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Question 61Question →

A registered nurse is preparing to enter the airborne infection isolation room (AIIR) of a client admitted with disseminated varicella-zoster virus. The client requires both airborne and contact precautions. Arrange the following steps for donning personal protective equipment (PPE) in the correct chronological order from first to last.

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Answer

The correct sequence for donning PPE is: 1) Perform hand hygiene, 2) Don isolation gown, 3) Place N95 respirator, 4) Apply face shield or goggles, 5) Put on clean gloves.
According to CDC guidelines, the standard sequence for donning PPE begins with hand hygiene to prevent contaminating the clean PPE. Next, the isolation gown is applied to cover the body. The N95 respirator is placed next to ensure a proper seal against the face, followed by eye protection (goggles or face shield). Finally, gloves are donned last so they can securely cover the cuffs of the gown, completing the barrier.

Step-by-Step Solution

1
Identify the appropriate transmission-based precautions for disseminated varicella-zoster virus.
Determine that Airborne and Contact precautions, plus standard precautions, are required.
Disseminated varicella spreads through both aerosolized airborne particles and direct contact with lesions.
2
Select the first action in the standard CDC PPE donning sequence.
Identify hand hygiene as the starting step.
Hands must be clean before touching clean PPE to prevent transmission of pathogens onto the equipment.
3
Select the first piece of physical PPE to don.
Identify the isolation gown.
The gown covers the torso and arms, providing the largest area of protection, and is secured at the neck and waist before applying facial gear.
4
Determine the correct order for facial protection.
Place the N95 respirator first, followed by the face shield or goggles.
The N95 respirator must be applied directly to the face to ensure an adequate seal; eye protection is then placed over the top.
5
Identify the final step in the sequence.
Put on clean gloves.
Gloves are placed last so they can be pulled up and over the cuffs of the isolation gown, closing any gaps at the wrists.

Key Concept

Standard and Transmission-Based Precautions: PPE Donning Sequence
Question 62Question →

A nurse is assisting with the delivery of a newborn. Immediately after birth, the newborn is apneic and limp. Arrange the following neonatal resuscitation interventions in the correct chronological sequence according to standard clinical guidelines.

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Answer

The correct sequence is to first warm, dry, and stimulate the newborn; then evaluate the respiratory effort and heart rate; next, initiate positive-pressure ventilation if needed; followed by chest compressions if the heart rate remains critically low; and finally, administer epinephrine if all previous steps fail.
The Neonatal Resuscitation Program (NRP) algorithm dictates a step-wise approach based on the newborn's response. The foundational steps are to provide warmth, dry, and stimulate. This is immediately followed by an evaluation of heart rate and breathing. If the infant is apneic or the heart rate is less than 100 beats/min, positive-pressure ventilation (PPV) is the critical next intervention. If the heart rate falls below 60 beats/min despite effective PPV, chest compressions are initiated. Finally, if the heart rate remains below 60 beats/min despite PPV and compressions, epinephrine is administered.

Step-by-Step Solution

1
Perform initial steps of resuscitation.
The newborn is placed on a radiant warmer, dried, and stimulated.
These actions prevent cold stress, clear the airway, and encourage spontaneous respirations.
2
Assess the newborn's physiological status.
Respiratory effort and heart rate are evaluated.
Assessment determines the need for advanced resuscitation measures based on the standard algorithm.
3
Provide ventilatory support.
Positive-pressure ventilation (PPV) is initiated.
PPV is required if the newborn remains apneic, is gasping, or has a heart rate less than 100 beats/min.
4
Perform circulatory support.
Chest compressions are started.
Compressions are indicated if the heart rate remains less than 60 beats/min despite effective PPV.
5
Administer emergency medications.
Epinephrine is administered.
Medication is used as a last resort when the heart rate remains less than 60 beats/min despite PPV and compressions.

Key Concept

Neonatal Resuscitation Program (NRP) Algorithm
Question 63Question →

A nurse is preparing to transfer a client who has bilateral lower extremity weakness from a hospital bed to a wheelchair using a one-person assist technique. Place the following steps in the sequence the nurse should perform them.

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Answer

The correct sequence begins with positioning and locking the wheelchair, followed by assisting the client to dangle on the bed edge, applying the transfer belt, assisting the client to stand, and finally pivoting to sit in the wheelchair.
The correct sequence prioritizes environmental safety first by placing and locking the wheelchair in an optimal position. Once the environment is secure, the client is brought to a sitting position to stabilize their blood pressure and establish a firm base of support. Only after the client is safely seated should the transfer belt be applied. Finally, the nurse and client execute a coordinated stand, pivot, and sit maneuver, ensuring the client secures their balance by reaching for the armrests before lowering into the chair.

Step-by-Step Solution

1
Position the wheelchair at a 45-degree angle to the bed on the client's stronger side and lock the wheels.
The environment is safe and ready for the transfer.
Locking the brakes prevents the chair from moving out from under the client, and positioning it on the stronger side allows the client to use their intact strength to assist with the pivot.
2
Assist the client to sit on the edge of the bed and ensure both feet are resting flat on the floor.
The client establishes balance and a stable base of support.
Dangling allows the cardiovascular system to adjust to the position change, preventing orthostatic hypotension, while flat feet provide stability.
3
Apply the transfer belt securely around the client's waist, over their clothing.
The nurse secures a safe handhold for the upcoming lift.
The belt must be applied while the client is seated upright to ensure a snug fit that will not slide up the rib cage during the transfer.
4
Stand facing the client, grasp the transfer belt on both sides, and cue the client to stand on the count of three.
The client is safely assisted to a standing position.
Using a coordinated countdown and proper grips prevents sudden, jerky movements and protects both the client and the nurse from musculoskeletal injury.
5
Pivot with the client toward the wheelchair and instruct them to reach back for the armrests before sitting.
The client is safely seated in the wheelchair.
Reaching back for the armrests ensures the wheelchair is directly behind the client and provides additional upper body support during the descent.

Key Concept

Safe Client Transfer and Mobility
Question 64Question →

A nurse is monitoring a client who is 15 minutes into a packed red blood cell (PRBC) transfusion. The client suddenly reports severe lower back pain, chills, and a feeling of impending doom. The nurse observes that the client's urine in the Foley catheter tubing has become dark red. Arrange the following nursing interventions in the correct order of priority from first to last.

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Answer

The correct sequence is to first stop the transfusion, then disconnect the blood tubing, maintain access with normal saline using new tubing, assess the client's vital signs, and finally notify the provider and blood bank.
In any severe adverse reaction to a parenteral infusion, especially a blood product, the absolute first priority is to stop the infusion to prevent further harm. Following this, the nurse must ensure the toxic substance is disconnected and secure patent IV access using entirely new tubing and a compatible solution (0.9% sodium chloride). Once the immediate threat of further exposure is mitigated and the airway/circulation is supported with IV access, the nurse gathers assessment data (vital signs) to provide an accurate SBAR report to the healthcare provider and blood bank for further emergency orders.

Step-by-Step Solution

1
Stop the blood transfusion immediately.
Further administration of incompatible blood is halted.
The client is exhibiting classic signs of an acute hemolytic transfusion reaction (flank pain, chills, hemoglobinuria). The source of the antigen must be eliminated instantly.
2
Disconnect the blood administration set from the client's intravenous catheter.
The blood tubing is completely separated from the client.
This prevents the remaining blood in the IV tubing from entering the client's bloodstream during subsequent interventions.
3
Attach new intravenous tubing primed with 0.9% sodium chloride and maintain the infusion.
Venous access is maintained with a safe, compatible solution.
Patent IV access is critical for administering emergency medications (e.g., vasopressors, diuretics) and IV fluids to maintain renal perfusion. Flushing the old tubing would push more incompatible cells into the client, which is a lethal error.
4
Assess the client's vital signs and respiratory status.
Baseline data on the severity of the reaction is obtained.
The nurse needs current hemodynamic and respiratory parameters to accurately communicate the client's status to the healthcare provider.
5
Notify the healthcare provider and the hospital blood bank.
Medical intervention is ordered and the facility's reaction protocol is initiated.
The provider will prescribe treatments to manage shock and preserve renal function. The blood bank must receive the remaining blood and tubing to determine the cause of the incompatibility.

Key Concept

Management of Acute Hemolytic Transfusion Reaction
Question 65Question →

A 68-year-old client is receiving mechanical ventilation in the intensive care unit following a coronary artery bypass graft. The client's oxygen saturation drops to 89%, and auscultation reveals coarse crackles over the mainstem bronchi. The nurse prepares to perform open endotracheal suctioning. To reduce the risk of severe hypoxia and mucosal trauma, arrange the following procedural steps in the correct sequence.

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Answer

The correct sequence requires the nurse to first hyperoxygenate the client, safely advance the catheter without suction, reposition the tip to protect the carina, apply intermittent suction during withdrawal, and conclude with re-oxygenation and assessment.
Endotracheal suctioning carries significant physiological risks, including profound hypoxemia, cardiac dysrhythmias (often due to vagal stimulation), and mucosal trauma. Proper procedural sequencing mitigates these risks. The nurse must initially hyperoxygenate the client to establish a protective oxygen reserve. Next, the catheter is advanced without suction to avoid unnecessary oxygen depletion and mucosal stripping. Once resistance is met or a cough is stimulated (indicating the catheter has reached the carina), the nurse must pull the catheter back 1 to 2 centimeters to avoid applying direct suction to the sensitive carinal tissue. Suction is then applied intermittently while rotating the catheter during withdrawal, strictly limited to 10 to 15 seconds to prevent dangerous oxygen desaturation. Finally, the nurse provides post-suction hyperoxygenation and assesses the client's clinical response to ensure airway patency.

Step-by-Step Solution

1
Hyperoxygenate the client with 100% oxygen.
The client's oxygen reserve is maximized prior to the intervention.
Suctioning extracts oxygen along with secretions; pre-oxygenation is critical to prevent dangerous hypoxemia and subsequent cardiac dysrhythmias.
2
Advance the catheter into the artificial airway without applying suction.
The catheter reaches the level of the carina safely.
Applying suction during advancement strips oxygen from the airway prematurely and increases the likelihood of mucosal tearing.
3
Withdraw the catheter 1 to 2 centimeters.
The suction tip is repositioned off the carinal tissue.
Resting the catheter directly on the carina while applying suction causes severe mucosal trauma and can trigger a dangerous vagal response.
4
Apply intermittent suction while rotating and withdrawing.
Airway secretions are effectively cleared from the respiratory tract.
Rotating the catheter prevents it from adhering to one area of the mucosa, and limiting the time to 10-15 seconds mitigates prolonged airway occlusion.
5
Reassess the client and hyperoxygenate.
The client's respiratory status stabilizes.
Post-oxygenation replenishes lost oxygen, and auscultation confirms whether further suctioning is necessary.

Key Concept

To minimize complications such as hypoxemia, dysrhythmias, and mucosal trauma during endotracheal suctioning, strict adherence to evidence-based sequencing—including hyperoxygenation, suction-free insertion, carinal protection, and strict time limits on suction—is required.
Question 66Question →

A nurse is caring for a conscious client with diabetes mellitus who suddenly becomes diaphoretic, tachycardic, and reports feeling shaky. In what order should the nurse perform the following actions? Arrange the actions in the correct sequence from first to last.

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Answer

The correct sequence follows the 'Rule of 15' for hypoglycemia management: First, check the blood glucose level; second, administer 15 grams of a fast-acting carbohydrate; third, recheck the blood glucose in 15 minutes; and finally, provide a complex carbohydrate and protein snack.
The sequence follows standard physiological adaptation protocols for acute hypoglycemia, known as the 'Rule of 15'. The nurse must first confirm the suspected hypoglycemia with a capillary blood glucose check to ensure safe practice. Once confirmed, 15 grams of a fast-acting carbohydrate is administered because it absorbs rapidly to correct the deficit. The nurse then waits 15 minutes and re-evaluates the blood glucose to confirm the intervention worked. Finally, because simple sugars metabolize quickly, a complex carbohydrate and protein snack is given to stabilize the blood sugar and prevent a rebound hypoglycemic episode.

Step-by-Step Solution

1
Assess the client's current status.
Capillary blood glucose is measured.
Objective data is required to validate the clinical signs of diaphoresis and shakiness.
2
Provide rapid intervention.
15 grams of simple carbohydrates are absorbed quickly.
Fast-acting carbohydrates immediately reverse the acute hypoglycemic state.
3
Evaluate the intervention.
Blood glucose is rechecked after exactly 15 minutes.
Reassessment determines if another 15 grams of carbohydrates is needed or if the crisis has resolved.
4
Stabilize the physiological state.
A complex carbohydrate and protein snack is consumed.
Slower-digesting macronutrients provide sustained glucose release to prevent a secondary crash.

Key Concept

Hypoglycemia Management Protocol (Rule of 15)
Estimated Time:45s
Question 67Question →

A nurse is educating a client who sustained a right fractured tibia and is prescribed non-weight-bearing status on the affected leg. The client is learning how to ascend a flight of stairs using a three-point crutch gait. Arrange the following instructions in the correct chronological sequence.

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Answer

The correct sequence involves establishing a tripod position, shifting weight completely to the crutches, advancing the unaffected leg to the step, transferring weight to the unaffected leg, and finally bringing the crutches and affected leg up to the same step.
When ascending stairs with crutches, the client must first establish a stable base (tripod position) and support their body weight on the crutches. This securely frees the unaffected (strong) leg to be lifted onto the step. Once the strong leg is on the higher step, the client shifts their weight onto it, utilizing the strength of the unaffected leg to elevate the rest of the body. Finally, the crutches and the affected leg are brought up to the same step. This exact sequence follows the fundamental orthopedic principle of 'up with the good'.

Step-by-Step Solution

1
Analyze the client's clinical status and the requested procedure.
The client is non-weight-bearing on the right leg and must safely ascend stairs using a three-point gait.
Understanding the weight-bearing status dictates which extremity must support the client's weight during the elevation change.
2
Identify the foundational physiological rule for crutch walking on stairs.
The core rule is 'up with the good, down with the bad'. The unaffected leg always leads when ascending.
This principle ensures the strong leg performs the lifting work against gravity while the affected leg remains protected.
3
Determine the chronological sequence of the physical movements.
Tripod stance -> weight to crutches -> step up with strong leg -> weight to strong leg -> bring up crutches and weak leg.
This specific sequence maintains continuous stability and prevents falls while navigating the stairs.

Key Concept

Assistive Device Ambulation: Three-Point Gait Stair Ascent
Question 68Question →

A nurse is removing a client's central venous access device (CVAD). As the catheter is withdrawn, the client suddenly gasps, reports severe chest pain, and becomes acutely dyspneic. The oxygen saturation drops abruptly to 83%. Suspecting a venous air embolism, in what order should the nurse perform the following actions? (Arrange the items in the correct sequence from first to last.)

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Answer

The correct sequence for managing a suspected venous air embolism is: 1) Apply an occlusive dressing, 2) Position in left lateral Trendelenburg, 3) Administer 100% oxygen, 4) Activate rapid response, and 5) Monitor and prepare for CPR.
In the event of a venous air embolism, the nurse must act immediately to prevent cardiovascular collapse. The first action is always source control: sealing the entry point (occlusive dressing) to prevent more air from entering. The second immediate action is positioning the client in the left lateral Trendelenburg position (Durant's maneuver), which uses gravity to trap the air in the apex of the right ventricle, away from the pulmonary valve. Third, administering 100% oxygen treats hypoxia and shrinks the nitrogen-rich air bubble. Only after these immediate, life-saving nursing actions are taken should the nurse leave the client's side to call the rapid response team and continue monitoring for cardiac arrest.

Step-by-Step Solution

1
Apply a sterile occlusive dressing over the insertion site.
Stops further entry of air into the venous system.
During inspiration, negative intrathoracic pressure can draw significant amounts of room air into an open central venous tract. Source control is the paramount first step.
2
Place the client in the left lateral Trendelenburg position.
Traps the air embolism in the right ventricle.
This specific positioning (Durant's maneuver) utilizes buoyancy. It keeps the air bubble away from the pulmonary valve, maintaining blood flow and preventing cardiovascular collapse.
3
Administer 100% oxygen via a non-rebreather mask.
Treats severe hypoxia and shrinks the air bubble.
Room air is primarily nitrogen. Providing 100% oxygen creates a concentration gradient that pulls nitrogen out of the air bubble and into the bloodstream to be exhaled, reducing the bubble's size.
4
Activate the rapid response team and notify the healthcare provider.
Secures advanced medical intervention.
After immediate life-saving nursing actions are completed, emergency medical support is required for further stabilization and potential diagnostic procedures.
5
Continuously monitor vital signs and prepare for resuscitation.
Ensures readiness for acute decompensation.
The client is at extreme risk for obstructive shock and cardiac arrest. Continuous monitoring allows for immediate recognition of deterioration.

Key Concept

Venous Air Embolism Emergency Management (Durant's Maneuver)
Question 69Question →

A severe hurricane has caused catastrophic structural damage and total power failure at a long-term care and rehabilitation center. The incident commander orders an immediate, full-scale facility evacuation. Arrange the following client evacuation steps in the order the nursing supervisor should prioritize them, from first to last.

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Answer

The correct sequence is to evacuate ambulatory clients first, followed by wheelchair-bound clients, then stable bedbound clients, and finally clinically unstable clients requiring life-support.
In a facility-wide disaster evacuation, the principle of doing the greatest good for the greatest number applies. Evacuation occurs in reverse order of medical acuity. Ambulatory clients are evacuated first because they require minimal assistance, clearing the facility quickly. Those needing wheelchairs follow. Bedbound but stable clients are next, as they require stretchers and more staff. Finally, unstable clients requiring intensive care and life support are evacuated last, as their transport is highly complex, resource-heavy, and requires specialized external vehicles.

Step-by-Step Solution

1
Identify the type of emergency and the required response protocol.
The scenario dictates a rapid, full-scale facility evacuation due to an imminent external/structural threat.
Understanding the context is required to determine which triage or prioritization framework applies.
2
Apply the principles of disaster evacuation prioritization.
The overarching goal shifts to doing the greatest good for the greatest number of people with the limited resources available.
In mass casualty or emergency evacuation situations, normal clinical prioritization is inverted to save the most lives quickly.
3
Order the client groups based on their mobility and the staff resources required to move them.
Ambulatory clients (least resources) are moved first, followed by wheelchair-dependent, then bedbound, and finally the most unstable clients (most resources).
Moving the most mobile clients first quickly secures their safety and clears physical pathways, preventing bottlenecks for the more difficult extractions that follow.

Key Concept

Disaster Evacuation Prioritization
Estimated Time:1m 15s
Question 70Question →

A nurse has just completed suctioning the tracheostomy of a client infected with methicillin-resistant Staphylococcus aureus (MRSA) in the sputum. The client is on contact and droplet precautions. The nurse is wearing a gown, gloves, a face shield, and a surgical mask. Place the following steps for removing personal protective equipment (PPE) in the correct chronological order.

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Answer

The correct sequence for removing PPE is: 1) Remove gloves, 2) Remove face shield, 3) Remove gown, 4) Remove surgical mask, 5) Perform hand hygiene.
The standard sequence for removing PPE ensures that the most contaminated items are removed first while minimizing the risk of self-contamination. Gloves are the most contaminated and are removed first, followed by eyewear (face shield or goggles) handled by the clean straps. The gown is then removed by pulling it away from the neck and rolling it inside out. The mask is removed next by handling only the ties. Finally, hand hygiene is performed immediately to destroy any pathogens transferred during the removal process.

Step-by-Step Solution

1
Remove and discard gloves.
The most contaminated PPE is safely removed.
Prevents cross-contamination of the head, face, and uniform during subsequent doffing steps.
2
Remove the face shield by handling the clean headband.
Facial protection is discarded without touching the contaminated front.
The outside of the shield is heavily contaminated; handling only the clean band protects the eyes and mucous membranes.
3
Untie the gown and pull it downward, rolling it inside out.
The gown is bundled and discarded.
Rolling the gown inside out traps the contaminated exterior surface within the bundle.
4
Remove the surgical mask by handling the ties or elastic bands.
The mask is safely discarded.
The front of the mask is highly contaminated from droplet exposure; touching only the ties prevents hand contamination.
5
Perform hand hygiene.
Pathogens are completely removed from the hands.
Ensures any transient flora transferred to the hands during the doffing process are eliminated.

Key Concept

The chronological sequence for removing (doffing) personal protective equipment (PPE) to minimize the risk of self-contamination.
Question 71Question →

A client with acute kidney injury is admitted to the intensive care unit. The client's serum potassium level is 7.57.5 mEq/L (7.57.5 mmol/L), and the bedside cardiac monitor shows a widened QRS complex with tall, peaked T waves. The healthcare provider prescribes several interventions. In what order should the nurse execute these actions? Arrange the sequence from first to last.

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Answer

The correct sequence is to first administer intravenous calcium gluconate, followed by intravenous regular insulin and 50%50\% dextrose, then auscultate for bowel sounds, administer oral sodium polystyrene sulfonate, and finally draw a venous blood sample for reassessment.
The management of severe hyperkalemia with electrocardiographic changes follows a strict physiological priority to prevent cardiac arrest. Calcium gluconate is administered first to immediately stabilize the cardiac membrane. Next, regular insulin and dextrose rapidly shift potassium from the intravascular space into the intracellular space. Before administering sodium polystyrene sulfonate for permanent potassium removal, the nurse must assess for bowel sounds to prevent intestinal necrosis. Finally, a repeat blood draw evaluates the effectiveness of these sequential interventions.

Step-by-Step Solution

1
Recognize life-threatening hyperkalemia with cardiac toxicity and administer intravenous calcium gluconate.
The cardiac membrane is stabilized.
Widened QRS complexes indicate an imminent risk of ventricular fibrillation. Calcium immediately antagonizes the cardiac toxicity of hyperkalemia without actually lowering the potassium level.
2
Administer intravenous regular insulin and 50%50\% dextrose.
Potassium is shifted temporarily into the intracellular space.
This is the fastest method (acting within 1515 to 3030 minutes) to reduce circulating serum potassium levels and further protect the heart.
3
Auscultate the abdomen for bowel sounds.
Gastrointestinal motility is confirmed.
Sodium polystyrene sulfonate can cause fatal colonic necrosis if administered to a client with a paralytic ileus. Bowel function must be verified first.
4
Administer oral sodium polystyrene sulfonate.
Potassium binds in the gastrointestinal tract for excretion.
This provides a permanent reduction in total body potassium, though it takes several hours to become effective.
5
Draw a venous blood sample for a repeat basic metabolic panel.
The client's response to therapy is evaluated.
Laboratory reassessment must be performed after interventions have had adequate time to alter the serum potassium concentration.

Key Concept

Prioritization of severe hyperkalemia management follows a specific physiological sequence: stabilize the myocardium, shift potassium intracellularly, remove potassium from the body, and evaluate therapy.
Question 72Question →

A nurse is preparing to transfer a client with right-sided weakness from the bed to a wheelchair. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence.

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Answer

The correct sequence is: Position the wheelchair on the strong side and lock wheels, assist the client to sit on the edge of the bed, apply a transfer belt, face the client and brace the weak knee, and finally instruct the client to push off and pivot using their strong side.
Safe transfer of a client with unilateral weakness requires a systematic approach that maximizes the use of the client's strong side while providing structural support to the weak side. The sequence begins with environmental preparation (placing the chair on the strong left side and locking wheels), followed by positioning the client safely on the bed edge. A gait belt is then applied for safety, and the nurse assumes a stance that supports the weak right leg. Finally, the physical pivot is executed using the strong side.

Step-by-Step Solution

1
Determine the optimal placement for the wheelchair.
The wheelchair is placed on the client's left (unaffected) side at a 45-degree angle with wheels locked.
Always transfer toward the strong side so the client can bear weight and pivot safely without collapsing.
2
Mobilize the client to a ready position.
The client sits on the edge of the bed with feet flat on the floor.
Sitting on the edge allows the client to stabilize physically and prevents orthostatic hypotension before standing.
3
Secure safety equipment.
A transfer belt is applied securely around the client's waist.
The belt provides a firm handhold for the nurse, significantly reducing the risk of dropping or injuring the client.
4
Establish a supportive stance.
The nurse faces the client, holds the belt, and braces the client's weak right knee with their own knee.
Bracing the affected knee prevents it from buckling when the client attempts to bear weight during the transfer.
5
Execute the transfer.
The client pushes off the bed, stands, pivots on the left leg, and gently sits in the wheelchair.
Using the strong arm and leg maximizes the client's independence and safety during the pivoting motion.

Key Concept

Safe client transfer techniques prioritizing weight-bearing on the unaffected side and proper use of safety equipment.
Question 73Question →

A nurse is caring for an oliguric client diagnosed with an acute kidney injury. The laboratory reports a stat serum potassium level of 8.28.2 mEq/L (8.28.2 mmol/L). The continuous bedside cardiac monitor suddenly displays widening QRS complexes and absent P waves. Arrange the following collaborative interventions in the priority sequence they should be implemented. (Place the most immediate life-saving action first and the final evaluative action last.)

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Answer

The correct sequence prioritizes immediate life safety, followed by myocardial stabilization, intracellular potassium shifting, potassium elimination, and therapeutic evaluation.
The correct sequence is rooted in the physiological principles of resuscitation and prioritization. Activating the emergency response system is the first step for any client facing imminent arrest. Following this, the absolute priority in severe hyperkalemia with ECG changes is preventing ventricular fibrillation; intravenous calcium gluconate achieves this within minutes by raising the threshold potential of the myocardium. Once the heart is protected, intravenous insulin and dextrose are administered to rapidly shift potassium out of the serum and into the cells, temporarily resolving the critical serum concentration. Because the potassium is still in the body, sodium polystyrene sulfonate is then administered to bind potassium in the gut for permanent excretion. Finally, drawing a follow-up serum potassium level evaluates the effectiveness of the entire intervention cascade.

Step-by-Step Solution

1
Call for the rapid response team while remaining at the client's bedside.
Additional medical personnel and resuscitation equipment are mobilized.
Severe hyperkalemia with widening QRS complexes indicates imminent cardiac arrest; the nurse must secure help without abandoning the unstable client.
2
Administer intravenous calcium gluconate.
The myocardial threshold potential is stabilized.
Calcium acts immediately to antagonize the toxic effects of potassium on the heart, preventing lethal dysrhythmias. It does not lower serum potassium but buys time for other treatments.
3
Administer intravenous regular insulin concurrently with 50% dextrose.
Potassium is forced from the bloodstream into the intracellular space.
This intervention rapidly but temporarily lowers the serum potassium level, reducing the immediate metabolic threat.
4
Administer oral sodium polystyrene sulfonate.
Potassium is bound in the intestines and excreted in the stool.
Because insulin only temporarily shifts potassium, a removal mechanism is required to permanently eliminate the excess total body potassium.
5
Obtain a follow-up serum potassium level.
Current laboratory values are collected.
The final step of the nursing process is evaluation, ensuring the interventions successfully corrected the severe hyperkalemia.

Key Concept

The emergency management of severe hyperkalemia with ECG changes follows a strict physiological priority: stabilize the myocardium (calcium), shift potassium intracellularly (insulin/dextrose), excrete potassium from the body (cation-exchange resins/dialysis), and evaluate the response.
Question 74Question →

A nurse is caring for a client who is 2 days postoperative following open abdominal surgery. The client coughs forcefully, and the nurse observes that the surgical incision has completely separated with loops of bowel protruding from the wound. In what order should the nurse perform the following actions? Arrange the actions in the correct sequence from first to last.

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Answer

The correct sequence is to first stay with the client and call for assistance, then place the client in a low Fowler's position with knees flexed, cover the viscera with sterile saline-moistened dressings, obtain vital signs, and finally prepare the client for surgery.
Wound evisceration is an acute medical emergency. The priority is to maintain patient safety by staying with them and calling for help. Immediately reducing intra-abdominal pressure by bending the knees and raising the head slightly prevents further organ protrusion. Protecting the exposed tissue with moist, sterile dressings prevents irreversible necrosis. Once the tissue is stabilized, monitoring for shock via vital signs and preparing for definitive surgical repair follow in logical sequence.

Step-by-Step Solution

1
Stay with the client and call for assistance.
Help is summoned while the client remains under continuous observation.
Leaving the client could result in severe anxiety or further mechanical injury to the protruding bowel.
2
Place the client in a low Fowler's position with knees flexed.
Abdominal muscle tension is significantly reduced.
This physical maneuver minimizes intra-abdominal pressure, effectively halting further evisceration.
3
Cover the protruding viscera with sterile dressings moistened with sterile normal saline.
The exposed bowel is protected from drying out and potential infection.
Tissue necrosis can occur rapidly if the highly vascular bowel tissue becomes dry.
4
Obtain vital signs.
The client's current hemodynamic status is established.
Evisceration can lead to rapid third-spacing of fluids and shock, requiring careful cardiovascular monitoring.
5
Prepare the client for surgery.
The client is readied for definitive surgical repair.
This is a life-threatening surgical emergency that cannot be resolved at the bedside.

Key Concept

Management of Wound Evisceration
Question 75Question →

A nurse is preparing to administer a mixed dose of NPH insulin and regular insulin to a client with diabetes mellitus. Arrange the steps of the medication preparation procedure in the correct chronological order.

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Answer

The correct sequence is to first roll the NPH vial, then 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 NPH (intermediate-acting) and regular (short-acting) insulin, the standard safety protocol is 'clear before cloudy' for drawing up the medication, while injecting air follows the 'cloudy before clear' sequence. Rolling the NPH vial first safely suspends the particles. Injecting air into the NPH vial first, followed by the regular vial, ensures pressure is equalized without transferring medication. Withdrawing the regular insulin first ensures that if any accidental transfer occurs, the short-acting regular insulin remains uncontaminated, preventing dangerous alterations to its rapid onset and peak times.

Step-by-Step Solution

1
Roll the NPH insulin vial.
The NPH suspension is evenly mixed.
Mixing ensures accurate dosing, and rolling (instead of shaking) prevents the formation of air bubbles.
2
Inject air into the NPH vial.
Air is added to the NPH vial without insulin touching the needle.
Prevents a vacuum from forming later. It is done first so the needle is still completely clean and empty.
3
Inject air into the regular insulin vial.
Air is added to the regular insulin vial.
Equalizes pressure in the vial to make withdrawing the medication easier.
4
Withdraw the regular insulin.
The correct dose of regular insulin is drawn into the syringe.
Drawing the clear (regular) insulin first prevents it from being contaminated by the cloudy (NPH) insulin.
5
Withdraw the NPH insulin.
The correct dose of NPH insulin is added to the syringe.
Completes the mixture. The exact dose must be drawn carefully, as you cannot push mixed insulin back into the vial.

Key Concept

Insulin Mixing Sequence (Clear before Cloudy)
Question 76Question →

A nurse enters a client's room and discovers a small fire in the wastebasket. The client is resting in bed, receiving intravenous fluids, and is physically unharmed but highly anxious. According to standard internal disaster protocols, arrange the nurse's immediate actions in the correct priority sequence.

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Answer

The correct sequence adheres to the RACE (Rescue, Alarm, Confine, Extinguish) and PASS (Pull, Aim, Squeeze, Sweep) protocols: First, rescue the client; second, activate the alarm; third, confine the fire by closing the door; fourth, prepare the extinguisher by pulling the pin; and finally, aim and sweep at the base of the fire.
The correct sequence strictly follows the universally accepted nursing emergency response protocols for a fire: RACE (Rescue, Alarm, Confine, Extinguish) and PASS (Pull, Aim, Squeeze, Sweep). The nurse must prioritize human life above all else by rescuing the client first. Activating the alarm follows immediately to ensure hospital-wide response. Confining the fire by closing the door limits damage and smoke spread. Only after these steps are complete should the nurse attempt to extinguish the fire using the proper mechanical technique.

Step-by-Step Solution

1
Relocate the client from the room to a designated safe area beyond the fire doors.
The client is removed from immediate danger.
Life safety is the highest priority. The 'Rescue' phase must occur before any other action to prevent injury or fatality.
2
Trigger the facility's emergency fire alarm system to alert emergency services.
Facility staff and local fire departments are mobilized.
The 'Alarm' phase ensures that additional resources and personnel are deployed to manage the disaster.
3
Shut the door to the client's room tightly to restrict oxygen flow and contain smoke.
The fire is isolated to its room of origin.
The 'Confine' phase minimizes oxygen supply to the fire and protects the rest of the unit from toxic smoke inhalation.
4
Obtain a fire extinguisher from the corridor and pull the safety pin from the handle.
The fire extinguisher is unlocked and ready to discharge.
Once the area is secure and alarms are active, the 'Extinguish' phase begins by applying the first step of the PASS technique.
5
Aim the extinguisher nozzle at the base of the flames and sweep from side to side.
The extinguishing agent targets the fuel source, suppressing the fire.
Proper extinguisher technique is essential to successfully put out a small fire without spreading the flames.

Key Concept

Internal Disaster Management: Fire Emergency Response (RACE and PASS protocols)
Question 77Question →

A nurse is caring for a client who sustained a complete cervical spinal cord injury at the C6 level two months ago. The client suddenly reports an intense, pounding headache and blurred vision. The nurse notes profound diaphoresis on the client's face and neck, nasal congestion, and a blood pressure reading of 214/112 mm Hg. Arrange the following nursing interventions in the correct priority order from first to last to mitigate the risk of severe complications.

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Answer

The correct sequence prioritizes immediate physiological safety using gravity to lower blood pressure, followed by the systematic removal of the most statistically probable noxious stimuli, and finally escalating to pharmacological intervention.
In autonomic dysreflexia, a noxious stimulus below the level of the spinal cord injury causes an uninhibited sympathetic response, leading to severe hypertension. The nurse must first lower the blood pressure immediately by sitting the client upright. Next, the nurse must systematically search for and eliminate the trigger, starting with external factors (tight clothing), then the most common internal factor (bladder distention), followed by the next most common (bowel impaction). Antihypertensive medications are a last resort if the trigger cannot be found or resolving it does not lower the blood pressure.

Step-by-Step Solution

1
Elevate the head of the bed to a high-Fowler's position.
Immediate induction of orthostatic hypotension.
Rapidly decreases blood pressure to mitigate the immediate risk of stroke or hemorrhage.
2
Loosen any constrictive clothing or tight devices.
Removal of external sensory triggers.
Tight clothing is a common, easily reversible noxious stimulus that triggers sympathetic surging.
3
Assess the urinary drainage system for kinks or obstruction.
Identification or resolution of bladder distention.
A distended bladder is the leading cause of autonomic dysreflexia and must be addressed before invasive measures.
4
Evaluate the rectum for fecal impaction using a topical anesthetic.
Identification of bowel distention.
Bowel impaction is the second most common trigger; anesthetic ointment prevents further sympathetic stimulation during the exam.
5
Administer the prescribed as-needed intravenous antihypertensive agent.
Pharmacological reduction of blood pressure.
Used only when non-invasive removal of noxious stimuli fails to lower the life-threatening blood pressure.

Key Concept

Autonomic Dysreflexia Emergency Management
Estimated Time:1m 30s
Question 78Question →

A nurse is monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs) for severe anemia. Ten minutes after the infusion begins, the client reports sudden, intense lower back pain and a feeling of impending doom. The nurse notes that the client is tachycardic, tachypneic, and hypotensive. To safely manage this suspected acute hemolytic transfusion reaction and reduce the risk of further physiological compromise, arrange the following nursing actions in the correct priority sequence.

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Answer

The correct sequence is to first stop the transfusion, then replace the tubing to infuse saline, conduct a rapid assessment, notify the provider and blood bank, and finally collect the necessary diagnostic specimens.
In a suspected acute hemolytic transfusion reaction, the primary goal is to minimize physiological harm. The nurse must immediately stop the exposure (halt transfusion), maintain systemic perfusion and venous access without introducing more blood (attach new tubing with saline), evaluate the client's current status (rapid assessment), communicate findings for medical intervention (notify HCP), and finally assist in determining the cause and extent of the injury (collect specimens).

Step-by-Step Solution

1
Stop the transfusion.
The influx of the incompatible blood product is halted.
Continuing the transfusion exacerbates the immune response, increasing the risk of acute kidney injury and cardiovascular collapse.
2
Change the IV tubing and initiate normal saline.
Intravenous access is maintained without infusing residual blood.
Flushing the existing tubing would push more incompatible blood into the client. A new primed line ensures safe volume expansion to treat hypotension and maintain renal perfusion.
3
Assess the client.
Current vital signs and cardiopulmonary status are obtained.
The nurse must gather objective data regarding the severity of the reaction to communicate effectively with the healthcare provider.
4
Notify the provider and blood bank.
The medical team is alerted and the transfusion reaction protocol is initiated.
The provider needs the assessment data to prescribe emergency interventions. The blood bank must begin investigating the cause of the reaction.
5
Collect specimens.
Blood and urine samples are secured for laboratory analysis.
A urine specimen is critical to assess for hemoglobinuria resulting from red blood cell destruction. Blood samples confirm hemolysis and cross-matching errors.

Key Concept

Prioritization in Emergency Transfusion Reactions
Question 79Question →

A conscious client with diabetes mellitus reports feeling shaky, diaphoretic, and weak. Arrange the following nursing actions in the correct chronological sequence according to the standard management of hypoglycemia.

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Answer

The correct sequence follows the 'Rule of 15': First, perform a blood glucose test to confirm the condition. Second, administer 15 grams of simple carbohydrates. Third, wait 15 minutes. Fourth, recheck the blood glucose level. Finally, provide a complex carbohydrate and protein snack to stabilize the blood sugar.
The 'Rule of 15' provides a systematic, safe, and effective physiological response to hypoglycemia. Assessment always precedes intervention to establish a baseline. Simple carbohydrates are utilized first for their rapid effect, followed by a mandatory waiting period to avoid overtreatment. Reassessment confirms the intervention's success, and a final complex snack prevents secondary hypoglycemic events.

Step-by-Step Solution

1
Assess the client's current blood glucose level.
Hypoglycemia is verified objectively.
The nursing process mandates assessment prior to intervention to ensure accurate and safe treatment.
2
Provide 15 grams of simple carbohydrates.
Rapid absorption of glucose begins in the digestive tract.
Simple sugars rapidly elevate blood glucose to resolve acute neuroglycopenic symptoms.
3
Wait exactly 15 minutes.
Time is provided for systemic glucose metabolism.
Checking too soon can lead to overtreatment and subsequent rebound hyperglycemia.
4
Reassess the blood glucose level.
Determines if the blood glucose has risen above 70 mg/dL.
Reassessment evaluates if the initial intervention was successful or if another 15 grams of carbohydrates is required.
5
Provide a complex carbohydrate and protein snack.
Blood glucose levels are stabilized for the long term.
Simple carbohydrates act quickly but deplete rapidly; complex carbohydrates provide sustained energy to prevent another sudden drop.

Key Concept

Hypoglycemia Management Protocol (The Rule of 15)
Question 80Question →

A nurse is caring for a client who is receiving a transfusion of packed red blood cells. The client suddenly reports severe lower back pain and chills. Arrange the following nursing actions in the correct order of priority to minimize physiological risk to the client.

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Answer

The correct sequence is to first stop the transfusion, then initiate normal saline with new tubing, assess the client's status, notify the healthcare provider, and finally send the blood bag and specimens to the laboratory.
When an acute hemolytic transfusion reaction is suspected, the highest priority is to limit the client's exposure to the offending agent by stopping the transfusion immediately. Next, the nurse must maintain a patent IV line for emergency drugs by using normal saline and completely new tubing, avoiding the accidental bolus of remaining incompatible blood. After stabilizing the IV site, the nurse conducts a rapid assessment of vital signs and cardiopulmonary status to gather critical data. This data is then communicated to the healthcare provider. Finally, as a follow-up action, the nurse collects necessary specimens and returns the blood products to the lab for analysis.

Step-by-Step Solution

1
Stop the blood transfusion immediately.
The infusion of the potentially incompatible blood product is completely halted.
The client is exhibiting classic signs of an acute hemolytic transfusion reaction (lower back pain, chills). Stopping the infusion immediately is the absolute highest priority to minimize the amount of antigen entering the client's systemic circulation.
2
Disconnect the blood tubing and infuse normal saline through new tubing.
Intravenous access is maintained without infusing residual blood.
Patent IV access is essential for emergency medication administration (e.g., vasopressors, fluids). The nurse must use completely new tubing; flushing the existing tubing would dangerously push the remaining incompatible blood directly into the client.
3
Assess the client's vital signs, breath sounds, and urine output.
Baseline clinical data on the client's physiological decompensation is gathered.
The nurse must have current clinical data to communicate to the healthcare provider. Checking urine output is particularly important due to the high risk of acute kidney injury from hemoglobinuria during a hemolytic reaction.
4
Notify the healthcare provider of the client's status.
The provider is informed of the adverse reaction and the current assessment findings.
The provider needs accurate, up-to-date assessment data to rapidly prescribe targeted emergency interventions.
5
Send the blood bag, attached tubing, and client specimens to the laboratory.
The blood bank and laboratory receive the necessary materials for investigation.
Once the client is hemodynamically stabilized and initial emergency protocols are enacted, the remaining blood product and new client blood/urine samples are analyzed to confirm the precise type of reaction.

Key Concept

Management of a suspected acute hemolytic transfusion reaction requires immediate cessation of the blood product, maintenance of IV access using new tubing, and rapid clinical assessment prior to provider notification.
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