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Question 801Question →

A nurse is assessing a client who is 4 days postoperative following an exploratory laparotomy. The client reports feeling a sudden "tearing" sensation in the abdomen after coughing forcefully. Upon inspection, the nurse observes that the surgical incision has separated and loops of bowel are protruding. Place the following nursing interventions in the correct order of priority.

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Answer

The correct priority sequence is: 1) Call for immediate assistance, 2) Position the client in low Fowler's with flexed knees, 3) Cover the organs with sterile saline-moistened dressings, 4) Assess vital signs, and 5) Prepare the client for emergency surgery.
The correct priority addresses immediate safety first, followed by tension reduction, tissue preservation, systemic assessment, and definitive treatment. Calling for assistance ensures help arrives while the nurse remains with the client. Positioning the client with knees flexed immediately reduces abdominal tension. Covering the organs prevents tissue necrosis. Assessing vital signs evaluates for shock, and preparing for surgery anticipates the necessary medical intervention.

Step-by-Step Solution

1
Call for immediate assistance and instruct responding staff to notify the surgeon.
The primary nurse secures help and initiates the medical response while remaining at the client's bedside.
Leaving the client increases the risk of further injury and severe anxiety. Help is required to gather supplies.
2
Position the client in a low Fowler's position with the knees flexed.
Intra-abdominal pressure decreases, and tension on the suture line is relieved.
This is the most critical immediate physical intervention to prevent further protrusion of the abdominal contents.
3
Cover the protruding bowel with sterile dressings moistened with sterile 0.9% sodium chloride.
The exposed bowel is protected from the external environment.
Sterile, moist dressings prevent the bowel tissue from drying out, protecting it from irreversible ischemia.
4
Assess the client's vital signs to monitor for indications of shock.
A baseline assessment of the client's hemodynamic status is obtained.
The client is at extreme risk for shock due to fluid shifts and severe physical stress.
5
Prepare the client for emergency surgical intervention.
The client is readied for definitive medical treatment.
Wound evisceration is a surgical emergency requiring operative repair.

Key Concept

Management of Wound Evisceration
Question 802Question →

A 68-year-old client with a history of severe chronic obstructive pulmonary disease (COPD) and a recent tracheostomy requires open airway suctioning. The client exhibits audible coarse crackles, restlessness, and an oxygen saturation drop to 88%. To mitigate the risk of physiological decompensation during the procedure, arrange the following nursing actions in the correct chronological sequence from first to last.

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Answer

The correct sequence for open airway suctioning prioritizes equipment safety, physiological preparation, atraumatic insertion, limited active suctioning, and post-procedure evaluation: First, verify the wall suction pressure; second, hyperoxygenate the client; third, advance the catheter without suction; fourth, apply intermittent suction during withdrawal; and fifth, flush the catheter and reassess.
The physiological priority during open tracheostomy suctioning is maintaining oxygenation and preventing tissue trauma. The nurse must first ensure equipment safety by checking the suction pressure (80 to 120 mm Hg). Next, hyperoxygenation is crucial to build up oxygen reserves. The catheter is then advanced without suction to avoid depleting oxygen or damaging the airway during entry. Once inserted to the proper depth, intermittent suction is applied only during withdrawal to clear secretions safely. Finally, clearing the line with sterile saline and reassessing the client ensures the procedure was effective and the client has stabilized.

Step-by-Step Solution

1
Verify the wall suction pressure is set between 80 and 120 mm Hg.
Safe negative pressure limits are established before the procedure begins.
Excessive suction pressure can cause significant trauma to the tracheal mucosa and induce bleeding, while insufficient pressure will not clear thick secretions.
2
Hyperoxygenate the client with 100% oxygen.
The client's functional residual capacity of oxygen is maximized.
Suctioning inevitably removes oxygen from the airway along with secretions. Pre-oxygenating prevents severe procedure-induced hypoxemia and resulting dysrhythmias.
3
Advance the catheter into the tracheostomy tube without applying suction.
The catheter is placed safely down to the level of the carina.
Applying active suction during insertion strips oxygen from the airway unnecessarily and significantly increases the risk of the catheter adhering to and tearing the mucosal wall.
4
Apply intermittent suction while rotating and withdrawing the catheter.
Secretions are effectively cleared from the airway.
Rotating the catheter cleans all surfaces of the airway, and limiting active suction to the withdrawal phase for no more than 10 to 15 seconds minimizes hypoxia and tissue damage.
5
Flush the catheter with sterile saline and reassess the client's respiratory status.
The tubing is cleared of thick mucus, and the efficacy of the intervention is thoroughly evaluated.
Flushing prevents catheter occlusion for subsequent passes. Reassessing lung sounds and oxygen saturation determines if further suctioning is required or if the client has returned to baseline.

Key Concept

Safe sequence for open tracheostomy suctioning to reduce the risk of hypoxia and mucosal trauma.
Estimated Time:1m 30s
Question 803Question →

While caring for a client with a history of hepatic cirrhosis on the hepatology unit, the nurse observes the client suddenly vomit a copious amount of bright red blood. The client is lethargic, with a heart rate of 142 beats per minute and a blood pressure of 76/42 mm Hg. In what order should the nurse implement the following interventions? Place the actions in sequence from first to last.

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Answer

The correct sequence prioritizes immediate airway protection, followed by oxygenation, establishing vascular access, initiating fluid resuscitation, and finally administering targeted pharmacological therapy.
In any life-threatening emergency, the nurse must strictly adhere to the Airway, Breathing, and Circulation (ABC) prioritization framework. For a client actively vomiting blood with a lethargic level of consciousness, positional airway protection is the immediate first step to prevent fatal aspiration. This is followed immediately by oxygenation to treat hypoxia. Only after the airway and breathing are secured should the nurse address circulation by establishing large-bore intravenous access and administering fluids to combat hypovolemic shock. Pharmacological interventions specifically targeting the pathology, such as octreotide for varices, are initiated only after the foundational ABCs are completely stabilized.

Step-by-Step Solution

1
Turn the client into a lateral decubitus position.
The airway is mechanically protected.
Active hematemesis in a lethargic client presents an immediate risk of aspiration and asphyxiation, making physical airway protection the most critical independent action.
2
Provide supplemental oxygen via a non-rebreather mask.
Tissue oxygenation is maximized.
Hemorrhagic shock and potential airway compromise necessitate high-flow oxygen to maintain cellular perfusion and hemoglobin saturation.
3
Insert two 18-gauge peripheral intravenous catheters.
Reliable vascular access is secured.
Aggressive fluid and blood product resuscitation is imminent for this hemodynamically unstable client, requiring adequate large-bore access.
4
Initiate a rapid infusion of 0.9% sodium chloride.
Intravascular volume is expanded.
Rapid infusion of isotonic crystalloids treats the hypovolemia and improves the client's critically low blood pressure.
5
Begin a continuous intravenous infusion of octreotide.
Variceal bleeding is therapeutically reduced.
After the fundamental ABCs (Airway, Breathing, Circulation) are stabilized, a splanchnic vasoconstrictor is administered to address the specific source of hemorrhage.

Key Concept

Prioritization of acute variceal hemorrhage management strictly follows the Airway, Breathing, Circulation (ABC) framework.
Estimated Time:1m 30s
Question 804Question →

A nurse is preparing to administer a prescribed dose of intravenous phenytoin by direct injection (IV push). The client has a single peripheral intravenous catheter currently infusing 5% dextrose in water (D5W) continuously. Knowing that phenytoin is incompatible with dextrose solutions, arrange the following nursing actions in the correct sequence to safely administer the medication.

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Answer

The correct sequence is to first stop the incompatible dextrose infusion, flush the line with normal saline, administer the phenytoin slowly, flush the line again with normal saline at the same slow rate, and finally resume the dextrose infusion.
When administering an intravenous push medication through a line infusing an incompatible solution, the nurse must ensure the two fluids never mix in the tubing. The strict sequence must be: stop the incompatible fluid, flush with a compatible fluid (0.9% sodium chloride) to clear the line, administer the medication, flush again with the compatible fluid to clear the medication from the line, and finally restart the continuous infusion. Crucially, the post-medication flush must be administered at the same slow rate as the medication to avoid inadvertently pushing a bolus of the medication remaining in the tubing into the client's circulation.

Step-by-Step Solution

1
Pause the continuous infusion of D5W.
The flow of the incompatible fluid is stopped.
Prevents the mixing of phenytoin and dextrose in the IV tubing, which would cause immediate crystallization.
2
Flush the IV line with 0.9% sodium chloride.
The IV tubing is cleared of dextrose.
Normal saline is compatible with phenytoin and creates a safe, clear environment in the tubing for the medication to pass through.
3
Administer the IV push phenytoin slowly.
The medication is delivered safely into the bloodstream.
Slow administration (maximum 50 mg/min) prevents severe hypotension and cardiac arrhythmias associated with rapid phenytoin delivery.
4
Flush the line again with 0.9% sodium chloride at the same slow rate.
Phenytoin is completely cleared from the tubing dead space.
Ensures the entire dose reaches the patient and prevents precipitation when D5W is resumed. Flushing slowly prevents the remaining drug from being delivered as a rapid bolus.
5
Restart the D5W infusion.
Continuous intravenous fluids are resumed.
Maintains the client's prescribed hydration and glucose support after the medication has been safely delivered.

Key Concept

Safe administration of intravenous medications via a line with an incompatible continuous infusion requires the 'flush-administer-flush' technique using a compatible solution to prevent drug precipitation.

Alternative Method

If the client requires uninterrupted dextrose infusion (e.g., for severe hypoglycemia), the nurse should establish a second peripheral intravenous site specifically for the phenytoin administration rather than interrupting the primary line.
Estimated Time:2m 0s
Question 805Question →

A nurse is preparing to administer a prescribed unit of packed red blood cells (PRBCs) to a client with severe anemia. In what order should the nurse perform the following actions? Arrange the steps in the correct chronological sequence.

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Answer

The correct chronological sequence is: Verify prescription/consent/vitals, Retrieve blood from the blood bank, Verify with a second nurse at the bedside, Initiate the transfusion slowly, and Remain with the client for 15 minutes to reassess vital signs.
Safe administration of packed red blood cells requires strict adherence to chronological safety checkpoints. First, the nurse must ensure the client is ready (consent, baseline vitals, patent IV) before retrieving the blood, as it expires in 30 minutes at room temperature. Once retrieved, two-nurse verification must occur at the bedside to prevent ABO incompatibility. The transfusion is initiated slowly to mitigate the severity of any potential reaction, and the nurse must remain with the client for the first 15 minutes, as this is when life-threatening reactions are most likely to occur.

Step-by-Step Solution

1
Verify the provider's prescription, confirm informed consent is signed, and assess baseline vital signs.
Ensures legal readiness and establishes a baseline to monitor for reactions.
Blood must be initiated within 30 minutes of leaving the blood bank. Gathering baseline vital signs first ensures the client does not have a fever that might delay the transfusion.
2
Retrieve the unit of packed red blood cells from the blood bank.
The specific unit of PRBCs is brought to the nursing unit.
This is done only after confirming the client is clinically ready and IV access is patent.
3
Verify the blood product, blood type, and client identity with a second registered nurse at the bedside.
Confirms an exact match between the client's identification band, the blood type, and the unit number.
Prevents fatal ABO incompatibility reactions. This must be done directly at the bedside, not at the nurses' station.
4
Spike the blood bag and initiate the transfusion at a slow rate of 2 mL/min.
The blood transfusion begins.
A slow initial rate limits the volume of blood infused, minimizing the severity of a reaction if one occurs.
5
Remain with the client and reassess vital signs 15 minutes after the transfusion begins.
The client is closely monitored during the most critical period.
Most severe transfusion reactions (e.g., acute hemolytic or anaphylactic) happen within the first 15 minutes or first 50 mL of blood.

Key Concept

Blood Transfusion Administration Safety and Sequencing
Question 806Question →

A nurse is preparing to transfer a client with right-sided weakness from the bed to a wheelchair. Arrange the following steps in the correct sequence to ensure a safe transfer.

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Answer

The correct sequence involves preparing the environment, assisting the client to a seated position, applying safety equipment, assuming proper stance, and executing the pivot transfer toward the strong side.
Safe transfer of a client with hemiparesis requires a systematic approach. First, the environment must be secured by locking the wheelchair on the client's strong (left) side. Next, the client is brought to a seated position to allow blood pressure to stabilize. Safety equipment (footwear and gait belt) is then applied. The nurse must then position themselves to protect the client's weak (right) side by bracing the knee. Finally, the transfer is executed by pivoting toward the strong side, maximizing the client's ability to assist and maintain balance.

Step-by-Step Solution

1
Prepare the environment by positioning the wheelchair on the strong side and locking brakes.
The destination is safe and ready for the client.
Prevents leaving the client unsupported while managing equipment.
2
Assist the client to sit on the edge of the bed and observe.
The client acclimates to the upright position.
Minimizes the risk of orthostatic hypotension and syncope.
3
Put non-skid footwear on the client and apply a transfer belt.
The client and nurse are equipped for a safe transfer.
Footwear prevents slipping; the belt allows the nurse to maintain a firm, safe hold.
4
Face the client, grasp the belt, and brace the weak right knee.
The nurse is in position to support the client's weakness.
Bracing prevents the weak knee from collapsing when bearing weight.
5
Execute the stand and pivot toward the strong left side.
The client is successfully seated in the wheelchair.
Pivoting toward the unaffected side allows the client to use their strength to guide the movement.

Key Concept

Safe client transfer techniques and body mechanics
Question 807Question →

An adult client on a medical-surgical unit is undergoing a packed red blood cell (PRBC) transfusion for symptomatic anemia. Shortly after the initiation of the blood product, the client suddenly develops severe flank pain, chills, and shortness of breath. Place the following nursing interventions in the correct sequential order of priority.

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Answer

1. Stop the blood transfusion immediately. 2. Disconnect the blood tubing and maintain the IV line with normal saline using new tubing. 3. Obtain the client's vital signs and perform a focused cardiopulmonary assessment. 4. Notify the healthcare provider and the blood bank of the suspected reaction. 5. Return the blood bag, attached tubing, and transfusion record to the blood bank.
The correct sequence prioritizes removing the offending agent immediately, maintaining venous access with safe fluids, assessing the client's current status, communicating with the medical team for further orders, and finally preserving evidence for laboratory investigation.

Step-by-Step Solution

1
Determine the immediate life-saving priority action.
The blood transfusion is stopped immediately.
Halting the infusion prevents any further incompatible blood from entering the circulation, mitigating the severity of the acute hemolytic reaction.
2
Determine the secondary priority to support hemodynamics and venous access.
The IV line is maintained with normal saline using completely new IV tubing.
New tubing ensures that the remaining blood in the old tubing is not inadvertently pushed into the client, while normal saline preserves venous access for emergency medications.
3
Gather objective data to determine the client's physiological baseline after the reaction.
Vital signs and a focused cardiopulmonary assessment are obtained.
Objective data is required to determine the severity of the client's compromise and to accurately report the condition to the healthcare provider.
4
Communicate findings and coordinate interdisciplinary care.
The healthcare provider and blood bank are notified.
The provider will prescribe subsequent emergency interventions, and the blood bank must initiate an investigation into the reaction.
5
Ensure appropriate laboratory follow-up.
The blood bag, tubing, and associated paperwork are returned to the blood bank.
This allows the facility to analyze the blood product and determine the exact cause of the hemolytic reaction.

Key Concept

Prioritization of emergency nursing actions during an acute hemolytic transfusion reaction.
Question 808Question →

While monitoring a client receiving a newly prescribed intravenous cephalosporin, the nurse observes sudden-onset audible stridor, diffuse urticaria, and a precipitous drop in blood pressure to 78/46 mm Hg. Arrange the following nursing interventions in the correct order of priority.

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Answer

The correct sequence for managing acute anaphylaxis is to first stop the offending medication, secure the airway and provide oxygen, administer intramuscular epinephrine, initiate volume expansion with intravenous fluids, and finally administer adjunctive medications like antihistamines and corticosteroids.
In any acute hypersensitivity reaction, the standard of care dictates removing the offending trigger first. Once stopped, the nurse must follow the ABC prioritization framework. Stridor represents an immediate threat to the airway, making oxygenation the next priority. This is followed immediately by epinephrine to treat the systemic physiological collapse. Fluids are then pushed to treat the profound distributive shock. Finally, secondary medications (antihistamines and steroids) are given to manage ongoing inflammation.

Step-by-Step Solution

1
Stop the infusion
Halts the delivery of the allergen into the bloodstream.
Removing the trigger is the most critical first action to prevent the anaphylactic reaction from worsening.
2
Maintain airway and oxygenate
Ensures oxygen delivery despite airway edema.
Stridor indicates upper airway compromise; oxygenation must be secured before administering medications.
3
Administer intramuscular epinephrine
Reverses bronchoconstriction and vasodilation.
Epinephrine is the life-saving, first-line drug for anaphylaxis and must be given as soon as the airway is managed.
4
Administer intravenous fluids
Expands intravascular volume.
Anaphylaxis causes severe distributive shock; fluid boluses are required to maintain blood pressure and tissue perfusion.
5
Administer adjunctive medications
Blocks histamine receptors and reduces inflammation.
These medications help resolve lingering symptoms and prevent a delayed secondary reaction, but they do not treat acute cardiovascular collapse.

Key Concept

Management of Anaphylactic Shock
Question 809Question →

A nurse in the intensive care unit is caring for a client who is receiving a continuous intravenous infusion of norepinephrine through a peripheral venous catheter. During the hourly assessment, the nurse notes blanching, coolness, and swelling at the insertion site, and the client reports severe burning pain. In what order should the nurse perform the following actions to minimize tissue injury? Arrange the actions from first to last.

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Answer

The correct sequence is to first stop the infusion, disconnect the tubing while leaving the cannula in place, aspirate residual medication, administer the prescribed antidote through the existing cannula, and finally elevate the extremity.
Norepinephrine is a potent alpha-adrenergic agonist and a known vesicant. When it extravasates into surrounding tissues, it causes severe, localized vasoconstriction that rapidly leads to tissue ischemia and necrosis. Risk reduction protocols dictate a specific sequence to mitigate this damage. The very first action must always be stopping the infusion. However, unlike a standard IV infiltration where the catheter is immediately pulled, the cannula must be left in place. This allows the nurse to aspirate any remaining drug and provides a direct route to administer a neutralizing antidote (such as phentolamine) deep into the affected tissues. Only after the active chemical threat is managed should supportive measures like elevation be implemented.

Step-by-Step Solution

1
Stop the continuous intravenous infusion.
Further delivery of the vesicant is halted.
The primary cause of the ongoing injury must be removed immediately to prevent further ischemic damage to the tissues.
2
Disconnect the administration tubing, leaving the cannula in place.
The source tubing is isolated while maintaining direct venous access to the extravasation site.
If the cannula is removed immediately, the nurse loses the most direct anatomical route to withdraw the drug and administer the necessary rescue antidote.
3
Aspirate residual medication.
Remaining norepinephrine is physically removed from the catheter and surrounding tissue pocket.
Physical removal decreases the total concentration of the vesicant in the tissue, limiting the extent of necrosis.
4
Administer the prescribed antidote (e.g., phentolamine).
The vasoconstrictive effects of the extravasated norepinephrine are reversed.
Phentolamine is an alpha-adrenergic antagonist that causes vasodilation, restoring blood flow to the ischemic tissue and preventing necrosis.
5
Elevate the affected extremity.
Capillary hydrostatic pressure is reduced in the limb.
Elevation promotes fluid return to the central circulation, reducing the severe swelling associated with the extravasation.

Key Concept

Vesicant Extravasation Management
Question 810Question →

A nurse is preparing to draw up a mixed dose of Regular insulin and NPH insulin into a single syringe. Arrange the following steps of the procedure in the correct chronological sequence.

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Answer

The correct sequence is to roll the NPH vial, inject air into the NPH vial, inject air into the Regular vial, withdraw the Regular insulin, and finally withdraw the NPH insulin.
To safely mix insulin without cross-contamination, the mnemonic 'RN' (Regular then NPH) or 'Clear before Cloudy' is universally applied. The sequence requires pressurizing the NPH vial first with air, then pressurizing the Regular vial, immediately withdrawing the Regular insulin, and finally withdrawing the NPH insulin.

Step-by-Step Solution

1
Roll the vial of NPH insulin gently between the palms of the hands.
The NPH insulin suspension is evenly mixed without creating air bubbles.
NPH insulin is a cloudy suspension that settles over time. Rolling resuspends it safely; shaking creates bubbles that can cause inaccurate dosing.
2
Inject a volume of air equal to the prescribed dose into the NPH insulin vial.
The NPH vial is pressurized for later withdrawal.
Air must be injected to prevent a vacuum, but the medication is not withdrawn yet to maintain the critical 'clear before cloudy' drawing sequence.
3
Inject a volume of air equal to the prescribed dose into the Regular insulin vial.
The Regular insulin vial is pressurized.
The nurse pressurizes the second vial and leaves the needle in place to immediately begin withdrawing the clear insulin.
4
Withdraw the prescribed dose of Regular insulin from its vial.
The exact dose of clear, rapid-acting insulin is drawn into the syringe.
Regular insulin (clear) must always be drawn up first to prevent accidental contamination of the vial with intermediate-acting (cloudy) NPH insulin.
5
Withdraw the prescribed dose of NPH insulin from its vial.
The exact dose of NPH insulin is added to the syringe, completing the mixed dose.
The cloudy insulin is drawn last. The nurse must carefully withdraw the exact amount, as pushing fluid back into the NPH vial would contaminate it with Regular insulin.

Key Concept

When mixing insulins in a single syringe, the clear (short-acting, Regular) insulin must always be drawn up before the cloudy (intermediate-acting, NPH) insulin to prevent altering the rapid-acting properties of the clear insulin vial.
Question 811Question →

Two nurses are preparing to move a conscious, partially mobile client up in bed using a friction-reducing draw sheet. Place the steps of this procedure in the correct chronological order.

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Answer

The correct sequence begins with positioning the bed for safety and body mechanics, followed by protecting the client's head, positioning the client to assist, grasping the draw sheet securely, and finally performing the synchronized movement.
The procedure for moving a client up in bed requires sequential prioritization of nurse ergonomics and client safety. The environment is prepared first by flattening and raising the bed to prevent staff injury. Next, the client's head is protected with a pillow against the headboard. The client is then positioned to actively assist by bending their knees, which reduces the nurses' workload. Finally, the nurses establish a secure grip and use momentum via weight shifting to safely complete the task.

Step-by-Step Solution

1
Adjust the bed to a flat position and raise it to the working height of the nurses' waists.
The bed is flat, reducing gravity, and is at a height that prevents strain.
Proper body mechanics dictate working at waist level to prevent back injuries. A flat bed prevents working against gravity during the pull.
2
Remove the pillow from under the client's head and place it upright against the headboard.
The client's head rests on the mattress and the headboard is padded.
This crucial safety step protects the client's head from accidentally striking the hard headboard when gliding toward the top of the bed.
3
Instruct the client to cross their arms over the chest and bend their knees with feet flat on the mattress.
The client is in a compact position ready to assist with the move.
Crossing arms reduces surface friction. Bending the knees allows the client to push with their legs, decreasing the physical effort required from the nursing staff.
4
Roll the edges of the draw sheet tightly against the client's sides and grasp it securely.
The nurses have a firm grip close to the client's body.
Grasping close to the client's center of gravity maximizes biomechanical leverage, making the lift safer and more controlled.
5
Synchronize the movement by shifting weight from the back leg to the front leg on a count of three.
The client is successfully and safely moved up in the bed.
A synchronized count ensures smooth movement. Shifting weight uses the nurses' larger leg and core muscles, preventing dangerous lower back strain.

Key Concept

Basic Care and Comfort: Safe Client Handling and Mobility
Question 812Question →

A nurse is caring for a client who sustained a spinal cord injury at the T4 level one month ago. The client suddenly reports a severe, pounding headache and blurred vision. The nurse observes profuse diaphoresis and flushing above the level of injury, and the blood pressure is 215/115 mmHg215/115 \text{ mmHg}. Arrange the following nursing actions in the priority order they should be performed.

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Answer

The correct sequence prioritizes immediate physiological safety by altering hemodynamics, followed by systematically identifying and removing the physical triggers, utilizing pharmacological therapy if conservative measures fail, and concluding with documentation.
In autonomic dysreflexia, a massive sympathetic response occurs due to a noxious stimulus below the level of the spinal cord injury. The absolute priority is to immediately lower the blood pressure to prevent a stroke, which is achieved first by elevating the head of the bed. Next, the nurse must systematically identify and eliminate the stimulus. Bladder issues are the most common cause, followed by bowel impaction. If removing these physical triggers does not resolve the crisis, antihypertensive medications are administered. Documentation is completed last.

Step-by-Step Solution

1
Elevate the head of the bed to a high Fowler's position.
Blood pressure begins to decrease due to orthostatic changes.
Reduces venous return and immediate risk of intracranial hemorrhage.
2
Assess the urinary catheter for kinks and the bladder for distension.
Identifies or resolves the most frequent cause of the sympathetic surge.
Bladder distension is the leading noxious stimulus that triggers autonomic dysreflexia.
3
Assess for bowel impaction if the urinary system is draining appropriately.
Rules out or resolves the second most common trigger.
Gastrointestinal irritation, such as constipation or impaction, can sustain the reflex.
4
Administer the prescribed PRN rapid-acting antihypertensive medication.
Pharmacological reduction of severe hypertension.
Necessary if the blood pressure remains dangerously high despite removing physical triggers.
5
Document the precipitating trigger, nursing interventions, and the client's physiological response.
Maintains accurate medical records.
Documentation occurs after the client is safe and stabilized.

Key Concept

Management of Autonomic Dysreflexia
Question 813Question →

A nurse is preparing to administer a scheduled dose of intravenous (IV) push metoprolol through a client's peripheral saline lock. In what order should the nurse perform the following actions? Arrange the steps in the correct chronological sequence.

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Answer

The correct sequence is: Assess the IV site, cleanse the injection port, aspirate and flush with saline, administer the medication, and finally flush with saline at the same rate as the medication.
The sequence for administering an IV push medication through a saline lock is built on patient safety and the standard SAS (Saline, Administer, Saline) method. First, the nurse visually and physically assesses the site for complications. Second, the port is cleansed to maintain asepsis. Third, a pre-flush with normal saline verifies patency and intravascular placement. Fourth, the medication is administered at the prescribed rate. Finally, a post-flush is administered at the exact same rate as the medication to ensure the drug remaining in the extension tubing is not inadvertently delivered as a rapid bolus.

Step-by-Step Solution

1
Assess the intravenous insertion site.
Ensures the site is free of complications like infiltration or phlebitis.
Safety verification must occur before physically manipulating the site.
2
Cleanse the injection port with an antiseptic swab.
Removes pathogens from the access hub.
Strict asepsis is required before accessing the vascular system.
3
Aspirate for blood return and flush the catheter with normal saline.
Confirms catheter patency and correct placement in the vein.
Prevents inadvertent administration of medication into surrounding subcutaneous tissue.
4
Administer the medication slowly over the recommended time.
Delivers the therapeutic agent safely.
Rapid administration of IV push medications can cause severe adverse reactions, such as speed shock or severe bradycardia in the case of metoprolol.
5
Flush the catheter with normal saline at the same rate as the medication.
Clears the residual medication from the extension tubing into the client's circulation.
If the final flush is administered too quickly, the medication lingering in the tubing will be delivered as a rapid bolus, negating the safety of the slow medication push.

Key Concept

Safe administration of IV push medications via a saline lock follows the SAS (Saline-Administer-Saline) method, prioritizing site assessment, asepsis, patency verification, and controlling the post-flush rate to prevent bolus effects.
Question 814Question →

A 42-year-old client with severe iron deficiency anemia is receiving a transfusion of packed red blood cells (PRBCs) on the medical-surgical unit. Fifteen minutes into the transfusion, the client suddenly reports severe lower back pain, shortness of breath, and a feeling of impending doom. The nurse observes that the client is flushed and shivering. Place the following nursing actions in the correct priority sequence.

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Answer

The correct sequence is to first stop the transfusion, then maintain intravenous access with new tubing, assess the client's status, notify the healthcare provider and blood bank, and finally send all required specimens and equipment to the laboratory.
In the event of an acute hemolytic transfusion reaction, the sequence of actions must prioritize preventing further harm. The absolute first action is to stop the transfusion. Second, the nurse must maintain patent intravenous access for emergency fluids and medications; crucially, this requires disconnecting the old blood tubing at the hub and attaching completely new tubing primed with normal saline to avoid pushing residual incompatible blood into the client. Third, with the threat stopped and access secured, the nurse rapidly assesses the client's vital signs and respiratory status. Fourth, the nurse notifies the healthcare provider to obtain emergency prescriptions and alerts the blood bank. Finally, per facility protocol, the remaining blood, tubing, and newly drawn client samples (blood and urine) are sent to the laboratory to identify the specific cause of the reaction.

Step-by-Step Solution

1
Immediately stop the infusion of the packed red blood cells.
The flow of the potentially incompatible blood product into the client's bloodstream is halted.
This is the most critical immediate action to minimize the volume of incompatible blood entering the systemic circulation and to reduce the severity of the acute hemolytic reaction.
2
Disconnect the blood tubing at the catheter hub and initiate normal saline with new intravenous tubing.
Intravenous access is maintained for emergency medications and fluid resuscitation without exposing the client to more blood.
Using completely new tubing prevents the residual blood contained in the old tubing from being inadvertently flushed into the client's vein during line maintenance.
3
Assess the client's hemodynamic status, lung sounds, and vital signs.
The nurse obtains critical baseline physiological data regarding the client's respiratory and cardiovascular status.
Rapid assessment dictates the immediate emergency interventions required and provides essential data to communicate to the healthcare provider.
4
Notify the prescribing healthcare provider and the facility's blood bank.
The medical team is activated to provide emergency prescriptions and blood bank protocols are initiated.
The provider must prescribe interventions (such as vasopressors, antihistamines, or fluids) to manage the reaction, and the blood bank must prepare for a transfusion reaction investigation.
5
Collect the blood bag, attached tubing, and newly drawn client blood and urine samples to send to the laboratory.
All required specimens and materials are sent for diagnostic analysis.
The blood bank analyzes the remaining product and client samples to confirm the type of reaction (such as ABO incompatibility) and rule out bacterial contamination or other causes.

Key Concept

Prioritization and Management of Acute Hemolytic Transfusion Reactions
Question 815Question →

A nurse is caring for a client on a medical-surgical unit who suddenly develops severe dyspnea, a respiratory rate of 34/min, and produces pink, frothy sputum. Crackles are auscultated throughout both lung fields. Arrange the following nursing actions in the priority order they should be performed.

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Answer

The correct sequence for managing acute pulmonary edema is to first position the client upright with legs dangling, then apply high-flow oxygen, followed by administering intravenous furosemide, and finally inserting an indwelling urinary catheter.
In cases of acute pulmonary edema, nursing priorities follow the airway, breathing, and circulation (ABC) framework combined with hemodynamic principles. Positioning the client upright with legs dangling is the fastest way to reduce venous return (preload) and improve lung expansion. Oxygen is applied immediately after to treat severe hypoxemia. Intravenous diuretics are then given to actively remove excess fluid. Finally, a urinary catheter is placed to monitor the therapeutic response to the diuretic.

Step-by-Step Solution

1
Position the client upright with legs dangling over the edge of the bed.
Immediate reduction in venous return and improvement in lung expansion.
Airway and Breathing take priority. Positioning uses gravity to reduce preload, instantly decreasing pulmonary congestion without needing to wait for equipment or medication.
2
Apply high-flow oxygen via a non-rebreather face mask.
Increased alveolar oxygen concentration.
Pink, frothy sputum and profound tachypnea indicate severe pulmonary edema and hypoxemia. Supplying oxygen maximizes gas exchange in the unaffected alveoli.
3
Administer the prescribed intravenous furosemide.
Initiation of rapid diuresis and vasodilation.
Once immediate cardiopulmonary support is established, pharmacological intervention is required to actively pull fluid out of the pulmonary circulation by reducing overall vascular volume.
4
Insert an indwelling urinary catheter.
Continuous monitoring of urine output.
This is a necessary monitoring step to evaluate the therapeutic effect of the loop diuretic, but it must not delay the life-saving interventions in steps 1-3.

Key Concept

Prioritization of interventions in acute pulmonary edema (ABC approach combined with preload reduction).
Question 816Question →

A nurse is assessing a client with a severe traumatic brain injury and notes a sudden, profound decline in the level of consciousness. The client's vital signs are heart rate 44 beats/min, blood pressure 196/60 mm Hg, and irregular, shallow respirations. The nurse immediately calls out for emergency assistance. Arrange the following subsequent nursing actions in the priority order they should be performed.

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Answer

The correct sequence is: Assess airway/oxygenation, elevate the head of the bed, notify the healthcare provider, administer an osmotic diuretic, and finally prepare for a CT scan.
In any acute neurological crisis involving Cushing's triad (bradycardia, widened pulse pressure/hypertension, and irregular respirations), the client is at imminent risk of brainstem herniation. The nurse must follow the ABCs, prioritizing airway and oxygenation to prevent hypercapnia-induced vasodilation. Next, the nurse performs the immediate independent intervention of elevating the head of the bed and maintaining neutral neck alignment to promote venous drainage. After stabilizing the client with these immediate actions, the nurse notifies the healthcare provider to obtain stat orders. Dependent interventions, such as administering osmotic diuretics (mannitol), are then implemented based on these orders. Finally, once initial medical stabilization is achieved, the client is transported for diagnostic imaging (CT scan) to determine the need for surgical decompression.

Step-by-Step Solution

1
Assess airway patency and administer high-flow supplemental oxygen.
Hypoxia and hypercapnia are prevented or corrected.
Airway and breathing are the absolute highest priorities. Hypercapnia causes cerebral vasodilation, which exponentially increases intracranial pressure.
2
Elevate the head of the bed to 30 degrees and ensure neutral neck alignment.
Cerebral venous outflow is optimized.
This is a rapid, independent nursing action that facilitates jugular venous drainage, thereby directly lowering intracranial pressure.
3
Notify the neurosurgical healthcare provider of the vital sign changes.
The medical provider is informed of the emergent clinical deterioration.
Cushing's triad indicates imminent brainstem herniation. After securing the ABCs and optimal positioning, the nurse must obtain stat medical orders for further intervention.
4
Ensure intravenous access and administer a prescribed osmotic diuretic.
Fluid is drawn from the cerebral tissue into the vascular space.
Osmotic diuretics like mannitol are dependent interventions that require a provider order to aggressively reduce cerebral edema.
5
Prepare and accompany the client for an emergent computed tomography (CT) scan.
Diagnostic imaging is obtained to identify the cause of the elevated ICP.
Once the client is medically stabilized, identifying the structural cause (e.g., hemorrhage expansion) is required to determine if surgical decompression is necessary.

Key Concept

Prioritization in the management of increased intracranial pressure (Cushing's Triad)
Estimated Time:2m 0s
Question 817Question →

A nurse is preparing to discontinue a client's non-tunneled central venous catheter (CVC) located in the right subclavian vein. To minimize the risk of a potential air embolism, arrange the following nursing actions in the correct physiological sequence. (Place the first action at the top and the final action at the bottom.)

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Answer

1. Position the client flat in bed (supine) or in a slight Trendelenburg position.
2. Instruct the client to take a deep breath and bear down (Valsalva maneuver).
3. Withdraw the catheter smoothly and continuously while the client bears down.
4. Apply immediate, firm pressure to the insertion site using sterile gauze.
5. Apply a sterile, occlusive dressing over the site.
Removing a central venous catheter carries a high risk of an air embolism, which can be fatal. The nurse must systematically manipulate pressure gradients to keep air out of the venous system. First, placing the client supine or in Trendelenburg increases central venous pressure at the site. Second, instructing the client to bear down (the Valsalva maneuver) creates positive intrathoracic pressure. Third, actually removing the catheter during this positive pressure phase ensures air cannot enter the exposed tract. Fourth, applying immediate manual pressure physically seals the tract and achieves hemostasis. Finally, securing an occlusive (air-tight) dressing provides a long-term barrier against air entry while the skin and venous tract heal over the subsequent days.

Step-by-Step Solution

1
Ensure the client is in a supine or slight Trendelenburg position.
The insertion site is positioned below or at the level of the heart.
This increases central venous pressure and reduces the immediate risk of an air embolism.
2
Ask the client to perform the Valsalva maneuver.
Intrathoracic pressure momentarily spikes.
This creates positive pressure inside the vessel, preventing outside air from being sucked in when the catheter is removed.
3
Remove the central venous catheter.
The catheter is fully withdrawn from the subclavian vein.
This is performed during the Valsalva maneuver to ensure continuous positive intrathoracic pressure during the vulnerable moment of removal.
4
Apply immediate pressure with sterile gauze.
Bleeding is controlled and the tract is physically sealed.
Immediate pressure prevents air from entering the open tract before a permanent dressing is applied.
5
Secure a sterile, occlusive dressing.
The site is sealed airtight.
An occlusive dressing blocks air from entering the healing tract over the next 24 to 72 hours.

Key Concept

Central Venous Catheter Removal and Air Embolism Prevention
Estimated Time:1m 30s
Question 818Question →

During a shift assessment of a client recovering from an exploratory laparotomy 48 hours ago, the client coughs violently. The nurse witnesses the surgical incision suddenly separate, revealing protruding loops of intestine. Arrange the following interventions in the correct chronological sequence to prioritize client safety.

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Answer

The correct priority sequence is: remain with the client and call for help, position the client in low Fowler's with flexed knees, cover the protruding organs with sterile saline-moistened dressings, obtain vital signs to monitor for shock, and prepare the client for emergency surgery.
Wound evisceration is a critical surgical emergency. The nurse's first absolute priority is safety, which means staying with the client and calling for immediate assistance. Second, while waiting for supplies to be brought into the room, the nurse places the client in a low Fowler's position with the knees bent to immediately reduce abdominal muscle tension and prevent further organ protrusion. Third, once supplies are available, the nurse applies sterile, saline-moistened dressings over the exposed intestine to prevent necrosis and infection. Fourth, the nurse assesses vital signs to ensure the client is not entering physiological shock. Finally, the nurse prepares the client for immediate transport to the operating room for definitive surgical management.

Step-by-Step Solution

1
Remain with the client and activate the unit emergency call system for assistance.
Assistance is summoned without abandoning the clinically unstable client.
Immediate help is required to obtain sterile supplies and contact the surgical team.
2
Place the client in a low Fowler's position with the knees flexed.
Tension across the abdominal wall is minimized.
This specific position relaxes the rectus abdominis muscles, preventing additional bowel loops from eviscerating.
3
Cover the eviscerated tissue with sterile dressings moistened in normal saline.
The internal organs are shielded from environmental contaminants and desiccation.
Exposed bowel can quickly become ischemic and necrotic if allowed to dry out.
4
Obtain a full set of vital signs to monitor for physiological shock.
The client's hemodynamic stability is evaluated.
Rapid fluid shifts and systemic stress from the evisceration strongly predispose the client to hypovolemic or neurogenic shock.
5
Prepare the client for immediate transport to the surgical suite.
The client is readied for definitive operative repair.
An evisceration is a surgical emergency that requires immediate operative closure.

Key Concept

Emergency Management of Wound Evisceration
Estimated Time:1m 0s
Question 819Question →

A nurse is caring for a client who is 4 days postoperative following an exploratory laparotomy. The client experiences a severe coughing episode and reports a sudden "tearing" sensation in the abdomen. Upon inspection, the nurse observes a portion of the small intestine protruding through the surgical incision. Place the following nursing actions in the correct chronological order to minimize the risk of tissue ischemia and further complications.

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Answer

The correct sequence is: Call for assistance, position the client in low Fowler's with flexed knees, cover the organs with sterile saline dressings, assess vital signs, and prepare for emergency surgery.
Managing a wound evisceration requires rapid, prioritized intervention to preserve tissue viability and prevent systemic shock. The absolute priority is safety; the nurse must stay with the client while calling for help to obtain necessary supplies. Immediately following this, positioning the client with a slightly elevated head and flexed knees mechanically reduces intra-abdominal pressure, halting further evisceration. Once sterile supplies are brought to the bedside, covering the exposed bowel with moistened sterile dressings is critical to prevent drying, ischemia, and infection. With the immediate local threat managed, the nurse then assesses systemic stability by monitoring vital signs for shock. Finally, the client is prepared for emergency surgical repair, which is the definitive treatment.

Step-by-Step Solution

1
Call for immediate assistance and request emergency sterile supplies.
Help is initiated without the nurse having to abandon the client.
The nurse must not leave the client alone during a critical evisceration. Another staff member is needed to gather sterile supplies and notify the healthcare provider.
2
Place the client in a low Fowler's position with the hips and knees flexed.
Intra-abdominal pressure is rapidly reduced.
This specific position minimizes tension on the abdominal muscles and the compromised suture line, acting as an immediate mechanical intervention to prevent further bowel protrusion.
3
Apply sterile, saline-soaked dressings over the protruding abdominal organs.
The exposed bowel is protected from environmental drying and contaminants.
Once the requested supplies arrive, the exposed tissue must be kept moist with sterile normal saline to maintain viability, prevent ischemia, and reduce the risk of severe infection.
4
Assess vital signs and monitor the client for indications of hypovolemic shock.
The client's systemic hemodynamic stability is evaluated.
With the immediate local threat to the tissue managed, the nurse must assess for signs of shock (e.g., tachycardia, hypotension) resulting from fluid shifts or potential internal bleeding.
5
Prepare the client for emergency surgical intervention.
The client is readied for definitive operative treatment.
An evisceration cannot be managed conservatively; it requires immediate surgical repair to return the organs to the abdominal cavity and close the fascia.

Key Concept

Prioritization of emergency interventions for surgical evisceration to prevent tissue necrosis and shock.
Question 820Question →

A nurse is preparing a prescribed intramuscular dose of a medication that is supplied as a dry powder in a sterile vial. The medication requires reconstitution with bacteriostatic water before administration. In what chronological sequence should the nurse perform the following actions to safely prepare the medication?

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Answer

The correct sequence begins with maintaining asepsis by performing hand hygiene and swabbing the stoppers. Next, air is injected into the diluent vial to equalize pressure, allowing the fluid to be withdrawn. The diluent is then injected into the powder, and the vial is gently rolled to dissolve the medication without creating bubbles. Finally, the stopper is cleansed again to safely withdraw the prescribed dose.
The standard procedure for reconstituting medication requires strict aseptic technique and pressure equalization. Cleansing stoppers first prevents contamination. Injecting air into the diluent vial allows for smooth fluid withdrawal. The diluent is then added to the powder, and the vial is rolled gently to mix without creating bubbles. Finally, the reconstituted medication is withdrawn for administration using continued aseptic practices.

Step-by-Step Solution

1
Maintain asepsis by cleansing vials
Sterile entry points are prepared
To prevent the introduction of microorganisms into the medication
2
Inject air into the diluent vial
Positive pressure is created in the vial
To prevent a vacuum and allow for the easy withdrawal of the liquid diluent
3
Transfer diluent to the powder
Diluent and powder are combined
To initiate the dissolving process for the medication
4
Gently roll the vial between palms
Medication is thoroughly dissolved without bubbling
To prevent frothing or air bubbles which can cause inaccurate dosing
5
Cleanse stopper, inject air, and withdraw dose
Final medication dose is ready in the syringe
To safely extract the exact volume needed for administration

Key Concept

Safe Preparation and Reconstitution of Parenteral Medications
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