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Question 61Question →

A nurse on a medical-surgical unit realizes that a client has inadvertently received the wrong medication. Arrange the following nursing actions in the correct priority order, from first to last.

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Answer

The correct sequence is to first assess the client, then notify the healthcare provider, implement any new orders, and finally complete the incident report.
When a medication error occurs, the nurse's absolute first priority is client safety. According to the nursing process, the nurse must assess the client and obtain vital signs before taking any other action. Once the client's physiological condition is known, the nurse contacts the healthcare provider with the pertinent assessment data. After receiving and implementing any new orders from the provider to stabilize or treat the client, the nurse completes the facility incident report as a final administrative step.

Step-by-Step Solution

1
Assess the client for adverse reactions and obtain vital signs.
The client's physiological stability and current status are determined.
Assessment is always the first step in the nursing process to ensure immediate client safety.
2
Notify the primary healthcare provider about the medication error.
The provider is made aware of the error and the client's current condition.
The provider needs the assessment data to make informed decisions about necessary counteractive treatments.
3
Implement any new orders prescribed by the provider.
Medical interventions are applied to counteract or monitor the effects of the wrong medication.
Prompt execution of new orders is critical to mitigate potential harm from the error.
4
Complete an objective facility incident report.
The error is formally documented according to facility policy.
Administrative documentation is important for quality improvement but must wait until the client is safe and stable.

Key Concept

Prioritization of Care and Error Management
Question 62Question →

A registered nurse is caring for an adult client admitted with a deep vein thrombosis. The client suddenly becomes frustrated, packs their belongings, and states, 'I am leaving this hospital right now, no matter what.' The client is alert, oriented, and legally competent. Arrange the following nursing actions in the correct sequence to ensure the client's legal rights are protected while minimizing facility liability. (Place the first action at the top and the final action at the bottom.)

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Answer

The correct sequence prioritizes client advocacy and assessment first, followed by chain-of-command notification, ensuring an informed refusal, obtaining legal documentation, and finally comprehensively documenting the event.
The legally sound process for an Against Medical Advice (AMA) discharge requires the nurse to first act as an advocate by assessing the client's concerns. If the issue cannot be resolved, the nurse must notify the provider. Next, the client must be educated on the risks to ensure an 'informed refusal.' Only after risks are explained should the AMA signature be requested. Finally, the nurse must document the entire objective sequence in the medical record to protect against liability.

Step-by-Step Solution

1
Assess the client's reasons for wanting to leave and attempt to resolve their concerns.
The nurse identifies the root cause of the client's frustration.
Advocacy and problem resolution are the primary nursing responsibilities before accepting an AMA discharge.
2
Notify the attending healthcare provider regarding the client's intent to leave against medical advice.
The healthcare provider is made aware of the situation.
The provider must be informed so they can intervene, discuss risks directly with the client, or provide necessary discharge prescriptions.
3
Ensure the client is informed of the specific medical risks and potential complications of leaving the facility.
The client understands the consequences of their decision.
A legal 'informed refusal' requires that the client fully understands the risks of leaving without completing treatment.
4
Request that the client sign the official facility Against Medical Advice (AMA) form.
The facility obtains legal documentation of the client's refusal.
The signed form provides legal protection by acknowledging that the client was informed of risks and chose to leave anyway.
5
Document the client's departure, the education provided, and the refusal of treatment in the medical record.
A permanent, objective record of the event is created.
Comprehensive documentation is the final legal safeguard to protect the nurse and the healthcare facility from liability.

Key Concept

Against Medical Advice (AMA) Procedure and Legal Liability
Question 63Question →

During a midday interdisciplinary huddle on a neurology acute care unit, the nursing staff reviews sudden changes in the conditions of several assigned clients. Which of the following client situations require immediate nursing intervention? Select all that apply.

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Answer: A client with Guillain-Barré syndrome whose forced vital capacity has decreased from 25 mL/kg to 12 mL/kg over the past four hours.; A client with a T6 spinal cord injury who suddenly reports a severe, pounding headache and exhibits profuse diaphoresis.; A client recovering from a traumatic brain injury who develops new-onset restlessness and a widened pulse pressure.

Answer

The situations requiring immediate intervention are the client with Guillain-Barré syndrome experiencing a decrease in forced vital capacity, the client with a T6 spinal cord injury developing a severe headache and diaphoresis, and the client with a traumatic brain injury showing new-onset restlessness and a widened pulse pressure.
The correct choices all describe acute, life-threatening neurological emergencies. A decreasing forced vital capacity in Guillain-Barré syndrome indicates the paralysis has reached the respiratory muscles, which will cause respiratory failure (Airway/Breathing). A sudden severe headache and diaphoresis in a client with an injury at or above T6 are hallmark signs of autonomic dysreflexia, leading to a severe hypertensive crisis (Circulation). New-onset restlessness and a widened pulse pressure in a traumatic brain injury client are components of Cushing's triad, indicating rapidly increasing intracranial pressure (Disability). All three require immediate nursing intervention and provider notification.

Step-by-Step Solution

1
Evaluate each client's presentation against the Airway-Breathing-Circulation (ABC) framework.
The Guillain-Barré client has a breathing/airway threat, the spinal cord injury client has a circulatory threat (hypertensive crisis), and the brain injury client has a severe neurological/disability threat.
Prioritization requires the nurse to address immediate threats to life or profound physiological instability first.
2
Analyze the remaining neurological symptoms to distinguish between expected chronic findings and acute deterioration.
The symptoms presented by the clients with myasthenia gravis and Parkinson's disease are expected chronic manifestations of their respective illnesses.
Clients with expected, stable manifestations of chronic diseases do not require immediate life-saving interventions compared to those with newly developing acute complications.

Key Concept

Prioritizing Acute Neurological Emergencies Over Expected Chronic Findings
Question 64Question →

An alert and oriented 78-year-old client with end-stage heart failure is admitted to the progressive care unit. The client explicitly requests a "Do Not Resuscitate" (DNR) status and refuses any future mechanical ventilation. The client's adult child, who is the legally designated healthcare proxy, arrives and demands that the healthcare team "do everything possible," including intubation if necessary. Which of the following ethical nursing actions should the nurse take? Select all that apply.

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Answer: Communicate the client's explicit end-of-life wishes to the primary healthcare provider.; Explain to the adult child that the healthcare proxy designation is only active if the client loses decision-making capacity.; Reassure the client that their right to refuse medical treatment will be respected by the healthcare team.

Answer

The correct actions are to communicate the client's wishes to the provider, explain the limitations of the healthcare proxy to the adult child, and reassure the client that their autonomous decisions will be respected.
The core ethical principle of autonomy guarantees a competent client the right to make their own healthcare decisions, including the refusal of life-sustaining treatment. A healthcare proxy (durable power of attorney for healthcare) only holds decision-making authority when the client is deemed legally or clinically incompetent. Therefore, the nurse must advocate for the client by ensuring their wishes are immediately communicated to the provider for formal orders, educating the family on these legal boundaries, and validating the client's autonomous choices.

Step-by-Step Solution

1
Assess the client's current competency and decision-making capacity.
The client is alert, oriented, and competent to make healthcare decisions.
Competency determines who holds the legal right to dictate the plan of care.
2
Identify the ethical conflict between the client's autonomy and the family member's demands.
The client's right to refuse treatment supersedes the adult child's wishes, as a healthcare proxy is only enacted when the client is incapacitated.
Ethical practice requires prioritizing the competent client's autonomy over surrogate demands.
3
Select interventions that advocate for the client's rights.
The nurse must notify the provider to obtain the DNR order, educate the family on legal boundaries, and support the client emotionally.
These actions directly uphold the principles of autonomy, veracity, and advocacy without causing harm or unnecessary delay.

Key Concept

Client Autonomy and Healthcare Proxy Activation
Question 65Question →

A registered nurse is preparing to initiate a patient-controlled analgesia (PCA) pump with intravenous morphine for a client who is two hours post-operative. To ensure client safety and prevent medication errors, which of the following actions should the nurse perform? (Select all that apply.)

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Answer: Verify the pump settings, medication concentration, and client identification independently with a second registered nurse.; Assess the client's cognitive and physical ability to understand instructions and independently press the dosing button.; Maintain continuous pulse oximetry or capnography monitoring to detect early signs of respiratory depression.

Answer

The nurse must verify pump settings with a second registered nurse, assess the client's cognitive and physical ability to use the PCA independently, and maintain continuous respiratory monitoring.
Patient-controlled analgesia (PCA) involves high-alert medications (opioids) that pose a significant risk for overdose and respiratory depression. Safe initiation requires an independent double-check by two registered nurses to prevent programming and calculation errors. The nurse must also ensure the client is cognitively intact and physically capable of pressing the button themselves, as PCA by proxy is strictly prohibited. Furthermore, continuous pulse oximetry or capnography is critical to monitor for adverse effects such as hypoxia or hypoventilation.

Step-by-Step Solution

1
Identify the high-risk nature of patient-controlled analgesia (PCA).
Recognize that IV opioids pose a significant risk for respiratory depression and require strict safety protocols.
High-alert medications have a narrow therapeutic index and high potential for client harm if a medication error occurs.
2
Evaluate mandatory error-prevention steps prior to initiating the infusion.
Confirm the requirement for an independent double-check by two RNs and the use of an actual measured weight for dose calculation.
Independent verification and precise math calculations prevent pump programming and dosage errors.
3
Analyze safe delegation and ongoing monitoring requirements.
Determine that baseline assessments cannot be delegated to UAP, and continuous capnography/pulse oximetry is necessary.
Only registered nurses hold the scope of practice for initial clinical assessments, and continuous monitoring mitigates the risk of unrecognized respiratory failure.
4
Review standards for intravenous line safety.
Identify that checking IV compatibility is mandatory before administering any secondary medication into the PCA line.
Incompatible drugs can crystallize in the tubing, preventing the analgesic from reaching the client or causing an embolus.

Key Concept

Patient-Controlled Analgesia (PCA) Safety and Medical Error Prevention
Question 66Question →

An oncology nursing team consists of a registered nurse (RN) and an unlicensed assistive personnel (UAP). They are providing care for several clients receiving active treatment for various malignancies. Which of the following tasks are appropriate for the RN to delegate to the UAP? Select all that apply.

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Answer: Emptying a closed-wound drainage device and recording the output volume for a client recovering from a mastectomy; Assisting a client with mild chemotherapy-induced stomatitis to perform oral hygiene using a normal saline rinse; Applying a protective skin barrier paste to the intact skin around a client's established colostomy stoma

Answer

The correct tasks to delegate are emptying the closed-wound drainage device, assisting with oral hygiene, and applying barrier paste to an established colostomy stoma.
The RN can safely delegate routine tasks that have predictable outcomes and do not require nursing assessment, clinical judgment, or teaching. Emptying a closed-wound drainage device, assisting with normal saline oral hygiene, and applying barrier paste to an established colostomy stoma are all standard, unchanging procedures that fall within the scope of practice for a UAP.

Step-by-Step Solution

1
Analyze the scope of practice for an unlicensed assistive personnel (UAP).
UAPs can perform routine, standard, and unchanging tasks that do not require clinical judgment, nursing assessment, or client teaching.
Delegation decisions must adhere to National Council of State Boards of Nursing (NCSBN) guidelines and the five rights of delegation.
2
Evaluate the options for tasks involving assessment and clinical judgment.
Assessing an intravenous site for extravasation and monitoring a client during the first 15 minutes of a blood transfusion require RN-level clinical judgment and cannot be delegated.
These activities involve interpreting clinical data and identifying potential high-risk complications.
3
Evaluate the options for tasks involving client education.
Teaching family members about neutropenic precautions is an RN responsibility.
Providing initial education and evaluating the comprehension of complex safety protocols are strictly outside the UAP's scope of practice.
4
Identify the routine, standard tasks appropriate for the UAP.
Emptying a drainage device, assisting with oral hygiene, and applying skin barrier paste to an established stoma are appropriate.
These are routine activities of daily living (ADLs) or standard procedures with predictable outcomes performed on stable clients.

Key Concept

Delegation of Care to Unlicensed Assistive Personnel (UAP)
Question 67Question →

Analyze the following nursing interventions and clinical scenarios. Match each specific nursing action on the left with the core ethical principle it primarily demonstrates or violates on the right.

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Items

Documenting that a client tolerated a procedure well while deliberately omitting their expressions of extreme distress to avoid an incident report.
Advocating for an uninsured, unhoused client to receive the exact same priority for physical therapy resources as a privately insured client.
Supporting a competent adult client's decision to legally refuse life-saving mechanical ventilation despite the family's aggressive demands to treat.
Questioning and withholding a provider's prescription for a standard dose of digoxin for a client presenting with critical hypokalemia.
Staying at the bedside of an anxious client during a painful procedure exactly as promised, while delegating other routine tasks to assistive personnel.

Matches

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Answer

The correct pairings are: omitting distress in documentation matches Veracity; advocating for equal resources matches Justice; supporting treatment refusal matches Autonomy; withholding digoxin during hypokalemia matches Nonmaleficence; and keeping a bedside promise matches Fidelity.
Each nursing action directly corresponds to a fundamental ethical principle. Veracity requires truthfulness in documentation. Justice demands fair allocation of care regardless of status. Autonomy respects the client's right to choose or refuse treatment. Nonmaleficence requires nurses to protect clients from harm, such as withholding dangerous medication. Fidelity requires keeping promises and honoring commitments to clients.

Step-by-Step Solution

1
Analyze the first scenario regarding documentation omission.
The nurse is not telling the truth about the client's tolerance of the procedure.
Truth-telling in clinical practice and documentation is governed by the principle of Veracity.
2
Examine the second scenario regarding the uninsured client.
The nurse is ensuring fair and equal treatment across different socioeconomic backgrounds.
Equitable distribution of care and resources is the core of Justice.
3
Evaluate the third scenario regarding the refusal of mechanical ventilation.
The nurse is upholding the client's right to make their own healthcare decisions over the family's wishes.
The right to self-determination and independent decision-making represents Autonomy.
4
Assess the fourth scenario regarding withholding digoxin.
The nurse prevents potential harm, as hypokalemia increases the risk of fatal digoxin toxicity.
The fundamental duty to prevent harm to the client is defined as Nonmaleficence.
5
Analyze the fifth scenario regarding staying with the client as promised.
The nurse honors a specific commitment made to the client despite competing priorities.
Keeping promises and maintaining loyalty to the client represents Fidelity.

Key Concept

Core Ethical Principles in Nursing Practice
Question 68Question →

A registered nurse (RN) on a surgical step-down unit plans to delegate a sterile wound dressing change to a licensed practical/vocational nurse (LPN/VN). Place the RN's actions in the correct chronological order according to the National Council of State Boards of Nursing (NCSBN) delegation process.

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Answer

The correct sequence is: Assess the client, verify competency, provide specific instructions, observe/supervise periodically, and finally evaluate outcomes and provide feedback.
According to the NCSBN National Guidelines for Nursing Delegation, the delegation process follows a systematic sequence: 1) Assess and plan (evaluating client stability), 2) Communicate (providing clear directions to a competent delegatee), 3) Surveillance and supervision (monitoring the performance), and 4) Evaluation and feedback (reviewing the outcomes). Verifying competency is a critical component that immediately follows client assessment to ensure the 'Right Person' is chosen before providing instructions.

Step-by-Step Solution

1
Assess the client
Determines client stability and task appropriateness.
Delegation must always begin with an assessment of the client's current needs.
2
Verify competency
Confirms the delegatee is legally and institutionally permitted to perform the task.
The RN is responsible for ensuring the right person is assigned the right task.
3
Provide instructions
Establishes clear expectations and communication parameters.
The delegatee needs to know exactly what to do and when to report back (Right Direction/Communication).
4
Supervise periodically
Ensures the task is being executed safely and correctly.
The RN retains accountability and must provide appropriate surveillance (Right Supervision).
5
Evaluate and give feedback
Closes the delegation loop by reviewing outcomes and performance.
Evaluation is an exclusive RN responsibility that cannot be delegated.

Key Concept

NCSBN Delegation Process
Question 69Question →

The infection prevention coordinator is reviewing isolation protocols for a newly opened pediatric and adult infectious disease unit. Match each client's clinical presentation to the precise combination of transmission-based precautions required according to standard clinical guidelines.

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Items

A young adult client from a university dormitory presenting with acute bilateral parotitis and fever
An infant presenting with severe, watery diarrhea and dehydration confirmed as a rotavirus infection
An adult client with a history of night sweats presenting with severe hoarseness and a persistent, blood-tinged cough
A pediatric client admitted with severe pneumonia and concurrent purulent conjunctivitis, suspected to be adenovirus

Matches

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Answer

The client with acute parotitis (mumps) pairs with Standard and Droplet Precautions. The infant with rotavirus pairs with Standard and Contact Precautions. The client with hoarseness and a blood-tinged cough (suspected laryngeal TB) pairs with Standard and Airborne Precautions. The pediatric client with suspected adenovirus pairs with Standard, Droplet, and Contact Precautions.
Correct isolation depends on the pathogen's primary and secondary modes of transmission. Mumps requires Droplet Precautions. Rotavirus requires Contact Precautions due to fecal-oral transmission. Laryngeal TB requires Airborne Precautions due to a high risk of aerosolization. Adenovirus uniquely requires a combination of Droplet and Contact Precautions.

Step-by-Step Solution

1
Analyze the clinical presentation of the young adult with acute bilateral parotitis.
Identified as mumps.
Mumps is a classic respiratory virus transmitted via large droplets, indicating the need for Droplet Precautions (surgical mask).
2
Analyze the clinical presentation of the infant with rotavirus.
Identified as a highly contagious gastrointestinal pathogen.
Rotavirus is transmitted via the fecal-oral route and survives well on environmental surfaces, requiring Contact Precautions (gown and gloves).
3
Analyze the clinical presentation of the adult with night sweats, hoarseness, and hemoptysis.
Identified as highly suspicious for laryngeal or pulmonary tuberculosis.
Tuberculosis is transmitted via small airborne droplet nuclei, requiring a negative-pressure room and N95 respirator (Airborne Precautions).
4
Analyze the clinical presentation of the pediatric client with pneumonia and conjunctivitis.
Identified as a suspected adenovirus infection.
Adenovirus is unique because it is highly contagious through both large respiratory droplets and direct contact with ocular/respiratory secretions, thus requiring both Droplet and Contact Precautions.

Key Concept

Selecting the correct combination of transmission-based precautions by identifying the specific epidemiological transmission routes of various infectious pathogens.
Question 70Question →

The hospital's emergency response plan has been activated due to a nearby industrial explosion, creating an urgent need to free up inpatient beds for incoming victims. The charge nurse on a medical-surgical unit is identifying current clients who can be safely discharged. Which of the following clients should the nurse recommend for immediate discharge? Select all that apply.

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Answer: A client admitted 24 hours ago for observation of a minor head injury who has a normal neurological assessment.; A client scheduled for a routine elective inguinal hernia repair later this afternoon.; A client who is 48 hours post-operative from an uncomplicated appendectomy and is tolerating a regular diet.

Answer

The clients who should be recommended for discharge are the client admitted for observation of a minor head injury, the client scheduled for an elective hernia repair, and the client who is 48 hours post-operative from an appendectomy.
During an emergency response that requires freeing up inpatient beds, clients who are the most clinically stable and require the least amount of ongoing nursing care should be discharged first. The client with a normal neurological assessment after a minor head injury, the client scheduled for a non-urgent elective procedure, and the client recovering well after an uncomplicated surgery are all hemodynamically stable and safe to discharge.

Step-by-Step Solution

1
Analyze the scenario and the goal of the emergency operations plan.
The goal is to rapidly and safely discharge current inpatients to accommodate an influx of disaster victims.
Understanding the objective establishes the criteria for discharge: identifying the most clinically stable clients.
2
Evaluate the clinical stability and ongoing care needs of each client in the options.
Clients needing continuous intravenous infusions or frequent respiratory treatments are highly unstable. Clients awaiting elective procedures, those with resolved minor injuries, and those recovering well post-operatively are stable.
Applying the ABCs (Airway, Breathing, Circulation) and Maslow's Hierarchy of Needs helps separate acute, life-threatening needs from routine care.
3
Select the clients who can safely continue their care at home.
The observation client, the elective surgery client, and the appendectomy client are selected.
These clients have the lowest risk of sudden deterioration and do not require acute nursing interventions.

Key Concept

During an external disaster with a mass casualty influx, the emergency response plan includes discharging the most stable clients (e.g., those awaiting elective surgery, those ready for routine discharge, or those requiring minimal care) to free up beds for critically ill incoming victims.
Estimated Time:1m 0s
Question 71Question →

A nurse is preparing to enter the room of a client placed on airborne and contact precautions. The nurse has gathered the necessary personal protective equipment (PPE). In what order should the nurse don the PPE? Arrange the steps in the correct sequence from first to last.

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Answer

The correct sequence is: 1. Perform hand hygiene, 2. Don the isolation gown, 3. Apply the N95 respirator, 4. Place the face shield or goggles, and 5. Don clean gloves.
The Centers for Disease Control and Prevention (CDC) guidelines establish a specific sequence for donning personal protective equipment (PPE) to maximize protection and minimize the risk of cross-contamination. Hand hygiene is universally performed first. The isolation gown is applied next because it provides foundational body coverage. The N95 respirator is applied and seal-checked before eyewear so the straps do not interfere with the goggles. Eye protection follows. Finally, gloves are donned last so they can be pulled securely over the gown's cuffs, establishing a continuous protective barrier.

Step-by-Step Solution

1
Identify the first priority before handling clean PPE.
Perform hand hygiene.
Hand hygiene removes existing pathogens from the hands and ensures the clean PPE remains uncontaminated during the donning process.
2
Select the piece of PPE that provides core body coverage.
Don the isolation gown.
The gown covers the torso and arms and must be tied securely behind the neck and waist to prevent shifting during patient care.
3
Apply respiratory protection.
Apply the N95 respirator.
The respirator must be fitted directly to the face before applying eye protection to ensure the straps are positioned correctly and the seal is completely intact.
4
Apply eye protection.
Place the face shield or goggles.
Eye protection sits over or adjacent to the respirator, providing droplet and splash protection for the mucous membranes of the eyes without interfering with the respirator.
5
Apply the final barrier.
Don clean gloves.
Gloves are placed last so they can be stretched over the edges of the gown cuffs, sealing the wrists and completing the continuous barrier.

Key Concept

Personal Protective Equipment (PPE) Donning Sequence
Question 72Question →

A triage nurse in a primary care clinic is reviewing intake notes for four awaiting clients. Which client requires immediate medical evaluation?

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Answer: A client who sustained a minor head injury yesterday and now presents with projectile vomiting and lethargy

Answer

The client who sustained a head injury and is now exhibiting projectile vomiting and lethargy requires immediate evaluation.
Projectile vomiting without nausea and increasing lethargy following a head injury are classic, emergent signs of increased intracranial pressure (ICP). This represents an acute, life-threatening neurological deterioration that mandates immediate medical intervention over chronic or expected clinical findings.

Step-by-Step Solution

1
Evaluate the first client's symptoms (dry mouth, dark urine) in the context of their recent illness.
Symptoms indicate mild to moderate dehydration from gastroenteritis, which is expected and not immediately life-threatening.
To determine if fluid loss has progressed to an acute shock state requiring priority intervention.
2
Assess the second client's presentation of projectile vomiting and lethargy following a head injury.
These are classic signs of increased intracranial pressure (ICP), representing an acute and potentially fatal neurological deterioration.
To identify acute, unexpected complications that compromise airway, breathing, circulation, or neurological stability.
3
Review the remaining clients for acute versus chronic findings.
The client with venous insufficiency has expected chronic skin changes, and the client with Alzheimer's disease has an expected chronic progressive cognitive decline.
To apply the 'acute versus chronic' framework to rule out non-emergent presentations.
4
Compare all client presentations to identify the highest priority.
The client with signs of increased ICP is the only one experiencing an acute, life-threatening emergency.
To ensure prioritization aligns with the principles of immediate risk to life or limb.

Key Concept

Prioritization using the 'acute versus chronic' and 'unexpected versus expected' frameworks, specifically recognizing signs of increased intracranial pressure.
Question 73Question →

A client admitted with septic shock is currently receiving a continuous intravenous (IV) infusion of pantoprazole through a single peripheral IV catheter. The client's blood pressure drops to 74/42 mmHg74/42\text{ mmHg} with a heart rate of 122 bpm122\text{ bpm}, prompting the healthcare provider to prescribe a stat continuous IV infusion of norepinephrine. Upon checking a pharmacological reference, the nurse discovers that norepinephrine and pantoprazole are incompatible at the Y-site. Which action should the nurse take first?

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Answer: Pause the pantoprazole, flush the IV catheter with normal saline, and immediately initiate the norepinephrine.

Answer

The most appropriate action is to pause the pantoprazole infusion, thoroughly flush the intravenous catheter with normal saline, and immediately initiate the norepinephrine infusion.
The client is experiencing profound hypotension associated with septic shock and urgently requires vasopressor support to maintain tissue perfusion. When two incompatible medications are ordered for a client with single intravenous access, the nurse must prioritize the life-saving drug. Pantoprazole (a proton pump inhibitor) can be safely paused while the emergency vasopressor is initiated. The line must be thoroughly flushed with a compatible solution, such as normal saline, before and after the change to prevent chemical precipitation in the tubing or catheter.

Step-by-Step Solution

1
Assess the client's clinical status and recognize the immediate life-threatening priority.
The client's blood pressure of 74/42 mmHg indicates severe hemodynamic instability requiring urgent intervention.
Airway, Breathing, and Circulation (ABC) prioritization dictates that life-threatening shock must be addressed before routine or prophylactic therapies.
2
Evaluate the intravenous access and medication compatibility.
The client has only one patent IV line, and the required life-saving norepinephrine is incompatible with the currently infusing pantoprazole.
Co-administering incompatible medications can cause dangerous chemical precipitation, leading to catheter occlusion or fatal emboli.
3
Execute the safest and most rapid intervention to restore systemic circulation.
The non-critical pantoprazole infusion is paused, the line is flushed with compatible normal saline, and the norepinephrine is initiated.
This action immediately delivers the critical vasopressor without risking chemical incompatibility. A secondary IV line can be established subsequently without delaying life-saving care.

Key Concept

Prioritization of life-saving intravenous therapies and emergency management of drug incompatibilities.
Question 74Question →

A nurse evaluates a client with distributive shock who is receiving a continuous intravenous (IV) infusion of norepinephrine through a peripheral venous catheter in the right forearm. The nurse observes that the skin around the insertion site is severely blanched, cold to the touch, and edematous. Which of the following actions should the nurse perform? Select all that apply.

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Answer: Stop the norepinephrine infusion immediately.; Attach a syringe to the IV hub and aspirate residual medication.; Prepare to administer prescribed subcutaneous phentolamine around the affected site.

Answer

The correct actions are to stop the infusion immediately, attach a syringe to aspirate any residual medication, and prepare to administer subcutaneous phentolamine.
Norepinephrine is a potent vesicant that causes severe vasoconstriction, leading to localized tissue ischemia and necrosis if extravasation occurs. The immediate priorities are to stop the infusion to halt further infiltration, aspirate any residual drug from the catheter to minimize tissue exposure, and prepare to administer an alpha-adrenergic antagonist, such as phentolamine, into the surrounding tissues to induce vasodilation and restore perfusion.

Step-by-Step Solution

1
Identify signs of vesicant extravasation.
The nurse recognizes blanching, coldness, and edema as indicators of norepinephrine tissue infiltration.
Norepinephrine is a severe vesicant that causes intense vasoconstriction, requiring immediate intervention to prevent tissue necrosis.
2
Halt the medication delivery.
The norepinephrine infusion is stopped immediately.
Stopping the pump prevents any additional vesicant from entering the subcutaneous tissue.
3
Evacuate the remaining medication.
A syringe is used to aspirate residual drug from the catheter hub while leaving the catheter in place.
Aspiration removes the vesicant without pushing it further into the tissue, minimizing damage and maintaining a route if intravenous antidote administration is required by protocol.
4
Administer the specific antidote.
Phentolamine is prepared for subcutaneous injection around the site.
Phentolamine reverses the severe localized vasoconstriction and ischemia caused by the extravasated norepinephrine.

Key Concept

Vesicant Extravasation Management
Question 75Question →

A nurse is assisting a healthcare provider with a bedside thoracentesis for a client diagnosed with a right-sided pleural effusion. Which nursing actions are appropriate to reduce the risk of procedural complications? Select all that apply.

Select all that apply

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Answer: Ensure the client is positioned upright, leaning forward with arms resting on an overbed table.; Instruct the client to refrain from coughing, taking deep breaths, or talking during needle insertion.; Verify that the client's most recent coagulation studies and platelet count have been evaluated prior to the procedure.

Answer

The correct actions include positioning the client upright and leaning forward, instructing them to avoid coughing or deep breathing, and verifying coagulation studies prior to the procedure.
To reduce the risk of potential complications during a thoracentesis, the nurse must ensure interventions promote safe access to the pleural space, prevent bleeding, and monitor for respiratory distress. Positioning the client upright and leaning forward widens the intercostal spaces. Instructing the client to avoid moving or coughing prevents the needle from puncturing the lung. Verifying coagulation studies minimizes the risk of severe bleeding.

Step-by-Step Solution

1
Analyze the procedure and its inherent risks.
Identify that a thoracentesis involves inserting a needle into the pleural space, carrying high risks for lung puncture, bleeding, and respiratory decompensation.
Understanding potential complications guides the prioritization of clinical safety measures.
2
Evaluate pre-procedure and positioning interventions.
Upright positioning expands intercostal spaces safely; verifying coagulation labs prevents excessive bleeding.
These actions directly reduce anatomical and physiological risks associated with needle insertion.
3
Evaluate intra-procedure and post-procedure priorities.
The RN must directly monitor the client's stability, and immediate post-procedure focus must be on respiratory status (ABCs), not peripheral pulses.
Ensures early detection of life-threatening complications such as tension pneumothorax or hypovolemic shock.

Key Concept

Thoracentesis Risk Reduction and Safety
Question 76Question →

A nurse is developing a plan of care for an adult client recovering from a right-sided cerebrovascular accident (stroke), which has resulted in left-sided hemiplegia and dysphagia. Which basic care and comfort interventions should the nurse include in the client's plan? Select all that apply.

Select all that apply

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Answer: Position the client upright at 90 degrees with the chin tucked slightly downward during meals.; Support the affected left arm with pillows while the client is resting in a chair.; Perform passive range-of-motion (ROM) exercises on the affected extremities to maintain joint mobility.

Answer

The correct interventions are positioning the client upright with the chin tucked during meals, supporting the affected arm with pillows, and performing passive range-of-motion exercises.
Providing basic care for a client with stroke-related deficits focuses on safety, maintaining physical function, and promoting comfort. Upright positioning with a chin tuck is essential for safe swallowing and aspiration prevention. Supporting the hemiplegic arm prevents painful shoulder subluxation. Finally, passive range-of-motion exercises maintain joint mobility and prevent contractures in the paralyzed limbs.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has a right-sided CVA resulting in left-sided hemiplegia and dysphagia.
Identifying the specific physical and neurological deficits determines the necessary basic care and comfort interventions.
2
Evaluate the proposed interventions for dysphagia management.
Upright positioning with a chin tuck is required to prevent aspiration; delegating initial assessment and utilizing supine positioning post-meals are unsafe and contraindicated.
Dysphagia significantly increases aspiration risk, dictating safe feeding practices, RN-led assessments, and appropriate positioning.
3
Evaluate the proposed interventions for hemiplegia and immobility.
Supporting the affected arm and performing passive ROM are correct; immediate application of restraints without alternatives is inappropriate.
Immobile limbs require physical support and consistent movement to prevent contractures, avoid subluxation, and promote overall comfort.

Key Concept

Basic care and comfort for a client with hemiplegia and dysphagia involves strict airway protection during and after feeding, joint mobility maintenance, and safe delegation practices.
Question 77Question →

A client who underwent the surgical creation of a descending colostomy two days ago reports abdominal discomfort and asks for assistance with pouch maintenance before going to sleep. Which nursing action is most appropriate to promote the client's comfort and physical hygiene?

Show answer & explanation

Answer: Empty the ostomy appliance when it is one-third to one-half full to prevent the weight of the effluent from pulling on the skin barrier.

Answer

The most appropriate action is to empty the ostomy appliance when it is one-third to one-half full.
Emptying the ostomy appliance before it becomes too full (typically at one-third to one-half capacity) is a fundamental comfort and hygiene measure. As the pouch fills with effluent and gas, it becomes heavy. This added weight can pull on the adhesive skin barrier, leading to a compromised seal, leakage of acidic stool onto the sensitive peristomal skin, and significant physical discomfort. Maintaining a lighter pouch before sleep ensures the skin remains protected, the seal stays intact, and the client can rest comfortably.

Step-by-Step Solution

1
Identify the client's primary needs based on the clinical scenario.
The client requires comfort measures and ostomy pouch maintenance two days post-surgery.
Understanding the timeline (2 days post-op) highlights the vulnerability of the new stoma and the surgical incision.
2
Evaluate the positioning intervention for safety.
Prone positioning is determined to be unsafe.
Lying on the abdomen places direct pressure on the newly created stoma and incision, which would increase pain and risk tissue damage.
3
Evaluate the delegation intervention for scope of practice compliance.
Delegating the stoma assessment is outside the UAP's scope of practice.
Evaluating stoma color and skin integrity requires specialized nursing judgment and must be performed by the registered nurse.
4
Evaluate the communication approach.
The statement is non-therapeutic and dismissive.
Using 'why' questions induces defensiveness, and telling the client they will 'get used to it' minimizes their current discomfort.
5
Determine the safest and most effective comfort measure.
Emptying the pouch at one-third to one-half capacity is the correct action.
This prevents the appliance from becoming excessively heavy, which protects the skin barrier seal and prevents irritating leaks.

Key Concept

Ostomy Pouch Maintenance and Client Comfort
Question 78Question →

A nurse is developing a plan of care for an older adult client who is receiving continuous enteral tube feedings and is on bedrest due to generalized weakness. Which of the following interventions should the nurse include in the client's plan of care to promote basic care, comfort, and safety? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Maintain the head of the bed at an elevation of 30 to 45 degrees at all times.; Provide comprehensive oral hygiene every 4 hours using a soft-bristled toothbrush.; Apply a moisture barrier ointment to the perineal skin after each incontinent episode.

Answer

The correct interventions are maintaining the head of the bed at an elevation of 30 to 45 degrees, providing comprehensive oral hygiene every 4 hours, and applying a moisture barrier ointment to the perineal skin.
Maintaining the head of the bed elevated prevents aspiration of continuous enteral feedings. Providing frequent oral hygiene keeps the mucosa moist and intact, while applying a moisture barrier protects the skin from breakdown due to incontinence. These actions directly support basic care, comfort, and physiological safety.

Step-by-Step Solution

1
Analyze the client's clinical presentation and risks.
The client is an older adult on bedrest receiving continuous enteral tube feedings, placing them at high risk for aspiration, skin breakdown, and poor oral hygiene.
Identifying the client's risk factors determines the appropriate basic care and comfort interventions.
2
Evaluate each intervention for safety and clinical appropriateness.
Head elevation, oral care, and moisture barriers are safe and indicated. Flat positioning, delegating assessments, and dismissing new incontinence are unsafe or incorrect actions.
Nursing interventions must align with standard practice guidelines and the legal scope of practice.

Key Concept

Basic care and comfort for a client on continuous enteral feedings requires interventions that maintain skin integrity, promote oral health, and prevent aspiration without compromising safety or proper delegation.
Question 79Question →

After receiving the morning handoff report, a nurse reviews the prescribed therapies and planned interventions for four clients. Which planned intervention poses the highest risk for severe client injury and must be questioned immediately?

Show answer & explanation

Answer: Administering a scheduled dose of intravenous ceftriaxone as a secondary piggyback through a continuous infusion of Lactated Ringer's solution.

Answer

The planned intervention of administering intravenous ceftriaxone through a continuous infusion of Lactated Ringer's solution poses the highest risk and must be questioned.
Administering intravenous ceftriaxone alongside Lactated Ringer's is strictly contraindicated. Lactated Ringer's is a calcium-containing solution, and calcium binds with ceftriaxone to form a precipitate. This precipitate can lodge in the microvasculature of the lungs and kidneys, leading to life-threatening emboli and organ failure. Preventing this specific medication error is a critical safety priority.

Step-by-Step Solution

1
Analyze each planned intervention for potential safety hazards, adverse effects, or protocol violations.
Identified that three interventions are standard safe practices, while one presents a critical physiological risk.
Prioritization requires identifying the action that poses an immediate threat to the client's life or limb.
2
Evaluate the intravenous compatibility of ceftriaxone and Lactated Ringer's solution.
Lactated Ringer's contains calcium, which is strictly incompatible with ceftriaxone.
Understanding pharmacological contraindications is a core component of accident and error prevention.
3
Determine the clinical consequence of this incompatibility.
Mixing these solutions creates calcium-ceftriaxone crystals (precipitate) that can lodge in the lungs and kidneys, causing fatal organ failure.
This establishes the intervention as the highest priority error requiring immediate prevention.

Key Concept

Preventing adverse clinical events requires verifying intravenous medication compatibility, specifically avoiding the potentially fatal combination of ceftriaxone and calcium-containing solutions like Lactated Ringer's.
Estimated Time:1m 30s
Question 80Question →

A nurse in a gastrointestinal outpatient clinic is instructing a client with a new colostomy on how to independently change their one-piece ostomy pouching system at home. In what order should the client be taught to perform these actions? Arrange the steps in the correct sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: remove the used pouch, cleanse and dry the stoma and skin, measure the stoma, cut the opening on the new barrier, and apply the new skin barrier.
When changing an ostomy pouch, the client must first carefully remove the old appliance. The peristomal area is then cleaned with warm water and dried completely to ensure a healthy, residue-free skin surface. Next, the stoma is measured, as its size decreases over time. The client then cuts the skin barrier to fit the measurement, leaving a small gap (about 1/8 inch) to avoid strangulating the stoma. Finally, the protective backing is removed, and the appliance is pressed firmly onto the skin to create a secure, leak-free seal.

Step-by-Step Solution

1
Remove the used pouch and skin barrier.
The old appliance is detached without trauma.
Pushing the skin away from the adhesive prevents mechanical skin stripping.
2
Cleanse the stoma and surrounding skin.
The skin is free of effluent and old adhesive.
Warm water is sufficient; soaps can leave residue. The skin must be completely dry for the new barrier to adhere properly.
3
Measure the stoma using the template.
The exact current size of the stoma is determined.
Stoma size fluctuates, especially in the first few months, requiring measurement before each change.
4
Cut the opening on the new skin barrier.
A custom hole is prepared for the stoma.
The hole should be about 1/8 inch larger than the stoma to prevent constriction while protecting the peristomal skin.
5
Apply the new skin barrier firmly.
The new appliance is securely attached.
Pressing firmly ensures a proper seal, which prevents leaks and skin breakdown.

Key Concept

Ostomy Self-Care and Appliance Management
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