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A client with a history of cirrhosis is being monitored $2$ hours after a large-volume paracentesis in which $6$ liters of ascitic fluid were removed. The client's current vital signs are: blood pressure $94/78$ mm Hg, heart rate $116$ bpm, and respiratory rate $24$ /min. An arterial blood gas (ABG) analysis reveals a pH of $7.29$ , a $PaCO_2$ of $31$ mm Hg, and an $HCO_3^-$ of $15$ mEq/L. The unlicensed assistive personnel (UAP) is preparing to assist the client into a high-Fowler's position to eat a meal. Which action should the nurse take first to reduce the risk of a severe complication?

Administer the client's scheduled dose of oral metoprolol to correct the tachycardia and decrease cardiac workload

Administer a prescribed dose of intravenous sodium bicarbonate to correct the client's uncompensated respiratory acidosis

Stop the UAP and place the client in a supine position with the lower extremities elevated

Assist the UAP in raising the head of the bed to a high-Fowler's position to maximize diaphragmatic excursion

Show answer & explanation

Answer: Stop the UAP and place the client in a supine position with the lower extremities elevated

Answer

The nurse must immediately stop the UAP from elevating the head of the bed and instead place the client in a supine position with the lower extremities elevated to address the impending hypovolemic shock.

The client is demonstrating early signs of hypovolemic shock (narrow pulse pressure, compensatory tachycardia) and poor tissue perfusion (metabolic acidosis), a known risk called post-paracentesis circulatory dysfunction. Placing the client in a high-Fowler's position will trap blood in the lower extremities and splanchnic bed, decreasing venous return and potentially precipitating immediate cardiovascular collapse. The nurse must immediately intervene to position the client supine with legs elevated to promote venous return to the vital organs.

Step-by-Step Solution

Analyze the client's vital signs and clinical context.

The removal of

6

liters of fluid places the client at high risk for fluid shifts. The narrow pulse pressure (

16

mm Hg) and tachycardia (

116

bpm) are early indicators of post-paracentesis circulatory dysfunction (hypovolemic shock).

Recognizing early shock is critical before profound hypotension occurs.

Interpret the arterial blood gas (ABG) values.

The ABG shows a low pH (

7.29

) and low

HCO_3^-

(

15

mEq/L), indicating metabolic acidosis. The

PaCO_2

(

31

mm Hg) is appropriately low as the lungs attempt to compensate.

Metabolic acidosis in this context is likely lactic acidosis caused by poor tissue perfusion, further confirming a state of shock.

Evaluate the proposed action of placing the client in a high-Fowler's position.

A high-Fowler's position uses gravity to pool blood in the splanchnic bed and lower extremities, significantly decreasing venous return.

Decreased venous return will worsen the client's already compromised cardiac output.

Determine the priority nursing intervention to reduce risk.

The nurse must intervene to place the client flat with elevated legs (modified Trendelenburg).

This position optimizes venous return to the heart and brain, temporarily stabilizing hemodynamics while fluid resuscitation (e.g., albumin) is prepared.

Key Concept

Early recognition and positional management of hypovolemic shock

Question 1002Question →

A palliative care team is managing an older adult client who is completely bedbound due to profound cachexia and intractable bone pain. The client exhibits significant muscle wasting and thin, fragile skin. Which interventions are appropriate to include in the client's non-pharmacologic comfort and skin integrity regimen? Select all that apply.

Select all that apply

Limit the elevation of the head of the bed to 30 degrees or less during rest periods.

Utilize a friction-reducing glide sheet when repositioning the client.

Place a ring-type air cushion under the client's sacral area to alleviate direct bone pressure.

Direct the unlicensed assistive personnel (UAP) to conduct the staging of newly discovered skin alterations.

Advise the family that the development of non-blanchable sacral erythema is an expected physiological outcome of the normal aging process.

Insert soft foam padding between the client's knees and ankles when placed in a lateral position.

Show answer & explanation

Answer: Limit the elevation of the head of the bed to 30 degrees or less during rest periods.; Utilize a friction-reducing glide sheet when repositioning the client.; Insert soft foam padding between the client's knees and ankles when placed in a lateral position.

Answer

The appropriate interventions are limiting head-of-bed elevation to 30 degrees or less, using a friction-reducing glide sheet, and inserting foam padding between bony prominences.

The correct interventions focus on minimizing mechanical forces that cause tissue damage. Limiting the head of bed elevation to 30 degrees or less minimizes shearing forces on the sacral area. Using a friction-reducing glide sheet prevents epidermal stripping caused by friction when moving the client. Placing foam padding between the knees and ankles prevents tissue ischemia resulting from direct bone-on-bone contact.

Step-by-Step Solution

Analyze the client's risk factors.

The client has profound cachexia, intractable bone pain, muscle wasting, and fragile skin.

Identifying specific vulnerabilities determines which preventative measures are most critical for avoiding skin breakdown and promoting comfort.

Evaluate positioning and mobility interventions for safety and efficacy.

Limiting the head of the bed to 30 degrees, using glide sheets, and padding bony prominences are evidence-based practices that reduce shear, friction, and pressure.

These interventions specifically address the mechanical forces that lead to pressure injuries in immobile, cachectic clients.

Identify contraindicated practices and scope of practice violations.

Using a ring cushion, dismissing non-blanchable erythema as normal aging, and delegating assessment to UAP must be rejected.

Ring cushions cause venous congestion, non-blanchable erythema is a Stage 1 pressure injury requiring nursing intervention, and assessment cannot be legally delegated.

Key Concept

Evidence-Based Pressure Injury Prevention and Comfort Care

Question 1003Question →

A registered nurse (RN) is providing care for a client who is receiving intravenous antibiotics for a localized skin infection. Which of the following activities is most appropriate for the RN to delegate to the unlicensed assistive personnel (UAP)?

Documenting the client's oral fluid intake during the shift.

Assessing the intravenous insertion site for redness or swelling.

Explaining the importance of keeping the affected limb elevated.

Monitoring the client for early signs of an allergic reaction to the antibiotic.

Show answer & explanation

Answer: Documenting the client's oral fluid intake during the shift.

Answer

Documenting the client's oral fluid intake during the shift.

Measuring and documenting intake and output (such as oral fluid intake) is a standard, unchanging procedure with a predictable outcome. It does not require nursing judgment, making it safe and appropriate to delegate to an unlicensed assistive personnel (UAP).

Step-by-Step Solution

Identify the role and scope of practice of the unlicensed assistive personnel (UAP).

The UAP can perform routine, standard, and non-invasive tasks such as hygiene, ambulation, and measuring intake and output.

Understanding the limitations of the UAP's role is necessary to ensure safe delegation.

Review the National Council of State Boards of Nursing (NCSBN) delegation guidelines.

The registered nurse cannot delegate tasks that involve the nursing process, specifically assessment, clinical judgment, teaching, or evaluation.

These activities require the specialized knowledge and critical thinking of a registered nurse.

Evaluate each option against the delegation guidelines.

Documenting oral fluid intake is a routine task. Assessing an IV site, explaining treatments, and monitoring for allergic reactions all require assessment, teaching, or clinical judgment.

Applying the rules of delegation isolates the only task that is safe and appropriate to assign to the UAP.

Key Concept

Delegation of routine tasks to Unlicensed Assistive Personnel (UAP)

Question 1004Question →

During the night shift, a client who sustained a moderate traumatic brain injury becomes profoundly disoriented. The client repeatedly attempts to leave the neurological step-down unit, claiming they need to 'go to work.' An unlicensed assistive personnel (UAP) asks the registered nurse (RN) to authorize a vest restraint for safety. Which legal and professional actions must the RN take? (Select all that apply)

Select all that apply

Perform a comprehensive assessment to determine if underlying factors such as pain or a full bladder are causing the agitation

Request an as-needed (PRN) prescription for physical restraints from the healthcare provider to use if the wandering continues

Transfer the client to a vacant bed immediately adjacent to the main nurses' station for closer monitoring

Delegate the application of bilateral soft wrist restraints to the UAP until a formal medical evaluation can be completed

Initiate continuous, one-to-one direct observation by a dedicated staff member to ensure client safety

Show answer & explanation

Answer: Perform a comprehensive assessment to determine if underlying factors such as pain or a full bladder are causing the agitation; Transfer the client to a vacant bed immediately adjacent to the main nurses' station for closer monitoring; Initiate continuous, one-to-one direct observation by a dedicated staff member to ensure client safety

Answer

The correct actions are to perform a comprehensive assessment for underlying causes of agitation, transfer the client closer to the nurses' station, and initiate continuous one-to-one observation.

Under legal and regulatory standards, clients have the right to be cared for in the least restrictive environment. Before considering any physical restriction, the registered nurse must assess for reversible causes of confusion (such as pain, hypoxia, or a full bladder) and implement all feasible less restrictive alternatives. Relocating the client closer to the nurses' station and providing one-to-one observation are legally sound, proactive safety measures that protect the client from harm while preserving their autonomy.

Step-by-Step Solution

Analyze the legal framework governing client safety and restraint usage.

Identify that the law mandates utilizing the least restrictive environment and interventions possible.

Protecting the client's legal rights prevents false imprisonment and battery charges.

Evaluate the proposed less restrictive alternatives.

Determine that assessing for physiological needs, moving the client closer to the station, and using a sitter all qualify as appropriate early interventions.

These actions address the safety risk without unlawfully restricting the client's movement.

Identify legally prohibited actions within the distractors.

Rule out obtaining PRN restraint prescriptions and delegating the initial restraint decision/application to a UAP.

PRN restraint orders are illegal, and initial restraint assessment falls strictly outside a UAP's scope of practice.

Key Concept

Legal Rights and Responsibilities: Restraint Regulations and Least Restrictive Environment

Question 1005Question →

An outpatient clinic registered nurse (RN) is assessing a 78-year-old client with a history of severe major depressive disorder. The RN observes bilateral, thumb-sized contusions on the client's inner upper arms. The client's adult child, who serves as the primary caregiver, interrupts to state, 'My parent is just getting clumsy and bumps into door frames.' The client remains silent, then calmly hands the RN a cherished family watch, stating with a sudden, serene expression, 'I finally feel completely at peace; I will not be needing this anymore.' Based on legal and professional responsibilities, which of the following is the priority action for the RN?

Interview the client privately to assess for a suicide plan, implement continuous supervision, and subsequently file a mandatory report for suspected elder abuse.

Implement emergency psychiatric protocols for imminent self-harm risk and document the contusions as accidental blunt trauma based on the caregiver's provided history.

File an immediate report with Adult Protective Services regarding the suspicious contusions and document the client's sudden serene expression as an indicator of therapeutic improvement.

Delegate the completion of the suicide lethality assessment to the clinic's unlicensed assistive personnel (UAP) while the RN immediately steps out to contact Adult Protective Services.

Show answer & explanation

Answer: Interview the client privately to assess for a suicide plan, implement continuous supervision, and subsequently file a mandatory report for suspected elder abuse.

Answer

The RN must interview the client privately to assess for a suicide plan, implement continuous supervision, and subsequently file a mandatory report for suspected elder abuse.

The correct answer addresses the two concurrent, high-priority legal and safety issues without violating scope of practice. Sudden peace and giving away possessions in a severely depressed client are hallmark signs of an active suicide plan, requiring the RN to immediately prioritize life safety through a private assessment. Simultaneously, the bilateral thumb-sized contusions (classic grab marks) and the caregiver's dismissive explanation create a reasonable suspicion of physical elder abuse, invoking a non-delegable, mandatory legal duty to report.

Step-by-Step Solution

Analyze the client's physical findings and the caregiver's statements.

Identified bilateral upper arm contusions inconsistent with the caregiver's explanation of 'bumping into door frames', raising high suspicion for physical elder abuse (grab marks).

RNs are mandatory reporters and must recognize signs of non-accidental trauma in vulnerable populations.

Evaluate the client's psychological presentation and actions.

Recognized that a sudden serene expression and giving away a cherished watch in a severely depressed client are critical warning signs of an imminent, lethal suicide plan.

Immediate life safety (risk of suicide) takes precedence over all other interventions.

Determine the legal and professional priorities based on the assessment.

Prioritized securing the client's immediate safety through a private suicide assessment and continuous supervision, followed by fulfilling the mandatory legal requirement to report suspected elder abuse.

Delegation of unstable assessments is illegal, and failing to report suspected abuse violates mandatory reporting laws.

Key Concept

Mandatory Reporting and Imminent Self-Harm Prioritization

Question 1006Question →

A non-English speaking client on the acute medical-surgical unit is scheduled for a percutaneous liver biopsy. The healthcare provider has just finished discussing the procedure with the client via a hospital-approved remote video interpreter. The nurse enters the room to facilitate the signing of the informed consent document. Which of the following actions by the nurse are legally and ethically appropriate? Select all that apply.

Select all that apply

Assess the client's cognitive status to ensure they are not impaired by recently administered sedatives

Act as a legal witness that the client's signature is authentic and provided voluntarily

Notify the healthcare provider to return to the unit if the client asks about alternative treatments

Delegate the task of witnessing the client's signature to the unit's unlicensed assistive personnel (UAP)

Provide a detailed explanation of the potential procedural complications if the client expresses uncertainty

Ask the client's bilingual family member to translate the written consent document into the client's native language

Show answer & explanation

Answer: Assess the client's cognitive status to ensure they are not impaired by recently administered sedatives; Act as a legal witness that the client's signature is authentic and provided voluntarily; Notify the healthcare provider to return to the unit if the client asks about alternative treatments

Answer

The legally and ethically appropriate actions are to assess the client's cognitive status, act as a legal witness to the voluntary signature, and notify the provider if the client asks about alternative treatments.

The nurse's legal and ethical duties during the informed consent process involve verifying that the client is competent (not influenced by sedatives), acting as a witness that the signature is authentic and voluntary, and acting as a patient advocate by pausing the process and notifying the provider if the client has questions regarding risks, benefits, or alternatives.

Step-by-Step Solution

Identify the nurse's specific legal role in the informed consent process.

The nurse's role is to act as a witness, ensure the client is competent, and verify the signature is voluntary.

Differentiating between provider and nursing responsibilities prevents practicing outside the scope of nursing.

Evaluate the option regarding cognitive assessment.

Assessing that the client is not impaired by sedatives is a mandatory nursing action.

A client cannot legally sign a consent form if their judgment is impaired by medications like opioids or benzodiazepines.

Evaluate the option regarding client questions about alternatives or risks.

The nurse must notify the healthcare provider to return and re-explain.

Providing primary education about the procedure's risks or alternatives falls strictly under the healthcare provider's scope of practice.

Evaluate the options regarding delegation and translation.

Witnessing cannot be delegated to a UAP, and family members cannot be used as official medical interpreters for legal documents.

Witnessing requires nursing judgment, and relying on family for translation risks misinterpretation and violates standards for culturally and linguistically appropriate care.

Key Concept

The nurse's role in informed consent is to witness the signature, confirm the client is competent and acting voluntarily, and advocate for the client by notifying the provider if further clarification is needed. The nurse does not provide primary education about the procedure or delegate the witnessing assessment.

Question 1007Question →

An oncology nurse is reviewing the most recent clinical updates for $4$ assigned clients. Based on the principles of prioritization, which client requires the nurse's immediate assessment?

A client with acute myelogenous leukemia (AML) who has a temperature of

102.4^\circ

F (

39.1^\circ

C), a blood pressure of

88/54

mm Hg, and an absolute neutrophil count of

150/\text{mm}^3

A client with small cell lung cancer who has progressive facial edema and reports a new onset of dysphagia and throat tightness

A client with multiple myeloma who has a serum calcium level of

14.8

mg/dL (

3.7

mmol/L) and is exhibiting profound lethargy and a heart rate of

48

beats/min

A client with tumor lysis syndrome who has a serum potassium level of

6.4

mEq/L (

6.4

mmol/L) and is reporting new-onset perioral paresthesia

Show answer & explanation

Answer: A client with small cell lung cancer who has progressive facial edema and reports a new onset of dysphagia and throat tightness

Answer

The client with small cell lung cancer reporting a new onset of dysphagia and throat tightness requires immediate assessment.

The correct answer is the client with small cell lung cancer reporting dysphagia and throat tightness. These symptoms, combined with facial edema, are classic signs of Superior Vena Cava (SVC) syndrome complicated by laryngeal or tracheal compression. In the Airway-Breathing-Circulation (ABC) prioritization framework, an impending airway obstruction represents the most immediate threat to life and requires instantaneous intervention to secure the airway before complete respiratory arrest occurs.

Step-by-Step Solution

Analyze the clinical presentation of each client to identify the underlying pathophysiological emergency.

Identified four oncologic emergencies: neutropenic sepsis, superior vena cava (SVC) syndrome with airway compression, hypercalcemic crisis, and tumor lysis syndrome with hyperkalemia.

Accurate identification of the underlying crisis is required before prioritizing care.

Categorize each emergency using the Airway-Breathing-Circulation (ABC) prioritization framework.

SVC syndrome with dysphagia (Airway), neutropenic sepsis (Circulation), hyperkalemia (Circulation/Cardiac), and hypercalcemia (Neurological/Cardiac).

The ABC framework provides a standardized, evidence-based method for determining survival priority.

Rank the clients based on the highest level of physiological threat.

The client with SVC syndrome and throat tightness is ranked first because airway obstruction causes death more rapidly than distributive shock, dysrhythmias, or metabolic crises.

Without a patent airway, all other interventions (such as fluid resuscitation or electrolyte correction) are futile.

Key Concept

Applying the Airway-Breathing-Circulation (ABC) framework to prioritize among multiple life-threatening oncologic emergencies.

Question 1008Question →

A staffing shortage on an acute medical-surgical unit requires the immediate reassignment of several clients. The interdisciplinary care team available consists of a registered nurse (RN) floated from the maternal-newborn unit, an experienced licensed practical nurse (LPN/VN), and an unlicensed assistive personnel (UAP). Which client care assignment demonstrates the safest and most appropriate application of delegation principles?

Assigning the maternal-newborn float registered nurse (RN) to administer a prescribed unit of packed red blood cells to a client with stable, chronic anemia.

Assigning the experienced licensed practical nurse (LPN/VN) to administer intravenous (IV) push diltiazem to a client experiencing new-onset atrial fibrillation with a rapid ventricular response.

Delegating to the unlicensed assistive personnel (UAP) the initial oral feeding of a client who sustained an acute ischemic stroke two days ago and exhibits unilateral facial paralysis.

Assigning the maternal-newborn float registered nurse (RN) to perform the admission assessment and manage a continuous regular insulin infusion for a client with severe diabetic ketoacidosis.

Show answer & explanation

Answer: Assigning the maternal-newborn float registered nurse (RN) to administer a prescribed unit of packed red blood cells to a client with stable, chronic anemia.

Answer

Assigning the maternal-newborn float registered nurse (RN) to administer a prescribed unit of packed red blood cells to a client with stable, chronic anemia.

The safest and most appropriate assignment involves matching the client's acuity with the nurse's scope of practice and core competencies. A float registered nurse, regardless of their home unit, possesses core nursing competencies which include the administration of blood products. Because the client has chronic anemia, their condition is stable and predictable. Assigning a stable client to a float RN perfectly aligns with the principles of safe delegation and prioritization.

Step-by-Step Solution

Analyze the competencies and scope of practice for the available staff: a maternal-newborn float RN, an experienced LPN/VN, and a UAP.

Float RNs can perform core RN skills (like blood administration) for stable clients; LPN/VNs care for stable clients but generally cannot administer high-alert IV push medications; UAPs assist with standard activities of daily living but cannot perform initial clinical assessments.

Delegation requires matching the task to the right person based on their legal scope of practice and demonstrated competency.

Evaluate the acuity and stability of each client in the proposed assignments.

The chronic anemia client is stable. The atrial fibrillation client (rapid ventricular response) and the diabetic ketoacidosis client (insulin infusion) are highly unstable. The stroke client has a high aspiration risk, making the initial feeding an unstable task requiring assessment.

The 'Right Circumstance' of delegation dictates that unstable clients with unpredictable outcomes must be cared for by an RN with appropriate, unit-specific expertise.

Match the safest staff member to the appropriate client based on the evaluations.

The stable client with chronic anemia receiving blood is the only assignment that safely aligns client stability with the core competencies of the assigned staff member (the float RN).

This ensures adherence to the NCSBN guidelines for safe delegation and supervision while appropriately utilizing available staff.

Key Concept

Delegation and Scope of Practice for Float Nurses and Assistive Personnel

Question 1009Question →

A nurse is coordinating care for a client who had a permanent colostomy placed 2 days ago and is preparing for discharge. The client is tearful, refuses to look at the stoma, and states, 'I do not know how I will ever afford all of these pouches and supplies.' Which of the following actions by the nurse reflect appropriate collaboration and delegation? (Select all that apply.)

Select all that apply

Request a consultation with the wound, ostomy, and continence nurse (WOCN) for specialized stoma care education.

Refer the client to a medical social worker to assist with identifying financial assistance programs for ostomy supplies.

Delegate the initial emptying and assessment of the ostomy pouch to the unlicensed assistive personnel (UAP).

Arrange for a registered dietitian to review dietary modifications that help minimize ostomy output odor and gas.

Assign the licensed practical nurse (LPN/LVN) to develop the comprehensive home discharge teaching plan.

Delay the social worker consultation until the client demonstrates emotional readiness to look at the stoma.

Show answer & explanation

Answer: Request a consultation with the wound, ostomy, and continence nurse (WOCN) for specialized stoma care education.; Refer the client to a medical social worker to assist with identifying financial assistance programs for ostomy supplies.; Arrange for a registered dietitian to review dietary modifications that help minimize ostomy output odor and gas.

Answer

The nurse should consult the WOCN for stoma education, refer to a medical social worker for financial assistance, and arrange for a registered dietitian for dietary modifications.

Effective interdisciplinary collaboration involves utilizing the specialized expertise of various team members to meet comprehensive client needs. A WOCN addresses the complex clinical and educational needs of a new ostomy, a social worker navigates critical financial barriers, and a dietitian manages nutritional adjustments. Together, these referrals ensure a safe and holistic discharge plan.

Step-by-Step Solution

Analyze the client's current clinical and psychosocial needs.

The client has a new ostomy (needs specialized teaching), financial concerns (needs resources), and potential dietary management needs.

Identifying specific deficits allows the nurse to determine the appropriate interdisciplinary team members for collaboration.

Evaluate the correct roles for interdisciplinary referrals.

WOCN is selected for expert stoma care, social worker for financial resources, and dietitian for nutrition management.

Effective collaboration requires matching the client's needs with the specific expertise of allied health professionals.

Assess the appropriateness of delegation to other nursing staff.

Initial assessments (UAP) and developing initial teaching plans (LPN/LVN) are identified as inappropriate delegation.

The RN must retain tasks requiring advanced clinical judgment and the nursing process.

Key Concept

Interdisciplinary collaboration and appropriate delegation in complex discharge planning

Question 1010Question →

A 55-year-old client returns to the medical-surgical unit following an esophagogastroduodenoscopy (EGD) with banding of esophageal varices. The client received intravenous midazolam and fentanyl during the procedure and is currently lethargic but arousable. The client's vital signs are: BP 110/70 mmHg, HR 85 bpm, RR 14/min, and SpO2 96% on room air. Which of the following actions is the most appropriate priority for the nurse to reduce the client's risk of physiological complications?

Maintain the client strictly NPO until the return of the gag reflex is clinically confirmed.

Place the client in a flat, supine position to promote peripheral circulation and hemodynamic stability.

Palpate the client's abdomen deeply for signs of visceral bleeding before auscultating for bowel sounds.

Prepare to draw an arterial blood gas (ABG) sample to evaluate for metabolic alkalosis caused by the sedation.

Show answer & explanation

Answer: Maintain the client strictly NPO until the return of the gag reflex is clinically confirmed.

Answer

The correct action is to maintain the client strictly NPO until the return of the gag reflex is clinically confirmed.

Following an upper endoscopy (EGD), the client's throat is numbed with a topical anesthetic, temporarily abolishing the gag reflex. Combined with the lingering effects of procedural sedation, the client is at a high risk for aspiration. The nurse must withhold all oral fluids and food (NPO) until the gag reflex has demonstrably returned.

Step-by-Step Solution

Analyze the procedure and medications administered.

The client underwent an EGD with variceal banding and received conscious sedation (midazolam, fentanyl) along with a topical anesthetic spray to the posterior pharynx.

Understanding the procedural interventions helps identify the most immediate physiological risks.

Identify the greatest physiological risk.

The combination of sedation (causing lethargy) and topical throat anesthesia (suppressing the gag reflex) creates a severe risk for aspiration of oral secretions or emesis.

Aspiration can lead to airway obstruction, hypoxia, and aspiration pneumonia, making airway protection the top priority based on the ABCs (Airway, Breathing, Circulation).

Evaluate the nursing actions to mitigate the identified risk.

Keeping the client NPO directly prevents aspiration until the protective gag reflex is fully restored. The other options introduce new risks or are clinically inappropriate.

This action directly addresses the highest priority physiological need and prevents a life-threatening complication.

Key Concept

Post-procedure airway protection and aspiration prevention

Question 1011Question →

A client is brought to the emergency department experiencing a severe asthma exacerbation. The client is initially restless and tachypneic with an arterial blood gas (ABG) showing a pH of $7.50$ , $PaCO_2$ of $28 \text{ mm Hg}$ , and $HCO_3^-$ of $24 \text{ mEq/L}$ . One hour later, the nurse notes that the client has become lethargic and the respiratory rate has decreased to $10$ breaths per minute. A repeat ABG shows a pH of $7.28$ , $PaCO_2$ of $58 \text{ mm Hg}$ , and $HCO_3^-$ of $24 \text{ mEq/L}$ . Which of the following is the priority nursing action?

Prepare the client for immediate endotracheal intubation and mechanical ventilation.

Administer a prescribed dose of intravenous sodium bicarbonate to correct the acidosis.

Notify the respiratory therapist to administer a scheduled albuterol nebulizer treatment.

Place the client in a supine position to facilitate a comprehensive physical assessment.

Show answer & explanation

Answer: Prepare the client for immediate endotracheal intubation and mechanical ventilation.

Answer

Prepare the client for immediate endotracheal intubation and mechanical ventilation.

The correct action addresses the immediate life-threatening issue. The client's transition from hyperventilation (respiratory alkalosis) to hypoventilation with lethargy and carbon dioxide retention (respiratory acidosis) signals the exhaustion of the respiratory muscles. This is a classic presentation of impending respiratory failure in status asthmaticus, which requires prompt airway management and ventilatory support.

Step-by-Step Solution

Analyze the initial ABG results.

A pH of

7.50

(alkalosis),

PaCO_2

28

(decreased), and

HCO_3^-

24

(normal) indicates uncompensated respiratory alkalosis due to hyperventilation.

Early asthma exacerbations cause hyperventilation, leading to an excessive 'blowing off' of carbon dioxide.

Evaluate the clinical changes and the repeat ABG results.

The client became lethargic with a decreased respiratory rate. The repeat ABG shows a pH of

7.28

(acidosis),

PaCO_2

58

(increased), and

HCO_3^-

24

(normal).

These findings indicate uncompensated respiratory acidosis and a significant clinical deterioration.

Determine the pathophysiological mechanism.

The client has developed respiratory muscle fatigue, leading to hypoventilation, carbon dioxide retention, and impending respiratory failure.

A transition from respiratory alkalosis to respiratory acidosis in a client having an asthma attack is a medical emergency.

Select the priority intervention based on the ABCs (Airway, Breathing, Circulation).

Airway protection and breathing support are the absolute immediate priorities.

Mechanical ventilation is required to restore adequate gas exchange, remove retained carbon dioxide, and prevent cardiac arrest.

Key Concept

Impending respiratory failure in severe asthma is clinically indicated by a transition from respiratory alkalosis to respiratory acidosis accompanied by fatigue, requiring immediate mechanical ventilation.

Question 1012Question →

The charge nurse is observing a newly licensed nurse provide care for a client who is receiving continuous enteral nutrition through a percutaneous endoscopic gastrostomy (PEG) tube. Which of the following actions by the newly licensed nurse indicate appropriate basic care and comfort measures? Select all that apply.

Select all that apply

Flushes the enteral tube with 30 mL of sterile water every 4 hours.

Lowers the head of the bed completely flat to perform a bed bath without pausing the continuous feeding pump.

Maintains the client's bed elevation at a 30-degree angle or higher throughout the duration of the infusion.

Instructs the unlicensed assistive personnel to evaluate the skin integrity around the gastrostomy insertion site.

Palpates the client's abdomen for distention prior to auscultating for the presence of bowel sounds.

Cleanses the skin surrounding the gastrostomy stoma daily using mild soap and warm water.

Show answer & explanation

Answer: Flushes the enteral tube with 30 mL of sterile water every 4 hours.; Maintains the client's bed elevation at a 30-degree angle or higher throughout the duration of the infusion.; Cleanses the skin surrounding the gastrostomy stoma daily using mild soap and warm water.

Answer

The correct actions include flushing the tube with 30 mL of water every 4 hours, maintaining the bed elevation at 30 degrees or higher, and cleansing the stoma site daily with mild soap and water.

The correct actions align with fundamental safety and comfort standards for enteral nutrition. Flushing the tube every 4 hours ensures it remains patent and delivers necessary hydration. Keeping the head of the bed elevated at 30 degrees or higher uses gravity to prevent gastric reflux and subsequent aspiration. Daily cleansing of the stoma site with mild soap and warm water removes drainage and prevents excoriation, thereby maintaining skin integrity.

Step-by-Step Solution

Evaluate each action for its impact on patient safety regarding aspiration.

Maintaining a 30-degree head-of-bed elevation is required. Leaving the feeding running while the bed is flat is dangerous.

Enteral feedings can easily reflux into the esophagus and airway if gravity is not utilized to keep contents in the stomach.

Assess the appropriateness of delegation to assistive personnel.

Evaluating skin integrity cannot be delegated.

Assessments require nursing judgment and must be performed by the registered nurse.

Determine the correct physical assessment sequence.

Palpating before auscultating is incorrect.

Touching the abdomen can stimulate bowel motility, creating inaccurate auscultation findings.

Identify standard maintenance and hygiene practices for PEG tubes.

Flushing every 4 hours and washing the site daily with mild soap and water are correct.

These actions prevent tube occlusion, provide hydration, and protect the peri-stomal skin from breakdown.

Key Concept

Basic Care and Comfort: Enteral Nutrition Management

Question 1013Question →

A nurse is preparing to administer an intravenous piggyback (IVPB) dose of a prescribed antibiotic through a client's continuous primary intravenous infusion of 0.9% sodium chloride. 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

Show answer & explanation

Answer

The correct sequence is to first verify compatibility, then spike the bag, prime the tubing, scrub the primary line port, and finally connect the secondary tubing while lowering the primary fluid bag.

The correct sequence prioritizes safety, infection control, and proper fluid dynamics. Compatibility must always be verified first to prevent precipitation. Once verified, the equipment is prepared by clamping and spiking the bag, followed by priming to eliminate air. After the equipment is ready, the access port is scrubbed to ensure asepsis immediately prior to connection. Finally, connecting the tubing and lowering the primary bag allows the secondary medication to infuse via gravity.

Step-by-Step Solution

Verify the compatibility of the prescribed antibiotic with the primary intravenous fluid.

The nurse confirms it is safe to administer the medications together.

Checking compatibility is the first critical safety step to prevent adverse chemical reactions or precipitation in the intravenous line.

Close the roller clamp on the secondary tubing and spike the antibiotic infusion bag.

The secondary bag is successfully connected to the tubing without spilling medication.

Closing the clamp ensures the medication does not immediately run through the line and spill out before the nurse is ready to prime it.

Prime the secondary tubing by slowly opening the roller clamp to clear air from the line.

The secondary tubing is filled with fluid and free of air bubbles.

Removing air from the intravenous tubing is essential to prevent a potentially fatal air embolism.

Scrub the uppermost Y-port on the primary intravenous tubing with an antiseptic swab.

The injection port is disinfected.

Cleansing the access port with friction removes pathogens and prevents the introduction of microorganisms into the bloodstream.

Connect the secondary tubing to the primary line and lower the primary fluid bag using an extension hook.

The intravenous piggyback is correctly attached and positioned for gravity infusion.

Lowering the primary bag ensures the piggyback medication, positioned higher, will overcome the hydrostatic pressure of the primary line and infuse completely before the primary fluid resumes.

Key Concept

Safe administration of intravenous piggyback (IVPB) medications requires verifying compatibility, maintaining aseptic technique, preventing air embolisms, and utilizing gravity principles.

Question 1014Question →

A client diagnosed with meningococcal meningitis is transferred to the general medical unit. Which infection control measures are appropriate for this client? Select all that apply.

Select all that apply

Place the client in a single-patient room.

Wear a surgical mask when entering the client's room.

Place a surgical mask on the client during transport to other departments.

Ensure the client is placed in a negative-pressure isolation room.

Don an N95 respirator before performing the physical assessment.

Require all staff to wear a protective gown for any entry into the room.

Show answer & explanation

Answer: Place the client in a single-patient room.; Wear a surgical mask when entering the client's room.; Place a surgical mask on the client during transport to other departments.

Answer

The correct infection control measures for a client with meningococcal meningitis include placing the client in a single-patient room, wearing a surgical mask when entering the room, and placing a surgical mask on the client during transport.

Meningococcal meningitis is transmitted through large respiratory droplets. Droplet precautions require a private room (or cohorting with clients having the same active infection), healthcare workers to wear a standard surgical mask upon entry or when within 3 feet of the client, and the client to wear a surgical mask if they must leave the room for essential transport.

Step-by-Step Solution

Identify the pathogen and its specific mode of transmission.

Meningococcal meningitis is caused by Neisseria meningitidis and is transmitted via large respiratory droplets.

Knowing the transmission route dictates the required isolation category.

Determine the appropriate isolation category based on the transmission route.

Droplet precautions must be initiated.

Droplet precautions are specifically designed to reduce the risk of transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions.

Select the interventions that align with droplet precaution guidelines.

A single-patient room, surgical masks for staff entering the room, and surgical masks for the client during transport are selected.

These measures directly block the transmission of large droplets.

Key Concept

Droplet Precautions

Question 1015Question →

During a psychosocial assessment, a 77-year-old client tearfully states, 'When I look back on my life, I realize I accomplished very little, and now my time has simply run out.' Based on Erikson's theory of psychosocial development, which developmental outcome is this client demonstrating?

Despair, reflecting a sense of failure and regret over past life choices

Stagnation, resulting from an inability to contribute meaningfully to the next generation

Isolation, triggered by a lack of intimate social connections in late adulthood

Inferiority, stemming from a perceived lack of meaningful personal achievements

Show answer & explanation

Answer: Despair, reflecting a sense of failure and regret over past life choices

Answer

The client is demonstrating despair, which is characterized by a sense of failure and regret over past life choices in late adulthood.

According to Erikson's theory of psychosocial development, older adults (65 years and older) are in the 'Integrity vs. Despair' stage. During this stage, individuals engage in a retrospective accounting of their lives. If they feel a sense of fulfillment and pride in their accomplishments, they achieve ego integrity. If they feel their life was unproductive or filled with missed opportunities, they develop despair, which is clearly demonstrated by this client's feelings of regret and statements about running out of time.

Step-by-Step Solution

Identify the client's chronological age and determine their current developmental stage.

The client is 77 years old, which places them in the late adulthood stage of life.

Applying Erikson's theory requires matching the individual's age to the correct psychosocial conflict.

Determine the specific psychosocial conflict associated with late adulthood.

The core conflict for this age group is 'Integrity vs. Despair'.

Older adults reflect on their lives to determine if they feel fulfilled (integrity) or unfulfilled (despair).

Analyze the client's statements against the possible outcomes of this stage.

The client expresses deep regret, feeling they accomplished little and that it is too late to make changes.

These statements directly align with the defining characteristics of despair, confirming the correct developmental outcome.

Key Concept

Erikson's Psychosocial Theory: Integrity vs. Despair

Question 1016Question →

A clinic nurse is providing education to new parents about the sequence of expected motor skill progression during early childhood development. Place the following fine motor milestones in the chronological order in which they are typically achieved. Arrange the items from the earliest acquired skill to the latest.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct chronological sequence of fine motor milestone acquisition is: maintaining hands closed in a fist (1 month), bringing hands to the midline (3-4 months), transferring objects between hands (7 months), utilizing a crude pincer grasp (9 months), and finally constructing a tower of two blocks (12-15 months).

Fine motor development progresses in a predictable proximodistal pattern (from the center of the body outward to the fingertips). The infant begins with involuntary reflexes (fists closed at 1 month), progresses to bilateral midline play (3-4 months), develops unilateral voluntary control to transfer objects (7 months), refines finger dexterity to a pincer grasp (9 months), and finally achieves the precision and deliberate release required to stack blocks (12-15 months).

Step-by-Step Solution

Identify the earliest milestone associated with the neonatal period.

Maintaining hands in a tight fist is selected first.

This is a primitive reflex characteristic of a 1-month-old infant before voluntary fine motor control develops.

Determine the next milestone as voluntary bilateral control begins.

Bringing hands to the midline is placed second.

As the grasp reflex fades by 3-4 months, infants begin to deliberately engage both hands together.

Identify the milestone that requires independent control of each hand.

Transferring an object from one hand to the other is placed third.

By 7 months, infants master the ability to grasp with one hand and voluntarily release it into the other.

Locate the milestone indicating refined finger dexterity.

Utilizing a crude pincer grasp is placed fourth.

By 9 months, infants transition from grasping with the whole palm to using the thumb and index finger.

Identify the most advanced milestone requiring precise object placement.

Constructing a small tower using two blocks is placed last.

This requires highly controlled intentional release and spatial coordination, typical of a 12 to 15-month-old toddler.

Key Concept

Fine Motor Development Timeline

Question 1017Question →

A nurse is assessing a client who is recovering in the intensive care unit following a coronary artery bypass graft (CABG) surgery. Which of the following clinical findings should indicate to the nurse that the client is developing cardiac tamponade? Select all that apply.

Select all that apply

Distant, muffled heart sounds upon auscultation

Distended neck veins while the head of the bed is elevated at 45 degrees

A drop in systolic blood pressure of 15 mm Hg during inspiration

A widening difference between the systolic and diastolic blood pressure

An abrupt and significant increase in mediastinal chest tube drainage

Show answer & explanation

Answer: Distant, muffled heart sounds upon auscultation; Distended neck veins while the head of the bed is elevated at 45 degrees; A drop in systolic blood pressure of 15 mm Hg during inspiration

Answer

The correct findings are distant, muffled heart sounds, distended neck veins while the head of the bed is elevated, and a drop in systolic blood pressure of 15 mm Hg during inspiration.

Cardiac tamponade is a life-threatening complication where fluid or blood rapidly accumulates in the pericardial space, severely restricting ventricular filling and causing obstructive shock. The classic presentation, known as Beck's triad, includes distant or muffled heart sounds (due to fluid muffling the sound), jugular venous distension (due to impaired right ventricular filling causing systemic venous congestion), and hypotension. Another hallmark sign is pulsus paradoxus, which is an exaggerated drop in systolic blood pressure (greater than 10 mm Hg) during inspiration.

Step-by-Step Solution

Analyze the client's postoperative context and the pathophysiology of cardiac tamponade.

Cardiac tamponade involves fluid or blood accumulating in the pericardial sac, which compresses the heart and restricts ventricular filling (obstructive shock).

Understanding the mechanism helps identify the resulting hemodynamic changes.

Evaluate each option against the expected signs of cardiac tamponade (Beck's triad and pulsus paradoxus).

Muffled heart sounds, jugular venous distension, and pulsus paradoxus (systolic drop greater than 10 mm Hg during inspiration) are classic signs.

These findings directly reflect the fluid accumulation and increased intrapericardial pressure.

Identify and exclude findings that contradict the pathophysiology of tamponade.

Widening pulse pressure and increased chest tube drainage are excluded. Tamponade causes a narrowing pulse pressure, and it often occurs when chest tube drainage suddenly stops.

Accurate clinical judgment requires distinguishing true complications from unrelated or opposite signs.

Key Concept

Recognition of Cardiac Tamponade

Question 1018Question →

A nurse is preparing to enter the room of a client who requires contact and droplet precautions. In what order should the nurse don (put on) the required personal protective equipment (PPE)? 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 for donning PPE is: 1) Perform hand hygiene, 2) Put on the isolation gown, 3) Put on the surgical mask, 4) Put on eye protection, and 5) Put on clean gloves.

According to the Centers for Disease Control and Prevention (CDC) guidelines, when full PPE is required, the correct donning sequence begins with hand hygiene to ensure clean hands are used to handle the equipment. The gown is applied first to cover the torso, followed by the mask to protect the respiratory tract, and eye protection to protect the mucous membranes. Gloves are always donned last so they can be pulled securely over the cuffs of the isolation gown, completing the protective barrier without gaps.

Step-by-Step Solution

Identify the necessary PPE based on the prescribed isolation precautions.

Contact precautions require a gown and gloves; droplet precautions require a surgical mask and eye protection.

Correctly identifying the required equipment ensures comprehensive protection against specific transmission routes.

Apply the Centers for Disease Control and Prevention (CDC) sequence for donning PPE.

The sequence follows the principle of covering the body first, then the face/respiratory tract, and finally the hands.

This standardized sequence minimizes the risk of self-contamination during the donning process and ensures gloves overlap the gown cuffs.

Key Concept

Standard transmission-based precautions and correct sequencing for donning Personal Protective Equipment (PPE).

Question 1019Question →

Review the clinical profiles of the following five clients. Evaluate the infectious agent, phase of illness, and presenting symptoms to select the most appropriate transmission-based precaution category for each client.

Click a left item, then click its matching right item

Show answer & explanation

Answer

Correct matches: Meningitis at 36 hours requires Standard Precautions only. Suspected Pertussis requires Standard and Droplet Precautions. Disseminated Herpes Zoster requires Standard, Contact, and Airborne Precautions. Suspected C. difficile requires Standard and Contact Precautions. Adenovirus requires Standard, Contact, and Droplet Precautions.

Each correct pairing reflects advanced application of CDC isolation guidelines. It tests the ability to move beyond simple pathogen memorization by factoring in the phase of treatment (e.g., discontinuation after 24 hours of antibiotics for meningococcal disease), the extent of the disease (disseminated versus localized zoster), the critical necessity of empiric isolation (suspected C. diff), and pathogens requiring multiple simultaneous transmission-based precautions (adenovirus).

Step-by-Step Solution

Analyze the duration of therapy for the client with Neisseria meningitidis.

Determine that 36 hours exceeds the 24-hour requirement for droplet precautions.

Droplet precautions can be safely discontinued after 24 hours of effective antimicrobial therapy, reverting to standard precautions.

Evaluate the isolation requirements for suspected Bordetella pertussis.

Select standard and droplet precautions.

Pertussis is highly contagious and transmitted via large respiratory droplets during coughing fits.

Assess the presentation of herpes zoster (shingles) in the older adult.

Identify the infection as disseminated (crossing multiple dermatomes) and select airborne and contact precautions.

While localized zoster in an immunocompetent adult may only require standard precautions if lesions are covered, disseminated zoster requires strict airborne and contact isolation.

Determine the priority intervention for the client with acute, severe diarrhea and a history of antibiotic use.

Initiate empiric standard and contact precautions immediately.

Infection control protocols dictate that contact precautions for suspected C. difficile must be implemented prior to laboratory confirmation to prevent widespread unit outbreaks.

Identify the specific transmission routes for adenovirus respiratory infections.

Select a combination of standard, contact, and droplet precautions.

Adenovirus is highly resilient on environmental surfaces and spreads via both respiratory droplets and direct or indirect contact with fomites.

Key Concept

Advanced Application of Transmission-Based Precautions: Duration, Empiric Isolation, and Combined Routes

Question 1020Question →

Shift responsibilities on a high-acuity cardiopulmonary and renal unit must be distributed by the coordinating RN. The available personnel for task distribution include one LPN/VN and one UAP. Based on the principles of safe delegation and scope of practice, which task assignment is correct?

Directing the UAP to gather a clean-catch urine specimen and teach the client the proper cleansing technique required before the collection.

Entrusting the LPN/VN to deliver an intravenous push (IVP) dose of furosemide and monitor the immediate respiratory changes in a client with acute pulmonary edema.

Assigning the LPN/VN to administer an oral phosphate binder and auscultate the arteriovenous (AV) fistula bruit for a stable client with end-stage renal disease.

Having the UAP reapply a non-invasive ventilation mask and secure the head straps for a client who just reported a sudden onset of chest tightness and severe dyspnea.

Show answer & explanation

Answer: Assigning the LPN/VN to administer an oral phosphate binder and auscultate the arteriovenous (AV) fistula bruit for a stable client with end-stage renal disease.

Answer

Assigning the LPN/VN to administer an oral phosphate binder and auscultate the arteriovenous (AV) fistula bruit for a stable client with end-stage renal disease.

The correct assignment applies the five rights of delegation by pairing a legally appropriate task with a clinically stable client. Auscultating a mature arteriovenous (AV) fistula for a bruit is a focused, predictable assessment, and administering oral medications falls well within the LPN/VN scope of practice. Because the client with end-stage renal disease is described as stable, this delegation decision is safe, correct, and properly utilizes the care team.

Step-by-Step Solution

Analyze the acuity and clinical stability of each client presented in the assignment options.

The client with end-stage renal disease is explicitly described as stable. The clients with acute pulmonary edema and sudden chest tightness are highly unstable, experiencing acute respiratory compromise.

Delegation requires adherence to the 'Right Circumstance,' meaning the delegated task must involve a stable client with predictable health outcomes.

Evaluate the scope of practice and authorized tasks for the assigned team member in each scenario.

The UAP is improperly assigned patient teaching (proper cleansing technique), and the LPN/VN is improperly assigned a high-alert IV push medication.

The RN must adhere to the 'Right Task' and 'Right Person' principles by ensuring the delegatee is legally and educationally permitted to perform the task.

Identify the option that correctly matches a stable client with a task appropriate for the delegatee's legal scope of practice.

Assigning the oral medication administration and a protocol-driven, focused assessment (auscultating the AV fistula) to the LPN/VN is the only fully appropriate choice.

This decision correctly applies all five rights of delegation, maintaining patient safety while efficiently utilizing the healthcare team.

Key Concept

Scope of Practice and the Five Rights of Delegation

Estimated Time:1m 30s

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