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Question 921Question →

A medical-surgical nurse is monitoring a client who is undergoing conservative management for severe acute pancreatitis. The client is increasingly restless and reports persistent, agonizing pain in the left upper quadrant. Which subsequent assessment finding represents the highest priority and warrants immediate provider notification?

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Answer: A current blood pressure of 102/84 mmHg, compared to a baseline of 128/78 mmHg, along with a heart rate of 118 beats per minute.

Answer

The priority finding is the narrowing pulse pressure (102/84 mmHg) and tachycardia (118 bpm), which indicate impending hypovolemic shock.
Acute pancreatitis can cause severe retroperitoneal fluid shifts (third-spacing), leading to profound hypovolemia. A narrowing pulse pressure (the difference between systolic and diastolic pressure) coupled with tachycardia is a classic, early hallmark of compensatory shock. A baseline of 128/78 mmHg has a pulse pressure of 50 mmHg, whereas 102/84 mmHg has a narrowed pulse pressure of 18 mmHg. This represents a critical decrease in stroke volume that requires immediate fluid resuscitation to prevent irreversible circulatory collapse.

Step-by-Step Solution

1
Analyze the client's underlying condition and associated risks.
The client has severe acute pancreatitis, which carries a high risk for massive fluid shifts (third-spacing) into the retroperitoneal cavity, potentially leading to hypovolemia.
Identifying condition-specific risks helps the nurse anticipate life-threatening complications before profound decompensation occurs.
2
Evaluate the clinical significance of each assessment finding.
The vital signs show a drop in systolic pressure and a rise in diastolic pressure, creating a narrow pulse pressure of 18 mmHg. Combined with tachycardia, this reflects decreased stroke volume and a compensatory sympathetic nervous system response.
Early detection of subtle hemodynamic trends is critical for recognizing the compensatory stage of shock.
3
Prioritize the findings based on immediate threat to life (ABCs).
While the ABG shows mild respiratory acidosis and the enzymes remain high, these are expected or less acute issues. The hemodynamic instability (shock) poses the most immediate threat to circulation and tissue perfusion.
Using the ABC (Airway, Breathing, Circulation) framework ensures that life-threatening issues are addressed before expected or chronic findings.

Key Concept

Early recognition of hypovolemic shock in acute pancreatitis involves identifying subtle vital sign changes, such as a narrowing pulse pressure and mild tachycardia, caused by massive retroperitoneal fluid sequestration.
Estimated Time:1m 15s
Question 922Question →

A client receiving care on an oncology unit has a newly inserted multi-lumen central venous catheter (CVC) for the administration of chemotherapy and total parenteral nutrition. The nurse is preparing to administer several prescribed intravenous medications. Which of the following actions indicate correct understanding of central line and parenteral therapy safety? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Use a syringe size of 10 mL10 \text{ mL} or larger when flushing the catheter lumens.; Aspirate the line to verify a brisk blood return prior to the administration of any intravenous vesicant medication.; Scrub the needleless connector hub with an approved antiseptic for at least 15 seconds and allow it to dry before accessing.

Answer

The correct actions include using a 10 mL10 \text{ mL} or larger syringe for flushing, aspirating for blood return before giving vesicants, and scrubbing the hub for at least 15 seconds before access.
The correct actions ensure patient safety during central line use. A 10 mL10 \text{ mL} or larger syringe must be used because smaller syringes exert excessive pressure that can rupture the central venous catheter. Aspirating for blood return is a critical step prior to administering any vesicant to confirm the catheter tip is properly placed in the vein, thus preventing severe extravasation injury. Scrubbing the needleless hub with an antiseptic for at least 15 seconds creates mechanical friction that significantly reduces the risk of central line-associated bloodstream infections (CLABSI).

Step-by-Step Solution

1
Evaluate the requirement for syringe size when flushing a central line.
Syringes smaller than 10 mL10 \text{ mL} generate too much pressure.
High pressure can cause catheter rupture or dislodgment.
2
Determine the appropriate scope of practice for assessing the insertion site.
Assessment requires clinical judgment.
Assessment cannot be delegated to unlicensed assistive personnel (UAP).
3
Review the protocol for administering vesicant medications.
Blood return must be verified.
Ensuring the catheter is correctly situated in the vein prevents severe tissue damage from extravasation.
4
Analyze the rules for medication compatibility.
Incompatible medications cannot be mixed.
Administering them in the same lumen, regardless of speed, can cause dangerous precipitates to form.
5
Identify infection control standards for accessing a central line.
The hub must be scrubbed thoroughly.
Friction and antiseptic application for at least 15 seconds prevent central line-associated bloodstream infections (CLABSI).
6
Establish the correct emergency positioning for a suspected air embolism.
The client should be placed in the left lateral Trendelenburg position.
High Fowler's position would exacerbate the issue; the left lateral Trendelenburg position helps trap air in the right atrium and prevents it from entering the pulmonary circulation.

Key Concept

Central Venous Catheter Safety and Parenteral Administration Protocols
Question 923Question →

An occupational health nurse is counseling a 48-year-old client with a body mass index (BMI) of 29 and a highly sedentary lifestyle. The client states, "I know I need to be more active to avoid developing diabetes like my parents did, but I simply have no time to join a gym due to my work schedule." Which of the following responses by the nurse is the most appropriate?

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Answer: Let's explore some ways you might incorporate brief periods of moderate activity, such as walking, into your regular workday.

Answer

The response suggesting the exploration of brief periods of moderate activity into the workday is the most appropriate.
The correct response demonstrates therapeutic communication by collaborating with the client to find a practical solution to their identified barrier. By suggesting ways to integrate activity into the existing daily routine, the nurse promotes self-efficacy and supports primary prevention without requiring a significant time commitment or gym membership.

Step-by-Step Solution

1
Analyze the client's statement and identify the core issue.
The client recognizes the need for primary prevention (lifestyle changes) to avoid diabetes but perceives a barrier (lack of time for a gym).
Understanding the client's readiness to change and identified barriers is essential for tailoring effective health promotion strategies.
2
Evaluate the nurse's response options based on therapeutic communication principles and accurate health promotion concepts.
The correct response must address the client's barrier collaboratively without being judgmental, confusing prevention levels, or dismissing the risk as normal aging.
Effective nursing interventions in lifestyle modification rely on partnering with the client to set realistic, achievable goals.
3
Select the option that facilitates realistic lifestyle changes.
Exploring ways to incorporate walking into the workday provides a practical alternative to a gym membership, supporting the client's goal.
This approach empowers the client and promotes adherence to physical activity guidelines.

Key Concept

Therapeutic Communication in Health Promotion and Lifestyle Modification
Question 924Question →

A nurse is preparing to discontinue a non-tunneled central venous catheter (CVC) located in the right subclavian vein of a 68-year-old client who has completed a course of intravenous antibiotics for osteomyelitis. To strictly reduce the risk of a life-threatening physiological complication during this procedure, in what order should the nurse perform the following actions? Arrange the steps from first to last.

Drag items to arrange them in the correct order

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Answer

The correct sequence is to position the client flat, remove the dressing, instruct the Valsalva maneuver, withdraw the catheter, and immediately apply pressure.
Removing a central venous catheter carries a high risk of air embolism. The procedure must be precisely sequenced to maximize intrathoracic and central venous pressure before the catheter is withdrawn. Positioning the client flat or in Trendelenburg must occur first to raise central venous pressure. Only then should the nurse remove the dressing to prepare the site. Immediately before pulling the catheter, the client performs the Valsalva maneuver to further spike intrathoracic pressure. The catheter is then swiftly removed during this maneuver, followed by the immediate application of firm pressure to seal the tract.

Step-by-Step Solution

1
Position the client in a flat, supine or Trendelenburg position.
Central venous pressure is increased in the upper body.
This creates a positive pressure gradient that is the fundamental baseline requirement to reduce the risk of an air embolism.
2
Remove the existing transparent dressing while stabilizing the catheter.
The insertion site is safely exposed.
Performing this step after positioning ensures the client is already hemodynamically safe in the event of accidental catheter dislodgement during dressing removal.
3
Instruct the client to take a deep inhalation, hold it, and bear down.
Intrathoracic pressure is acutely elevated.
The Valsalva maneuver strictly prevents air entry into the venous system during the high-risk moment when the vein communicates with the atmosphere.
4
Withdraw the catheter completely in a swift, continuous motion.
The catheter is removed from the vascular space.
Swift removal during the Valsalva maneuver minimizes the duration the venous tract remains open.
5
Apply immediate firm pressure to the site with sterile gauze.
Hemostasis is achieved and air tracking is prevented.
Direct pressure physically blocks air from entering the venous tract and controls bleeding until an occlusive dressing is applied.

Key Concept

Central Venous Catheter Discontinuation and Air Embolism Prevention
Question 925Question →

A nurse in a women's health clinic is planning care for a healthy 26-year-old client. The nurse incorporates various disease prevention strategies into the client's plan of care. Which of the following nursing actions represents an appropriate secondary prevention strategy specifically indicated for this client?

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Answer: Performing a routine Papanicolaou (Pap) test to evaluate for cervical cellular abnormalities.

Answer

Performing a routine Papanicolaou (Pap) test to evaluate for cervical cellular abnormalities.
Secondary prevention involves interventions aimed at early detection and screening for diseases before they become clinically symptomatic. Performing a Papanicolaou (Pap) test is a classic secondary prevention measure because it screens for early cellular changes in the cervix, allowing for prompt intervention. This is highly appropriate for a healthy 26-year-old client.

Step-by-Step Solution

1
Identify the core concept being tested in the scenario.
The question requires identifying a secondary prevention strategy appropriate for a 26-year-old client.
Accurate classification of prevention levels is essential for appropriate care planning.
2
Define the goal of secondary prevention.
Secondary prevention focuses on early detection and screening of disease in asymptomatic individuals.
Understanding the definition helps distinguish it from primary (prevention) and tertiary (treatment or rehabilitation) strategies.
3
Evaluate each option against the definition of secondary prevention.
Vaccination and contraceptive education are primary. Cryotherapy is tertiary. The Pap test is a screening tool, making it secondary prevention.
Systematically categorizing each intervention ensures the correct level of prevention is selected.

Key Concept

Levels of Disease Prevention
Question 926Question →

A nurse is assessing a client who was admitted 6 hours ago with severe acute pancreatitis. The client has become increasingly restless. Which of the following assessment findings indicate severe physiological decompensation requiring immediate intervention? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Blood pressure change from 122/78 mm Hg to 94/76 mm Hg; Arterial blood gas values of pH 7.28, PaCO2 54 mm Hg, and PaO2 58 mm Hg; Hourly urine output of 15 mL over the past two hours

Answer

The correct findings are the narrowing pulse pressure, the arterial blood gas showing respiratory acidosis with hypoxemia, and the decreased hourly urine output.
Severe acute pancreatitis leads to massive retroperitoneal fluid shifts (third-spacing), resulting in severe hypovolemia and decreased systemic perfusion. A narrowing pulse pressure and oliguria (urine output less than 30 mL/hr) are critical early indicators of compensatory hypovolemic shock. Additionally, the release of systemic inflammatory mediators can trigger Acute Respiratory Distress Syndrome (ARDS), which is evidenced by uncompensated respiratory acidosis (pH < 7.35, PaCO2 > 45) and severe hypoxemia (PaO2 < 60). These three findings demand immediate life-saving interventions.

Step-by-Step Solution

1
Analyze the client's condition and pathophysiology.
Severe acute pancreatitis causes massive systemic inflammation and retroperitoneal fluid shifts (third-spacing).
Understanding the disease process helps predict potential life-threatening complications, primarily hypovolemic shock and Acute Respiratory Distress Syndrome (ARDS).
2
Evaluate cardiovascular and renal assessment findings.
The blood pressure shows a narrowing pulse pressure (from 44 to 18 mm Hg), and the urine output is oliguric (15 mL/hr).
A narrowing pulse pressure and decreased urine output are classic early signs of compensatory hypovolemic shock and inadequate organ perfusion.
3
Evaluate respiratory and laboratory findings.
One ABG shows pH 7.28, PaCO2 54, and PaO2 58. The other shows pH 7.48, PaCO2 32.
The first ABG indicates severe respiratory acidosis and hypoxemia (ARDS), requiring immediate intervention. The second is an expected respiratory alkalosis resulting from pain and anxiety.
4
Evaluate the remaining assessment data.
Temperature is 38.3°C, and skin is described as warm and flushed with bounding pulses.
Fever is an expected inflammatory response. Warm/flushed skin is a sign of early septic shock, which conflicts with the expected hypovolemic presentation caused by third-spacing.

Key Concept

Early recognition of hypovolemic shock (third-spacing) and Acute Respiratory Distress Syndrome (ARDS) in acute pancreatitis.
Question 927Question →

A nurse is preparing to administer an intermittent intravenous (IV) piggyback medication using the backpriming method through an existing continuous primary IV infusion. Assuming hand hygiene and medication verification have been completed, place the following steps in the correct sequence for setting up the IV piggyback.

Drag items to arrange them in the correct order

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Answer

The correct sequence is: 1) Close the clamp and spike the bag, 2) Scrub the primary port, 3) Attach and lower the secondary bag, 4) Open the clamp to backprime, and 5) Close the clamp, hang the bag, and program the pump.
The correct sequence ensures patient safety, maintains asepsis, and prevents medication waste. By closing the clamp before spiking, the system remains closed. Scrubbing the hub is a mandatory aseptic step before any connection. Lowering the secondary bag below the primary bag creates the necessary hydrostatic pressure gradient. When the clamp is opened, the primary fluid flows backward, clearing air from the secondary line without wasting medication. Finally, closing the clamp and hanging the bag high allows the medication to infuse first when the pump is programmed.

Step-by-Step Solution

1
Close the roller clamp on the secondary IV tubing and spike the secondary medication bag.
The medication is secured in a closed system.
Closing the clamp prevents medication waste and air entry during spiking.
2
Scrub the needleless connector on the primary IV tubing located above the infusion pump.
The Y-site is disinfected.
Strict aseptic technique is required to prevent catheter-related bloodstream infections.
3
Attach the secondary IV tubing to the cleansed primary port and lower the secondary bag below the primary fluid bag.
The secondary set is connected and positioned for gravity backflow.
Lowering the secondary bag creates hydrostatic pressure that allows primary fluid to flow backward into the secondary line.
4
Open the secondary roller clamp to allow primary IV fluid to flow backward into the secondary tubing until the drip chamber is half full.
The secondary tubing and drip chamber fill with primary fluid.
Backpriming displaces air in the secondary tubing without losing any of the ordered medication.
5
Close the secondary roller clamp, hang the secondary bag higher than the primary bag, and program the infusion pump.
The IV piggyback is ready to infuse.
Hanging the secondary bag higher ensures it will infuse first, and programming the pump ensures the correct administration rate.

Key Concept

Intravenous Piggyback (IVPB) Backpriming Procedure
Estimated Time:1m 30s
Question 928Question →

A nurse is conducting serial assessments on a client who sustained blunt abdominal trauma three hours ago. The client's initial vital signs and physical assessments were within normal limits. Based on the understanding of hemodynamic compensatory mechanisms, which of the following physiological changes should the nurse identify as the earliest indicator that the client is developing hemorrhagic shock?

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Answer: A progressive elevation in the diastolic blood pressure while the systolic pressure remains stable

Answer

The earliest indicator is a progressive elevation in the diastolic blood pressure while the systolic pressure remains stable.
The correct answer is a progressive elevation in the diastolic blood pressure. During the early compensatory stage of hemorrhagic shock, the sympathetic nervous system is stimulated in response to decreased cardiac output. This causes peripheral vasoconstriction, which primarily raises the diastolic blood pressure. Because the systolic pressure is temporarily maintained by an increased heart rate, the difference between the two (the pulse pressure) narrows. This narrowing is one of the most sensitive and earliest hemodynamic indicators of volume loss.

Step-by-Step Solution

1
Analyze the client's clinical scenario.
The client has sustained blunt abdominal trauma and is at high risk for internal bleeding leading to hemorrhagic (hypovolemic) shock.
Identifying the primary risk factor helps anticipate expected physiological complications.
2
Recall the physiological mechanisms of early shock.
In the initial stages of blood volume loss, the body compensates by activating the sympathetic nervous system, leading to peripheral vasoconstriction and increased heart rate to maintain cardiac output.
Understanding compensatory physiology is necessary to recognize the earliest clinical manifestations of shock.
3
Evaluate the assessment findings against early compensatory signs.
Peripheral vasoconstriction increases systemic vascular resistance, which elevates the diastolic blood pressure. This narrows the pulse pressure before the systolic blood pressure begins to drop.
This subtle hemodynamic change occurs prior to overt signs of decompensation.
4
Differentiate early signs from late signs or expected local findings.
Hypotension and metabolic acidosis are late signs of decompensation, while localized guarding is an expected injury-specific finding rather than a systemic hemodynamic indicator.
Eliminating late or unrelated findings confirms the correct early indicator.

Key Concept

Early compensatory mechanisms in hemorrhagic shock primarily involve sympathetic nervous system activation, which causes peripheral vasoconstriction and elevates diastolic blood pressure, leading to a narrowing pulse pressure before frank hypotension occurs.
Question 929Question →

Following a percutaneous liver biopsy, a client rests on their right side. As the nurse monitors the client for potential complications, which vital sign change provides the earliest indication of internal hemorrhage?

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Answer: Heart rate increases from 74 to 108 beats per minute

Answer

An increase in heart rate (tachycardia) is typically the earliest vital sign change indicating internal hemorrhage.
An unexplained increase in heart rate (tachycardia) is typically the earliest physiological sign of bleeding and hypovolemia. The sympathetic nervous system triggers this response to maintain cardiac output and tissue perfusion despite a falling blood volume.

Step-by-Step Solution

1
Identify the primary complication risk associated with a percutaneous liver biopsy.
The liver is highly vascular, making internal hemorrhage a significant post-procedure risk.
Understanding the procedural risks guides targeted assessment.
2
Recall the body's immediate physiological adaptation to acute blood loss.
The sympathetic nervous system activates, causing an immediate increase in heart rate.
This mechanism aims to maintain cardiac output and tissue perfusion despite a drop in circulating blood volume.
3
Differentiate between early and late signs of hemorrhagic shock.
Tachycardia is an early compensatory sign, whereas hypotension and altered oxygenation are later signs that occur when compensation fails.
Prioritizing early recognition allows for timely, life-saving interventions before the client decompensates.

Key Concept

Early recognition of hemorrhagic shock
Estimated Time:45s
Question 930Question →

A nurse is caring for a client who recently experienced a right-hemisphere ischemic stroke. The client has developed left-sided hemiplegia, left homonymous hemianopsia, and mild dysphagia. Which of the following basic care interventions should the nurse implement during mealtime?

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Answer: Arrange all food items and eating utensils on the right side of the client's overbed table.

Answer

Arrange all food items and eating utensils on the right side of the client's overbed table.
A right-hemisphere ischemic stroke frequently results in left homonymous hemianopsia, which is the loss of the left half of the visual field in both eyes. By deliberately placing the meal tray, food items, and utensils on the client's right side, the nurse ensures that all items fall within the client's intact visual field. This intervention prevents unilateral neglect, promotes client independence, and facilitates adequate nutritional intake.

Step-by-Step Solution

1
Analyze the specific neurological deficits resulting from a right-hemisphere stroke.
The client experiences left-sided hemiplegia (weakness) and left homonymous hemianopsia (loss of the left visual field in both eyes).
Identifying the affected side is crucial for determining how to position the client's environment and food.
2
Determine the impact of left homonymous hemianopsia on basic care and nutrition.
The client cannot see objects placed on their left side, leading to a high risk of unilateral neglect where they may ignore half of their meal.
Interventions must compensate for the visual deficit to promote independence and adequate nutritional intake.
3
Identify the appropriate environmental adaptation for this visual deficit.
Food, beverages, and utensils must be placed within the intact right visual field so the client can clearly see and access them.
This directly addresses the sensory deficit and ensures safe, independent feeding.
4
Evaluate the distractors regarding dysphagia protocols and delegation rules.
Dysphagia requires a high-Fowler's position (90 degrees) and a chin-tuck swallowing technique. Additionally, the RN cannot delegate the initial feeding assessment to a UAP.
Ruling out unsafe positioning, improper swallowing mechanics, and out-of-scope delegation confirms the correct intervention.

Key Concept

Basic Care and Comfort for Stroke Clients (Nutrition, Positioning, and Safety)
Question 931Question →

While conducting hourly rounds on a surgical unit, a nurse encounters a client who is two days post-operative from an open bowel resection. The client is extremely restless, clutching their chest, and gasping for air. The bedside monitor displays a heart rate of 124 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 90/62 mm Hg, and an oxygen saturation of 84% on room air. The rapid response team is activated, and immediate arterial blood gas (ABG) results show a pH of 7.52, PaCO2 of 28 mm Hg, PaO2 of 54 mm Hg, and HCO3 of 23 mEq/L. Which of the following actions should the nurse execute first to mitigate the risk of cardiopulmonary arrest?

Show answer & explanation

Answer: Apply oxygen via a non-rebreather mask and elevate the head of the bed to a high-Fowler's position.

Answer

The priority action is to apply oxygen via a non-rebreather mask and elevate the head of the bed to a high-Fowler's position.
The correct action directly addresses the client's most critical, life-threatening problem: severe hypoxemia and respiratory compromise (likely secondary to a pulmonary embolism). Utilizing the ABCs (Airway, Breathing, Circulation) framework, optimizing oxygen delivery via a non-rebreather mask and facilitating maximum lung expansion by elevating the head of the bed are the absolute highest priorities to prevent cardiopulmonary arrest.

Step-by-Step Solution

1
Analyze the clinical presentation and vital signs.
The client is experiencing acute, severe respiratory distress, hypoxia (SpO2 84%), tachycardia, and chest pain, which are hallmark indicators of a potential pulmonary embolism.
Identifying the primary physiological failure guides immediate prioritization.
2
Interpret the arterial blood gas (ABG) values.
pH 7.52 (alkaline), PaCO2 28 mm Hg (low, respiratory origin), and HCO3 23 mEq/L (normal) indicate uncompensated respiratory alkalosis, accompanied by severe hypoxemia (PaO2 54 mm Hg).
Accurate ABG interpretation confirms the client is hyperventilating to compensate for profound hypoxia, ruling out acidosis.
3
Apply the ABC (Airway, Breathing, Circulation) prioritization framework.
The most critical, life-threatening deficit is oxygenation. Supplying high-flow oxygen and optimizing anatomical positioning for lung expansion (high-Fowler's) are the immediate required actions.
Airway and breathing interventions must always precede circulation interventions or further diagnostic assessments when a client is actively decompensating.

Key Concept

Prioritization of oxygenation and correct positioning for acute respiratory distress, coupled with accurate ABG interpretation.
Estimated Time:1m 30s
Question 932Question →

A nurse is managing the care of a client admitted with diabetic ketoacidosis. The client is receiving a continuous intravenous (IV) infusion of regular insulin through a single peripheral IV catheter. The healthcare provider prescribes an intermittent IV infusion of a broad-spectrum antibiotic for a concurrent infection. The nurse consults a drug compatibility reference and discovers the antibiotic is chemically incompatible with regular insulin at the Y-site. Which of the following actions is the most appropriate for the nurse to take?

Show answer & explanation

Answer: Insert a second peripheral intravenous catheter to administer the intermittent antibiotic infusion.

Answer

Insert a second peripheral intravenous catheter to administer the intermittent antibiotic infusion.
Regular insulin is a critical continuous infusion for a client with diabetic ketoacidosis and must not be interrupted, as doing so can rapidly worsen the client's metabolic state. Because the prescribed antibiotic is incompatible with insulin, the two medications cannot share the same IV line, even with flushing, as the insulin must run continuously. Therefore, establishing a second peripheral IV catheter is the only safe and effective method to administer both therapies simultaneously.

Step-by-Step Solution

1
Identify the nature of the primary infusion.
Regular insulin for diabetic ketoacidosis is a critical, continuous infusion that cannot be safely interrupted.
Maintaining steady blood insulin levels is required to reverse ketoacidosis; pausing the infusion risks metabolic deterioration.
2
Evaluate the compatibility of the prescribed secondary medication.
The prescribed antibiotic is chemically incompatible with the regular insulin infusion at the Y-site.
Mixing incompatible medications can cause crystallization or precipitation in the tubing.
3
Determine the safest administration strategy.
A new, separate peripheral IV catheter must be inserted.
Because the primary infusion cannot be paused for a flush-and-run approach, and the medications cannot mix, a dedicated secondary line is required.

Key Concept

Management of incompatible intravenous medications with continuous critical infusions
Question 933Question →

A healthcare provider prescribes a continuous intravenous dopamine infusion at 5 mcg/kg/min5\text{ mcg/kg/min} to support the blood pressure of a client in cardiogenic shock. The client's body weight is recorded as 176 lb176\text{ lb}. The medication is supplied in an intravenous bag containing 400 mg400\text{ mg} of dopamine mixed in 250 mL250\text{ mL} of 5% dextrose in water (D5W). At what rate, in mL/hr\text{mL/hr}, should the infusion pump be programmed? (Record your answer as a whole number)

Show answer & explanation

Answer: 15

Answer

15
The correct rate of 15 mL/hr is achieved by converting the client's weight to kg (80 kg), calculating the hourly dose in mg (24 mg/hr), and dividing by the IV bag's concentration (1.6 mg/mL).

Step-by-Step Solution

1
Convert the client's weight from pounds to kilograms.
176 lb÷2.2=80 kg176\text{ lb} \div 2.2 = 80\text{ kg}
The prescribed dose is based on the client's weight in kilograms.
2
Calculate the required dose per minute.
5 mcg/kg/min×80 kg=400 mcg/min5\text{ mcg/kg/min} \times 80\text{ kg} = 400\text{ mcg/min}
To determine the total micrograms of medication the client needs every minute.
3
Calculate the total dose required per hour.
400 mcg/min×60 min/hr=24,000 mcg/hr400\text{ mcg/min} \times 60\text{ min/hr} = 24,000\text{ mcg/hr}
Infusion pumps are programmed in fluid volume per hour, so the dose must be scaled to an hourly rate.
4
Convert the hourly dose from micrograms to milligrams.
24,000 mcg÷1000=24 mg/hr24,000\text{ mcg} \div 1000 = 24\text{ mg/hr}
The supplied medication in the IV bag is measured in milligrams.
5
Determine the medication concentration in the supplied IV bag.
400 mg÷250 mL=1.6 mg/mL400\text{ mg} \div 250\text{ mL} = 1.6\text{ mg/mL}
To know how many milligrams of dopamine are contained in each milliliter of the solution.
6
Calculate the required volume to be infused per hour.
24 mg/hr÷1.6 mg/mL=15 mL/hr24\text{ mg/hr} \div 1.6\text{ mg/mL} = 15\text{ mL/hr}
To determine the final setting for the infusion pump in mL/hr.

Key Concept

Weight-based intravenous continuous infusion rate calculation
Question 934Question →

A nurse is evaluating a client who was admitted following a severe pelvic crush injury. Which of the following assessment findings should the nurse identify as indicators that the client is in the early (compensatory) stage of hypovolemic shock? Select all that apply.

Select all that apply

Show answer & explanation

Answer: A change in blood pressure from 124/76 mm Hg to 112/84 mm Hg; Unexplained restlessness and mild agitation; Arterial blood gas results showing pH 7.48, PaCO2 30 mm Hg, and HCO3 22 mEq/L

Answer

The correct assessment findings are a narrowing pulse pressure (blood pressure changing to 112/84 mm Hg), unexplained restlessness and mild agitation, and an arterial blood gas showing respiratory alkalosis (pH 7.48).
During the early (compensatory) stage of hypovolemic shock, the body activates the sympathetic nervous system. This causes peripheral vasoconstriction, which increases diastolic blood pressure and creates a narrowed pulse pressure. Mild cerebral hypoxia presents as restlessness or agitation. Additionally, a compensatory increase in respiratory rate leads to the blowing off of carbon dioxide, resulting in respiratory alkalosis.

Step-by-Step Solution

1
Analyze the physiological changes that occur during the early (compensatory) stage of shock.
The body activates the sympathetic nervous system to maintain cardiac output and tissue perfusion in response to a drop in effective circulating volume.
Understanding the timeline of shock stages is necessary to differentiate early compensatory signs from late progressive signs.
2
Evaluate the hemodynamic and neurological options.
A narrowing pulse pressure (from 48 mm Hg to 28 mm Hg) and mild restlessness indicate early compensatory vasoconstriction and initial cerebral hypoxia. A MAP of 56 mm Hg indicates failure of compensation.
The sympathetic response increases diastolic pressure before systolic pressure falls significantly, while early hypoxia affects the sensitive cerebral cortex first.
3
Evaluate the arterial blood gas (ABG) options.
Tachypnea in early shock causes respiratory alkalosis. Metabolic acidosis occurs later in the progressive stage.
The initial respiratory response to stress and hypoxia blows off CO2, whereas anaerobic metabolism is a later consequence of prolonged hypoperfusion.

Key Concept

Early (Compensatory) Stage of Shock
Question 935Question →

A charge nurse is reviewing the electronic health record of a pregnant client undergoing labor induction. The prescribed oxytocin protocol dictates a starting dose of 22 milliunits/min, with increases of 22 milliunits/min every 3030 minutes until an adequate contraction pattern is established. The IV bag contains 2020 units of oxytocin mixed in 1,0001,000 mL of 0.9%0.9\% sodium chloride. If the protocol has been strictly followed without any pauses or decelerations requiring dose reduction, how many mL/hr should the infusion pump be delivering exactly 120120 minutes after the induction began? (Record your answer as a whole number).

Show answer & explanation

Answer: 30

Answer

The correct infusion rate at 120 minutes is 30 mL/hr.
At 120 minutes, the client has undergone 4 titrations (at 30, 60, 90, and 120 minutes), bringing the dose from 2 milliunits/min to 10 milliunits/min. The solution concentration is 20 milliunits/mL (20,000 milliunits divided by 1,000 mL). Dividing the required 10 milliunits/min by the 20 milliunits/mL concentration yields 0.5 mL/min. Multiplying this by 60 minutes per hour gives the final required pump setting of 30 mL/hr.

Step-by-Step Solution

1
Determine the current dose at exactly 120 minutes.
1010 milliunits/min
The infusion starts at 22 milliunits/min. Increases of 22 milliunits/min occur at 3030, 6060, 9090, and 120120 minutes (a total of 44 increases). Therefore, 2+(4×2)=102 + (4 \times 2) = 10 milliunits/min.
2
Calculate the concentration of the oxytocin solution.
2020 milliunits/mL
First, convert the total units to milliunits: 20 units×1,000=20,000 milliunits20 \text{ units} \times 1,000 = 20,000 \text{ milliunits}. Then divide by the total volume: 20,000 milliunits1,000 mL=20 milliunits/mL\frac{20,000 \text{ milliunits}}{1,000 \text{ mL}} = 20 \text{ milliunits/mL}.
3
Calculate the required volume to be infused per minute.
0.50.5 mL/min
Divide the prescribed minute dose by the concentration: 10 milliunits/min20 milliunits/mL=0.5 mL/min\frac{10 \text{ milliunits/min}}{20 \text{ milliunits/mL}} = 0.5 \text{ mL/min}.
4
Convert the minute rate to an hourly pump rate.
3030 mL/hr
Multiply the volume per minute by 6060 minutes: 0.5 mL/min×60 min/hr=30 mL/hr0.5 \text{ mL/min} \times 60 \text{ min/hr} = 30 \text{ mL/hr}.

Key Concept

Titration of high-alert maternity medications (oxytocin) requires calculating progressive dose increases over time and converting prescribed milliunits per minute into an hourly volumetric pump rate.
Estimated Time:2m 30s
Question 936Question →

A nurse evaluates a client with a history of hepatic cirrhosis who is being monitored for a suspected gastrointestinal bleed. The client is alert but frequently shifts positions in bed and appears restless. The current vital signs are: blood pressure 114/86114/86 mm Hg (admission baseline 134/74134/74 mm Hg), heart rate 112112 beats/min, and respiratory rate 2222 breaths/min. The client repeatedly complains of severe thirst. Which action should the nurse take first?

Show answer & explanation

Answer: Initiate continuous pulse oximetry and establish large-bore intravenous access.

Answer

Initiate continuous pulse oximetry and establish large-bore intravenous access.
The client is exhibiting early compensatory signs of hypovolemic shock secondary to a suspected gastrointestinal bleed. These indicators include a narrowing pulse pressure (a drop from a baseline of 6060 mm Hg down to 2828 mm Hg), tachycardia, mild tachypnea, severe thirst, and restlessness (an early sign of cerebral hypoxia). The priority nursing action according to the ABC (Airway, Breathing, Circulation) framework is to secure oxygenation monitoring and establish large-bore intravenous access to prepare for rapid fluid and blood product administration.

Step-by-Step Solution

1
Analyze the client's current clinical presentation compared to baseline.
The client has a narrowing pulse pressure (decreased from 6060 mm Hg to 2828 mm Hg), tachycardia (112112 beats/min), tachypnea (2222 breaths/min), restlessness, and severe thirst.
Identifying trends in vital signs and recognizing new symptoms is critical for detecting physiological deterioration.
2
Correlate the findings with the client's risk factors.
The client has a history of cirrhosis and suspected gastrointestinal bleeding, making hypovolemia/hemorrhage the most likely cause of these symptoms.
Understanding the underlying pathology provides context for the compensatory mechanisms being observed.
3
Determine the priority nursing intervention based on ABCs (Airway, Breathing, Circulation).
The most urgent need is to manage potential hypoxia and impending circulatory collapse by preparing for aggressive fluid and blood product resuscitation.
Prioritization frameworks dictate that physiological stability and perfusion take precedence over comfort, routine reassessment, or symptom-masking.

Key Concept

Early indicators of hypovolemic shock include a narrowing pulse pressure, tachycardia, and altered mental status (restlessness), requiring immediate circulatory support.
Question 937Question →

A nurse is preparing a client with ascites for a bedside abdominal paracentesis. In which order should the nurse perform the following actions to ensure the client's safety and reduce the risk of physiological complications? Arrange the actions in the correct chronological sequence.

Drag items to arrange them in the correct order

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Answer

The correct sequence is to first verify informed consent, then instruct the client to void, followed by obtaining baseline measurements, and finally positioning the client upright for the procedure.
Preparing a client for a paracentesis requires a deliberate, sequential approach focused on risk reduction. First, the nurse must ensure legal consent is obtained. Next, instructing the client to void is the most critical physiological safety step to prevent accidental bladder injury. Once the bladder is empty, accurate baselines (vital signs, dry weight, abdominal girth) are recorded to later assess fluid shifts and signs of hemodynamic instability. Finally, positioning the client upright uses gravity to safely pool fluid in the lower abdomen, keeping floating bowel loops and the decompressed bladder away from the insertion site.

Step-by-Step Solution

1
Verify informed consent
Legal requirements and client understanding are confirmed.
Consent must be verified before any procedure-specific physical preparation begins.
2
Instruct the client to void
The bladder is fully decompressed.
An empty bladder minimizes the physiological risk of an iatrogenic bladder puncture when the trocar is inserted into the abdomen.
3
Obtain baseline measurements
Vital signs, dry weight, and abdominal girth are recorded.
Baselines taken after voiding provide accurate clinical data to evaluate the volume of fluid removed and to monitor for post-procedure hypovolemic shock.
4
Position the client upright
Ascitic fluid pools in the dependent areas of the abdomen.
An upright position uses gravity to concentrate fluid safely away from major abdominal organs, reducing the risk of accidental bowel perforation.

Key Concept

Prioritization of safety and risk reduction interventions during preparation for an invasive procedure (paracentesis).
Question 938Question →

A nurse is assisting with a vaginal delivery. Following the delivery of the fetal head, the head retracts tightly against the maternal perineum. Arrange the following nursing actions in the correct sequence of priority.

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Answer

The correct sequence is: stop pushing and call for help, perform the McRoberts maneuver, apply suprapubic pressure, assist with internal maneuvers, and assess the newborn for trauma.
Shoulder dystocia is a critical emergency requiring immediate sequential actions. First, pushing must cease to prevent further impaction, and additional help is summoned (including neonatal staff). Next, the McRoberts maneuver (hyperflexion of legs) is performed to widen the pelvic outlet. If unsuccessful, suprapubic pressure is applied to manually dislodge the anterior shoulder. If these external maneuvers fail, the nurse prepares to assist the provider with internal maneuvers. Finally, after delivery, the newborn is at high risk for trauma (e.g., fractured clavicle, brachial plexus injury) and must be thoroughly assessed.

Step-by-Step Solution

1
Identify the complication.
The retraction of the fetal head (turtle sign) indicates shoulder dystocia.
Recognizing the emergency dictates the immediate algorithm for intervention.
2
Initiate emergency protocols.
Instruct the client to stop pushing and call for help.
Pushing further impacts the shoulder. Additional staff, including the neonatal resuscitation team, are necessary for maneuvers and potential newborn distress.
3
Implement first-line physical maneuvers.
Perform the McRoberts maneuver (hyperflexing the maternal legs).
This non-invasive maneuver changes the maternal pelvic geometry and resolves many cases of shoulder dystocia.
4
Add secondary pressure maneuvers.
Apply suprapubic pressure.
Suprapubic pressure aims to dislodge the anterior shoulder from behind the pubic bone. Fundal pressure must never be used.
5
Progress to advanced obstetric interventions.
Assist with internal rotational maneuvers.
If external maneuvers fail, the provider will need to manually rotate the fetus or deliver the posterior arm.
6
Perform post-delivery evaluation.
Assess the newborn for birth trauma.
Shoulder dystocia carries a high risk for clavicular fractures, brachial plexus injuries (such as Erb's palsy), and hypoxia.

Key Concept

Management of shoulder dystocia follows a specific algorithmic sequence prioritizing non-invasive maneuvers to safely dislodge the fetal shoulder and prevent birth trauma or hypoxia.
Question 939Question →

During a routine assessment of a client who underwent a right-sided thoracentesis 45 minutes ago, the nurse notes several clinical changes. Which observation represents the highest priority for immediate provider notification and intervention?

Show answer & explanation

Answer: The client exhibits asymmetrical chest wall movement and new-onset tracheal deviation to the left.

Answer

The observation of asymmetrical chest wall movement and tracheal deviation to the left indicates a tension pneumothorax and requires immediate intervention.
A tension pneumothorax occurs when air enters the pleural space but cannot escape, causing increasing intrathoracic pressure. This rapidly collapses the affected lung (indicated by asymmetrical chest movement) and pushes mediastinal structures, including the trachea, to the opposite, unaffected side. This is a life-threatening emergency requiring immediate needle decompression or chest tube insertion.

Step-by-Step Solution

1
Analyze the procedure and its potential physiological complications.
Thoracentesis involves needle insertion into the pleural space, carrying a high risk of puncturing the lung parenchyma and causing a pneumothorax.
Identifying procedure-specific risks is essential for focused and accurate post-procedure assessment.
2
Evaluate the clinical findings in the options against known life-threatening complications.
Asymmetrical chest movement and contralateral tracheal deviation are classic signs of a tension pneumothorax, which is a medical emergency.
Early recognition of tension pneumothorax prevents cardiopulmonary arrest.
3
Differentiate expected outcomes and normal findings from pathological changes.
Mild pain and normal ABG values are expected. Lying on the unaffected side is a correct therapeutic intervention.
Eliminating expected findings or correct interventions isolates the true pathological emergency requiring action.

Key Concept

Early recognition of a tension pneumothorax following a thoracentesis is a critical risk reduction skill.
Question 940Question →

A nurse is caring for a client who is receiving an initial intravenous dose of ceftriaxone for a severe respiratory infection. Ten minutes after the infusion begins, the client develops sudden wheezing, facial swelling, and reports a feeling of impending doom. Which of the following nursing actions are appropriate? (Select all that apply.)

Select all that apply

Show answer & explanation

Answer: Stop the ceftriaxone infusion immediately.; Attach new intravenous tubing primed with 0.9% sodium chloride to the catheter hub.; Prepare to administer intramuscular epinephrine.

Answer

The correct actions are to stop the ceftriaxone infusion immediately, attach new intravenous tubing primed with 0.9% sodium chloride, and prepare to administer intramuscular epinephrine.
Anaphylaxis is a severe, life-threatening hypersensitivity reaction. The absolute first priority is to stop the offending medication. Following this, the nurse must maintain intravenous access using new tubing (to avoid pushing remaining antibiotic into the client) and prepare to administer epinephrine, which is the first-line medication for reversing anaphylactic shock.

Step-by-Step Solution

1
Analyze the client's sudden onset of symptoms (wheezing, facial swelling, impending doom).
Identify these manifestations as classic signs of a severe, life-threatening anaphylactic reaction.
Early recognition of anaphylactic shock dictates the speed and direction of emergency nursing interventions.
2
Determine the first priority action regarding the intravenous therapy.
Stop the ceftriaxone infusion immediately.
Stopping the infusion prevents further exposure to the allergen triggering the anaphylactic cascade.
3
Determine how to safely maintain intravenous access.
Change the IV tubing and attach new tubing primed with normal saline at the catheter hub.
Intravenous access is vital for emergency drugs, but flushing the existing tubing would push the remaining antibiotic allergen into the client's circulation.
4
Identify the primary pharmacological intervention for anaphylaxis.
Prepare to administer intramuscular epinephrine.
Epinephrine is the first-line medication required to reverse the life-threatening bronchoconstriction and vasodilation of anaphylaxis.

Key Concept

Management of Anaphylactic Shock During Parenteral Therapy
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