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Question 741Question →

A nurse enters a client's room and observes smoke and visible flames coming from a wastebasket near the client's bed. Arrange the following immediate actions in the correct priority sequence.

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Answer

The correct sequence is to first assist the client to safety, then activate the alarm, next close the room door, and finally attempt to extinguish the fire.
In any fire emergency within a healthcare facility, the standard protocol follows the internationally recognized acronym RACE. The absolute first priority is always to Rescue (or Relocate) anyone in immediate danger to protect life. After securing the client's safety, the nurse must Alarm (activate the fire response system) to alert the facility and fire department. Next, the nurse should Confine the fire by closing doors and windows to restrict oxygen and prevent the spread of smoke and flames. Finally, if the fire is small and it is safe, the nurse may Extinguish the fire. This sequence prioritizes life safety over property preservation.

Step-by-Step Solution

1
Assist the client out of the room to a secure area.
The client is removed from the immediate physical threat of fire and smoke.
Life safety is the absolute first priority in any emergency. The Rescue phase of the RACE protocol dictates moving individuals in direct danger before taking any other action.
2
Activate the facility's emergency fire alarm system.
Emergency services and the facility's internal response teams are notified.
Once immediate life safety is secured, the Alarm phase ensures that broader help is on the way and other staff can begin systematically responding.
3
Close the door to the client's room to contain the smoke.
The fire's oxygen supply is limited, and toxic smoke is prevented from entering the hallway.
The Confine phase isolates the hazard, protecting the rest of the unit and allowing more time for a safe facility-wide response if needed.
4
Discharge a fire extinguisher at the base of the flames.
The small fire is suppressed or put out entirely.
The Extinguish phase is only attempted after all life safety, notification, and containment measures are complete, and only if it is safe to do so.

Key Concept

RACE Fire Safety Protocol
Estimated Time:45s
Question 742Question →

A nurse is preparing to collect a sterile urine specimen for a culture and sensitivity test from a client who has a closed indwelling urinary catheter system. In which order should the nurse perform the following actions to reduce the risk of infection and ensure an accurate diagnostic sample? Arrange the steps from first to last.

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Answer

The correct sequence is to first clamp the tubing to collect fresh urine, cleanse the port to maintain sterility, aspirate the urine with a sterile syringe, transfer the sample into a sterile container, and finally unclamp the tubing to restore urinary flow.
Obtaining a sterile urine specimen from an indwelling catheter requires strict adherence to sequence to ensure diagnostic accuracy and client safety. The nurse must first clamp the tubing to gather fresh urine. Next, the port must be cleansed to maintain strict asepsis before accessing it. Once disinfected, the urine is aspirated with a sterile syringe and placed securely in a sterile cup. Finally, the paramount safety step is unclamping the tubing to prevent bladder distension and subsequent kidney injury or infection.

Step-by-Step Solution

1
Clamp the drainage tubing just below the sampling port.
Fresh urine accumulates in the tubing above the port.
Ensures an adequate volume of freshly produced urine is available for the sample, as urine from the drainage bag is stagnant and not suitable for culture.
2
Cleanse the needleless sampling port with an antiseptic swab.
The surface of the sampling port is disinfected.
Prevents environmental pathogens from being pushed into the closed urinary system during aspiration, reducing the risk of CAUTI.
3
Attach a sterile syringe and aspirate the urine.
Urine is safely extracted from the closed system.
Maintains the sterility of both the diagnostic sample and the client's internal catheter system.
4
Transfer the urine into a sterile specimen container.
The sample is secured in an appropriate transport vessel.
Preserves the integrity of the diagnostic sample for accurate culture and sensitivity testing in the laboratory.
5
Unclamp the catheter drainage tubing.
Continuous urinary drainage is restored.
Prevents urine backflow, bladder distension, and associated complications that could increase the risk of injury or infection.

Key Concept

Reduction of Risk Potential: Diagnostic Test Preparation and Infection Control
Question 743Question →

A nurse is preparing to administer a dissolved oral medication through a client's established nasogastric (NG) tube. To reduce the risk of complications, in what order should the nurse perform the following actions? Arrange the steps from first to last.

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Answer

The correct sequence is to position the client, verify tube placement, perform an initial flush, administer the medication, and perform a final flush.
To reduce the risk of potential complications such as aspiration and tube occlusion, the nurse must follow a strict sequence. First, elevating the head of the bed prevents reflux. Second, verifying placement ensures the tube is not in the respiratory tract. Third, an initial flush confirms the tube is patent. Fourth, the medication is administered. Finally, a post-flush clears the tubing, preventing blockages and ensuring complete medication delivery.

Step-by-Step Solution

1
Elevate the head of the bed.
The client is placed in a semi-Fowler's position.
This physical intervention immediately reduces the risk of aspiration.
2
Verify tube placement.
The location of the distal tip of the tube is confirmed.
This ensures the medication will enter the stomach, not the lungs.
3
Perform the initial flush.
The tube is cleared with water.
This checks tube patency and clears any formula or residual contents.
4
Administer the medication.
The prescribed medication is delivered into the stomach.
Provides the required therapeutic intervention.
5
Perform the final flush.
The tube is cleared of medication residue.
Prevents tube occlusion and ensures the full dose is received.

Key Concept

Safe administration of medications via a nasogastric tube requires a systematic approach to prevent aspiration (positioning and placement verification) and maintain tube patency (flushing before and after).
Question 744Question →

A triage nurse receives a client with type 1 diabetes mellitus who presents with deep, rapid breathing, a fruity breath odor, and increasing lethargy. The initial point-of-care blood glucose is 512512 mg/dL (28.428.4 mmol/L). Arrange the following nursing interventions in the priority order they should be implemented.

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Answer

The priority sequence is to first establish IV access, then rapidly infuse normal saline, check potassium levels, initiate the continuous insulin infusion, and finally add dextrose when blood glucose drops to 250250 mg/dL.
The correct physiological adaptation sequence for DKA emphasizes circulation first. The nurse must establish IV access to deliver rapid fluid boluses (0.9% sodium chloride). Once vascular volume is stabilizing, the nurse must verify the serum potassium level, as insulin forces potassium into cells and can cause fatal hypokalemia. After confirming safe potassium levels, regular insulin is continuously infused. Finally, when the blood glucose level lowers to 250250 mg/dL, dextrose is added to the IV fluids to prevent sudden hypoglycemia while continuing to treat the acidosis.

Step-by-Step Solution

1
Identify the primary physiological threat.
The client is in Diabetic Ketoacidosis (DKA) and is at highest risk for hypovolemic shock due to severe osmotic diuresis.
According to Maslow's hierarchy and ABC (Airway, Breathing, Circulation) principles, restoring circulation (intravascular volume) is the top priority.
2
Sequence the interventions for fluid resuscitation.
Establishing IV access must occur before normal saline can be infused.
A route is required before the treatment can be delivered.
3
Determine the timing for medication administration.
Insulin administration must follow fluid resuscitation and potassium verification.
Administering insulin without fluids can worsen vascular collapse. Giving insulin without knowing potassium levels can trigger fatal hypokalemia.
4
Plan for ongoing complication prevention.
Dextrose is added late in the sequence.
Once blood glucose falls to 250250 mg/dL, dextrose prevents hypoglycemia while insulin continues to resolve the acidosis.

Key Concept

Management of Diabetic Ketoacidosis (DKA) prioritizes fluid resuscitation followed by electrolyte evaluation and insulin administration.
Question 745Question →

A nurse is caring for a client receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes after the infusion begins, the client develops sudden chills, severe lower back pain, and dyspnea. Arrange the following nursing actions in the priority order they should be performed, from first action to last.

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Answer

The correct priority sequence is to first stop the transfusion, then maintain the IV line with normal saline using new tubing, followed by assessing the client's vital signs, notifying the healthcare provider and blood bank, and finally returning the blood products to the blood bank for testing.
In any acute physiological reaction to an intravenous infusion, the universal first step is to stop the infusion. Once stopped, IV access must be maintained with new tubing and normal saline to allow for emergency medication administration without infusing more of the offending agent. After securing the airway and circulation (ABCs), the nurse assesses the client to gather data, reports this data to the provider for orders, and finally addresses administrative and diagnostic protocols like returning the bag to the lab.

Step-by-Step Solution

1
Stop the blood transfusion immediately.
Halts the delivery of the offending blood product.
The client is exhibiting classic signs of an acute hemolytic transfusion reaction. The immediate priority is to limit the physiological insult by stopping the source.
2
Disconnect the blood tubing and infuse normal saline through new tubing.
Keeps the vein open and flushes the system safely.
Flushing through the old tubing would push more incompatible blood into the client. New tubing ensures only saline enters the bloodstream.
3
Assess the client's vital signs and respiratory status.
Establishes the severity of the client's physiological compromise.
Objective data (blood pressure, heart rate, oxygen saturation) is urgently needed to guide emergency pharmacological interventions.
4
Notify the healthcare provider and the blood bank.
Mobilizes the medical team and initiates the institutional reaction protocol.
Collaborative care is required to treat the systemic shock and renal complications associated with a hemolytic reaction.
5
Return the equipment to the blood bank.
Facilitates diagnostic testing.
The blood bank must analyze the product and tubing to identify the exact cause of the reaction, such as ABO incompatibility.

Key Concept

Management of Acute Hemolytic Transfusion Reactions
Question 746Question →

A nurse is monitoring an adult client who is receiving a transfusion of packed red blood cells for symptomatic anemia. Twenty minutes after the infusion begins, the client suddenly reports severe lower back pain, chills, and a sensation of chest tightness. In what order should the nurse perform the following interventions to minimize the client's risk of physiological deterioration?

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Answer

The correct sequence is: 1) Stop the blood transfusion immediately, 2) Disconnect the blood tubing and initiate an infusion of 0.9% sodium chloride using a new administration set, 3) Assess the client's vital signs, breath sounds, and urine output, 4) Notify the healthcare provider and the blood bank of the suspected reaction, and 5) Return the blood bag, attached administration set, and all labels to the blood bank.
An acute hemolytic transfusion reaction is a life-threatening emergency. The absolute priority is to stop the infusion of the incompatible blood. Next, intravenous access must be maintained to treat potential shock, which requires infusing 0.9% sodium chloride through a completely new administration set. Assessing the client follows immediately to gauge the severity of the reaction. With complete assessment data, the nurse then notifies the healthcare provider for emergency orders and contacts the blood bank. Finally, the blood bag and tubing are returned to the laboratory for diagnostic analysis.

Step-by-Step Solution

1
Stop the transfusion.
Further entry of incompatible blood into the circulation is halted.
This is the most critical immediate action to mitigate the physiological risk of a severe acute hemolytic reaction.
2
Maintain IV access with normal saline using new tubing.
The vein remains open for emergency medications and renal perfusion is supported.
Normal saline prevents hemolysis. New tubing ensures the blood remaining in the old line is not flushed into the client.
3
Assess the client.
Objective clinical data regarding hemodynamic and respiratory stability is obtained.
Assessment data is required to determine the severity of the reaction and to provide accurate information to the healthcare provider.
4
Notify the healthcare provider and blood bank.
Medical interventions are prescribed and the reaction investigation is initiated.
Collaborative care is necessary to manage potential shock or acute kidney injury resulting from the reaction.
5
Send materials to the blood bank.
The laboratory can analyze the blood and tubing for errors or incompatibilities.
This is a required protocol for all suspected transfusion reactions to identify the root cause.

Key Concept

Management of an acute hemolytic transfusion reaction requires immediate cessation of the blood product, maintenance of intravenous access with normal saline via new tubing, and rapid assessment to minimize physiological risk.
Question 747Question →

A public health nurse is conducting a disaster preparedness drill for newly hired emergency department staff. The nurse is reviewing the Simple Triage and Rapid Treatment (START) algorithm for adult mass casualty incidents. Place the following triage assessment actions in the correct sequential order from first to last.

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Answer

The correct sequence for the START triage algorithm is to first direct the walking wounded to safety, then assess respirations, followed by perfusion, and finally mental status.
The START triage algorithm is designed for rapid assessment during a mass casualty incident. The process begins by clearing all ambulatory victims to a designated area. For the remaining non-ambulatory victims, the nurse sequentially assesses Respirations, Perfusion, and Mental status (remembered by the mnemonic RPM). This systematic approach ensures that victims with the most critical, life-threatening compromises are identified and tagged first.

Step-by-Step Solution

1
Identify the first priority in the START algorithm.
Directing ambulatory clients to a safe zone.
This quickly removes the 'walking wounded' (minor/green tags) from the immediate scene, freeing up space and time to evaluate non-ambulatory victims.
2
Determine the next assessment step using the RPM mnemonic.
Assess Respirations.
Airway and breathing are the most critical physiological functions to assess first in immobile victims to prevent immediate death from hypoxia.
3
Identify the subsequent assessment parameter.
Evaluate Perfusion.
Once breathing is established, circulation must be confirmed to ensure oxygen is being delivered to tissues and to identify life-threatening hemorrhage.
4
Identify the final assessment parameter.
Determine Mental status.
Neurological function is assessed last to determine if the victim can follow commands, separating immediate (red) from delayed (yellow) tags.

Key Concept

The Simple Triage and Rapid Treatment (START) algorithm sequences assessment using the 'RPM' (Respirations, Perfusion, Mental Status) mnemonic after initially removing ambulatory victims.
Question 748Question →

A nurse is instructing a client with a right fractured tibia who is non-weight-bearing on how to ascend stairs using axillary crutches. In what order should the nurse teach the client to perform the following actions? Arrange the steps in the correct sequence from first to last.

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Answer

The correct sequence for ascending stairs with crutches is: establish a tripod stance, bear weight on the crutches, move the unaffected leg up, shift weight to the unaffected leg, and finally bring the crutches and affected leg up.
When ascending stairs with crutches (non-weight-bearing), the standard nursing principle is 'up with the good, down with the bad'. The client begins in a secure tripod stance and transfers their body weight to the crutches. The strong, unaffected leg steps up first to act as the primary lifter. The client then shifts their weight onto this strong leg, allowing them to safely bring the crutches and the affected, non-weight-bearing leg up to the same step.

Step-by-Step Solution

1
Identify the core principle for ascending stairs with crutches.
The general rule is 'up with the good, down with the bad', meaning the unaffected leg must advance first when going up.
This principle ensures the strong leg provides the lifting power.
2
Determine the initial positioning and weight transfer.
The client starts in a stable tripod stance and transfers their weight entirely to the crutches.
A tripod stance provides the necessary base of support, and weight must be off the unaffected leg so it can move.
3
Sequence the movement of limbs.
The unaffected leg steps up, weight is shifted to it, and then the crutches and the affected leg are lifted together.
This maintains the non-weight-bearing status on the injured leg while safely elevating the body.

Key Concept

Assistive Devices: Crutch Walking on Stairs
Question 749Question →

A nurse is preparing to administer an intravenous (IV) push medication that is incompatible with the client's continuous IV fluid infusion. The client has a single peripheral IV access. Arrange the following actions in the correct sequence to safely administer this medication. (Place the first action at the top and the last action at the bottom.)

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Answer

The correct sequence is to first stop the continuous infusion, clamp the tubing above the lowest port, scrub the hub and flush with saline to clear the line, administer the medication over the prescribed time, flush again with saline at the same slow rate as the medication, and finally unclamp and restart the infusion.
Safely administering an IV push medication into a line with an incompatible continuous infusion requires creating a saline barrier and preventing the two medications from mixing. By stopping the pump and clamping the tubing, the nurse prevents retrograde flow. Flushing with saline before and after the medication creates a liquid barrier. Most importantly, flushing after the medication at the same slow rate is critical to prevent a rapid bolus of the medication remaining in the tubing's dead space.

Step-by-Step Solution

1
Stop the continuous intravenous infusion pump.
The active flow of the incompatible fluid is halted.
It is critical to stop the incompatible fluid from infusing while the line is being manipulated and flushed.
2
Clamp the primary intravenous tubing above the injection port closest to the client.
The pathway back into the main IV bag and tubing is blocked.
Clamping prevents the subsequent flush and medication from traveling backward up the tubing (retrograde flow) and mixing with the incompatible primary fluid.
3
Scrub the injection port hub, aspirate for blood return, and flush with normal saline.
The line from the port to the vein is cleared of incompatible fluid.
This establishes a sterile access point, confirms venous placement, and creates a physical saline barrier between the incompatible fluids.
4
Administer the prescribed intravenous push medication over the recommended time.
The medication is safely delivered into the vein.
Pushing the medication slowly over the recommended duration prevents toxicity and severe adverse reactions.
5
Flush the injection port with normal saline at the same rate the medication was administered.
The residual medication in the IV tubing is pushed into the bloodstream at a safe speed.
Flushing too rapidly will forcefully push the medication occupying the dead space of the tubing into the client, essentially administering a rapid bolus and risking speed shock.
6
Unclamp the primary intravenous tubing and restart the continuous infusion.
The continuous therapy is resumed.
Once the medication is safely cleared from the line, it is safe to restart the primary continuous infusion.

Key Concept

Safe administration of an intravenous push medication through a line with an incompatible continuous infusion.
Question 750Question →

A critically ill adult client is admitted to the intensive care unit with severe diabetic ketoacidosis (DKA). The initial laboratory results indicate a blood glucose level of 715 mg/dL715\text{ mg/dL}, an arterial pH of 7.127.12, and a serum potassium level of 3.1 mEq/L3.1\text{ mEq/L}. To reduce the risk of fatal complications during treatment, arrange the following collaborative interventions in the safest chronological order from first to last.

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Answer

The correct sequence is to first initiate intravenous fluid resuscitation, followed by intravenous potassium chloride, then continuous intravenous regular insulin, followed by adding dextrose to the fluids, and finally administering subcutaneous basal insulin.
The prioritization of DKA management centers on mitigating life-threatening physiological decompensation. First, the profound osmotic diuresis caused by severe hyperglycemia leads to hypovolemic shock; therefore, restoring intravascular volume with isotonic fluid (0.9%0.9\% sodium chloride) is the paramount initial action. Second, while insulin is the definitive treatment for DKA, this client has a critically low serum potassium of 3.1 mEq/L3.1\text{ mEq/L}. Insulin drives potassium into the intracellular space. Administering insulin before correcting the hypokalemia would cause a precipitous drop in serum potassium, placing the client at imminent risk for fatal ventricular arrhythmias. Thus, intravenous potassium chloride must be infused prior to initiating insulin. Third, once potassium reaches ≥3.3 mEq/L\ge 3.3\text{ mEq/L}, a continuous intravenous insulin infusion is started to halt ketogenesis. Fourth, as blood glucose levels drop to approximately 250 mg/dL250\text{ mg/dL}, 5%5\% dextrose is added to the maintenance fluids to prevent hypoglycemia and subsequent cerebral edema. Finally, once the anion gap has closed and DKA is resolved, subcutaneous basal insulin is administered. The intravenous insulin is continued for 11 to 22 hours post-subcutaneous injection to prevent rebound ketoacidosis.

Step-by-Step Solution

1
Analyze the client's laboratory values and physiological state.
The client is in severe DKA with critical hypokalemia (3.1 mEq/L3.1\text{ mEq/L}).
Identifying life-threatening abnormalities determines the priority of interventions.
2
Determine the priority of initial medical management.
Isotonic fluid resuscitation is the immediate priority.
DKA causes profound osmotic diuresis leading to hypovolemic shock. Restoring perfusion prevents cardiovascular collapse.
3
Evaluate the safety of initiating insulin therapy.
Insulin must be held until the serum potassium is replaced.
Insulin rapidly drives potassium into cells. Administering insulin when serum potassium is <3.3 mEq/L< 3.3\text{ mEq/L} causes fatal hypokalemia and arrhythmias.
4
Sequence the remaining interventions as the client's condition stabilizes.
Insulin is started, followed by adding dextrose when glucose falls, and finally overlapping with subcutaneous insulin.
Dextrose prevents cerebral edema, and overlapping insulin prevents rebound ketoacidosis.

Key Concept

Reduction of Risk Potential: DKA Protocol Sequencing
Question 751Question →

A registered nurse is preparing to administer a mixed dose of NPH and regular insulin to a client with diabetes mellitus. In what order should the nurse perform the following actions to safely prepare the injection? Arrange the steps in the correct sequence.

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Answer

The correct sequence is: roll the NPH vial, cleanse both stoppers, inject air into the NPH vial, inject air into the regular insulin vial, withdraw the regular insulin, and finally withdraw the NPH insulin.
When mixing regular (short-acting, clear) and NPH (intermediate-acting, cloudy) insulin in the same syringe, the nurse must prevent contamination of the regular insulin with the NPH insulin. The correct process follows the 'clear before cloudy' principle. First, the NPH vial is rolled to suspend the particles safely. Both stoppers are cleansed to maintain asepsis. Air is injected into the NPH vial first, then into the regular vial, to equalize pressure without mixing the liquids. The nurse then withdraws the regular (clear) insulin first, followed by the NPH (cloudy) insulin.

Step-by-Step Solution

1
Gently roll the vial of NPH insulin between the palms of the hands.
The suspension is mixed evenly without creating froth.
NPH insulin is a suspension that must be mixed before use; shaking vigorously can cause bubbles that lead to inaccurate dosing.
2
Cleanse the rubber stoppers of both insulin vials with alcohol swabs.
The entry points on the vials are disinfected.
Prevents the introduction of microorganisms into the sterile medication vials.
3
Inject a volume of air equal to the prescribed dose into the NPH insulin vial.
Pressure is equalized in the NPH vial without the needle touching the insulin.
Injecting air prevents a vacuum. Doing this first in the NPH vial prevents accidental contamination later.
4
Inject a volume of air equal to the prescribed dose into the regular insulin vial.
Pressure is equalized in the regular insulin vial.
Prepares the regular insulin vial for immediate withdrawal of the medication.
5
Withdraw the prescribed dose of regular insulin into the syringe.
The short-acting (clear) insulin is drawn into the syringe first.
Drawing the clear insulin first prevents it from being contaminated by the longer-acting NPH insulin.
6
Insert the needle into the NPH insulin vial and withdraw the prescribed dose of NPH insulin.
The intermediate-acting (cloudy) insulin is added, completing the combined dose.
This final step ensures both insulins are accurately mixed in one syringe without altering the rapid action profile of the regular insulin.

Key Concept

Insulin Mixing Sequence (Clear before Cloudy)
Question 752Question →

A nurse is assessing a client who underwent a percutaneous coronary intervention (PCI) via the right femoral artery 2 hours ago. The client suddenly reports a warm, wet sensation in their right groin. The nurse immediately dons clean gloves and observes active arterial bleeding and a rapidly expanding hematoma. Place the following nursing interventions in the correct priority sequence to manage this complication.

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Answer

The correct sequence is: 1) Apply firm manual pressure above the site, 2) Activate the emergency call system, 3) Evaluate blood pressure and heart rate, 4) Assess the affected lower extremity, and 5) Apply a mechanical compression device.
In the event of an arterial hemorrhage post-cardiac catheterization, the nurse's first priority is to stop the bleeding by applying direct pressure slightly above the skin puncture site, following the anatomical track of the needle to the actual arteriotomy. Once pressure is applied, the nurse must immediately summon help without leaving the client. Next, systemic perfusion (vital signs) must be assessed to rule out life-threatening hypovolemic shock, followed by an assessment of the affected limb for localized ischemia. Finally, a definitive pressure dressing or mechanical device is applied once hemostasis is achieved.

Step-by-Step Solution

1
Identify the most immediate life-threatening issue.
The client is experiencing an active arterial hemorrhage from the femoral artery.
According to the ABCs (Airway, Breathing, Circulation) framework, severe arterial bleeding compromises circulation and requires immediate mechanical intervention (pressure) to prevent exsanguination.
2
Determine the next crucial action after controlling the bleeding.
The nurse must activate the emergency call system.
The nurse cannot safely leave the bleeding client to get supplies or call the provider, so help must be summoned directly to the bedside.
3
Prioritize systemic assessment over localized assessment.
Evaluate systemic vital signs, including blood pressure and heart rate.
Systemic perfusion takes priority over limb perfusion. The nurse must determine if the blood loss has caused systemic hemodynamic instability, such as hypovolemic shock.
4
Assess localized complications.
Evaluate the distal pulses, color, and temperature of the affected leg.
After systemic stability is addressed, the nurse must ensure that the hematoma or the applied manual pressure has not completely compromised arterial blood flow to the foot, which could cause tissue ischemia.
5
Identify the final resolution step.
Apply a mechanical compression device or pressure dressing.
This step replaces manual pressure only after hemostasis is successfully achieved and the client is hemodynamically stable.

Key Concept

Prioritization of care for post-cardiac catheterization complications
Question 753Question →

A nurse is preparing to remove a client's non-tunneled central venous catheter (CVC). After performing hand hygiene, donning appropriate personal protective equipment (PPE), and removing the old dressing, in what order should the nurse perform the following actions? Arrange the steps from first to last.

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Answer

The correct sequence for removing a central venous catheter is to first position the client appropriately (supine or Trendelenburg), instruct them to perform the Valsalva maneuver, withdraw the catheter during the maneuver, immediately apply firm pressure to the site, and finally secure an occlusive dressing.
This sequence systematically minimizes the risk of air embolism and bleeding. Proper positioning and the Valsalva maneuver create positive pressure in the central veins prior to removal. Immediate pressure and an occlusive dressing ensure the venous tract remains sealed from the atmosphere after the catheter is removed.

Step-by-Step Solution

1
Position the client supine or in a slight Trendelenburg position.
Central venous pressure is increased.
This reduces the risk of air entering the central veins due to negative pressure.
2
Instruct the client to perform the Valsalva maneuver.
Intrathoracic pressure is elevated.
Creating positive pressure in the chest prevents air from being sucked into the open vein during removal.
3
Withdraw the catheter smoothly.
The catheter is safely removed from the vein.
Removal must occur while the patient is actively bearing down to ensure the vein remains positively pressurized.
4
Apply firm pressure with sterile gauze.
Hemostasis is achieved and the entry point is temporarily sealed.
This prevents bleeding from the highly vascular site and immediately blocks air entry.
5
Apply an occlusive dressing.
The insertion site is completely sealed.
An airtight barrier prevents air from tracking down the subcutaneous tunnel into the vein while the site heals.

Key Concept

Safe removal of a central venous catheter requires meticulous interventions to prevent air embolism, a life-threatening complication caused by air entering the central circulation.
Question 754Question →

A nurse is preparing to administer a scheduled bolus enteral feeding via a percutaneous endoscopic gastrostomy (PEG) tube to a client who is receiving long-term nutritional support. Arrange the following nursing actions in the correct sequence.

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Answer

The correct sequence is to first elevate the head of the bed, then verify tube placement, check the gastric residual volume, flush the tube to ensure patency, and finally administer the feeding formula.
Safe enteral feeding administration follows a logical, safety-oriented progression. Elevating the head of the bed is the critical first step to protect the airway and prevent aspiration. Once the client is positioned safely, verifying placement ensures the tube is properly located in the stomach. Checking residual volume then assesses the client's physiological tolerance of the feeding. Flushing the tube ensures it is patent and clear. Finally, administering the formula is the last step, performed only after all safety parameters have been established.

Step-by-Step Solution

1
Elevate the head of the client's bed to at least 30 to 45 degrees.
The client is placed in a safe position to prevent aspiration.
Airway protection is the absolute priority. Manipulating the tube or feeding a flat client significantly increases the risk of aspiration pneumonia.
2
Verify tube placement by checking the external bumper marking at the stoma site.
The nurse confirms the tube has not migrated.
Ensuring correct tube placement prevents the accidental administration of formula into the peritoneal cavity or respiratory tract.
3
Aspirate to check the gastric residual volume and return the contents to the stomach.
The nurse assesses gastric emptying and prevents electrolyte loss.
High residual volumes indicate delayed gastric emptying. Returning the aspirate prevents acid-base and electrolyte imbalances.
4
Flush the gastrostomy tube with 30 mL of water.
The tube is cleared and patency is confirmed.
Flushing prevents tube clogging and ensures the pathway is clear before introducing the viscous feeding formula.
5
Administer the prescribed bolus feeding formula by gravity.
The client receives the prescribed nutrition.
Formula is administered only after safety checks (positioning, placement, tolerance, and patency) have been completed.

Key Concept

Safe administration of enteral tube feedings requires a sequential approach prioritizing aspiration prevention, verifying placement, assessing gastrointestinal tolerance, and maintaining tube patency.
Question 755Question →

A nurse is instructing a client with right-sided hemiparesis on how to safely ambulate using a single-point cane. Place the following steps of the ambulation sequence in the correct order. (Arrange the items from first to last.)

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Answer

The correct sequence for safe cane ambulation is: hold the cane in the strong hand, advance the cane, step forward with the weak leg, shift weight to the weak leg and cane, and finally step past the cane with the strong leg.
Safe ambulation with a cane requires the 'COAL' method (Cane Opposite Affected Leg). The client must hold the cane in the strong (left) hand. The sequence begins by advancing the cane to create a new, forward base of support. Next, the weak (right) leg is advanced to become even with the cane, ensuring the strong leg remains firmly planted for balance. Once the weak leg and cane are in position, the client shifts their weight onto them. This allows the strong (left) leg to safely step forward past the cane, completing the gait cycle.

Step-by-Step Solution

1
Identify the strong and weak sides based on the client's clinical presentation.
The right side is weak (hemiparesis), making the left side the strong (unaffected) side.
Assistive devices must be properly placed on the strong side to reduce stress on the affected joint or limb and maximize stability.
2
Determine the sequence of the initial forward movement.
The client must first advance the cane.
Advancing the cane establishes a forward base of support before any feet leave the ground.
3
Determine which leg must move first.
The weak (right) leg is advanced to align with the cane.
Moving the weak leg first allows the strong leg to remain firmly planted, providing maximum stability and balance during the vulnerable phase of the step.
4
Complete the gait cycle.
Weight is shifted to the weak leg and cane, allowing the strong (left) leg to advance past the cane.
The strong leg moves last so that it can smoothly propel the body forward while the cane and weak leg securely bear the shifted weight.

Key Concept

Assistive Device Ambulation (Cane Sequence)
Question 756Question →

A nurse is preparing to administer a prescribed parenteral medication from a glass ampule. Arrange the following actions in the correct chronological order to ensure safe preparation. (Place the first action at the top and the final action at the bottom.)

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Answer

The correct sequence is to tap the ampule to clear the stem, protect the fingers with gauze, snap the neck away from the body, draw the medication using a filter needle, and finally replace the filter needle with a standard administration device.
Safe medication preparation from a glass ampule requires a specific sequence to prevent injury and contamination. The medication must first be cleared from the stem to ensure accurate dosing. A barrier (gauze or alcohol swab) is then placed around the neck to protect the nurse's fingers before snapping the top away from the body to protect the face and eyes. A filter needle is essential to draw up the medication safely, preventing microscopic glass shards from entering the syringe. Finally, the filter needle must be discarded and replaced with a standard administration device, as using the same filter needle for injection would deliver trapped glass particles into the client.

Step-by-Step Solution

1
Tap the upper chamber of the ampule lightly.
Trapped medication falls into the lower chamber of the ampule.
This ensures the entire volume of medication is accessible for withdrawal and prevents dosing errors.
2
Wrap a sterile gauze pad or unopened alcohol swab around the neck of the ampule.
The nurse's fingers are shielded by a physical barrier.
This minimizes the risk of laceration from glass shards during the snapping motion.
3
Snap the neck of the ampule firmly and quickly away from the body.
The ampule is safely opened.
Directing the breaking force away from the body protects the nurse's face and eyes from flying glass fragments.
4
Attach a filter needle to a sterile syringe and withdraw the medication.
The prescribed dose is drawn into the syringe free of glass contamination.
When a glass ampule is broken, microscopic shards inevitably fall into the fluid. The filter needle traps these particles.
5
Remove the filter needle and attach an appropriate administration device.
The syringe is safely prepared for client administration.
Using the filter needle for client injection is strictly contraindicated, as it would introduce the trapped glass particles into the client.

Key Concept

Safe medication preparation from a glass ampule
Question 757Question →

A nurse is preparing to administer an intermittent bolus enteral feeding via a nasogastric (NG) tube to an adult client. In what order should the nurse perform the following actions? Arrange the steps in the correct chronological sequence from first to last.

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Answer

The correct sequence is to first elevate the head of the bed, then verify tube placement and check residual volume, flush the tube with water, administer the feeding formula, and finally flush the tube with water again.
Safe administration of an intermittent bolus enteral feeding requires a systematic approach to prevent severe complications such as aspiration or tube occlusion. The nurse must initially elevate the head of the bed to at least 30 to 45 degrees to protect the airway. Next, verifying tube placement and assessing the gastric residual volume ensures the tube remains in the stomach and the client is tolerating previous feedings. Once safety is confirmed, flushing the tube with 30 mL of water confirms patency. The formula is then administered by gravity to prevent rapid infusion complications like dumping syndrome or cramping. Finally, a post-feeding flush clears the viscous formula from the tube, preventing clogs and bacterial growth.

Step-by-Step Solution

1
Elevate the head of the bed.
The client is placed in a semi-Fowler's position.
This utilizes gravity to reduce the risk of gastroesophageal reflux and pulmonary aspiration during the procedure.
2
Verify placement and assess gastric residual volume (GRV).
Tube location in the stomach is confirmed and digestion rate is evaluated.
Ensures the feeding will be delivered to the correct anatomical location and prevents overfilling the stomach.
3
Flush the tube with 30 mL of water.
The internal lumen of the NG tube is cleared.
Confirms the tube is patent and ready to receive the thicker feeding formula.
4
Administer the bolus feeding.
The prescribed nutrition is infused into the client's stomach.
Gravity flow provides a steady, safe rate of administration to prevent nausea or cramping.
5
Perform a post-feeding water flush.
Residual formula is washed out of the tube.
Maintains tube patency for future use and prevents formula from spoiling inside the tube.

Key Concept

Procedural sequencing for safe enteral nutrition administration
Question 758Question →

The nurse is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, pounding headache and profuse diaphoresis above the level of the injury. The blood pressure is 198/104 mm Hg and heart rate is 52 beats per minute. Arrange the following nursing interventions in the correct priority order from first to last.

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Answer

The correct sequence is: Elevate the head of the bed, assess the urinary catheter or bladder, notify the healthcare provider, and administer antihypertensive medication.
The correct sequence prioritizes immediate physiological safety, followed by cause identification, and then medical escalation. Elevating the head of the bed utilizes orthostasis to immediately reduce blood pressure and prevent stroke. Finding and removing the noxious stimulus (commonly bladder distention) treats the root cause. If these measures do not resolve the crisis, the healthcare provider must be notified to provide orders for antihypertensives.

Step-by-Step Solution

1
Identify the complication based on the clinical presentation.
The client with a T4 spinal cord injury presenting with severe hypertension, bradycardia, pounding headache, and diaphoresis is experiencing autonomic dysreflexia.
Recognizing this life-threatening medical emergency is critical for determining the immediate interventions.
2
Determine the most immediate physical intervention to mitigate risk.
Elevate the head of the bed to a high Fowler's or sitting position.
Sitting the client upright takes advantage of gravity to induce orthostatic hypotension, which immediately helps lower the dangerously high blood pressure.
3
Investigate and remove the most likely noxious stimulus causing the reaction.
Assess the urinary catheter or bladder.
A distended bladder or kinked catheter is the most frequent trigger for autonomic dysreflexia. Removing the trigger is essential to stop the sympathetic nervous system response.
4
Escalate the situation and prepare for pharmacological management.
Notify the healthcare provider, followed by administering antihypertensive medications if needed.
If the blood pressure remains elevated after nursing interventions, medical management is required to prevent complications such as a cerebral hemorrhage.

Key Concept

Autonomic dysreflexia is a medical emergency characterized by extreme hypertension in clients with spinal cord injuries at or above T6. The immediate priority is placing the client in a sitting position to mechanically lower blood pressure, followed by identifying and removing the noxious stimulus.
Question 759Question →

A nurse is performing a tubing change on a client's central venous catheter. The tubing accidentally disconnects, and the client suddenly develops severe dyspnea, tachycardia, and a feeling of impending doom. Suspecting an air embolism, arrange the following nursing interventions in the order they should be performed to minimize client risk. All options must be used.

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Answer

The correct sequence is to first clamp the catheter, then position the client in the left lateral Trendelenburg position, administer oxygen, notify emergency personnel, and finally assess vital signs.
When an air embolism is suspected during central line care, prioritizing actions correctly is critical to reduce risk potential. The absolute first priority is to clamp the catheter to stop the source of the air. Next, the nurse must place the client in a left lateral Trendelenburg position (Durant's maneuver) to trap the air in the right ventricle apex. After positioning, 100% oxygen is applied to treat hypoxia and shrink the air bubble by washing out nitrogen. Once these immediate, life-saving actions are complete, the nurse activates the rapid response team. Finally, continuous monitoring and obtaining vital signs are performed while waiting for the team to arrive.

Step-by-Step Solution

1
Stop the source of the embolism.
The central venous catheter is clamped.
Prevents further air entrainment into the venous system, halting the progression of the complication.
2
Reposition the client to trap the air.
The client is placed in the left lateral Trendelenburg position.
This maneuver uses gravity to keep the air embolism in the right side of the heart, reducing the risk of a fatal pulmonary occlusion.
3
Address the resulting hypoxia.
100% oxygen is administered via a non-rebreather mask.
Treats systemic hypoxemia and accelerates the washout of nitrogen, effectively shrinking the air embolus.
4
Summon advanced medical help.
The rapid response team is activated.
The client requires immediate medical evaluation and potentially advanced hemodynamic support or interventions.
5
Monitor the client's physiological status.
A complete set of vital signs is obtained.
Provides essential baseline data on hemodynamic stability to guide further medical treatment once the rapid response team arrives.

Key Concept

Emergency management of a central venous air embolism requires immediate mechanical intervention (clamping and positioning) prior to oxygenation, notification, or assessment.
Question 760Question →

The nurse is preparing to administer a large-volume cleansing enema to an older adult client experiencing severe constipation. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence from first to last.

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Answer

First, prepare the solution and prime the tubing. Second, position the client in the left lateral Sims position. Third, lubricate the rectal tube. Fourth, have the client exhale while inserting the tube toward the umbilicus. Finally, raise the container to the proper height and begin the flow.
Administering a large-volume enema requires a systematic sequence to ensure safety, comfort, and efficacy. The nurse must first prepare the solution and prime the tubing to eliminate air that causes cramping. Next, the client is placed in the left lateral Sims position to take advantage of gravity for fluid flow into the descending colon. After positioning, the nurse lubricates the tube to prevent mucosal trauma. The tube is then inserted gently while the client exhales, following the natural anatomical angle toward the umbilicus. Finally, the container is raised to the correct height (no higher than 18 inches) to establish a safe hydrostatic pressure for the infusion.

Step-by-Step Solution

1
Fill the enema container with warmed solution and flush the administration tubing to remove air.
The enema setup is fully prepared and free of trapped air.
Air introduced into the colon causes severe cramping and discomfort. Preparing equipment beforehand limits the duration the client remains in an uncomfortable or exposed position.
2
Position the client in a left lateral Sims position with the upper knee flexed.
The client is anatomically positioned to receive the enema.
This specific position utilizes gravity to assist the flow of the enema solution directly into the descending colon and sigmoid colon, which are situated on the left side of the body.
3
Lubricate the distal tip of the rectal tube generously with a water-soluble jelly.
The rectal tube is slippery and ready for safe insertion.
Water-soluble lubricant minimizes friction, preventing mechanical trauma or abrasion to the delicate anal sphincter and rectal mucosa.
4
Instruct the client to exhale slowly while inserting the tube 3 to 4 inches toward the umbilicus.
The tube is successfully and safely placed in the rectum.
Exhaling actively relaxes the internal anal sphincter, reducing resistance. Directing the tip toward the umbilicus follows the natural curve of the lower bowel.
5
Raise the enema container no higher than 18 inches above the client's anus and initiate the flow.
The cleansing solution begins to flow at a safe and steady rate.
Raising the bag establishes hydrostatic pressure. Keeping it between 12 to 18 inches ensures the fluid instills at a safe rate; raising it higher causes rapid distention and painful cramping.

Key Concept

Administration of a Large-Volume Cleansing Enema
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