Examkin

All practice questions

862 questions

All types3,881Multiple choice1,926Multiple select908Numeric119Matching66Ordering862
Question 81Question →

A registered nurse is preparing to administer an intravenous (IV) push medication through a client's accessed, but currently inactive, implanted venous port (Port-a-Cath). Based on standard facility protocol for a heparin-locked central venous device, arrange the following steps in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence follows the SASH protocol: Saline flush (with aspiration), Administer medication, Saline flush, Heparin flush, followed by clamping the tubing with positive pressure.
The SASH protocol is the standard of practice for administering medications through a heparin-locked central venous device. The sequence ensures that the line is patent before medication is given, prevents chemical incompatibilities by flushing before and after administration, and secures the line with anticoagulant and positive pressure clamping to prevent future occlusions. Rigorous infection control is maintained by scrubbing the hub before every syringe attachment.

Step-by-Step Solution

1
Scrub the hub, aspirate, and flush with saline
Line patency and placement are confirmed
Ensures the catheter is in the vein and clears resting heparin
2
Scrub the hub and administer the medication
Medication is delivered safely
Provides the prescribed therapeutic intervention
3
Scrub the hub and flush with saline using a pulsatile method
Medication is cleared from the catheter
Prevents mixing of incompatible drugs and clears fibrin from catheter walls
4
Scrub the hub and instill the heparin flush
Catheter is filled with anticoagulant
Prevents clot formation while the port is inactive
5
Clamp the tubing while maintaining positive pressure
Catheter is safely locked
Prevents blood reflux into the catheter tip, avoiding occlusion

Key Concept

The SASH (Saline, Administer, Saline, Heparin) protocol and positive-pressure clamping technique for central venous access devices.
Estimated Time:1m 30s
Question 82Question →

A nurse is caring for a client with a history of severe anemia who is receiving a transfusion of packed red blood cells. Fifteen minutes after the transfusion begins, the client reports a sudden onset of lower back pain, chills, and difficulty breathing. Arrange the following nursing interventions in the prioritized sequence from first to last action.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct priority sequence for managing an acute hemolytic transfusion reaction is to first stop the transfusion, maintain the IV line with normal saline using new tubing, assess the client, notify the provider and blood bank, and finally return the blood bag and tubing to the laboratory.
When a client experiences an acute hemolytic transfusion reaction, the immediate priority is to stop the infusion to prevent further exposure to the antigen. Next, the nurse must maintain a patent IV line with normal saline using completely new tubing to avoid flushing residual blood from the old tubing into the client. Once the source is removed and the line is secured, the nurse performs a rapid assessment to gather vital data. This data is then reported to the healthcare provider to obtain emergency orders. Finally, the blood bag and tubing are sent to the blood bank for crossmatch re-evaluation.

Step-by-Step Solution

1
Stop the blood transfusion immediately.
The causative agent is halted.
To prevent any additional incompatible blood from entering the client's circulation.
2
Disconnect the blood tubing and initiate an infusion of normal saline using new IV tubing.
A patent intravenous access is maintained without infusing residual blood.
To ensure vascular access is available for emergency medications and fluid resuscitation.
3
Assess the client's vital signs and respiratory status.
Baseline clinical data is obtained.
To determine the severity of the hemolytic reaction and prepare to report accurate findings to the healthcare provider.
4
Notify the healthcare provider and the blood bank.
The medical team is alerted to the crisis.
To obtain prescriptions for emergency interventions and inform the blood bank of the adverse event.
5
Send the remaining blood product, bag, and tubing to the blood bank.
The materials are returned for laboratory analysis.
To allow the blood bank to investigate the cause of the transfusion reaction.

Key Concept

Management of Acute Hemolytic Transfusion Reaction
Question 83Question →

A nurse is preparing to perform open airway suctioning for a client who has a newly established tracheostomy. In what order should the nurse perform the following actions to minimize the risk of complications such as hypoxemia and mucosal trauma?

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct order is to first assess baseline respiratory status, then hyperoxygenate the client, advance the catheter without suction, apply intermittent suction upon withdrawal, and finally reassess respiratory status.
The correct sequence for airway suctioning prioritizes evidence-based steps to reduce risk potential. Establishing a baseline assessment ensures the procedure is indicated. Hyperoxygenation must immediately precede the intervention to protect against severe oxygen depletion. To prevent mucosal tearing, the catheter must be advanced without suction. Suction is then applied intermittently only during rotational withdrawal to safely clear the airway. Finally, post-procedure assessment evaluates the efficacy of the intervention and the client's physiological stability.

Step-by-Step Solution

1
Assess the client's baseline breath sounds and oxygen saturation.
A clinical baseline is established.
Assessment is always the first step of the nursing process before an intervention to verify the clinical indication.
2
Hyperoxygenate the client with 100% oxygen.
The client's oxygen reserves are temporarily maximized.
Suctioning removes oxygen from the airway along with secretions; hyperoxygenation significantly reduces the risk of procedure-induced hypoxemia.
3
Advance the sterile suction catheter into the airway without applying suction.
The catheter is positioned safely at the appropriate depth.
Applying suction during advancement can strip oxygen away prematurely and traumatize the delicate tracheal mucosa.
4
Apply intermittent suction while rotating and withdrawing the catheter.
Secretions are effectively cleared from the airway.
Rotating and intermittently suctioning during withdrawal limits mucosal adherence and minimizes localized tissue damage.
5
Reassess the client's breath sounds and respiratory status.
The effectiveness of the suctioning procedure is determined.
Post-procedure evaluation is required to ensure the airway is clear and the client has not experienced adverse physiological effects.

Key Concept

Proper sequencing of open airway tracheostomy suctioning to prevent hypoxemia and mucosal trauma.
Question 84Question →

A nurse is caring for a client with a T4 spinal cord injury who suddenly reports a severe, pounding headache and exhibits profuse diaphoresis. The client's blood pressure is 210/110 mm Hg210/110 \text{ mm Hg}. Arrange the following nursing actions in the correct priority sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct priority sequence is to first elevate the head of the bed, then assess the urinary catheter, followed by administering antihypertensive medication if needed, and finally documenting the event.
In the management of autonomic dysreflexia, the immediate priority is to lower the blood pressure to prevent a stroke by elevating the head of the bed. The nurse must then find and eliminate the cause (most often a full bladder or bowel impaction). If these measures fail, medications are administered. Documentation is always the final step.

Step-by-Step Solution

1
Elevate the head of the bed to a high Fowler's position.
Decreases venous return to the heart and lowers blood pressure via orthostasis.
This is the most rapid, non-pharmacological way to lower the blood pressure and prevent a cerebral hemorrhage during autonomic dysreflexia.
2
Assess the urinary catheter tubing for kinks or obstruction.
Identifies and potentially resolves the most common trigger (bladder distension).
Autonomic dysreflexia is triggered by a noxious stimulus below the level of the spinal cord injury; removing it often resolves the crisis.
3
Administer a prescribed short-acting antihypertensive medication.
Lowers blood pressure pharmacologically.
Required if the noxious stimulus cannot be found or if blood pressure remains dangerously high despite removing the stimulus.
4
Document the incident, the interventions provided, and the client's response.
Maintains an accurate legal and medical record.
Documentation should always occur after the client is stable and acute life-saving measures have been completed.

Key Concept

Prioritization in Autonomic Dysreflexia
Question 85Question →

A nurse is monitoring a client who is receiving an intravenous transfusion of packed red blood cells. Ten minutes after the transfusion begins, the client develops sudden severe lower back pain, tachycardia, and dyspnea. Place the following nursing interventions in the correct order of priority to mitigate further physiological risk to the client. (Arrange the steps from first action to last action.)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first stop the transfusion, then maintain intravenous access with normal saline using new tubing, followed by assessing the client's current status, notifying the provider and blood bank, and finally returning the discontinued blood products for laboratory analysis.
The priority in any acute adverse event is to remove or stop the offending agent immediately to reduce physiological risk. Once stopped, maintaining intravenous access is critical for resuscitation. Assessment must follow to gather current data before calling the provider, ensuring the nurse can provide an accurate SBAR report. Administrative and follow-up tasks, such as returning the bag to the laboratory, always occur last after the client is stabilized.

Step-by-Step Solution

1
Stop the blood transfusion.
Halts the administration of the offending blood product.
Immediate risk mitigation to prevent a worsening antigen-antibody reaction.
2
Connect a new 0.9% sodium chloride infusion.
Maintains intravenous patency without pushing residual blood.
Allows for emergency medication and fluid administration to treat potential shock.
3
Assess the client.
Obtains current vital signs and respiratory clinical data.
Guides further emergency interventions and prepares data for provider notification.
4
Notify the provider and blood bank.
Initiates collaborative emergency medical response.
Secures medical orders for treatment and triggers the hospital's adverse reaction protocol.
5
Send products to the blood bank.
Facilitates laboratory and hematological investigation.
Identifies the exact cause of the reaction, such as ABO incompatibility or bacterial contamination.

Key Concept

Prioritization of Care in Acute Transfusion Reactions
Question 86Question →

A triage nurse evaluates a client with type 1 diabetes mellitus who presents with a capillary blood glucose of 610 mg/dL, fruity breath odor, and profound lethargy. The client is exhibiting deep, rapid respirations. Arrange the following nursing interventions in the correct chronological order of execution.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct priority sequence is: 1) Assess airway patency, 2) Establish large-bore IV access, 3) Administer a bolus of 0.9% sodium chloride, 4) Review the serum potassium level, and 5) Initiate a continuous infusion of regular insulin.
The management of an acute physiological crisis like Diabetic Ketoacidosis strictly follows the ABCs (Airway, Breathing, Circulation) and specific metabolic safety guidelines. Airway is always verified first. Circulation is addressed next by securing IV access and administering isotonic fluids to resolve life-threatening hypovolemia. Finally, before the metabolic issue (hyperglycemia) can be treated with insulin, the nurse must ensure the serum potassium level is known, as insulin profoundly lowers serum potassium.

Step-by-Step Solution

1
Perform an airway and respiratory assessment.
Ensures adequate oxygenation and ventilation.
Following the ABCs (Airway, Breathing, Circulation), confirming airway patency is always the absolute first priority, particularly given the client's lethargy and abnormal breathing pattern.
2
Insert a large-bore IV catheter.
Provides a reliable route for rapid fluid administration.
Vascular access is a mechanical necessity before any pharmacological or fluid resuscitation can begin for a physiologically unstable client.
3
Infuse 0.9% sodium chloride rapidly.
Expands intravascular volume and improves tissue perfusion.
Clients with Diabetic Ketoacidosis (DKA) experience severe osmotic diuresis. Addressing the resulting hypovolemia takes precedence over correcting the blood glucose level.
4
Check the baseline serum potassium level.
Identifies current electrolyte status to prevent iatrogenic harm.
Insulin administration drives potassium back into the cells. If a client is already hypokalemic, giving insulin first can induce fatal cardiac arrhythmias.
5
Start an IV regular insulin infusion.
Drives glucose into cells and stops ketone production.
Once intravascular volume is being restored and potassium is confirmed safe, insulin is safely administered to resolve the underlying hyperglycemia and acidosis.

Key Concept

Prioritization of acute interventions in Diabetic Ketoacidosis (DKA) based on ABCs and physiological safety.
Question 87Question →

A nurse is managing the care of a client admitted to the intensive care unit with severe diabetic ketoacidosis (DKA). The client's initial blood glucose is 680 mg/dL (37.7 mmol/L), pH is 7.15, and blood pressure is 88/54 mm Hg. Arrange the following nursing interventions in the correct sequence of execution from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: fluid resuscitation, potassium evaluation, insulin infusion initiation, addition of dextrose to fluids, and transition to subcutaneous insulin.
In diabetic ketoacidosis, severe osmotic diuresis leads to profound dehydration and potential hypovolemic shock. Therefore, the absolute first priority is fluid resuscitation with isotonic saline to restore perfusion. Once fluids are running, the nurse must ensure the serum potassium is greater than 3.3 mEq/L before giving insulin, as insulin drives potassium back into the cells and can trigger lethal hypokalemia. Following potassium verification, a continuous regular insulin infusion is started to halt ketone production and resolve the acidosis. As the blood glucose falls to around 200-250 mg/dL (11.1-13.9 mmol/L), 5% dextrose is added to the IV fluids to prevent hypoglycemia and cerebral edema while the insulin continues to clear the remaining ketones. Finally, once the acidosis has completely resolved and the client can tolerate oral intake, a transition to subcutaneous insulin is initiated before stopping the IV insulin.

Step-by-Step Solution

1
Prioritize fluid resuscitation by administering 0.9% sodium chloride.
Intravascular volume is expanded, and blood pressure stabilizes.
Severe dehydration and hypovolemic shock are the most immediate life-threatening complications of the osmotic diuresis caused by DKA.
2
Assess the serum potassium level.
The nurse confirms the potassium is at a safe baseline level.
Insulin administration drives potassium into the intracellular space, which can cause severe hypokalemia and lethal arrhythmias if the baseline level is not adequate.
3
Initiate the continuous regular insulin infusion.
Blood glucose levels begin to steadily decline and ketogenesis is inhibited.
Insulin is required to correct the underlying metabolic acidosis by stopping the breakdown of fats into ketones.
4
Add 5% dextrose to the intravenous fluids once blood glucose reaches approximately 200-250 mg/dL (11.1-13.9 mmol/L).
The blood glucose decline is stabilized while insulin administration continues.
Dextrose prevents a rapid drop in blood glucose, which can lead to life-threatening cerebral edema and hypoglycemia, while allowing the insulin drip to continue clearing ketones.
5
Administer subcutaneous insulin.
The client is prepared for the discontinuation of the intravenous insulin infusion.
Transitioning to subcutaneous insulin occurs when the anion gap closes and the acidosis is resolved, providing basal glycemic control before the IV drip is turned off.

Key Concept

The physiological stabilization sequence for diabetic ketoacidosis requires treating hypovolemia first, then securing safe electrolyte levels before reversing the acidosis with insulin.
Question 88Question →

A nurse is preparing to administer a unit of packed red blood cells (PRBCs) to an adult client with symptomatic anemia. Arrange the following actions in the correct chronological order that the nurse should perform them, from first action to last action.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: prime the tubing with normal saline, verify the blood product with a second nurse, obtain baseline vital signs, initiate the transfusion slowly, and remain with the client for the first 15 minutes.
Safe administration of packed red blood cells requires strict adherence to a standardized sequence to prevent fatal errors and manage adverse reactions. The equipment must first be primed with normal saline, the only compatible fluid. Next, mandatory bedside verification by two nurses ensures the right blood goes to the right client. Baseline vitals must then be obtained immediately before starting the flow. The infusion is initiated slowly to limit exposure in case of an error, and the nurse must remain with the client for the first 15 minutes when acute, life-threatening reactions are most likely to occur.

Step-by-Step Solution

1
Prime the Y-type blood administration set with 0.9% sodium chloride.
The IV line is prepared, purged of air, and flushed with a compatible solution.
Normal saline is the only fluid compatible with blood products. Priming first prevents hemolysis and ensures the line is ready for the blood.
2
Verify the blood product and client identity with a second registered nurse at the bedside.
The correct blood component is confirmed for the correct client.
This is a critical safety standard to prevent fatal ABO incompatibility errors.
3
Obtain and document the client's baseline vital signs.
A pre-transfusion physiological baseline is established.
Accurate vital signs taken immediately before starting allow the nurse to identify subtle changes that indicate an adverse transfusion reaction.
4
Spike the blood bag and initiate the transfusion at a slow rate.
The blood begins infusing into the client.
Starting slowly limits the amount of incompatible blood received if an acute reaction occurs, minimizing potential harm.
5
Remain with the client for the first 15 minutes of the transfusion.
The client is closely observed during the highest-risk period.
Severe, life-threatening transfusion reactions typically manifest within the first 15 minutes or first 50 mL of the infusion.

Key Concept

Blood Product Administration Sequence and Safety
Estimated Time:1m 30s
Question 89Question →

A nurse is caring for a client who has a central venous catheter. While the nurse is changing the injection caps, the client suddenly becomes extremely restless, gasps for air, and reports severe chest pain. The nurse suspects a venous air embolism. In what order should the nurse perform the following actions? Arrange the items from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence of actions is to first clamp the catheter, then place the client in a left lateral Trendelenburg position, administer high-concentration oxygen, activate the rapid response team, and finally assess the client's vital signs.
When a venous air embolism is suspected during central line care, the nurse must act rapidly to prevent cardiopulmonary collapse. The immediate priority is to stop further air from entering the circulation by clamping the catheter. Next, the client must be placed in a left lateral Trendelenburg position (Durant's maneuver) to trap the air bubble in the apex of the right ventricle, preventing it from migrating into the pulmonary arterial system. Administering 100% oxygen helps correct hypoxia and speeds the reabsorption of nitrogen gas from the bubble. Once these immediate life-saving physical interventions are complete, the nurse activates the rapid response team to obtain advanced medical support, followed by continuous assessment of vital signs to monitor for hemodynamic deterioration.

Step-by-Step Solution

1
Clamp the central venous catheter immediately.
Further air entry into the venous system is stopped.
In any crisis, stopping the immediate cause of harm takes absolute precedence.
2
Place the client in a left lateral Trendelenburg position.
The client is positioned on their left side with their head lower than their feet.
This traps the air in the right ventricle, preventing it from entering and obstructing the pulmonary circulation.
3
Administer 100% oxygen via a non-rebreather mask.
The client receives maximal oxygen concentration.
Treats ischemia caused by the embolism and accelerates the reabsorption of nitrogen from the air bubble.
4
Activate the rapid response team.
Advanced medical providers are notified.
The client requires critical care interventions that exceed the scope of independent nursing practice.
5
Assess the client's vital signs and continuous pulse oximetry.
Baseline data post-intervention is established.
Monitors for signs of cardiovascular collapse and evaluates the effectiveness of the initial interventions.

Key Concept

Emergency Management of Venous Air Embolism
Question 90Question →

A nurse is monitoring a client who is receiving a transfusion of packed red blood cells. Ten minutes into the transfusion, the client reports sudden lower back pain, chills, and shortness of breath. Arrange the following nursing actions in the correct priority sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence of actions for a suspected acute hemolytic transfusion reaction is to first stop the transfusion, then maintain intravenous access with new tubing and normal saline, assess the client's vital signs, notify the healthcare provider and blood bank, and finally return the blood products to the blood bank for analysis.
When a client experiences symptoms of a severe transfusion reaction (such as lower back pain, which indicates an acute hemolytic reaction), the absolute first priority is to stop the offending agent. Immediately stopping the blood minimizes the volume of incompatible cells infused. The next step is to maintain a patent intravenous line for emergency medications; this must be done with entirely new tubing primed with normal saline so that the blood remaining in the old tubing is not flushed into the client. Next, the nurse performs a rapid assessment of vital signs and respiratory status to gather necessary clinical data. This data is then immediately communicated to the healthcare provider and blood bank. Finally, as a post-crisis procedural step, the blood bag and tubing are returned to the blood bank for serological testing and investigation.

Step-by-Step Solution

1
Stop the blood transfusion immediately.
Further entry of the incompatible blood product into the client's circulation is halted.
This is the absolute highest priority to prevent the acute hemolytic reaction from worsening and causing severe physiological harm.
2
Replace the blood tubing with a new set and initiate an infusion of 0.9% sodium chloride.
A patent intravenous line is maintained without pushing remaining blood into the client.
Intravenous access is required for emergency medications. New tubing is essential because flushing the old tubing would administer the remaining incompatible blood.
3
Assess the client's vital signs and oxygen saturation.
Current hemodynamic and respiratory data are obtained.
The provider will need baseline post-reaction vital signs to prescribe appropriate life-saving interventions.
4
Notify the healthcare provider and the blood bank.
The medical team is alerted and emergency protocols are initiated.
The provider must be informed of the assessment findings to direct medical care, and the blood bank must stop any further dispensations from that donor batch.
5
Return the remaining blood product and attached tubing to the blood bank.
Evidence is preserved for serological investigation.
Laboratory analysis of the blood and tubing determines the precise cause of the reaction and confirms if a mismatch occurred.

Key Concept

Nursing Priority Management of Acute Hemolytic Transfusion Reactions
Question 91Question →

A client receiving an intravenous transfusion of packed red blood cells (PRBCs) suddenly reports severe lower back pain, chills, and shortness of breath. To reduce the risk of severe physiological complications from a suspected acute hemolytic transfusion reaction, arrange the following nursing actions in the correct priority sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first stop the transfusion, second disconnect the tubing and initiate normal saline with new tubing, third assess the client's vital signs and clinical status, fourth notify the healthcare provider and blood bank, and fifth collect required specimens and send the blood product to the laboratory.
The priority in any acute hemolytic transfusion reaction is to immediately stop the exposure to the incompatible antigen. Following this, maintaining a patent IV with normal saline via new tubing ensures emergency access without infusing the residual blood in the old tubing. Only after the client is protected from further harm and IV access is secured should the nurse perform a full assessment, notify the provider with the assessment findings, and finally handle the collection of laboratory specimens.

Step-by-Step Solution

1
Identify the signs of an acute hemolytic transfusion reaction.
The nurse recognizes lower back pain, chills, and shortness of breath as medical emergencies requiring immediate intervention.
Early recognition is crucial for initiating risk reduction measures and preventing severe renal or cardiopulmonary failure.
2
Prioritize immediate physical risk reduction interventions.
The nurse stops the transfusion and secures IV access with a normal saline infusion via new tubing.
Stopping the infusion prevents further antigen exposure, and a new saline line ensures patent access for emergency medications without flushing residual blood into the client.
3
Gather clinical data and escalate care to the interdisciplinary team.
The nurse assesses vital signs, notifies the provider and blood bank, and sends required specimens to the laboratory.
Assessment data guides the provider's emergency prescriptions, while laboratory analysis of the blood and urine confirms hemolysis and dictates further systemic treatments.

Key Concept

Nursing management of an acute hemolytic transfusion reaction to reduce the risk of systemic complications.

Alternative Method

While the physical steps follow a strict chronological protocol, cognitive delegation can occur simultaneously. If a second nurse or rapid response team member is present, the primary nurse can delegate notifying the provider and blood bank while continuing to independently manage the airway and IV access.
Estimated Time:1m 30s
Question 92Question →

A nurse is preparing to administer an intravenous (IV) push dose of phenytoin to a client. The client has a single peripheral IV line currently infusing 5% dextrose in water (D5W) continuously. Phenytoin is physically incompatible with D5W. The nurse has already verified the client's identity, checked the medication prescription, and donned clean gloves. Arrange the following steps in the correct chronological order to safely administer the medication.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first stop the incompatible D5W infusion, clamp the tubing above the port, flush with normal saline to clear the line, administer the phenytoin, flush again with normal saline at the same slow rate, and finally unclamp and restart the D5W infusion.
When administering an IV push medication that is incompatible with the continuous IV fluid, the nurse must create a 'saline lock' environment within the active line. This requires stopping the pump, clamping the line to prevent backflow, and clearing the line with a compatible flush (normal saline) before the medication is introduced. After administration, the line must be flushed again with normal saline to clear the drug from the catheter before the incompatible continuous fluid is resumed. The post-flush must be given at the same rate as the medication to avoid speed shock from the drug remaining in the catheter's dead space.

Step-by-Step Solution

1
Stop the D5W continuous infusion.
The flow of the incompatible fluid is halted.
Prevents the incompatible solution from actively flowing into the line during the medication administration process.
2
Clamp the primary IV tubing above the lowest port.
The fluid pathway back to the IV bag is blocked.
Prevents the normal saline flush and the phenytoin from traveling retrogradely up the IV tubing.
3
Flush the IV line with 10 mL of 0.9% sodium chloride.
Residual D5W is cleared from the lower tubing and catheter.
Phenytoin is highly incompatible with dextrose and will precipitate (crystallize) if they mix, potentially causing an embolus.
4
Administer the IV push phenytoin.
The medication is delivered to the client safely.
The line is now clear and filled with compatible normal saline, allowing safe administration.
5
Flush the line again with 10 mL of 0.9% sodium chloride at the same rate as the medication.
Residual phenytoin is cleared from the catheter into the bloodstream.
Flushing at the same slow rate ensures the remaining medication in the dead space is not rapidly pushed into the client, preventing speed shock.
6
Unclamp the tubing and restart the D5W infusion.
The client's prescribed continuous fluid therapy is resumed.
The medication administration is complete and the line is cleared, allowing safe resumption of the primary fluid.

Key Concept

Safe administration of an IV push medication through a continuous infusion of an incompatible solution using the flush-administer-flush technique.
Question 93Question →

A clinical nurse is preparing to draw a blood specimen for a comprehensive metabolic panel (CMP) from an adult client's triple-lumen central venous access device (CVAD). The client currently has a continuous intravenous infusion of 0.9% sodium chloride with 20 mEq of potassium chloride infusing through the proximal lumen. To ensure accurate laboratory results and reduce the risk of infection, in what order should the nurse perform the following actions? Arrange the steps in the correct sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Pause the continuous intravenous infusion -> Scrub the needleless connector -> Aspirate 5 mL of blood to discard -> Withdraw the required volume of blood -> Flush the catheter lumen.
The correct sequence prioritizes analytical accuracy and infection control. First, pausing the infusion prevents drawing a diluted or contaminated sample. Scrubbing the hub is the primary defense against CLABSI. Discarding the initial 5 mL ensures the sample is pure whole blood, not the dwelling medication. Drawing the sample follows, and the procedure concludes with a thorough saline flush to clear the line and maintain patency.

Step-by-Step Solution

1
Pause the continuous intravenous infusion and wait at least one minute.
The active infusion is halted.
Prevents contamination of the blood sample with the infusing fluids, ensuring accurate lab results.
2
Scrub the needleless connector of the designated lumen with an antiseptic swab.
The connector is disinfected.
Reduces the risk of introducing pathogens into the bloodstream, preventing CLABSI.
3
Attach a syringe and aspirate 5 mL of blood to discard.
The clearance volume is removed.
Removes residual fluid and medication dwelling within the catheter lumen that would otherwise alter the laboratory specimen.
4
Attach a new syringe to withdraw the required volume of blood for the laboratory sample.
The pure blood specimen is collected.
Provides an uncontaminated, accurate representation of the client's systemic blood for the comprehensive metabolic panel.
5
Flush the catheter lumen with 10 to 20 mL of sterile 0.9% sodium chloride.
The lumen is cleared of residual blood.
Removes red blood cells from the catheter, maintains patency, and prevents thrombus formation.

Key Concept

Central Venous Access Device (CVAD) Blood Sampling Sequence
Question 94Question →

A nurse is caring for a client with a complete T4 spinal cord injury who suddenly reports a severe, pounding headache. The nurse notes facial flushing, profuse diaphoresis above the nipple line, and a blood pressure of 214/118214/118 mm Hg. Arrange the following nursing interventions in the correct order of clinical priority.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence of actions for managing autonomic dysreflexia is to first elevate the head of the bed, then loosen restrictive clothing, assess the bladder and catheter, evaluate for bowel impaction, and finally administer an antihypertensive medication.
Autonomic dysreflexia is a medical emergency in clients with spinal cord injuries at or above T6. The uninhibited sympathetic response below the level of injury causes severe vasoconstriction and hypertension. The absolute first priority is to lower the blood pressure immediately by elevating the head of the bed to induce orthostatic pooling. Next, the nurse must systematically identify and remove the noxious stimuli causing the reaction. External stimuli (tight clothing) are addressed first as they are quickest to resolve. Then, internal stimuli are assessed in order of frequency: bladder issues (most common) followed by bowel issues (second most common). Pharmacological interventions are reserved for situations where identifying and resolving the stimulus is ineffective or the blood pressure remains dangerously high.

Step-by-Step Solution

1
Elevate the head of the bed to a high Fowler's position.
Immediate mechanical reduction in systemic blood pressure.
Taking advantage of orthostatic pooling of blood in the lower extremities helps rapidly lower systemic blood pressure to prevent a hypertensive stroke, which is the immediate life threat.
2
Loosen any restrictive clothing, tight abdominal binders, or anti-embolism stockings.
Elimination of potential external noxious stimuli.
External pressure can trigger the exaggerated sympathetic nervous system response. Removing this pressure is rapid and non-invasive.
3
Palpate the bladder for distention and check the indwelling urinary catheter for kinks.
Identification and relief of the primary internal trigger.
A distended bladder is the most common cause of autonomic dysreflexia; emptying the bladder or removing a kink rapidly eliminates the primary stimulus.
4
Evaluate the rectum for fecal impaction after applying a topical anesthetic ointment.
Identification of secondary internal triggers.
Bowel impaction is the second most common cause. A topical anesthetic must be applied prior to the digital rectal exam to prevent further stimulation of the autonomic reflex during the procedure.
5
Administer a prescribed rapid-acting intravenous antihypertensive medication.
Pharmacological control of severe hypertension.
If identifying and removing the physical triggers does not resolve the crisis, or if the triggers cannot be immediately found, medical management is required to lower the blood pressure safely.

Key Concept

Management of autonomic dysreflexia prioritizes immediate blood pressure reduction through physical positioning, followed by the systematic elimination of noxious stimuli, before resorting to pharmacological intervention.
Question 95Question →

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

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: assist the client into the left lateral Sims position, lubricate the tip of the rectal tube, instruct the client to take deep breaths, gently insert the tube into the rectum, and finally unclamp the tubing and elevate the bag.
Administering an enema requires a systematic approach to ensure safety, comfort, and efficacy. The procedure begins with proper anatomical positioning (left lateral Sims) to utilize gravity for fluid flow. Next, the equipment must be prepared by lubricating the tip of the tube. Immediately before insertion, the nurse instructs the client to take deep breaths to relax the external anal sphincter. Once relaxed, the tube is safely inserted to the correct anatomical depth of 3 to 4 inches. Finally, the solution is administered by unclamping the tubing and holding the bag at the correct height (12 to 18 inches) to ensure steady, safe hydrostatic pressure.

Step-by-Step Solution

1
Assist the client into the left lateral Sims position with the right knee flexed.
The client is anatomically positioned for the procedure.
This position facilitates the gravity-assisted flow of the enema solution directly into the sigmoid colon and descending colon.
2
Lubricate the tip of the rectal tube with a water-soluble lubricant.
The tube is prepared for atraumatic entry.
Lubrication decreases friction, preventing tissue injury and minimizing discomfort during insertion.
3
Instruct the client to take slow, deep breaths through the mouth.
The client begins deep breathing exercises.
Deep breathing naturally relaxes the external anal sphincter, which is necessary before attempting insertion.
4
Gently insert the rectal tube 3 to 4 inches (7.5 to 10 cm) into the rectum.
The tube safely passes the internal anal sphincter.
This specific depth ensures the fluid is delivered adequately into the lower bowel without causing deep tissue trauma.
5
Unclamp the tubing and hold the enema bag 12 to 18 inches (30 to 45 cm) above the rectum.
The solution begins to flow at a controlled rate.
Maintaining this exact height controls the pressure of the fluid instillation, preventing rapid bowel distention and severe cramping.

Key Concept

Enema Administration Protocol
Estimated Time:1m 0s
Question 96Question →

A nurse is monitoring a client who is receiving a continuous intravenous infusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion begins, the client reports sudden lower back pain, chills, and dyspnea. Place the following nursing actions in the correct order of performance. (All steps must be used).

Drag items to arrange them in the correct order

Show answer & explanation

Answer

1. Stop the blood transfusion immediately. 2. Replace the intravenous tubing with a new set primed with 0.9% sodium chloride. 3. Assess the client's vital signs and oxygen saturation. 4. Notify the primary healthcare provider and the blood bank. 5. Return the blood bag and attached tubing to the blood bank.
In a suspected blood transfusion reaction, the priority is to stop the causative agent immediately to minimize harm. Next, IV access must be maintained with normal saline using completely new tubing to avoid flushing residual blood into the client. Assessment of vital signs follows to determine the client's physiological status, which is then reported to the provider. Finally, the blood products and equipment are returned to the blood bank for investigation.

Step-by-Step Solution

1
Stop the causative agent.
The blood transfusion is halted immediately upon recognizing signs of an acute hemolytic reaction.
Prevents further infusion of incompatible blood cells, which is the most critical life-saving intervention.
2
Maintain intravenous access safely.
The IV tubing is changed entirely and 0.9% sodium chloride is initiated.
Secures a patent line for emergency medications without infusing the remaining blood that is trapped in the old tubing.
3
Evaluate the client's current physiological status.
Vital signs and respiratory status are assessed.
Provides essential baseline data on hemodynamic stability to report to the healthcare provider for tailored interventions.
4
Escalate care and follow administrative protocols.
The healthcare provider and blood bank are notified.
Facilitates rapid medical intervention and initiates the facility's transfusion reaction investigation protocol.
5
Preserve evidence for investigation.
The blood bag and attached tubing are returned to the blood bank.
Allows the laboratory to analyze the blood products and determine the exact immunological or procedural cause of the adverse reaction.

Key Concept

Management of Acute Hemolytic Transfusion Reactions
Question 97Question →

A client who recently experienced a cerebrovascular accident requires an intermittent bolus enteral feeding through an established nasogastric (NG) tube. Place the following nursing actions in the correct sequence for safely delivering this nutrition. (Arrange the steps in chronological order.)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first elevate the head of the bed, then measure the gastric residual volume, reinstill the aspirated volume, administer the feeding by gravity, and finally flush the tube with water.
The correct sequence prioritizes airway safety by positioning the client first. Next, the nurse assesses feeding tolerance by checking the residual volume. To maintain physiological balance, the residual is reinstilled. Only after these safety and assessment steps are completed is the feeding administered. Finally, flushing the tube ensures it remains patent for future use. This logical progression aligns with standard nursing care for enteral nutrition.

Step-by-Step Solution

1
Elevate the head of the bed to at least 30 degrees.
The client is positioned safely to prevent reflux.
Reduces the risk of aspiration, which is the most critical safety concern during enteral feedings.
2
Aspirate gastric contents to measure residual volume.
The amount of undigested formula from previous feedings is quantified.
Evaluates gastric emptying and determines if it is safe to proceed with the next feeding.
3
Reinstill the aspirated gastric residual volume.
Gastric contents are returned to the client's stomach.
Prevents the loss of essential electrolytes, digestive enzymes, and fluid.
4
Administer the enteral feeding formula by gravity.
The client receives the prescribed nutrition.
Using gravity prevents the rapid instillation of formula, which can cause gastrointestinal distress.
5
Flush the tube with water.
The tube is cleared of any remaining nutritional formula.
Maintains tube patency, prevents clogging, and provides additional free water for hydration.

Key Concept

Safe Administration of Enteral Nutrition
Question 98Question →

A nurse is discontinuing a right subclavian non-tunneled central venous catheter for a client whose intravenous antibiotic therapy is complete. To minimize the risk of complications, in what order should the nurse perform the following actions?

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to position the client supine, instruct them to perform the Valsalva maneuver, withdraw the catheter, apply firm pressure to the site, and finally inspect the catheter tip.
Central venous catheter removal poses a significant risk for an air embolism because the intrathoracic pressure can drop below atmospheric pressure during inhalation, drawing air into the open vein. Placing the client in a supine position ensures the site is not elevated above the heart, increasing central venous pressure. Instructing the client to perform the Valsalva maneuver (bearing down) further raises intrathoracic pressure above atmospheric pressure. The catheter must be withdrawn precisely while this positive pressure is maintained. Immediately after removal, firm pressure is required to achieve hemostasis and physically block air entry. Finally, after the site is secure, inspecting the catheter tip ensures no fragments have embolized.

Step-by-Step Solution

1
Position the client flat in a supine position.
The insertion site is placed at or below the level of the heart.
This positioning decreases the risk of atmospheric air being drawn into the central circulation.
2
Instruct the client to take a deep breath and bear down.
The client increases their intrathoracic pressure.
Creating a positive pressure gradient in the thorax prevents an air embolism while the catheter tract is open.
3
Withdraw the catheter smoothly in one continuous motion.
The catheter is safely removed.
Removal must occur precisely during the Valsalva maneuver to minimize the risk of air entry.
4
Apply firm, direct pressure to the site with a sterile gauze pad.
Hemostasis is achieved at the removal site.
Immediate continuous pressure prevents bleeding and physically seals the venous pathway from air.
5
Inspect the distal tip of the removed catheter for intactness.
The integrity of the catheter is confirmed.
This verification ensures that a catheter fragment has not broken off, which could cause a catheter embolism.

Key Concept

The primary risks during central venous catheter removal are air embolism and bleeding. Nursing actions must follow a specific chronological sequence to maintain positive venous pressure and achieve hemostasis.
Estimated Time:1m 0s
Question 99Question →

A nurse is assessing a client who is receiving a continuous peripheral intravenous (IV) infusion of a vesicant antineoplastic agent. The client suddenly reports severe burning pain at the IV insertion site. The nurse observes local swelling, erythema, and a lack of blood return upon aspiration. In what order should the nurse perform the following interventions? Arrange the actions in the correct sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first stop the infusion, disconnect the tubing, attempt to aspirate residual drug through the existing catheter, remove the catheter, and finally elevate the extremity and apply a thermal compress.
When extravasation of a vesicant occurs, the immediate priority is to stop the infusion to prevent further tissue damage. The tubing should then be disconnected from the hub. Crucially, the catheter must be left in place temporarily so the nurse can attach a syringe and aspirate any residual medication from the line and subcutaneous tissue. Only after aspiration is attempted should the catheter be removed. Finally, the extremity is elevated to reduce edema, and the appropriate thermal compress is applied based on the specific pharmacological properties of the vesicant involved.

Step-by-Step Solution

1
Stop the continuous intravenous infusion immediately.
The flow of the vesicant medication into the tissue is halted.
The primary initial action is to prevent any additional tissue exposure to the highly toxic vesicant.
2
Disconnect the administration set from the peripheral catheter hub.
The primary source of the vesicant is completely separated from the client.
Disconnecting the tubing ensures that no additional medication remaining in the line can be inadvertently pushed into the tissue during subsequent steps.
3
Attach a sterile syringe to the catheter and attempt to aspirate residual drug.
Remaining vesicant medication is withdrawn from the catheter and surrounding subcutaneous tissue.
Aspirating before removing the catheter minimizes the amount of vesicant left in the tissue, significantly reducing the risk of severe local necrosis.
4
Remove the peripheral intravenous catheter from the client's arm.
The intravenous access device is successfully removed.
Once all possible residual medication has been aspirated, the catheter is removed to prevent further mechanical irritation and allow for external site care.
5
Elevate the affected extremity and apply the indicated thermal compress.
Edema is reduced and the local tissue reaction is managed.
Elevation promotes venous return and decreases swelling, while thermal compresses alter local blood flow to mitigate tissue damage based on the specific vesicant's properties.

Key Concept

Extravasation Management of Vesicant Medications
Estimated Time:1m 30s
Question 100Question →

A nurse is monitoring a client who is receiving an intravenous transfusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion is initiated, the client suddenly reports severe lower back pain, shortness of breath, and a feeling of impending doom. Arrange the following nursing actions in the correct priority sequence. All options must be used.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence of actions for a suspected hemolytic transfusion reaction is to first stop the transfusion, maintain IV access with new tubing and normal saline, assess the client's clinical status, notify the provider and blood bank, and finally return the blood products for analysis.
A hemolytic transfusion reaction is a life-threatening emergency characterized by flank pain, dyspnea, and hypotension. The first step is always to stop the infusion of the incompatible blood. Second, the nurse must maintain patent IV access for emergency drugs by using entirely new tubing primed with normal saline, because using the old tubing would flush more blood into the client. Third, the nurse conducts a rapid assessment to determine hemodynamic stability. Fourth, the nurse notifies the healthcare provider with the assessment data to obtain emergency prescriptions. Finally, the blood bag and tubing are sent to the blood bank for investigation.

Step-by-Step Solution

1
Stop the blood transfusion immediately.
Halts the administration of incompatible blood.
Preventing further exposure to the offending antigens is the absolute first priority in any hypersensitivity or hemolytic reaction to minimize systemic damage.
2
Disconnect the blood administration set and initiate an infusion of 0.9% sodium chloride using new tubing.
Maintains patent venous access without infusing more blood.
Using the existing tubing would flush the remaining blood into the client. New tubing ensures only normal saline is administered to keep the vein open for life-saving emergency drugs.
3
Assess the client's vital signs, respiratory status, and hemodynamic stability.
Provides objective baseline data regarding the severity of the reaction.
The nurse must gather accurate clinical data (e.g., degree of hypotension or hypoxia) to report to the provider for targeted interventions.
4
Notify the healthcare provider and the blood bank.
Activates the medical response and institutional protocols.
The provider must prescribe emergency treatments (e.g., vasopressors, antihistamines, diuretics), and the blood bank must initiate a mismatch investigation.
5
Return the remaining blood product, bag, and attached tubing to the blood bank.
Provides physical evidence for laboratory analysis.
The blood bank needs the original bag and tubing to re-crossmatch the blood and determine the exact cause of the hemolytic reaction.

Key Concept

Management of acute hemolytic transfusion reactions requires immediately halting the offending agent, maintaining venous access with new equipment, and rapidly assessing the client before notifying the provider.
Estimated Time:1m 30s
PreviousPage 5 / 44Next
All practice questions — NCLEX-RN | Examkin