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Question 1061Question →

In an inpatient clinical setting, effective interpersonal interactions require the application of specific communication techniques. Match each statement made by a client with the most appropriate therapeutic nursing response.

Click a left item, then click its matching right item

Items

"My family wants me to move into an assisted living facility, but I've lived in my house for forty years."
"I saw the doctor whispering to the nurse in the hallway. I know they are plotting to send me to a secret prison."
"I've been taking this antihypertensive medication for a week and I don't feel any different. It's completely useless."
"I don't want to talk about my new diagnosis today. Just leave me alone and let me rest."

Matches

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Answer

Match the client expressing reluctance to move with exploring their thoughts. Match the paranoid client with presenting reality. Match the frustrated client with reflection of feelings. Match the withdrawn client with offering self and respecting boundaries.
Each correct match applies a specific, evidence-based therapeutic communication technique tailored to the client's current emotional state and psychosocial needs. Exploring is utilized for ambivalence, presenting reality is utilized for paranoia, reflection is utilized for frustration, and offering self is utilized for withdrawal.

Step-by-Step Solution

1
Analyze the first client's statement regarding moving to an assisted living facility.
Identify that the client is experiencing ambivalence and a major life transition.
Recognizing the underlying issue helps select a response that encourages further expression, such as the technique of exploring.
2
Analyze the second client's statement about staff plotting against them.
Identify that the client is experiencing a delusion or paranoia.
Paranoia requires a response that presents reality gently without arguing, while also acknowledging the emotional tone of fear.
3
Analyze the third client's statement expressing frustration over medication efficacy.
Identify that the client is expressing a strong negative emotion due to unfulfilled expectations.
Reflecting the client's frustration validates their feelings and opens the door for subsequent medication education.
4
Analyze the fourth client's statement requesting to be left alone.
Identify that the client is currently overwhelmed and setting a firm boundary.
Respecting the boundary while offering self ensures the client feels supported without feeling pressured to converse immediately.

Key Concept

Therapeutic Communication
Question 1062Question →

A nurse is preparing to perform an abdominal assessment on an older adult client who reports new-onset abdominal cramping and altered bowel habits. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Select all that apply

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Answer: Instruct the client to empty their bladder before beginning the examination.; Auscultate all four quadrants of the abdomen before performing percussion or palpation.; Position the client supine with their knees slightly flexed to promote relaxation of the abdominal musculature.

Answer

The correct actions include asking the client to empty their bladder, auscultating before percussing or palpating, and positioning the client supine with knees flexed.
Proper abdominal assessment requires careful preparation, including having the client empty their bladder and positioning them supine with flexed knees to relax the abdominal wall. The sequence of examination must be inspection, auscultation, percussion, and palpation to ensure that mechanical stimulation does not alter bowel sounds.

Step-by-Step Solution

1
Analyze the procedure for preparing a client for an abdominal assessment.
The client should void to ensure comfort and an accurate examination of the pelvic area. They should also be positioned supine with knees flexed to relax the abdominal muscles.
Proper preparation prevents artifacts in assessment, such as mistaking a distended bladder for a mass or encountering voluntary guarding due to muscle tension.
2
Determine the correct sequence for assessing the abdomen.
The correct sequence is inspection, auscultation, percussion, and palpation. Painful areas must be palpated last.
Percussion or palpation before auscultation can alter the frequency and intensity of bowel sounds. Assessing painful areas first causes muscle guarding, compromising the rest of the exam.
3
Evaluate the clinical reasoning regarding delegation and aging.
Initial assessments cannot be delegated to UAPs, and sudden changes in bowel habits are pathological, not a normal part of aging.
The RN is responsible for the nursing process (including baseline assessments). Acute changes in older adults require thorough investigation to rule out serious conditions.

Key Concept

Abdominal physical assessment techniques and nursing principles
Question 1063Question →

A nurse is preparing to administer a prescribed intravenous (IV) push medication through a client's peripheral IV line. The client currently has a continuous primary IV infusion of a solution that is physically incompatible with the ordered IV push medication. In what order should the nurse perform the following actions to safely administer the medication? Arrange the steps from first to last.

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Answer

The correct sequence involves stopping the incompatible fluid, clamping the line to direct flow, flushing to clear the catheter, administering the medication, flushing again at the appropriate rate to clear residual drug, and finally restarting the primary fluid.
When administering an IV push medication through a line infusing an incompatible solution, the nurse must completely separate the two substances. The sequence starts with halting the pump and clamping the line to prevent retrograde flow. The first saline flush clears the line of the incompatible solution. The medication is then administered at the correct rate. Crucially, the second flush must be administered at the exact same rate as the medication to ensure the residual drug in the catheter is not pushed in too quickly. Finally, the line is unclamped and the pump is restarted.

Step-by-Step Solution

1
Stop the primary continuous IV infusion pump.
Incompatible fluid flow is halted.
Prevents the incompatible primary fluid from advancing into the lower tubing during preparation.
2
Clamp the primary IV tubing just above the injection port closest to the client.
Backward flow into the primary tubing is blocked.
Ensures that all injected fluids (flush and medication) are directed entirely into the client's vein rather than up the primary line.
3
Scrub the needleless connector and flush the port with 10 mL10\text{ mL} of sterile 0.9%0.9\% sodium chloride.
The IV catheter is cleared of incompatible fluid.
Prevents physical incompatibility (precipitation/crystallization) between the primary solution and the IV push medication.
4
Administer the prescribed IV push medication over the manufacturer's recommended time.
Therapeutic dose is delivered.
Ensures the medication is delivered safely according to pharmacological guidelines.
5
Flush the port again with 10 mL10\text{ mL} of 0.9%0.9\% sodium chloride at the same rate as the medication administration.
Residual medication in the catheter is cleared into the bloodstream.
Clears the medication from the catheter. Doing this at the same rate prevents the residual medication from being pushed into the circulation too rapidly (preventing speed shock).
6
Unclamp the primary IV tubing and restart the continuous IV infusion pump.
Primary continuous therapy is resumed.
Re-establishes the prescribed continuous maintenance or therapeutic IV fluids once the line is completely clear.

Key Concept

Safe administration of IV push medications through an incompatible infusing line requires strict isolation using a "flush-administer-flush" technique, with specific attention to clamping and flush administration rates.
Question 1064Question →

A nurse is reviewing the arterial blood gas (ABG) results for a client who is experiencing acute respiratory distress. The results show a pH of 7.257.25, PaCO2\text{PaCO}_2 of 60 mm Hg60\text{ mm Hg}, and HCO3−\text{HCO}_3^- of 24 mEq/L24\text{ mEq/L}. Based on these values, which acid-base imbalance is the client experiencing?

Show answer & explanation

Answer: Uncompensated respiratory acidosis

Answer

Uncompensated respiratory acidosis
The correct answer identifies uncompensated respiratory acidosis. The pH of 7.257.25 is below the normal range (7.357.35 to 7.457.45), which confirms an acidotic state. The PaCO2\text{PaCO}_2 of 60 mm Hg60\text{ mm Hg} is elevated above the normal range (3535 to 45 mm Hg45\text{ mm Hg}), matching the acidosis and indicating a respiratory etiology. Because the HCO3−\text{HCO}_3^- of 24 mEq/L24\text{ mEq/L} remains within the normal limits (2222 to 26 mEq/L26\text{ mEq/L}), the kidneys have not yet initiated compensation.

Step-by-Step Solution

1
Analyze the client's pH value.
The pH is 7.257.25, which is below the normal range of 7.357.35 to 7.457.45.
This establishes that the primary state is acidemia (acidosis).
2
Evaluate the PaCO2\text{PaCO}_2 value.
The PaCO2\text{PaCO}_2 is 60 mm Hg60\text{ mm Hg}, which is above the normal range of 3535 to 45 mm Hg45\text{ mm Hg}.
Because an elevated PaCO2\text{PaCO}_2 acts as an acid, this matches the acidotic pH and confirms a respiratory origin.
3
Assess the HCO3−\text{HCO}_3^- value.
The HCO3−\text{HCO}_3^- is 24 mEq/L24\text{ mEq/L}, which is well within the normal range of 2222 to 26 mEq/L26\text{ mEq/L}.
A normal bicarbonate level indicates that the kidneys have not yet started to compensate for the respiratory disturbance.

Key Concept

Arterial Blood Gas (ABG) Interpretation
Question 1065Question →

A nurse is caring for a client who is four hours post-operative following a total thyroidectomy. The client suddenly becomes highly agitated and reports a sensation of intense pressure and fullness in the neck. Upon inspection, the surgical dressing is dry and intact, but the nurse auscultates high-pitched, harsh respiratory sounds during inspiration. The client's voice has become noticeably muffled. Which action should the nurse take immediately?

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Answer: Elevate the head of the bed to a semi-Fowler's position and activate the rapid response team.

Answer

The nurse should immediately elevate the head of the bed to a semi-Fowler's position and activate the rapid response team.
The client's presentation of agitation, neck fullness, a muffled voice, and inspiratory stridor strongly indicates a rapidly expanding neck hematoma causing tracheal compression. This is a life-threatening airway emergency. The immediate priority is to elevate the head of the bed to a semi-Fowler's position to promote venous return, decrease local tissue edema, and facilitate breathing, while simultaneously activating the rapid response team for potential emergency intubation or bedside surgical decompression.

Step-by-Step Solution

1
Analyze the client's clinical presentation, noting the agitation, neck fullness, muffled voice, and inspiratory stridor.
These findings are classic indicators of a rapidly expanding neck hematoma causing tracheal compression.
Early recognition of post-operative complications is essential to prevent physiological collapse.
2
Prioritize interventions using the Airway, Breathing, Circulation (ABC) framework.
Airway compromise is the most imminent threat to the client's life and requires the highest priority action.
Metabolic issues (like hypocalcemia) or diagnostic testing must not delay life-saving airway management.
3
Implement the safest and most effective initial mechanical intervention while securing emergency assistance.
Elevating the head of the bed reduces venous pressure and tissue edema, temporarily easing breathing while the rapid response team prepares for emergency airway management.
Proper positioning mitigates further risk without placing tension on the surgical incision.

Key Concept

Early recognition and management of an expanding neck hematoma and airway compromise following a thyroidectomy.
Question 1066Question →

A nurse is assessing a client who has a suspected proximal small bowel obstruction and has experienced severe, persistent vomiting for the past 24 hours. Which of the following clinical findings should the nurse identify as physiological complications associated with this condition? Select all that apply.

Select all that apply

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Answer: Arterial blood pH of 7.51 and a PaCO2 of 48 mm Hg; Resting heart rate of 112 beats/min with a narrowing pulse pressure; Serum potassium level of 2.8 mEq/L (2.8 mmol/L)

Answer

The expected physiological complications include an elevated arterial blood pH with elevated PaCO2, tachycardia with a narrowing pulse pressure, and a decreased serum potassium level.
The client is experiencing severe fluid, electrolyte, and acid losses due to prolonged vomiting. This leads to metabolic alkalosis with compensatory respiratory acidosis (retained CO2), profound hypokalemia, and early hypovolemic shock characterized by tachycardia and a narrowed pulse pressure due to vasoconstriction.

Step-by-Step Solution

1
Analyze the pathophysiological effects of severe, persistent vomiting.
Vomiting causes profound loss of fluid, gastric acid (hydrochloric acid), and electrolytes, particularly potassium and sodium.
Identifying the lost substances is the first step in determining the expected systemic imbalances.
2
Determine the expected acid-base imbalance and associated compensatory mechanism.
The loss of stomach acid leads to metabolic alkalosis (pH > 7.45). The respiratory system attempts to compensate by hypoventilating to retain CO2 (PaCO2 > 45 mm Hg).
Understanding the body's compensatory mechanisms helps differentiate the expected ABG values from incorrect interpretations.
3
Evaluate the cardiovascular response to profound fluid volume loss.
The body compensates for hypovolemia via sympathetic nervous system activation, causing tachycardia and vasoconstriction, which narrows the pulse pressure.
Recognizing early physiological indicators of shock is crucial for timely intervention and prevents confusing different shock states.

Key Concept

Pathophysiological consequences of upper gastrointestinal fluid loss
Question 1067Question →

A nurse is assessing a client who is 4 hours post-admission for a severe pelvic fracture following a motor vehicle crash. The client's baseline vital signs upon admission were: blood pressure 130/76 mm Hg, heart rate 82/min, and respiratory rate 16/min. Which of the following current assessment findings indicate the client is entering the early (compensatory) stage of hypovolemic shock? Select all that apply.

Select all that apply

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Answer: Blood pressure of 116/92 mm Hg; Restlessness and apprehension; Respiratory rate of 28/min

Answer

The correct findings indicating early (compensatory) hypovolemic shock are a blood pressure of 116/92 mm Hg, restlessness and apprehension, and a respiratory rate of 28/min.
The compensatory stage of hypovolemic shock is characterized by the body's neural, hormonal, and biochemical mechanisms attempting to maintain perfusion. Sympathetic nervous system activation causes peripheral vasoconstriction, which increases diastolic blood pressure and results in a narrowed pulse pressure (a classic early sign). Decreased cerebral perfusion leads to early changes in level of consciousness, such as restlessness, anxiety, and apprehension. Additionally, the respiratory rate increases (tachypnea) to improve oxygenation and compensate for decreased tissue perfusion.

Step-by-Step Solution

1
Analyze the clinical scenario and the client's risk factors.
The client has a severe pelvic fracture, putting them at high risk for internal hemorrhage and subsequent hypovolemic shock.
Identifying the etiology of potential shock determines what physiological changes to anticipate.
2
Differentiate between the stages of shock (initial, compensatory, progressive, refractory).
The question specifically asks for early (compensatory) signs, which are driven by sympathetic nervous system activation aiming to preserve cardiac output.
Different stages of shock present with distinct clinical manifestations.
3
Evaluate each option against the expected physiological responses in the compensatory stage.
A narrowed pulse pressure, altered mental status (restlessness), and tachypnea align with early compensation. Metabolic acidosis, bounding pulses, and warm extremities align with other shock types or later stages.
Accurate clinical judgment requires distinguishing subtle early signs from overt late signs to initiate timely interventions.

Key Concept

Early recognition of hypovolemic shock requires identifying compensatory mechanisms such as narrowed pulse pressure, tachycardia, tachypnea, and subtle neurological changes rather than waiting for profound hypotension.
Estimated Time:1m 30s
Question 1068Question →

A client is receiving intravenous morphine via a patient-controlled analgesia (PCA) pump following a bowel resection. During hourly rounds, the nurse notes the client has a respiratory rate of 8 breaths/minute8 \text{ breaths/minute}, pinpoint pupils, and is unresponsive to physical stimulation. The nurse immediately stops the PCA pump, calls for assistance, and receives a verbal prescription for naloxone 0.4 mg0.4 \text{ mg} IV stat. Which action by the nurse demonstrates the safest administration technique for this medication?

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Answer: Dilute the medication in 9 mL9 \text{ mL} of normal saline and administer it incrementally over 22 to 3 minutes3 \text{ minutes}.

Answer

The safest administration technique is to dilute the naloxone in 9 mL9 \text{ mL} of normal saline and administer it incrementally over 22 to 3 minutes3 \text{ minutes}.
The standard of care for administering naloxone to a client with opioid-induced respiratory depression who is receiving pain management is to administer it slowly. Diluting an ampule of naloxone (0.4 mg0.4 \text{ mg} in 1 mL1 \text{ mL}) with 9 mL9 \text{ mL} of normal saline yields a concentration of 0.04 mg/mL0.04 \text{ mg/mL}. This allows the nurse to slowly titrate the medication (e.g., 11 to 2 mL2 \text{ mL} per minute) until the client's respiratory rate improves. This controlled reversal prevents acute opioid withdrawal, sudden excruciating pain, and sympathetic nervous system surges that can cause pulmonary edema or arrhythmias.

Step-by-Step Solution

1
Assess the client's condition and recognize signs of severe opioid toxicity.
Identified respiratory rate of 8 breaths/minute8 \text{ breaths/minute}, pinpoint pupils, and unresponsiveness.
Early recognition of life-threatening respiratory depression dictates immediate intervention.
2
Identify the risks associated with the administration of the prescribed antidote (naloxone).
Recognized that rapid administration can cause acute withdrawal, severe pain, and cardiovascular collapse.
Naloxone displaces opioids from receptors instantly; if done too rapidly, the sudden reversal causes a massive sympathetic nervous system response.
3
Determine the safest preparation and administration rate.
Dilute the 0.4 mg0.4 \text{ mg} dose in 9 mL9 \text{ mL} of normal saline (creating a 0.04 mg/mL0.04 \text{ mg/mL} concentration) and push slowly.
Titrating the dose incrementally allows the nurse to reverse the respiratory depression without completely reversing the analgesic effects.
4
Ensure a safe route of administration.
Avoid pushing the medication through the opioid-primed PCA tubing.
Pushing through the PCA tubing would flush a bolus of concentrated morphine into the client, worsening the toxicity.

Key Concept

Safe administration of opioid antagonists and management of patient-controlled analgesia (PCA) complications.
Estimated Time:1m 30s
Question 1069Question →

A triage nurse evaluates a client presenting with a 4-day history of frequent, watery diarrhea and an inability to drink fluids. The client is lethargic and exhibits delayed capillary refill. Assessment reveals a heart rate of 124 beats/minute, a respiratory rate of 30 breaths/minute with deep chest excursions, and a blood pressure of 94/76 mm Hg. Arterial blood gas (ABG) testing indicates a pH of 7.25, PaCO2 of 27 mm Hg, HCO3 of 12 mEq/L, and PaO2 of 96 mm Hg on room air. Which of the following actions should the nurse perform FIRST?

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Answer: Start a rapid infusion of prescribed isotonic crystalloid fluids.

Answer

The priority action is to start a rapid infusion of prescribed isotonic crystalloid fluids to treat hypovolemic shock and restore tissue perfusion.
The correct answer directly addresses the most life-threatening condition: hypovolemic shock. The client's history of severe fluid loss, combined with lethargy, tachycardia, and a dangerously narrowed pulse pressure, necessitates immediate intravascular volume replacement with isotonic fluids to ensure adequate tissue perfusion.

Step-by-Step Solution

1
Analyze the client's vital signs and clinical presentation.
The client has a heart rate of 124 beats/minute, a blood pressure of 94/76 mm Hg (narrowed pulse pressure of 18 mm Hg), lethargy, and delayed capillary refill.
These findings are classic early indicators of hypovolemic shock requiring immediate circulatory support.
2
Interpret the arterial blood gas (ABG) results in the context of the client's history.
The pH of 7.25 and HCO3 of 12 mEq/L indicate severe metabolic acidosis (from bicarbonate loss in diarrhea and lactic acid from poor perfusion). The PaCO2 of 27 mm Hg and deep, rapid respirations indicate respiratory compensation.
Understanding the acid-base imbalance confirms that the respiratory changes are compensatory and that the primary derangement is metabolic and circulatory.
3
Prioritize nursing interventions using the ABCs (Airway, Breathing, Circulation) and Maslow's Hierarchy of Needs.
Circulatory collapse is the most immediate life-threatening issue. Fluid resuscitation is the priority intervention.
Restoring intravascular volume will improve tissue perfusion, resolve the lactic acidosis component, and stabilize the client's hemodynamics.

Key Concept

Prioritization of care for a client experiencing hypovolemic shock and compensatory metabolic acidosis.
Question 1070Question →

A nurse is developing a plan of care for a client who will be returning to the medical-surgical unit following a percutaneous liver biopsy. Which of the following nursing actions should be included to reduce the risk of post-procedure complications? Select all that apply.

Select all that apply

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Answer: Position the client in a right lateral position with a small towel placed under the puncture site.; Maintain the client on strict bed rest for the first 2 to 4 hours after the procedure.; Assess for a subtle, sustained increase in heart rate and respiratory rate as signs of hypovolemia.

Answer

The appropriate interventions include positioning the client on their right side with a towel under the site, maintaining strict bed rest for 2 to 4 hours, and assessing for early indicators of shock such as a sustained increase in heart rate.
Following a percutaneous liver biopsy, the client is at high risk for significant bleeding due to the liver's dense vascularity. Positioning the client in a right lateral position with a small towel or pillow under the puncture site provides direct mechanical pressure to the liver capsule, which promotes hemostasis. Strict bed rest for 2 to 4 hours is necessary to minimize intra-abdominal pressure and prevent the dislodgment of forming clots. Finally, because internal bleeding can occur, the nurse must monitor for early compensatory signs of hypovolemia, most notably a subtle and sustained increase in heart rate and respiratory rate, which often precede an actual drop in blood pressure.

Step-by-Step Solution

1
Identify the primary risk associated with a percutaneous liver biopsy.
The liver is a highly vascular organ, making severe internal hemorrhage the most significant immediate post-procedure complication.
Understanding the most dangerous complication dictates the priority preventative interventions.
2
Determine the appropriate mechanical interventions to prevent bleeding.
The nurse must position the client in a right lateral position to compress the liver against the chest wall and maintain strict bed rest.
Direct pressure and immobility facilitate clot formation at the highly vascular puncture site.
3
Evaluate the remaining systemic monitoring and delegation options.
Recognize that narrowing (not widening) pulse pressure and tachycardia indicate early shock, and recall that initial post-procedure assessments cannot be delegated.
The RN is responsible for detecting early subtle signs of physiological decompensation before delegating routine tasks.

Key Concept

Reduction of Risk Potential: Post-Liver Biopsy Care
Question 1071Question →

While assessing a client receiving intravenous fluids via a central venous catheter (CVC), the nurse notes that the intravenous tubing has completely disconnected from the catheter hub. The client suddenly gasps, becomes severely dyspneic, and exhibits circumoral cyanosis. Arrange the following nursing actions in the correct order of prioritization.

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Answer

The correct priority sequence is to first clamp the catheter, then position the client in the left lateral Trendelenburg position, administer high-flow oxygen, activate the rapid response team, and finally continuously monitor vital signs.
When a central venous catheter becomes disconnected, the negative intrathoracic pressure during inspiration can draw a lethal amount of air into the venous system, creating an air embolism. The nurse's absolute first priority is to stop the influx of air by clamping the catheter. Once the source is secured, the nurse must immediately position the client in the left lateral Trendelenburg position. This specific positioning traps the air in the apex of the right atrium, preventing it from entering the right ventricle and pulmonary artery. Next, administering 100% oxygen helps treat the resulting hypoxia and promotes the resorption of the nitrogen gas within the air bubble. After these immediate life-saving measures are rapidly executed, the nurse should activate the rapid response team to obtain advanced medical support. Finally, the nurse must provide continuous monitoring of the client's vital signs and oxygen saturation to carefully assess for ongoing hemodynamic instability while awaiting the team's arrival.

Step-by-Step Solution

1
Clamp the central venous catheter.
The source of air entry is immediately occluded.
Preventing any further air from entering the venous circulation is the most critical immediate action to minimize the size of the air embolism.
2
Place the client in the left lateral Trendelenburg position.
Air is trapped in the apex of the right atrium.
This specific position utilizes gravity to keep the air bubble away from the pulmonary valve, preventing it from migrating into the pulmonary artery and causing a massive pulmonary embolism.
3
Administer 100% oxygen via a non-rebreather mask.
Hypoxia is treated and nitrogen washout occurs.
High-concentration oxygen relieves the severe hypoxemia caused by the embolism and helps dissolve the air bubble faster by reducing the partial pressure of nitrogen in the blood.
4
Activate the rapid response team.
Advanced medical assistance is summoned.
An air embolism is a life-threatening emergency that requires immediate advanced interventions, which the rapid response team can provide.
5
Monitor vital signs and pulse oximetry continuously.
The client's hemodynamic and respiratory status is closely tracked.
Continuous monitoring allows the nurse to detect further clinical deterioration and evaluate the effectiveness of the initial emergency interventions.

Key Concept

Establishing Priorities: Emergency Management of a Central Venous Air Embolism
Question 1072Question →

A nurse is providing care for a confused client who repeatedly attempts to dislodge their peripheral intravenous (IV) catheter. Which of the following actions should the nurse implement first as a less restrictive alternative to physical restraints?

Show answer & explanation

Answer: Cover the IV insertion site and tubing with a stockinette dressing to keep it out of the client's line of sight.

Answer

Cover the IV insertion site and tubing with a stockinette dressing to keep it out of the client's line of sight.
Concealing medical lines with a stockinette, long sleeves, or a light bandage removes the visual stimulus that often prompts confused clients to pull at their devices. This is a highly effective, non-restrictive, and safe first-line intervention that preserves the client's freedom of movement without the use of physical restraints.

Step-by-Step Solution

1
Identify the primary clinical problem and goal.
The confused client is at risk of removing their IV catheter, and the goal is to prevent this using the least restrictive method possible.
Regulatory standards and nursing ethics require exhausting all less restrictive alternatives before applying any form of restraint.
2
Evaluate the options for the least restrictive intervention.
Concealing the IV site is a non-restrictive environmental modification, whereas mitts and sedatives are physical and chemical restraints.
Confused clients often pull at tubes primarily because they can see them. Removing the visual trigger is a highly effective, non-restraint first step.

Key Concept

Less Restrictive Alternatives to Restraints
Question 1073Question →

A registered nurse enters a client's room and discovers the client lying supine on the floor next to the bed. Arrange the following nursing actions in the correct priority sequence from first to last.

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Answer

The correct sequence is to first assess the client's ABCs, then examine for physical injuries, obtain vital signs, safely return the client to bed, and finally notify the provider and complete an occurrence report.
The nursing process and prioritization frameworks (such as ABCs and 'assess before implementing') guide post-fall management. The nurse must first ensure immediate survival (ABCs), then evaluate for specific injuries caused by the fall. Vital signs provide hemodynamic context. Only when the client is deemed safe to move should they be returned to bed to prevent exacerbating any unidentified injuries. Finally, administrative and medical reporting is completed once the client is safe.

Step-by-Step Solution

1
Determine the client's level of consciousness and assess airway, breathing, and circulation.
The nurse confirms the client's immediate life stability.
Basic life support principles dictate that airway, breathing, and circulation are the highest priority in any found-down scenario.
2
Examine the client for any obvious physical injuries, active bleeding, or musculoskeletal deformities.
The nurse identifies any traumatic injuries sustained during the fall.
Musculoskeletal or spinal injuries must be identified before moving the client to prevent exacerbation, paralysis, or severe pain.
3
Measure the client's vital signs and conduct a baseline neurological assessment.
The nurse establishes baseline physiological data post-fall.
Vital signs and neurological status (e.g., pupil reactivity, motor function) help rule out acute causes of the fall like orthostatic hypotension or stroke.
4
Safely assist the client back into the bed using a mechanical lift or additional staff members.
The client is securely repositioned in a safe environment.
Once cleared of severe injury precluding movement, the client should be moved safely utilizing appropriate ergonomics and assistance.
5
Notify the primary healthcare provider and complete a facility occurrence report.
The healthcare team is informed, and administrative documentation is completed.
The provider must be notified to evaluate the client or order diagnostics. An incident report is required for facility safety tracking but is not placed in the medical record.

Key Concept

Post-fall nursing management and injury prevention requires a systematic assessment to stabilize the client before moving them, followed by appropriate reporting.
Question 1074Question →

While documenting at the central station of a high-risk perinatal unit, the registered nurse receives status updates from the care team regarding four clients. Which client presentation mandates the most urgent assessment by the nurse?

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Answer: A client at 34 weeks gestation with severe preeclampsia who newly reports unremitting, sharp right upper quadrant abdominal pain

Answer

The client with severe preeclampsia and new-onset right upper quadrant abdominal pain requires the most urgent assessment.
The correct answer identifies the client with severe preeclampsia and new-onset right upper quadrant (RUQ) pain. In the context of preeclampsia, RUQ or epigastric pain is a critical indicator of hepatic swelling and capsular distention. This is a primary manifestation of HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), placing the client at imminent risk for hepatic rupture, eclamptic seizures, and fetal compromise, which requires immediate life-saving intervention.

Step-by-Step Solution

1
Evaluate the clinical manifestations for each client to determine if they represent expected, chronic findings or acute, unexpected complications.
Three clients have expected or easily manageable findings, while one client has a new, acute symptom.
Prioritization requires identifying which client is at the highest risk for immediate physiological deterioration.
2
Analyze the significance of unremitting right upper quadrant pain in the context of severe preeclampsia.
The pain indicates hepatic ischemia, edema, and liver capsule distention.
This is a hallmark warning sign of HELLP syndrome and impending hepatic rupture or eclamptic seizure.
3
Compare the acute threat of HELLP syndrome against the other client presentations.
Impending liver rupture is immediately life-threatening to both mother and fetus, overriding expected spotting (placenta previa), mild dehydration (hyperemesis), and mild hypoglycemia (gestational diabetes).
The Airway-Breathing-Circulation and acute-versus-chronic prioritization frameworks dictate that immediate systemic threats take precedence.

Key Concept

Prioritization based on acute, life-threatening complications versus expected disease manifestations.
Question 1075Question →

A registered nurse (RN) is caring for a critically ill client diagnosed with sepsis. The client's current vital signs include a blood pressure of 88/54 mmHg88/54\text{ mmHg}, heart rate of 112 beats/min112\text{ beats/min}, and a temperature of 38.9∘C38.9^\circ\text{C} (102∘F102^\circ\text{F}). The client is receiving a continuous intravenous (IV) infusion of dopamine through a single-lumen peripheral IV catheter to maintain hemodynamic stability. The healthcare provider prescribes a new intermittent IV piggyback of piperacillin-tazobactam. Which of the following actions by the nurse demonstrate safe pharmacological and parenteral practices? (Select all that apply.)

Select all that apply

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Answer: Consult a drug reference guide or a clinical pharmacist to verify the Y-site compatibility of piperacillin-tazobactam and dopamine.; Assess the patency of the peripheral IV site and evaluate for signs of phlebitis or extravasation before initiating the antibiotic.; Calculate the piperacillin-tazobactam infusion rate in milliliters per hour (mL/hr) and administer the medication using an electronic infusion pump.

Answer

The correct actions are to verify Y-site compatibility between the two medications, assess the IV insertion site for patency and potential complications, and utilize an electronic infusion pump for precise delivery of the antibiotic.
The correct actions prioritize client safety and adherence to strict pharmacological standards. Verifying Y-site compatibility prevents adverse drug reactions and dangerous precipitation in the IV line. Assessing the IV site ensures the vein is patent, which is crucial when administering vesicant or irritant medications. Utilizing an electronic infusion pump guarantees that the antibiotic is delivered at a precise and safe rate, minimizing the risk of infusion-related toxicity.

Step-by-Step Solution

1
Analyze the client's clinical condition and current therapies.
The client is hemodynamically unstable (hypotensive) and relies on a continuous dopamine infusion to maintain adequate circulation and perfusion.
Understanding the purpose of continuous vasoactive medications is essential to prioritize actions related to the ABCs (Airway, Breathing, Circulation).
2
Evaluate the safety principles required for administering a new IV piggyback medication.
The nurse must verify Y-site compatibility, thoroughly assess the insertion site, and calculate the correct pump rate in mL/hr.
These standard practices ensure that the newly prescribed medication does not precipitate with the primary infusion and is delivered safely into a functioning vein.
3
Identify contraindicated actions and improper delegation choices.
Pausing the life-sustaining dopamine infusion, assuming universal IV compatibility, and delegating nursing assessments to a UAP are identified as incorrect.
These actions directly compromise client safety, violate the nursing scope of practice, and ignore fundamental pharmacological and prioritization principles.

Key Concept

Safe administration of multiple IV medications requires verifying Y-site compatibility, utilizing infusion pumps for precise delivery, and maintaining continuous life-sustaining infusions without dangerous interruptions.
Question 1076Question →

A pediatric nurse is assessing the developmental milestones of various clients. Arrange the following play behaviors in the chronological order in which they typically emerge, from the earliest stage of childhood to the latest.

Drag items to arrange them in the correct order

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Answer

The correct chronological order of play behaviors development is: Solitary play (infant playing alone), followed by Parallel play (toddler playing next to others), then Associative play (preschooler sharing without rules), and finally Cooperative play (school-age child playing a rule-based team sport).
Developmental play progresses sequentially as a child's cognitive and social skills mature. It begins with solitary play in infancy, moves to parallel play in toddlerhood, progresses to associative play during the preschool years, and matures into cooperative play with formal rules during the school-age years.

Step-by-Step Solution

1
Identify the developmental stage described by an infant playing alone.
This describes solitary play, which occurs in infancy (birth to 1 year).
Infants do not yet have the social development to interact with peers during play.
2
Identify the developmental stage described by a child playing next to another without interacting.
This describes parallel play, typical of toddlers (1 to 3 years).
Toddlers are egocentric but enjoy being near other children.
3
Identify the developmental stage described by children sharing toys without structured goals.
This describes associative play, typical of preschoolers (3 to 6 years).
Preschoolers develop the social skills to interact and share, though they lack formal organization.
4
Identify the developmental stage described by children playing a team sport with rules.
This describes cooperative play, typical of school-age children (6 to 12 years).
School-age children understand rules, teamwork, and shared objectives.
5
Sequence the identified stages chronologically.
Infancy (Solitary) -> Toddlerhood (Parallel) -> Preschool (Associative) -> School-age (Cooperative).
This order reflects the natural maturation of cognitive and psychosocial skills throughout childhood.

Key Concept

Progression of Social Play in Childhood Development
Question 1077Question →

A home health registered nurse is developing a care plan for a 78-year-old client who recently transitioned to living with their adult children. Which of the following actions should the nurse include in the client's comprehensive health screening plan? Select all that apply.

Select all that apply

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Answer: Administer the Timed Up and Go (TUG) test to evaluate mobility and fall risk.; Utilize the Geriatric Depression Scale (GDS) to screen for mood alterations.; Perform basic auditory and visual acuity testing to identify sensory impairments.

Answer

The nurse should administer the Timed Up and Go (TUG) test, utilize the Geriatric Depression Scale (GDS), and perform basic auditory and visual acuity testing.
Comprehensive geriatric screening requires prioritizing assessments that impact safety, functional status, and quality of life. The Timed Up and Go (TUG) test accurately evaluates mobility and fall risk. The Geriatric Depression Scale (GDS) is necessary because depression is prevalent yet often underdiagnosed in older adults, especially following major life transitions. Auditory and visual screenings are vital because sensory deficits contribute heavily to falls and cognitive decline.

Step-by-Step Solution

1
Analyze the client's demographic and situational context.
The client is 78 years old and recently underwent a major life transition (moving in with adult children).
Understanding the client's age and psychosocial stressors helps identify the highest priority health screenings.
2
Evaluate each screening action for appropriateness in the geriatric population.
Mobility (TUG), depression (GDS), and sensory (vision/hearing) screenings are evidence-based, high-priority assessments for older adults.
These screenings detect early signs of functional decline, fall risk, and mental health alterations.
3
Identify contraindicated or incorrect nursing actions among the choices.
Deferring cognitive assessment ignores potential pathology. Labeling a colonoscopy as primary prevention is a terminology error. Delegating initial assessment to a UAP violates nursing scope of practice.
Ensuring safe and effective care requires differentiating between correct screening protocols, accurate prevention levels, and proper delegation guidelines.

Key Concept

Geriatric Health Screening and Assessment
Question 1078Question →

A client with alcohol-induced major neurocognitive disorder is receiving intravenous antibiotics for healthcare-associated pneumonia on a medical-surgical unit. The client is profoundly disoriented and has successfully disconnected their intravenous infusion line twice during the current shift. After multiple less restrictive measures have failed to maintain line security, the healthcare provider prescribes physical limb restraints. Which comprehensive approach must the registered nurse implement to ensure compliance with legal mandates and client safety protocols?

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Answer: Anchor the device straps to the articulating section of the bed structure using a quick-release knot, confirm the prescription specifies a strict expiration timeframe, and remove the devices every two hours for tissue inspection and mobility exercises.

Answer

The nurse must anchor the straps to the articulating section of the bed with a quick-release knot, ensure the order is time-limited, and remove the restraints every two hours for assessment.
Clinical and legal guidelines for physical restraints require three critical components demonstrated in the correct answer: 1) Structural safety (tying to a movable part of the bed frame with a quick-release knot so the restraint adjusts with the client's position), 2) Legal compliance (ensuring the order is time-limited, as PRN orders are illegal), and 3) Physical monitoring (removing the devices at least every two hours for skin care, neurovascular assessment, and range of motion exercises).

Step-by-Step Solution

1
Evaluate the safety mechanics of restraint application.
Identify that restraints must be secured to the articulating (movable) portion of the bed frame using a quick-release knot.
Securing to an articulating section ensures the restraint moves with the client when the bed position is changed, preventing nerve damage or restriction of blood flow. A quick-release knot allows for immediate removal during a medical emergency.
2
Analyze the legal and regulatory requirements for the prescription.
Identify that restraint orders must have a strict expiration timeframe and can never be written as 'PRN' (as-needed).
Federal and facility regulations mandate continuous re-evaluation of the need for restraints to protect client rights and autonomy.
3
Determine the required nursing monitoring protocols.
Identify that non-violent (medical-surgical) restraints require removal at least every two hours to assess skin integrity, perform neurovascular checks, and provide range of motion.
Frequent removal and assessment by a registered nurse (which cannot be delegated to UAP) prevents complications such as pressure injuries, contractures, and ischemic damage.

Key Concept

Safe Application and Legal Management of Physical Restraints
Question 1079Question →

While delivering a meal tray, a staff nurse observes that a privacy curtain has caught fire from a malfunctioning electrical outlet in a semi-private room. Both clients are currently in their beds. Which action must the nurse take first?

Show answer & explanation

Answer: Relocate both clients out of the room to a safe area immediately.

Answer

Relocate both clients out of the room to a safe area immediately.
According to the RACE fire safety protocol (Rescue, Alarm, Confine, Extinguish), the absolute first priority is always to rescue and remove any individuals in immediate danger. Since both clients are in the room with an active fire, relocating them is the mandatory initial action.

Step-by-Step Solution

1
Assess the immediate environment for safety threats.
Identify that an active fire is occurring in close proximity to clients.
Rapid situational awareness is required to initiate emergency protocols.
2
Apply the standard facility fire emergency protocol (RACE).
Determine the sequence of actions: Rescue, Alarm, Confine, Extinguish.
Structured frameworks prevent panic and ensure critical life-saving steps are prioritized.
3
Execute the first step of the protocol ('R' - Rescue).
Move the clients away from the active fire source before doing anything else.
Protecting life and preventing injury is always the highest nursing priority in an emergency.

Key Concept

RACE Fire Safety Protocol
Question 1080Question →

A nurse is preparing a client with severe, treatment-resistant major depressive disorder for electroconvulsive therapy (ECT). Arrange the following nursing actions in the chronological order they should be performed, from first to last.

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Answer

The correct chronological order is: providing education, ensuring NPO status, requesting the client to void and remove prosthetics, applying monitoring equipment in the treatment room, and finally positioning the client on their side during recovery.
The nursing care for a client undergoing electroconvulsive therapy (ECT) follows a strict chronological protocol to ensure clinical safety. It begins with comprehensive pre-procedure education and consent verification. On the day of the procedure, verifying NPO status is crucial to prevent aspiration. Immediately prior to transport, the client is asked to void and remove items that could cause injury, such as dentures and eyeglasses. In the treatment room, monitoring equipment is applied before anesthesia and the muscle relaxant are administered. Finally, during the post-procedure recovery phase, the client is positioned on their side to maintain an open airway and prevent aspiration as they regain consciousness.

Step-by-Step Solution

1
Identify the initial preparatory phase of the procedure.
Providing education about expected side effects (e.g., short-term memory loss) occurs first.
Education and informed consent must be completed before any physical preparations begin to respect client autonomy and ensure readiness.
2
Identify the early physical preparation on the day of the procedure.
Ensuring the client has been NPO for 6 to 8 hours.
Confirming NPO status is a morning priority to ensure it is safe to proceed with anesthesia and to minimize the risk of pulmonary aspiration.
3
Identify the immediate pre-procedure interventions on the unit.
Requesting the client to void and remove eyeglasses and dentures.
Emptying the bladder prevents incontinence during the induced seizure, and removing prosthetics prevents physical injury. This is done right before transport.
4
Identify the intra-procedure preparations.
Applying monitoring equipment, including a blood pressure cuff and pulse oximeter.
Once the client arrives in the treatment suite, baseline vital signs must be established and continuous monitoring initiated prior to the administration of the short-acting anesthetic.
5
Identify the post-procedure recovery interventions.
Positioning the client on their side.
Following the seizure, protecting the airway and preventing aspiration is the highest nursing priority while the client is unconscious and recovering from anesthesia.

Key Concept

Electroconvulsive Therapy (ECT) Nursing Protocol
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