirements first, followed by anatomical risk reduction, baseline assessment, and finally procedural positioning. Verifying consent is always the initial action. Having the client void decreases bladder size, which is a critical safety step to reduce perforation risk. Baseline data is then collected (weight is most accurate after voiding) to monitor for subsequent fluid shifts or shock. Finally, the upright position allows ascitic fluid to pool in the lower abdomen for safe removal.

Step-by-Step Solution

1
Verify informed consent
Ensures legal authorization
Must be done before any procedure preparation begins.
2
Instruct client to void
Empty bladder
Reduces the risk of accidental bladder perforation during trocar insertion.
3
Obtain baseline data
Records vital signs, weight, and abdominal girth
Provides a baseline to monitor for post-procedure hypovolemic shock or bleeding.
4
Position client upright
Fluid pools in lower abdomen
Facilitates safe fluid aspiration by gravity.

Key Concept

Preparation for a paracentesis focuses on legal authorization, anatomical safety (emptying the bladder to prevent perforation), baseline assessment for monitoring complications, and proper positioning to facilitate the procedure.
Question 726Question →

A client presents to a crowded emergency department triage desk reporting a sudden onset of high fever, severe muscle pain, and unexplained epistaxis. The client reports returning three days ago from a region currently experiencing a high-consequence viral hemorrhagic fever outbreak. Activate the facility's emergency response plan by arranging the following immediate nursing actions in the correct priority sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence prioritizes immediate public safety via source control, followed by physical isolation, staff protection, institutional notification, and finally administrative security.
In a biological threat scenario involving a high-consequence infectious disease, the 'Identify, Isolate, Inform' framework dictates immediate priorities. Once the threat is identified at triage, the absolute first priority is source control (masking the client), followed instantly by physical isolation. Only after the immediate risk to the crowded waiting area is mitigated should the nurse step away to don time-consuming, high-level PPE. Once protected, the nurse notifies infection control to activate the emergency response plan. Finally, administrative controls, such as a personnel log, are established.

Step-by-Step Solution

1
Apply source control.
The client wears a medical mask.
Instantly prevents droplet dispersion in the waiting room before any movement occurs.
2
Isolate the client.
The client is moved to a private room.
Removes the biological hazard from the public area to contain the exposure risk.
3
Don appropriate PPE.
The nurse applies high-level protective gear.
Ensures the nurse is fully protected before conducting any direct care or extended assessment.
4
Notify authorities.
Infection control and public health are alerted.
Activates the facility's emergency response plan and mobilizes necessary specialized resources.
5
Secure the area.
An entry log and perimeter are established.
Prevents unauthorized exposure and facilitates strict contact tracing for all interacting staff.

Key Concept

Identify, Isolate, and Inform (High-Consequence Infectious Disease Protocol)
Question 727Question →

A nurse is preparing to mix and administer a prescribed dose of Regular insulin and NPH insulin in a single syringe. Arrange the steps of this procedure in the correct sequence from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for mixing insulins is to gently roll the NPH vial, inject air into the NPH vial, inject air into the Regular insulin vial, draw up the Regular insulin, and finally draw up the NPH insulin (Clear before Cloudy).
When mixing insulin, the fundamental rule is 'clear before cloudy' (Regular before NPH) to avoid contaminating the short-acting insulin with the intermediate-acting insulin. The correct sequence ensures the vials are pressurized properly while maintaining sterility and preventing cross-contamination.

Step-by-Step Solution

1
Roll the NPH insulin vial between the palms.
The cloudy suspension is thoroughly mixed.
NPH insulin contains particles that settle at the bottom; rolling prevents bubble formation that can alter the dose measurement.
2
Inject air into the NPH insulin vial.
The NPH vial is pressurized.
Pressurizing the vial prevents a vacuum, and doing this first prevents contamination of the clear insulin.
3
Inject air into the Regular insulin vial.
The Regular insulin vial is pressurized.
The needle can now remain in this vial to draw the first medication.
4
Withdraw the prescribed dose of Regular insulin.
The clear insulin is drawn into the syringe.
Drawing clear insulin before cloudy insulin prevents contamination of the rapid-acting or short-acting insulin vial.
5
Withdraw the prescribed dose of NPH insulin.
Both insulins are successfully mixed in the syringe.
This completes the combined dose preparation safely.

Key Concept

Safe Parenteral Medication Administration: Mixing Insulins
Question 728Question →

A nurse hears a loud noise from a client's room and enters to find the client lying on the floor. Arrange the following nursing actions in the correct chronological order from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first assess responsiveness and ABCs, then inspect for physical injuries, followed by obtaining vital signs, returning the client to bed, and finally notifying the provider and completing an incident report.
This sequence follows the nursing process and the ABCs prioritization framework. When a client falls, the immediate priority is to assess for life-threatening conditions (responsiveness and airway). Next, the nurse must rule out physical injuries (like a hip fracture or head trauma) before moving the client, as premature movement can exacerbate injuries. Vital signs provide further assessment data regarding the client's stability. Only after confirming the client is stable and uninjured should they be moved. Finally, reporting and documentation are completed once the client is safe.

Step-by-Step Solution

1
Assess responsiveness and ABCs.
Determines if there is an immediate life-threatening emergency.
Airway, breathing, and circulation are the highest priorities.
2
Inspect for visible injuries.
Identifies bleeding, skin tears, or deformities.
Rules out injuries that would contraindicate moving the client.
3
Obtain baseline vital signs.
Evaluates hemodynamic stability.
Helps identify physiological causes for the fall.
4
Return the client to bed.
Client is safely placed back in a secure environment.
Assessment is complete and client is cleared for safe movement.
5
Notify provider and document.
Healthcare team is informed and legal documentation is filed.
Ensures continuity of care and facility protocol compliance.

Key Concept

Post-Fall Nursing Assessment and Prioritization
Question 729Question →

Thick, black smoke begins pouring from a linen storage room on a medical-surgical floor. The fire alarm is activated, and the charge nurse initiates a horizontal evacuation to the adjacent fire compartment. In what order should the nurse direct the evacuation of the following clients? Arrange the clients from first to be evacuated to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first evacuate the client in immediate danger (adjacent to the fire), followed by the ambulatory client, then the semi-ambulatory client (wheelchair), and finally the non-ambulatory client (stretcher).
Facility fire evacuation protocols require staff to first rescue anyone in immediate danger (the client next to the fire). Once the immediate danger area is cleared, the strategy shifts to moving the greatest number of people in the shortest amount of time. This means directing ambulatory clients out first, as they require little to no assistance. Next, semi-ambulatory clients (wheelchair-bound) are moved. Finally, non-ambulatory or bedbound clients (requiring stretchers and multiple staff) are evacuated, as they are the most labor-intensive and time-consuming to transport.

Step-by-Step Solution

1
Identify the client in the most immediate danger from the fire.
The client with pelvic fractures is in the room sharing a wall with the fire source.
The 'R' in the RACE protocol stands for Rescue; anyone in immediate proximity to the hazard must be moved first to prevent injury or death.
2
Prioritize the remaining clients based on the principle of doing the greatest good for the greatest number in the shortest time.
The ambulatory client pacing with an IV pole is selected next.
Ambulatory clients can evacuate themselves with minimal direction, freeing up staff and clearing the hallways quickly.
3
Determine the next fastest group of clients to move.
The client requiring a wheelchair is selected third.
Semi-ambulatory clients require some staff assistance but are much faster to transport than fully bedbound clients.
4
Assign the most resource-intensive clients to be evacuated last.
The unarousable client requiring a stretcher is evacuated last.
Moving non-ambulatory clients requires multiple staff members and takes significant time, which could delay the evacuation of many others if done earlier.

Key Concept

During a facility fire, evacuation prioritization follows the RACE protocol (Rescue clients in immediate danger first) and then prioritizes based on mobility: ambulatory clients first, semi-ambulatory second, and non-ambulatory last.
Question 730Question →

A nurse is preparing to perform a routine central venous catheter (CVC) dressing change for a client receiving long-term parenteral nutrition. In what chronological order should the nurse perform the following steps to ensure strict aseptic technique and prevent catheter dislodgement?

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first apply respiratory precautions (masking the client and turning their head), then remove the old dressing using clean gloves by pulling toward the insertion site. Following this, the nurse must transition to sterile technique by removing clean gloves, performing hand hygiene, and donning sterile gloves. The site is then scrubbed with chlorhexidine using friction, allowed to air-dry completely without fanning, and finally covered with a new sterile transparent dressing.
The central venous catheter dressing change must adhere to strict surgical asepsis to prevent central line-associated bloodstream infections (CLABSI). The sequence begins with respiratory precautions to protect the site from droplet contamination. Next, the old dressing is removed using clean gloves and pulling toward the insertion site to prevent catheter migration. After removing the contaminated dressing, the nurse must discard the clean gloves and perform hand hygiene before donning sterile gloves, marking the crucial transition from clean to sterile technique. The site is then decontaminated with chlorhexidine using mechanical friction and allowed to air-dry completely, as the drying process is required for the antiseptic to destroy cell walls of pathogens. Finally, the sterile transparent dressing is applied to seal the site.

Step-by-Step Solution

1
Establish respiratory precautions
The client wears a mask and turns their head away from the field.
Prevents airborne and droplet contamination of the exposed CVC site from respiratory tracts.
2
Remove the existing dressing safely
Using clean gloves, the old dressing is peeled toward the catheter.
Clean gloves protect the nurse from exudate. Pulling toward the insertion site prevents accidental catheter migration or dislodgement.
3
Transition to a sterile field
Clean gloves are discarded, hand hygiene is performed, and sterile gloves are donned.
The exposed insertion site requires strict surgical asepsis for cleansing; the clean gloves used for removal are now contaminated.
4
Decontaminate the insertion site
Chlorhexidine is applied with vigorous back-and-forth friction.
Mechanical friction ensures the antiseptic penetrates the epidermis to eliminate resident skin flora.
5
Allow antimicrobial activation
The site air-dries completely on its own.
Chlorhexidine's bactericidal properties depend on the drying process. Active fanning introduces microorganisms.
6
Secure the site with a sterile barrier
A transparent semi-permeable dressing is applied over the dry site.
Seals the sterile site from environmental contaminants while allowing ongoing clinical assessment.

Key Concept

Central Venous Catheter (CVC) Infection Control and Sterile Technique
Estimated Time:2m 0s
Question 731Question →

A critical care nurse is tasked with obtaining a blood specimen for a complete blood count (CBC) from a client's multi-lumen central venous catheter (CVC). A continuous infusion of total parenteral nutrition (TPN) is currently infusing through the medial lumen. Place the following steps for obtaining the blood sample in the correct sequential order. (Arrange the steps from first to last).

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Pause the TPN, scrub the connector, flush with 10 mL of normal saline, discard the first 5 mL of blood, withdraw the sample, and finally flush with 20 mL of normal saline.
When obtaining blood from a CVC, the nurse must first pause any active infusions to avoid sample contamination. Aseptic technique is initiated by scrubbing the hub. A 10 mL normal saline flush confirms patency and clears the line. The discard method (removing 4 to 5 mL of blood) ensures the subsequent sample is undiluted. Finally, a larger volume flush (10 to 20 mL) using a push-pause technique clears the line of blood, reducing the risk of thrombosis.

Step-by-Step Solution

1
Pause the TPN infusion.
The flow of TPN is stopped.
Prevents contamination of the blood sample with TPN components, which would cause falsely elevated lab values.
2
Scrub the needleless connector.
The access port is disinfected.
Maintains strict asepsis and prevents central line-associated bloodstream infections (CLABSI).
3
Flush with 10 mL 0.9% sodium chloride.
The catheter is assessed for patency.
Ensures the line is open and functioning properly before attempting a blood draw.
4
Aspirate and discard 5 mL of blood.
Diluted blood is removed from the line.
Removes the saline flush and any residual fluid from the catheter space, ensuring the actual sample is pure.
5
Withdraw the required blood volume.
The diagnostic sample is obtained.
Provides an undiluted, accurate sample for the complete blood count (CBC).
6
Flush with 20 mL 0.9% sodium chloride.
The catheter is cleared of all blood.
Prevents blood from clotting inside the lumen, which could lead to catheter occlusion.

Key Concept

The discard method is the standard of practice for obtaining blood samples from a central venous catheter to ensure accurate laboratory results and maintain catheter patency.
Question 732Question →

While monitoring a client receiving an infusion of packed red blood cells, the nurse notes the client suddenly develops chills, dyspnea, and flank pain. Arrange the following nursing actions in the correct priority sequence to mitigate further physiological risk.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first stop the transfusion, maintain the IV line with normal saline using new tubing, assess the client, notify the provider and blood bank, and finally return the blood products for testing.
When a hemolytic transfusion reaction is suspected (indicated by chills, dyspnea, and flank pain), the absolute highest priority is stopping the source of harm. Immediately after stopping the transfusion, the nurse must maintain a patent IV line for emergency medications by infusing normal saline through entirely new tubing. Once the client's line is secure, the nurse assesses the client to gather data, notifies the provider to get medical orders, and finally sends the remaining blood products to the lab for investigation. This chronological sequence prioritizes immediate life-saving actions over assessment and reporting.

Step-by-Step Solution

1
Stop the blood transfusion immediately.
The administration of the incompatible blood product is halted.
Preventing further antigen exposure is the absolute highest priority to minimize physiological harm.
2
Disconnect the blood tubing and initiate a normal saline infusion with new IV tubing.
The IV line remains patent and free of additional blood.
Emergency medications and fluids will be needed; new tubing ensures that any blood left in the old tubing is not inadvertently flushed into the client.
3
Assess the client's vital signs and respiratory status.
Current physiological data is obtained.
The nurse needs a rapid, accurate clinical picture of the client's stability to communicate to the provider.
4
Notify the healthcare provider and the blood bank.
Medical interventions are ordered and the facility protocol is activated.
The provider will prescribe medications like antihistamines, corticosteroids, or vasopressors based on the assessment findings.
5
Send the blood bag, attached tubing, and labels back to the blood bank.
The physical evidence is secured for investigation.
Laboratory analysis is required to confirm a hemolytic reaction and prevent future mismatches.

Key Concept

Management of Acute Hemolytic Transfusion Reactions
Estimated Time:1m 0s
Question 733Question →

A nurse is preparing to administer a large-volume cleansing enema to an adult client experiencing severe constipation. Arrange the following nursing actions in the correct chronological sequence of execution.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: 1) position the client in the left lateral Sims position, 2) lubricate the tube, 3) insert the tube while the client exhales, 4) elevate the container to initiate flow, and 5) clamp or lower the container if cramping occurs.
The correct sequence for enema administration prioritizes safe anatomical positioning, proper preparation to minimize trauma, precise insertion technique, controlled gravity-based fluid delivery, and appropriate responsiveness to client complications such as cramping.

Step-by-Step Solution

1
Assist the client into a left lateral Sims position with the right knee flexed.
The client's descending colon is optimally positioned for gravity-assisted flow.
This alignment takes advantage of anatomical curves, allowing the enema solution to flow downward into the sigmoid colon.
2
Apply a water-soluble lubricant to the distal 3 to 4 inches of the rectal tube.
The tip of the enema tubing is coated and ready for smooth insertion.
Lubrication reduces friction, preventing damage to the delicate mucosal lining of the rectum and minimizing client discomfort.
3
Instruct the client to exhale gently while inserting the tip 3 to 4 inches toward the umbilicus.
The tube is safely placed into the rectum without forced resistance.
Exhaling relaxes the external anal sphincter. Directing the tube toward the umbilicus follows the natural anatomical angle of the rectum.
4
Hold the enema container 12 to 18 inches above the client's hips and open the roller clamp.
The enema solution begins flowing slowly into the colon.
Elevating the bag dictates the hydrostatic pressure. Placing it no higher than 18 inches ensures the fluid flows at a safe, tolerable rate.
5
Clamp the tubing or lower the container temporarily if the client reports severe abdominal cramping.
The flow is paused or slowed, reducing sudden bowel distention.
Cramping indicates rapid distention. Pausing or slowing the flow allows the bowel walls to accommodate the fluid volume.

Key Concept

Administration of a Large-Volume Cleansing Enema
Question 734Question →

A group of ambulatory clients arrives at the emergency department walk-in entrance reporting exposure to an unknown liquid chemical from an overturned transport vehicle. Arrange the following actions the triage nurse should take in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The nurse must first put on personal protective equipment, then keep the clients outside the facility, direct them to remove clothing in the decontamination area, flush their skin with water, and finally provide clean clothes and transfer them for medical triage.
In a hazardous materials (hazmat) incident, the sequential priority is to protect the staff, protect the facility, decontaminate the clients, and then provide medical treatment. The nurse must first don personal protective equipment to ensure personal safety. Next, the nurse must prevent the contaminated clients from entering the hospital building to avoid secondary contamination of the internal environment. The clients are then directed to an external decontamination area where they remove their clothing (which removes most of the contaminant) and are washed with copious amounts of water. Only after complete decontamination are they given clean gowns and brought into the facility for medical triage.

Step-by-Step Solution

1
Ensure personal safety.
The nurse dons personal protective equipment.
Rescuers cannot help others if they become casualties themselves. Donning protective gear is always the absolute first step in a hazardous materials scenario.
2
Protect the facility.
The nurse instructs clients to stay outside.
Allowing contaminated clients into the emergency department would contaminate the facility and expose other vulnerable clients and staff to the chemical.
3
Initiate decontamination by clothing removal.
Clients are directed to the decontamination area to undress.
Removing clothing is the single most effective decontamination step, often removing 80% to 90% of the physical contaminant.
4
Complete decontamination by washing.
The clients' skin is flushed with copious water.
Flushing with large amounts of water dilutes and removes any remaining chemical agent on the skin.
5
Proceed to medical evaluation.
Clients receive clean gowns and are transferred to triage.
Once fully decontaminated, clients are safe to enter the facility for standard medical triage and treatment.

Key Concept

Hazardous Materials (Hazmat) Decontamination Sequence
Estimated Time:1m 30s
Question 735Question →

A nurse is preparing to obtain a blood specimen for a comprehensive metabolic panel from a client's multi-lumen central venous catheter (CVC). A continuous infusion of parenteral nutrition is currently running through an adjacent lumen. To reduce the risk of pre-analytical laboratory errors and maintain line patency, in what order should the nurse perform the following actions? (Arrange the items in the correct chronological sequence.)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence requires the nurse to first halt the continuous infusion, verify patency with a saline flush, clear the dead space of residual fluid by discarding an initial blood volume, collect the pure diagnostic sample, and finally flush the line again before resuming the parenteral nutrition.
Drawing blood from a multi-lumen central venous catheter carries a high risk of pre-analytical laboratory error if the sample is contaminated by concurrent infusions or diluted by flush solutions. Adhering to the standard sequence—pausing adjacent infusions, scrubbing the hub and flushing to confirm patency, utilizing a discard volume to clear dead space, drawing the diagnostic sample, and providing a final flush—ensures highly accurate laboratory data and preserves long-term catheter function.

Step-by-Step Solution

1
Pause the continuous parenteral nutrition infusion.
Halts the delivery of intravenous fluids and nutrients.
Prevents the parenteral nutrition from artificially elevating glucose and electrolyte levels in the drawn blood sample.
2
Cleanse the needleless connector and flush with 0.9% sodium chloride.
Decontaminates the access point and verifies lumen patency.
Prevents intraluminal microbial contamination and ensures the catheter is viable for blood return without damaging the vessel.
3
Aspirate and discard the initial 5 mL of blood.
Removes the saline flush and stagnant fluid from the catheter.
Prevents hemodilution, ensuring the diagnostic sample accurately reflects the client's systemic venous blood composition.
4
Collect the required blood volume.
Secures the diagnostic specimen.
Fulfills the prescribed diagnostic test using an undiluted, uncontaminated blood source.
5
Flush the catheter with 0.9% sodium chloride and restart the infusion.
Clears residual blood from the line and resumes therapy.
Prevents fibrin formation and subsequent catheter occlusion while maintaining the client's vital nutritional support.

Key Concept

Strict sequential protocols for central venous catheter blood sampling—including pausing infusions and discarding initial waste volumes—are essential to mitigate the risk of pre-analytical laboratory errors and inappropriate clinical interventions.
Question 736Question →

A client receiving a first dose of an intravenous antibiotic suddenly reports difficulty swallowing and feeling faint. The nurse observes facial swelling, audible wheezing, and a rapidly dropping blood pressure. Place the following nursing interventions in the correct sequence to manage this acute physiological emergency.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct priority sequence is to first stop the antibiotic infusion, then assess the airway and provide oxygen, followed by administering intramuscular epinephrine, and finally initiating an intravenous normal saline infusion.
In any acute allergic or anaphylactic emergency, the clinical priority framework dictates that the nurse must first remove the offending agent to prevent further physiological deterioration. Following this, the nurse immediately applies the Airway, Breathing, Circulation (ABC) principles. The airway and breathing are stabilized through rapid assessment and supplemental oxygen. Circulation and systemic reversal of the pathophysiological response are then addressed with intramuscular epinephrine, the definitive life-saving treatment. Finally, the accompanying circulatory collapse and distributive shock are managed with rapid intravenous fluid boluses.

Step-by-Step Solution

1
Remove the causative agent
The intravenous antibiotic is immediately discontinued.
Further exposure to the allergen will worsen the anaphylactic cascade and physiological decompensation.
2
Support airway and breathing
The airway is assessed and high-flow oxygen is applied.
Anaphylaxis causes rapid airway compromise; establishing an open airway and ensuring adequate oxygenation is paramount for survival.
3
Administer primary pharmacological rescue
Intramuscular epinephrine is injected.
Epinephrine rapidly reverses the life-threatening bronchoconstriction and cardiovascular collapse associated with anaphylaxis.
4
Restore circulatory volume
An intravenous bolus of normal saline is administered.
Massive vasodilation leads to distributive shock, which requires immediate fluid resuscitation to restore adequate tissue perfusion.

Key Concept

Prioritization in Anaphylactic Shock Management
Question 737Question →

A nurse is removing a non-tunneled central venous catheter (CVC) from a client's right subclavian vein. Immediately following the catheter's removal, the client suddenly gasps, exhibits severe dyspnea, clutches their chest, and their oxygen saturation rapidly drops to 84%. Suspecting an acute venous air embolism, arrange the following collaborative and nursing interventions in the priority order they must be implemented to mitigate physiological risk.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for managing a suspected venous air embolism is to first seal the insertion site to prevent further air entry, position the client in the left lateral Trendelenburg position to trap the embolus, administer 100% oxygen to shrink the bubble, activate the rapid response team for advanced support, and continuously monitor for cardiovascular collapse.
The precise physiological management of an air embolism requires a deliberate deviation from standard algorithms. The absolute first priority is stopping the source of the lethal agent by sealing the open tract. The immediate second priority is mechanically sequestering the entrained air (via Durant's maneuver) to prevent it from obstructing pulmonary circulation. Only after the source is controlled and the embolus is trapped should the nurse proceed to chemical reduction of the embolus (100% oxygen) and escalating the level of care.

Step-by-Step Solution

1
Apply a sterile, impermeable occlusive dressing over the insertion site.
Halts further air entrainment into the central venous system.
During inspiration, negative intrathoracic pressure will continuously draw room air into the open venous tract, expanding the embolus. Sealing the site is the definitive first step to stop the source.
2
Place the client in the left lateral Trendelenburg position (Durant's maneuver).
Traps the air bubble in the apex of the right ventricle.
This dependent position utilizes buoyancy to keep the air embolus away from the right ventricular outflow tract, preventing it from migrating into the pulmonary artery and causing immediate cardiovascular collapse.
3
Administer 100% oxygen via a non-rebreather mask.
Improves tissue oxygenation and reduces the volume of the air embolus.
A high concentration of inspired oxygen creates a diffusion gradient that accelerates the reabsorption of nitrogen gas (which makes up 78% of room air) from the bubble back into the bloodstream.
4
Activate the rapid response team and notify the healthcare provider.
Mobilizes advanced critical care support.
The client requires immediate medical evaluation and potential advanced interventions, such as central venous catheterization to aspirate the air from the right atrium or inotropic support.
5
Initiate continuous hemodynamic monitoring and prepare for CPR.
Ensures readiness for sudden cardiac arrest.
A massive air embolism can rapidly precipitate acute cor pulmonale and full cardiovascular collapse, requiring immediate implementation of advanced cardiac life support (ACLS) protocols.

Key Concept

Risk reduction and emergency management of a venous air embolism following central venous catheter removal.
Question 738Question →

A nurse is caring for a laboring client who is receiving an intravenous oxytocin infusion for labor augmentation. Upon reviewing the electronic fetal monitor tracing, the nurse notes a pattern of recurrent late decelerations. In which order should the nurse perform the following interventions? (Arrange the actions in the correct sequence from first to last.)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first discontinue the oxytocin infusion, then reposition the client to a lateral side-lying position, administer oxygen, administer a bolus of intravenous fluid, and finally notify the healthcare provider.
Recurrent late decelerations indicate uteroplacental insufficiency. The nurse must immediately initiate intrauterine resuscitation steps to optimize fetal oxygenation. The sequence is driven by physiological priorities: first, stop any factors decreasing perfusion (discontinuing oxytocin); second, mechanically improve perfusion by relieving vena cava compression (lateral positioning); third, maximize the oxygen available in the maternal blood (oxygen administration); fourth, increase circulating volume to deliver that oxygen (intravenous fluid bolus); and finally, escalate the situation to the healthcare provider once these immediate stabilizing actions are in progress.

Step-by-Step Solution

1
Recognize the clinical significance of recurrent late decelerations.
Identify the immediate need for intrauterine resuscitation to correct fetal hypoxia.
Late decelerations indicate uteroplacental insufficiency, meaning the fetus is not receiving adequate blood flow and oxygen during contractions.
2
Prioritize independent, life-saving nursing interventions sequentially based on physiological impact.
Establish the intervention sequence: stop the oxytocin, reposition the client, apply oxygen, and increase intravenous fluids.
Interventions must follow a logical physiological sequence—first eliminating the immediate stressor (oxytocin), then mechanically opening blood flow (lateral positioning), then enhancing the oxygen content of that blood (O2 mask), and finally increasing the volume to deliver it (IV bolus).
3
Escalate the situation to the primary healthcare provider.
Notify the provider only after the initial stabilization steps have been executed.
The provider must evaluate the client for further medical interventions, but delaying independent nursing actions to make a phone call prolongs fetal hypoxia.

Key Concept

Intrauterine Resuscitation for Late Decelerations
Question 739Question →

The nurse is preparing to administer an intermittent bolus enteral feeding via a gastrostomy tube to a client with dysphagia. After verifying the provider's prescription, performing hand hygiene, and donning clean gloves, arrange the following nursing actions in the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

Elevate the head of the bed, check the gastric residual volume, perform an initial water flush, administer the feeding formula by gravity, and perform a final water flush.
The safest and most effective sequence for administering a gastrostomy tube feeding prioritizes airway protection first (elevating the head of the bed). Once the airway is protected, the nurse assesses the client's physiological tolerance (checking residual volume). After establishing it is safe to proceed, the nurse maintains equipment integrity (initial flush), delivers the therapeutic intervention (gravity feed), and finally secures the equipment for future use (final flush).

Step-by-Step Solution

1
Elevate the head of the bed to 30-45 degrees.
Positions the stomach below the esophagus.
Protects the airway and prevents aspiration of gastric contents.
2
Aspirate the gastric contents to measure residual volume.
Determines the amount of undigested formula from the previous feed.
Assesses gastric emptying and tolerance to prevent overfeeding and regurgitation.
3
Administer an initial flush of 30 mL of water.
Clears the tube of residual contents.
Verifies tube patency before the thicker nutritional formula is introduced.
4
Administer the enteral feeding formula via gravity.
Delivers the prescribed nutrition slowly over time.
Prevents rapid gastric distention, which can cause cramping, nausea, and diarrhea.
5
Administer a final flush of 30 mL of water.
Pushes the remaining formula out of the tube and into the stomach.
Maintains tube patency for future use and removes formula residue that could harbor bacterial growth.

Key Concept

Safe administration of intermittent enteral nutrition via gastrostomy tube
Question 740Question →

A registered nurse is preparing to provide care for a client admitted with a confirmed diagnosis of Middle East Respiratory Syndrome (MERS). The client is in a negative-pressure room requiring airborne and contact precautions. Arrange the following steps for donning the required personal protective equipment (PPE) in the correct chronological sequence prior to entering the client's room.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Perform hand hygiene, Put on isolation gown, Apply N95 respirator, Place face shield or goggles, Don clean gloves.
The correct sequence for donning personal protective equipment (PPE) for airborne and contact precautions follows CDC guidelines designed to prevent contamination of the equipment and the healthcare worker. Hand hygiene must be performed first. The gown is put on next to cover the torso and uniform. The N95 respirator is then applied and seal-checked. Eye protection (face shield or goggles) is placed over the face and respirator. Finally, gloves are donned last and pulled over the gown cuffs to ensure a complete barrier.

Step-by-Step Solution

1
Identify the foundational first step prior to handling any clean personal protective equipment.
Select performing hand hygiene.
Hand hygiene prevents the transfer of pathogens to the clean PPE before it is applied to the body.
2
Determine the first item of PPE to be put on to protect the torso and clothing.
Select putting on the fluid-resistant isolation gown.
The gown is the largest piece of equipment and forms the base layer for subsequent PPE. It is placed before facial protection.
3
Identify the next item needed to secure the airway before applying eye protection.
Select applying the fit-tested N95 respirator.
The respirator must be applied directly to the face and seal-checked without interference from eyewear straps.
4
Determine the appropriate step for applying eye protection.
Select placing the face shield or goggles.
Eye protection is placed over or alongside the respirator to protect the mucous membranes of the eyes without breaking the respirator seal.
5
Identify the final step to complete the protective barrier.
Select donning clean gloves.
Gloves are donned last and pulled over the gown cuffs to secure the sleeves and ensure the hands are freshly covered before any patient contact.

Key Concept

Donning sequence for Personal Protective Equipment (PPE)
PreviousPage 37 / 44Next
All practice questions — NCLEX-RN | Examkin