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Question 1041Question →

A nurse is caring for a client who is receiving total parenteral nutrition via a central venous catheter. The nurse discovers that the catheter tubing has become disconnected. The client suddenly develops severe dyspnea, a cough, chest pain, and extreme tachycardia. Arrange the following nursing interventions in the most appropriate order of priority.

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Answer

The correct sequence is to first clamp the catheter, then place the client in the left lateral Trendelenburg position, administer oxygen, notify the rapid response team, and finally assess vital signs and heart sounds.
The client's presentation of a disconnected central line with sudden severe respiratory distress and tachycardia is a hallmark sign of a central line-associated air embolism. The nurse's actions must prioritize immediate, independent life-saving interventions before gathering more data or calling for help. The very first action is to clamp the central line to stop the influx of air. Immediately following this, placing the client in the left lateral Trendelenburg position (Durant's maneuver) is critical, as it traps the air in the apex of the right ventricle, preventing it from entering the pulmonary circulation. Providing 100% oxygen treats the resulting hypoxia and helps dissolve the nitrogen in the air embolus. After these immediate stabilization steps, the nurse must notify the rapid response team and the healthcare provider for advanced support. Finally, obtaining a complete set of vital signs and auscultating for a classic 'mill wheel' murmur provides necessary data to guide further treatment.

Step-by-Step Solution

1
Clamp the central venous catheter.
Prevents additional air from being drawn into the central venous system.
Eliminating the source of the complication is the absolute first priority in emergency management.
2
Place the client in the left lateral Trendelenburg position.
Traps the air in the right ventricle.
This specific positioning utilizes gravity to keep the air bubble away from the pulmonary valve, preventing a catastrophic pulmonary embolism.
3
Administer 100% oxygen via a non-rebreather mask.
Treats hypoxia and promotes nitrogen washout.
Room air is primarily nitrogen. High-flow oxygen creates a concentration gradient that helps the nitrogen bubble dissolve faster.
4
Notify the rapid response team and the healthcare provider.
Summons advanced medical assistance.
The client requires critical care, continuous hemodynamic monitoring, and potential interventions (like needle aspiration) that are outside the nurse's independent scope of practice.
5
Obtain a complete set of vital signs and auscultate heart sounds.
Provides baseline data and checks for clinical signs of an air embolism.
Once life-saving interventions are established, ongoing assessment is necessary to monitor the client's stability and response.

Key Concept

The priority management of a suspected central line air embolism follows the sequence of stopping the source, positioning the client to prevent further harm, providing supplemental oxygenation, and escalating care.
Estimated Time:1m 30s
Question 1042Question →

A nurse is caring for an older adult client who returned to the inpatient unit 1 hour ago following a left-sided cardiac catheterization accessed via the femoral artery. The client is experiencing lower back discomfort from prolonged immobility, has been incontinent of urine, and is intermittently reaching toward the groin dressing. Which of the following nursing interventions are appropriate? Select all that apply.

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Answer: Utilize a fracture bedpan for elimination to avoid excessive flexion of the client's hips.; Provide a back massage by gently rolling the client slightly toward the right side while keeping the left leg straight.; Place a trochanter roll alongside the client's left leg to maintain neutral alignment and prevent external rotation.

Answer

The correct interventions are utilizing a fracture bedpan, providing a back massage by rolling the client slightly to the unaffected side, and placing a trochanter roll alongside the affected leg.
Utilizing a fracture bedpan safely manages urinary incontinence while preventing excessive hip flexion. Providing a back massage by slightly rolling the client to the unoperated side relieves back pain while keeping the affected leg completely straight. Applying a trochanter roll prevents external hip rotation, maintaining the neutral alignment strictly required to prevent stress on the femoral puncture site.

Step-by-Step Solution

1
Identify the client's current clinical situation and primary risks.
The client recently underwent a left femoral cardiac catheterization, which requires the left leg to remain strictly straight to prevent arterial hemorrhage.
Understanding the procedural constraints is essential before implementing any comfort or hygiene measures.
2
Evaluate each intervention for safety regarding the femoral puncture site.
Using a fracture bedpan, slight rolling to the unoperated side, and placing trochanter rolls all successfully maintain the required straight alignment of the left leg.
Any intervention that flexes the affected hip or disturbs the clot can cause severe, life-threatening bleeding.
3
Identify incorrect or unsafe interventions.
Elevating the head of the bed to 60 degrees bends the hip dangerously. Delegating pulse checks is outside the scope of practice for unlicensed personnel. Restraining the client skips required alternative safety measures.
Nursing actions must strictly adhere to scope of practice, safety protocols, and post-procedure guidelines.

Key Concept

Providing basic care, hygiene, and non-pharmacologic comfort measures while strictly adhering to post-procedural positioning requirements to prevent complications.
Question 1043Question →

A 24-year-old client with type 1 diabetes mellitus is brought to the emergency department after a 2-day history of vomiting and omitting insulin doses. The triage nurse suspects diabetic ketoacidosis (DKA). Which of the following clinical findings should the nurse expect to assess? Select all that apply.

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Answer: Deep, rapid respirations; Arterial pH of 7.287.28 and PaCO2PaCO_2 of 2828 mm Hg; Orthostatic hypotension and poor skin turgor

Answer

The expected clinical findings are deep and rapid respirations, an acidic pH with a low PaCO2PaCO_2 due to compensation, and signs of significant fluid volume deficit such as orthostatic hypotension and poor skin turgor.
The client is experiencing diabetic ketoacidosis (DKA), characterized by hyperglycemia, ketosis, and metabolic acidosis. The lack of insulin forces the body to break down fats, producing acidic ketones. This state of metabolic acidosis triggers a physiological adaptation: compensatory Kussmaul respirations (deep, rapid breathing) to blow off excess CO2CO_2, which subsequently lowers the PaCO2PaCO_2 while the overall pH remains acidic. Additionally, extreme hyperglycemia causes osmotic diuresis, leading to a profound fluid volume deficit that presents clinically as orthostatic hypotension, poor skin turgor, tachycardia, and weak pulses.

Step-by-Step Solution

1
Analyze the client's presentation and underlying pathophysiology.
A client with type 1 diabetes who has omitted insulin and is vomiting will experience absolute insulin deficiency, resulting in severe hyperglycemia and accelerated lipolysis (fat breakdown).
Identifying the primary pathophysiological trigger is required to predict subsequent systemic adaptations.
2
Evaluate the metabolic and acid-base consequences.
Fat breakdown produces ketones, causing metabolic acidosis characterized by a low pH and low HCO3−HCO_3^-. The respiratory system adapts by initiating Kussmaul respirations to decrease PaCO2PaCO_2.
DKA directly disrupts acid-base balance; recognizing compensatory respiratory mechanisms helps identify accurate assessment findings.
3
Evaluate the fluid and electrolyte consequences.
Severe hyperglycemia induces massive osmotic diuresis. This leads to profound dehydration and hypovolemia, resulting in tachycardia, orthostatic hypotension, and poor skin turgor.
Understanding fluid shifts is critical for differentiating expected compensatory signs of early hypovolemic shock from incorrect vital sign trends.

Key Concept

Diabetic Ketoacidosis Pathophysiology and Systemic Compensatory Mechanisms
Question 1044Question →

A client is being monitored on the medical-surgical unit shortly after a therapeutic thoracentesis that removed a large volume of pleural fluid. Upon entering the room, the nurse observes that the client is newly restless and confused. The client's respiratory rate is 28 breaths per minute, the apical pulse is 114 beats per minute, and the blood pressure has trended down to 88/64 mm Hg. Which of the following immediate nursing actions should be implemented? (Select all that apply)

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Answer: Provide supplemental oxygen using a high-flow delivery device; Auscultate bilateral lung fields and assess for tracheal deviation; Activate the rapid response team or notify the healthcare provider

Answer

The correct actions are to provide supplemental oxygen, auscultate the lung fields to assess for tracheal deviation, and activate the rapid response team.
The correct actions prioritize airway, breathing, and circulation in a rapidly deteriorating client. Providing supplemental oxygen directly addresses hypoxemia, assessing lung sounds and tracheal position identifies the specific etiology of the distress (such as a tension pneumothorax), and activating the rapid response team ensures the client receives life-saving advanced care.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client exhibits tachycardia, hypotension, tachypnea, and new-onset confusion shortly after an invasive pleural procedure.
Identifying abnormal physiological findings is the first step in recognizing an acute post-procedure complication such as a pneumothorax, hemothorax, or impending shock.
2
Prioritize nursing interventions using the Airway, Breathing, Circulation (ABC) framework.
Oxygen administration and a focused respiratory assessment are identified as the immediate priorities.
Hypoxemia and potential respiratory collapse must be addressed immediately to prevent cardiac arrest.
3
Determine the need for escalated medical care.
The rapid response team is activated.
The client is hemodynamically unstable and requires advanced medical interventions beyond independent nursing scope.
4
Evaluate the remaining options for safety and appropriateness.
Delegating to UAP, ignoring the symptoms as anxiety, and flat supine positioning are rejected as unsafe.
Unstable clients require RN assessment, signs of shock must never be dismissed, and supine positioning worsens respiratory distress.

Key Concept

Recognition and immediate management of acute physiological complications (such as tension pneumothorax or shock) following a thoracentesis.
Estimated Time:1m 30s
Question 1045Question →

A nurse is caring for a client at 34 weeks gestation who is receiving a continuous intravenous infusion of magnesium sulfate for severe preeclampsia. Which of the following nursing actions are appropriate to ensure safe administration and monitor for medication toxicity? Select all that apply.

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Answer: Assess the client's deep tendon reflexes (DTRs) every hour.; Ensure that calcium gluconate is readily available at the client's bedside.; Monitor the client's urine output to ensure it remains at or above 30 mL/hr.

Answer

The appropriate actions are assessing deep tendon reflexes hourly, ensuring calcium gluconate is available at the bedside, and monitoring urine output to ensure it is at least 30 mL/hr.
Magnesium sulfate is a high-alert parenteral medication used to prevent seizures in severe preeclampsia. Safe administration requires meticulous monitoring for signs of toxicity, which include diminished or absent deep tendon reflexes and respiratory depression. Because magnesium is primarily excreted by the kidneys, maintaining adequate urine output (at least 30 mL/hr) is critical to prevent dangerous accumulation of the drug. Additionally, calcium gluconate is the specific antidote for magnesium toxicity and must be kept immediately available to reverse severe respiratory or cardiac depression if toxicity occurs.

Step-by-Step Solution

1
Identify the medication and its primary clinical risks.
Magnesium sulfate is a central nervous system depressant used to prevent seizures in preeclampsia, but it carries a high risk for respiratory and cardiac toxicity.
Understanding the drug's physiological effects dictates the required nursing assessments and safety protocols.
2
Determine the early indicators of toxicity and how the drug is cleared from the body.
Loss of deep tendon reflexes is an early sign of toxicity, and the drug is cleared renally (low urine output increases toxicity risk).
Direct RN monitoring of these specific parameters is necessary to detect dangerous accumulation before respiratory collapse occurs.
3
Evaluate general parenteral safety and delegation protocols.
The antidote (calcium gluconate) must be present, incompatible lines (like TPN) cannot be used, and assessing unstable clients cannot be delegated to a UAP.
Strict adherence to administration rules prevents potentially fatal adverse events associated with high-alert medications.

Key Concept

Safe Administration and Monitoring of Intravenous Magnesium Sulfate
Question 1046Question →

A nurse is assessing a client admitted with acute hemorrhagic pancreatitis who is receiving continuous intravenous fluid resuscitation. Which of the following findings indicate the client is developing early hypovolemic shock? Select all that apply.

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Answer: A pulse pressure that narrows from 45 mmHg to 20 mmHg; Urine output of 15 mL/hour for the past two consecutive hours; New-onset restlessness and unexplained agitation

Answer

The correct findings indicating early hypovolemic shock are a narrowing pulse pressure, decreased urine output (15 mL/hour), and new-onset restlessness.
In early hypovolemic shock, compensatory mechanisms activate to maintain cardiac output. Sympathetic stimulation causes peripheral vasoconstriction, which raises diastolic blood pressure while decreased stroke volume lowers systolic pressure, resulting in a narrowed pulse pressure. Blood is shunted away from the kidneys, reducing glomerular filtration rate and causing oliguria (less than 30 mL/hr). Additionally, the brain is highly sensitive to slight decreases in oxygenation and perfusion, making new-onset restlessness, anxiety, or agitation an early hallmark of deterioration.

Step-by-Step Solution

1
Analyze the client's diagnosis and risk factors.
The client has acute hemorrhagic pancreatitis, which causes massive fluid shifts (third-spacing) and potential internal bleeding, putting them at high risk for hypovolemic shock.
Understanding the underlying pathophysiology establishes the context for recognizing specific complications.
2
Identify the physiological hallmarks of early hypovolemic shock.
Early shock triggers compensatory sympathetic responses: vasoconstriction (narrowed pulse pressure), tachycardia, shunting of blood from non-vital organs (oliguria), and mild cerebral hypoxia (restlessness).
Differentiating early shock from late shock (where profound hypotension and unresponsiveness occur) is critical for timely intervention.
3
Evaluate each option against the early signs of shock.
Narrowing pulse pressure, oliguria, and restlessness match the compensatory phase of shock. Normal capillary refill, respiratory acidosis, and localized pain do not reflect systemic hypoperfusion.
Systematically ruling out expected findings or unrelated pathologies isolates the correct indicators of hemodynamic deterioration.

Key Concept

Early recognition of systemic hypoperfusion and compensatory mechanisms in hypovolemic shock
Question 1047Question →

An adolescent client is brought to the emergency department exhibiting deep, rapid respirations, a fruity breath odor, and severe lethargy. The initial capillary blood glucose is 580 mg/dL580 \text{ mg/dL} (32.2 mmol/L32.2 \text{ mmol/L}). The healthcare provider diagnoses diabetic ketoacidosis (DKA). Arrange the following nursing actions in the priority order they should be performed.

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Answer

The correct sequence prioritizes immediate life support followed by specific DKA management: first, assess airway patency and apply oxygen; second, establish large-bore IV access; third, administer a rapid IV infusion of 0.9%0.9\% sodium chloride; fourth, initiate a continuous IV infusion of regular insulin; and finally, monitor serum potassium levels and replace as prescribed.
The correct sequence follows the ABCs (Airway, Breathing, Circulation) of emergency resuscitation combined with the standard protocol for Diabetic Ketoacidosis (DKA). Airway protection and oxygenation are always the first priority for a lethargic client. Once the airway is secured, IV access must be established to provide a route for rapid emergency interventions. The immediate medical priority in DKA is aggressive fluid resuscitation with isotonic saline to reverse severe dehydration and prevent hypovolemic shock. Only after fluid resuscitation has begun should continuous IV regular insulin be initiated to correct the hyperglycemia and acidosis. Finally, because insulin drives potassium into the intracellular space, continuous monitoring and subsequent replacement of potassium are essential to prevent life-threatening dysrhythmias.

Step-by-Step Solution

1
Apply the ABCs (Airway, Breathing, Circulation) framework to prioritize immediate life-saving actions.
Assessing airway patency and applying oxygen is identified as the absolute first action.
Airway and oxygenation always take precedence in an emergency, especially in a patient with a compromised neurological status and altered respiratory patterns (Kussmaul respirations).
2
Identify the next most critical requirement for treating a client in severe metabolic distress.
Establishing large-bore IV access is prioritized next.
Without reliable intravenous access, life-saving fluids and medications cannot be administered to the client.
3
Determine the initial circulatory intervention for DKA.
Administering a rapid infusion of 0.9%0.9\% sodium chloride is the third action.
Severe dehydration and hypovolemia from osmotic diuresis must be corrected first to restore tissue perfusion and prevent vascular collapse.
4
Sequence the treatment for the underlying metabolic acidosis and hyperglycemia.
Initiating a continuous IV infusion of regular insulin is the fourth action.
Insulin halts ketone production and drives glucose into the cells, directly treating the pathophysiology of DKA, but it must only be given after fluid resuscitation has started.
5
Anticipate the complications of the medical interventions.
Monitoring and replacing potassium is the final action in this immediate sequence.
Intravenous insulin therapy drives potassium into the intracellular space, causing hypokalemia. This requires continuous monitoring and replacement once adequate urine output is confirmed.

Key Concept

Prioritization of emergency interventions and the standard treatment algorithm for Diabetic Ketoacidosis (DKA).
Question 1048Question →

A client with a history of aggressive behavior is pacing rapidly in the day room, clenching their fists, and muttering angrily to themselves. The nurse needs to intervene to prevent an escalation of violence. Arrange the following behavioral interventions in chronological order from the least restrictive to the most restrictive approach.

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Answer

The correct order from least to most restrictive is: Attempt verbal de-escalation, offer PRN oral medication, administer PRN intramuscular medication, and finally apply physical restraints.
The legal and ethical principle of the least restrictive alternative mandates that healthcare providers use the least invasive interventions necessary to safely manage a client's behavior. The proper progression always begins with verbal and environmental modifications, moves to voluntary pharmacological interventions (oral route), then involuntary or invasive pharmacological interventions (intramuscular route), and concludes with physical restraints or seclusion only as an absolute last resort.

Step-by-Step Solution

1
Assess the level of restriction of verbal de-escalation.
Identified as the least restrictive measure.
It relies on interpersonal communication and voluntary cooperation without limiting physical movement.
2
Compare oral versus intramuscular medications.
Oral medication is determined to be less restrictive than IM medication.
Oral administration is voluntary and non-invasive, while an intramuscular injection is invasive and often administered involuntarily during a psychiatric crisis.
3
Assess the level of restriction of physical restraints.
Identified as the most restrictive measure.
It physically limits the client's freedom of movement and requires strict legal, ethical, and institutional justification.

Key Concept

Least Restrictive Environment and Behavioral Interventions
Question 1049Question →

A client experiencing severe depressive symptoms and active suicidal ideation is admitted to the behavioral health unit. Which actions should the registered nurse take to establish a safe therapeutic environment? Select all that apply.

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Answer: Remove all plastic bags, loose cords, and extra linens from the client's immediate access.; Ensure that all unit utility rooms, kitchens, and medication carts remain securely locked at all times.; Verify that the bathroom mirrors are made of polished metal or shatter-resistant plastic rather than standard glass.

Answer

The correct actions include removing potential hazards like plastic bags and cords, ensuring unit utility areas are securely locked, and verifying the presence of shatter-resistant mirrors.
Establishing a safe therapeutic milieu for a client at risk for suicide requires eliminating all potential means of self-harm. This includes actively removing strangulation and suffocation hazards (such as cords, belts, and plastic bags), securing areas that contain dangerous supplies (such as utility rooms and medication carts), and ensuring that room fixtures like mirrors cannot be broken and weaponized.

Step-by-Step Solution

1
Identify the client's specific safety risk based on their clinical presentation.
The client has active suicidal ideation, indicating a high and immediate risk for self-harm.
Establishing the baseline risk dictates the necessary environmental precautions.
2
Evaluate the physical environment for potential dangers and implement necessary modifications.
Removal of strangulation hazards, securing of dangerous areas, and verifying shatterproof fixtures are prioritized.
A therapeutic milieu must first ensure physical survival by eliminating all accessible lethal means.
3
Determine the appropriateness of nursing delegation and communication strategies.
The RN retains responsibility for the initial safety search and avoids non-therapeutic responses like false reassurance.
Initial safety assessments require professional judgment, and therapeutic communication is required to build a psychologically safe environment.

Key Concept

Maintaining a safe therapeutic environment for a suicidal client involves systematic hazard removal, strict access control to dangerous areas, and the use of least restrictive measures.
Question 1050Question →

A nurse is removing a central venous access device (CVAD) from a client's right subclavian vein. During the procedure, the client suddenly gasps for air, becomes profoundly dyspneic, and exhibits perioral cyanosis. The client's blood pressure drops to 72/40 mm Hg, and a loud 'churning' murmur is auscultated over the precordium. Arrange the following emergency nursing interventions in the correct physiological sequence from first to last.

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Answer

The correct sequence is to first immediately seal the insertion site to prevent further air entry, then place the client in the left lateral Trendelenburg position to trap the embolus, followed by administering 100% oxygen to shrink the bubble, activating the rapid response team, and finally preparing for advanced interventions.
The correct sequence prioritizes immediate source control (sealing the site) to prevent further harm, followed immediately by anatomical positioning (left lateral Trendelenburg) to prevent the fatal migration of the air embolus into the pulmonary artery. Once the embolus is contained, high-flow oxygen is administered to treat hypoxemia and reduce the bubble's size. Finally, summoning advanced help and preparing for definitive diagnostic procedures completes the emergency response.

Step-by-Step Solution

1
Seal the insertion site with an occlusive dressing.
Prevents further air entrainment into the central venous circulation.
Halting the source of the embolus is the primary step in resolving the crisis and preventing a larger, fatal air volume.
2
Position the client in the left lateral Trendelenburg position.
Traps the air bubble in the non-dependent apex of the right ventricle.
Prevents fatal obstructive shock caused by the air embolus migrating into the pulmonary artery.
3
Administer 100% oxygen via a non-rebreather mask.
Reverses hypoxemia and facilitates nitrogen washout.
High-concentration oxygen creates a gradient that shrinks the nitrogen-rich air embolus.
4
Activate the rapid response team.
Mobilizes advanced critical care providers.
Advanced pharmacological and mechanical interventions will be required to stabilize the client's hemodynamic status.
5
Prepare for advanced diagnostic and therapeutic interventions.
Facilitates definitive medical treatment.
Echocardiography or direct needle aspiration of the air from the heart may be necessary if conservative measures fail.

Key Concept

Venous Air Embolism Emergency Management
Question 1051Question →

A nurse is teaching a client who has a non-weight-bearing right leg fracture how to ascend stairs using axillary crutches. In what order should the nurse instruct the client to perform the following actions? Arrange the steps in the correct sequence.

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Answer

The correct sequence for ascending stairs with axillary crutches is to establish a tripod position, transfer weight to the crutches, step up with the unaffected leg, shift weight to the unaffected leg, and finally bring the crutches and affected leg up.
When ascending stairs with crutches, the primary safety principle is 'up with the good'. The client must first establish balance in the tripod position. By transferring weight to the crutches, the client frees the strong, unaffected leg to step up. Once the strong leg is on the stair, the client shifts their weight onto it. This strong leg then powers the lifting of the body, allowing the client to safely bring the crutches and the affected, non-weight-bearing leg up to the same step without compromising balance or the injury.

Step-by-Step Solution

1
Establish the tripod base.
The client achieves balance and stability.
Safety requires a solid base of support before attempting vertical movement.
2
Unweight the strong leg.
The body is supported entirely by the upper body and crutches.
The unaffected leg must be free to step upward.
3
Step up with the unaffected leg.
The strong leg is positioned on the next stair tread.
The strong leg acts as the elevator, doing the physical work of lifting the body against gravity.
4
Transfer body weight upward.
The client's weight shifts onto the strong leg.
This unloads the crutches and prepares them for advancement.
5
Advance the crutches and the affected leg.
The client stands fully on the new step with all devices.
This completes the stepping cycle while maintaining non-weight-bearing status on the injured leg.

Key Concept

Assistive Device Mobility: Ascending Stairs
Question 1052Question →

A nurse is preparing to administer a prescribed intravenous (IV) push analgesic to a client. The client has a single peripheral IV line currently infusing a continuous medication. The drug reference guide indicates that the continuous infusion is physically incompatible with the prescribed IV push analgesic. Arrange the following nursing actions in the correct sequence to safely administer the medication.

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Answer

The correct sequence is to first pause the pump, clamp the primary tubing, administer a pre-flush, administer the medication, administer a slow post-flush, and finally unclamp and resume the pump.
When administering an IV push medication through a line with a physically incompatible continuous infusion, the primary goal is to prevent the two medications from mixing and precipitating. The nurse must first pause the continuous infusion, then clamp the primary tubing above the lowest injection port to prevent the subsequent flush and medication from traveling backward up the line. A pre-flush clears the incompatible medication from the space between the port and the client. The medication is then administered safely. The post-flush must be administered at the same slow rate as the medication because the flush pushes the remaining medication residing in the IV catheter into the vein; pushing it too quickly would result in rapid administration of the analgesic, risking speed shock. Finally, the tubing is unclamped and the continuous infusion is resumed.

Step-by-Step Solution

1
Pause the electronic infusion pump delivering the continuous medication.
Stops the flow of the incompatible continuous medication.
Prevents further introduction of the incompatible drug into the system during the push procedure, which is the foundational step for preventing precipitation.
2
Clamp the primary intravenous tubing immediately above the lowest injection port.
Isolates the lower portion of the IV line from the main fluid bag.
Fluid follows the path of least resistance. Clamping prevents the flush and IV push medication from flowing retrogradely up the primary tubing and mixing with the incompatible medication.
3
Scrub the injection port with an antiseptic swab and administer a 10 mL 0.9% sodium chloride flush.
Clears the IV line from the injection port to the vein.
Ensures no incompatible continuous medication remains in the physical path of the IV push medication.
4
Inject the prescribed intravenous push analgesic over the manufacturer-recommended time.
Delivers the active medication safely into the systemic circulation.
Administering over the recommended time prevents adverse reactions such as speed shock, severe hypotension, or respiratory depression.
5
Administer a second 10 mL 0.9% sodium chloride flush at the identical rate used for the analgesic.
Clears the analgesic completely from the IV catheter and extension set.
The fluid inside the catheter and extension tubing contains the active analgesic. Flushing rapidly would inadvertently 'slam' this remaining dose into the vein too fast.
6
Unclamp the primary intravenous tubing and resume the continuous electronic infusion.
Restores the continuous therapy.
Ensures the client continues to receive the baseline prescribed infusion without unnecessary interruption.

Key Concept

Management of physically incompatible intravenous medications via a single peripheral access line requires strict procedural isolation using clamping and precise flushing techniques.
Question 1053Question →

An adult client with end-stage chronic obstructive pulmonary disease (COPD) is receiving palliative care on a hospice unit. During a visit, the client's eldest child insists that the nursing staff arrange for an immediate physical therapy evaluation, stating, "We need to build up my parent's stamina for our family hiking trip next month." Which of the following is the most therapeutic nursing response?

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Answer: It sounds like you have wonderful memories of hiking together. This must be a very difficult time for you.

Answer

The most therapeutic response is to reflect the feelings and acknowledge the special memories, stating: 'It sounds like you have wonderful memories of hiking together. This must be a very difficult time for you.'
The correct response utilizes the therapeutic techniques of empathy and reflecting feelings. Denial is a protective, temporary coping mechanism often seen in the early stages of grief. By focusing on the emotional meaning behind the adult child's statement (the cherished memories of hiking), the nurse validates their feelings and establishes a supportive relationship. This approach allows the individual to feel heard and understood without the nurse having to either confront the denial aggressively or support the unrealistic medical plan.

Step-by-Step Solution

1
Analyze the clinical scenario and the family member's behavior.
The adult child is exhibiting denial, a common defense mechanism in anticipatory grief, by planning an unrealistic future hiking trip despite the client's end-stage terminal illness.
Recognizing the underlying psychological state (denial and acute grief) is essential for selecting an appropriate therapeutic intervention.
2
Evaluate the nursing response options against principles of therapeutic communication.
Responses that confront the denial bluntly, ask 'why', or feed into the unrealistic expectation with false reassurance are non-therapeutic.
In the initial stages of severe grief, stripping away a protective coping mechanism without first providing emotional support can cause extreme distress and damage the nurse-client relationship.
3
Select the response that best addresses the underlying emotion.
The response acknowledging the special memories and validating the difficulty of the situation provides necessary emotional support.
Therapeutic communication prioritizes exploring feelings and showing empathy, which creates a safe environment for the family member to eventually process reality.

Key Concept

Therapeutic communication and management of denial in anticipatory grief.
Estimated Time:1m 15s
Question 1054Question →

A nurse is admitting a client with a history of alcohol use disorder who had their last alcoholic drink 6 hours ago. Arrange the following manifestations of alcohol withdrawal in the chronological order in which they typically appear, from earliest to latest.

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Answer

The correct chronological sequence is: 1) Mild tremors, anxiety, and diaphoresis, 2) Visual, auditory, or tactile hallucinations with intact orientation, 3) Generalized tonic-clonic seizures, 4) Delirium tremens with severe agitation and autonomic hyperactivity.
Alcohol withdrawal progresses through a predictable clinical timeline based on the central nervous system's rebound hyperactivity. Mild withdrawal symptoms like tremors and diaphoresis are the earliest signs, emerging 6 to 12 hours after cessation. Alcoholic hallucinosis follows next (12 to 24 hours) where the client experiences visual or auditory disturbances but remains oriented. Generalized tonic-clonic seizures typically peak between 24 to 48 hours. Finally, delirium tremens, a medical emergency involving severe confusion, agitation, and autonomic hyperactivity, is a late manifestation that usually begins 48 to 72 hours after the last drink.

Step-by-Step Solution

1
Identify the earliest signs of alcohol withdrawal.
Mild tremors, anxiety, and diaphoresis are placed first in the sequence.
These minor withdrawal symptoms typically emerge within 6 to 12 hours after the last drink as the central nervous system begins to experience rebound hyperactivity.
2
Determine the next manifestation in the clinical timeline.
Hallucinations with intact orientation are placed second.
Alcoholic hallucinosis generally develops 12 to 24 hours after alcohol cessation. The client experiences hallucinations but remains oriented, differentiating this from delirium.
3
Identify the peak risk period for withdrawal seizures.
Generalized tonic-clonic seizures are placed third.
The risk for alcohol withdrawal seizures is highest between 24 and 48 hours post-cessation.
4
Identify the latest and most severe withdrawal complication.
Delirium tremens is placed last in the sequence.
Delirium tremens is a late-stage, life-threatening complication that usually begins 48 to 72 hours after the last drink, characterized by global confusion and autonomic instability.

Key Concept

Chronological progression of alcohol withdrawal syndrome
Estimated Time:45s
Question 1055Question →

An adult client admitted with suspected sepsis is receiving a continuous intravenous infusion of lactated Ringer's solution at 150 mL/hr150\text{ mL/hr} through a single peripheral intravenous line. The healthcare provider prescribes a stat dose of intravenous ceftriaxone 1 g1\text{ g} in 50 mL50\text{ mL} of 0.9% sodium chloride to be infused over 30 minutes. Which action is most appropriate for the nurse to take?

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Answer: Stop the lactated Ringer's infusion, flush the line with 0.9% sodium chloride, infuse the ceftriaxone, and flush the line again before resuming the primary fluids.

Answer

Stop the lactated Ringer's infusion, flush the line with 0.9% sodium chloride, infuse the ceftriaxone, and flush the line again before resuming the primary fluids.
The correct action demonstrates knowledge of intravenous compatibility and safe administration principles. Ceftriaxone binds with calcium to form particulate matter (precipitate). Because lactated Ringer's contains calcium, the two cannot mix in the same line. If only one intravenous site is available, the nurse must temporarily pause the primary fluid, clear the line with a compatible flush (0.9% sodium chloride), administer the medication, and flush the line again before resuming the primary fluid.

Step-by-Step Solution

1
Identify the primary infusion and the prescribed secondary medication.
The client is receiving lactated Ringer's (which contains calcium) and is prescribed ceftriaxone.
Recognizing the specific intravenous fluids and medications is the first step in assessing for compatibility.
2
Determine the compatibility of ceftriaxone and lactated Ringer's.
Ceftriaxone and calcium-containing solutions (like lactated Ringer's) are incompatible and will form precipitates.
Simultaneous administration of incompatible intravenous medications can cause crystal formation, leading to line occlusion or fatal emboli.
3
Formulate a safe administration plan given the single intravenous line.
The nurse must stop the primary fluid, flush the line with a compatible solution (0.9% sodium chloride), administer the antibiotic, and flush again.
Sequential administration with thorough flushing prevents the incompatible substances from mixing in the intravenous tubing.

Key Concept

Ceftriaxone is incompatible with calcium-containing intravenous solutions and must be administered sequentially with thorough flushing if a dedicated line is unavailable.
Estimated Time:1m 30s
Question 1056Question →

A nurse is caring for a client who has just returned to the medical-surgical unit following a percutaneous liver biopsy. Which of the following actions is the priority for the nurse to take to reduce the risk of a post-procedure complication?

Show answer & explanation

Answer: Position the client on the right side with a small pillow or rolled towel under the puncture site.

Answer

Position the client on the right side with a small pillow or rolled towel under the puncture site.
Because the liver is a highly vascular organ located in the right upper quadrant, hemorrhage is the most significant risk following a percutaneous liver biopsy. Placing the client on their right side with a small pillow or towel underneath applies direct external pressure to the liver capsule and the puncture site. This mechanical pressure is essential to promote hemostasis and reduce the risk of severe internal bleeding.

Step-by-Step Solution

1
Identify the primary physiological risk associated with a percutaneous liver biopsy.
The primary risk is hemorrhage because the liver is a highly vascular organ and coagulation may be altered.
Recognizing the most life-threatening post-procedure complication dictates the priority nursing intervention.
2
Determine the physical location of the liver and the mechanics of hemostasis.
The liver is located in the right upper quadrant of the abdomen. Applying direct pressure to a bleeding site promotes clot formation.
Understanding anatomy allows the nurse to use positioning as a therapeutic intervention.
3
Select the nursing action that mechanically reduces the risk of bleeding.
Positioning the client on their right side applies the body's own weight to put pressure on the liver capsule.
This is the standard, evidence-based physical intervention to reduce the risk of internal bleeding immediately following the procedure.

Key Concept

Post-Procedure Complication Prevention (Liver Biopsy)
Question 1057Question →

An 82-year-old client with a history of vascular dementia and right-sided hemiparesis is receiving continuous enteral nutrition via a nasogastric (NG) tube. The client is currently positioned with the head of the bed elevated at 45 degrees. The nurse notes the client has become acutely restless, is repeatedly pulling at the NG tube, and has not voided in the past 8 hours. Which of the following nursing interventions best demonstrates appropriate management of this client's basic care and comfort needs?

Show answer & explanation

Answer: Temporarily pause the enteral feeding, maintain the head of the bed at 30 degrees while assessing for urinary retention, and wrap the NG tube out of the client's visual field.

Answer

The correct approach is to temporarily pause the enteral feeding, maintain safe head elevation while assessing for the underlying cause of the acute agitation (such as urinary retention), and use non-restrictive methods (like camouflage) to protect the feeding tube.
The correct intervention effectively synthesizes three critical elements of basic care: preventing aspiration by pausing the feed and maintaining head elevation during care, assessing for a physiological cause of acute agitation (urinary retention) rather than assuming it is cognitive decline, and utilizing a non-restrictive alternative (camouflage) to protect the medical device.

Step-by-Step Solution

1
Analyze the client's sudden change in behavior.
Identify that acute restlessness and pulling at devices in a client with dementia often indicates an unmet physiological need, such as a full bladder after 8 hours without voiding.
Clients with cognitive impairment may lack the ability to verbally communicate physical discomfort, expressing it through agitation instead.
2
Prioritize airway safety during the required physical assessment.
Determine that the continuous enteral feeding must be paused and the head of the bed maintained at a minimum of 30 degrees during any assessment or bedpan placement.
Supine or low-Fowler's positioning during active continuous enteral feeding significantly increases the risk of regurgitation and aspiration pneumonia.
3
Select the appropriate intervention for device protection.
Choose to route or wrap the NG tube out of the client's visual field rather than applying restraints.
Nursing standards require the implementation of the least restrictive alternatives (such as tube camouflage) before utilizing physical restraints.

Key Concept

Integration of Aspiration Precautions, Atypical Presentation in Older Adults, and Restraint Alternatives
Question 1058Question →

A nurse is preparing to provide oral care to a client who is comatose. Which of the following actions is the most appropriate for the nurse to take to ensure the client's safety?

Show answer & explanation

Answer: Position the client in a side-lying position with the head turned to the side.

Answer

The most appropriate action is to position the client in a side-lying position with the head turned to the side.
The correct action is to place the comatose client in a side-lying position. Unconscious clients lack an intact gag and swallow reflex, placing them at an exceptionally high risk for aspiration. The lateral position allows fluids and oral secretions to drain out of the mouth by gravity, thereby protecting the airway and preventing life-threatening respiratory complications.

Step-by-Step Solution

1
Identify the client's level of consciousness and associated safety risks.
The client is comatose, meaning they lack a gag or swallow reflex and cannot protect their own airway from fluids.
Assessing the client's physiological status determines the specific safety interventions required during basic care procedures.
2
Determine the safest anatomical position for performing oral care.
A side-lying (lateral) position is selected for the procedure.
Gravity will facilitate the drainage of oral secretions and fluids out of the mouth, protecting the airway and preventing aspiration into the lungs.

Key Concept

Aspiration precautions and safe oral care for the unconscious client
Question 1059Question →

An emergency department triage nurse assesses a 42-year-old client brought in by police after being found wandering near the edge of a highway overpass. The client is disheveled, avoids eye contact, and repeatedly mumbles, "There is no way out of this debt. It's better if I just disappear." The client's spouse recently filed for divorce and their small business declared bankruptcy last week. Which of the following immediate nursing actions are required? (Select all that apply.)

Select all that apply

Show answer & explanation

Answer: Place the client in a designated safe room with a 1:1 continuous observation sitter.; Ask the client directly if they have a specific plan to end their life.; Remove all personal belongings, including shoelaces, belts, and the client's mobile phone.

Answer

The correct actions include placing the client in a designated safe room with a 1:1 continuous observation sitter, directly asking if they have a specific suicide plan, and removing all personal belongings such as shoelaces and belts.
In a psychiatric emergency involving potential self-harm, the absolute highest priority is ensuring the client's immediate physical safety. Placing the client in a safe room with 1:1 continuous observation and removing potentially dangerous personal items (shoelaces, belts, phones) are critical first steps to prevent injury. Furthermore, evidence-based crisis intervention requires nurses to ask directly about suicidal ideation and specific plans to accurately assess lethality.

Step-by-Step Solution

1
Assess the client's immediate risk for self-harm.
The client is in an acute situational crisis with severe depressive symptoms and active suicidal ideation indicated by the statement, "It's better if I just disappear."
Safety is always the highest priority according to Maslow's Hierarchy of Needs and psychiatric crisis intervention protocols.
2
Implement immediate environmental safety protocols.
The client requires 1:1 continuous observation and the removal of all hazardous personal items.
To prevent the client from acting on self-harm impulses while in the emergency department.
3
Conduct a direct lethality assessment.
The nurse must explicitly ask about a suicide plan.
Direct questioning does not give the client ideas; rather, it is essential to determine the imminence and method of the threat.

Key Concept

Immediate Safety and Lethality Assessment in Crisis Intervention
Question 1060Question →

A healthcare provider prescribes oral amoxicillin 500 mg500\text{ mg} every 88 hours for a client with a respiratory tract infection. The pharmacy dispenses an amoxicillin oral suspension labeled 250 mg/5 mL250\text{ mg}/5\text{ mL}. How many milliliters (mL) should the nurse administer for a single dose? (Record answer as a whole number.)

Show answer & explanation

Answer: 10

Answer

10
Using the standard dosage calculation formula DesiredHave×Volume\frac{\text{Desired}}{\text{Have}} \times \text{Volume}, the correct setup is 500 mg250 mg×5 mL\frac{500\text{ mg}}{250\text{ mg}} \times 5\text{ mL}. Dividing 500500 by 250250 results in 22. Multiplying 22 by the supplied volume of 5 mL5\text{ mL} gives a final administrable dose of 10 mL10\text{ mL}.

Step-by-Step Solution

1
Identify the known variables from the provider's prescription and the available medication supply.
Desired dose = 500 mg500\text{ mg}, Available dose (Have) = 250 mg250\text{ mg}, Volume = 5 mL5\text{ mL}.
Accurate identification of given numerical values is necessary before setting up the dosage calculation equation.
2
Set up the dosage calculation using the appropriate formula.
500 mg250 mg×5 mL\frac{500\text{ mg}}{250\text{ mg}} \times 5\text{ mL}
The standard formula for liquid medication calculation is DesiredHave×Volume\frac{\text{Desired}}{\text{Have}} \times \text{Volume}.
3
Perform the mathematical calculation to find the final administration volume.
2×5 mL=10 mL2 \times 5\text{ mL} = 10\text{ mL}.
Executing the calculation yields the exact volume of oral suspension the nurse needs to pour or draw up for one dose.

Key Concept

Liquid medication dosage calculation using the desired over have method.
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