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Question 1081Question →

A charge nurse is guiding a newly licensed registered nurse (RN) through the process of delegating routine ambulation for a stable postoperative client to an unlicensed assistive personnel (UAP). In what chronological sequence should the RN perform the following steps?

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Answer

The correct sequence is: assess the client, verify the UAP's competency, communicate directions, supervise the task, and evaluate the response.
The NCSBN outlines a structured delegation process that aligns with the nursing process. It begins with assessing the client and planning (determining clinical stability). Next, the RN must ensure the right person is assigned by verifying the UAP's competency. This is followed by communication, where the RN provides specific directions and reporting parameters. The RN then provides supervision while the task is performed. The process concludes with evaluation, where the RN assesses the client's response and ensures proper documentation.

Step-by-Step Solution

1
Identify the initial step of the delegation process.
Assess the client's clinical stability to determine if delegating the ambulation is appropriate.
The RN must first assess the client's needs to ensure the 'Right Circumstance' and 'Right Task' before initiating delegation.
2
Identify the second step.
Verify that the selected UAP possesses the required competency and training to perform the task.
The RN must verify the 'Right Person' by ensuring the delegatee has the proper knowledge and skills.
3
Identify the third step.
Communicate explicit directions regarding the ambulation distance and specific parameters for reporting.
The RN provides the 'Right Direction and Communication' by detailing exactly what needs to be done.
4
Identify the fourth step.
Provide appropriate supervision and remain available while the UAP assists the client.
The RN provides the 'Right Supervision' by monitoring the ongoing activity and being ready to intervene.
5
Identify the final step.
Evaluate the client's physiological response to the activity and verify the task was documented.
The delegation process concludes with evaluating the client's outcome and verifying proper documentation.

Key Concept

The National Council of State Boards of Nursing (NCSBN) Delegation Process
Question 1082Question →

A nurse is caring for a 72-year-old client in the intensive care unit, 12 hours post-coronary artery bypass graft (CABG) surgery. The client was extubated 4 hours ago. Over the last hour, the mediastinal chest tube drainage has abruptly decreased from 120 mL/hr to 10 mL/hr. The client's current physiological data are as follows:

- Blood pressure: 86/68 mmHg
- Heart rate: 124 bpm
- Respiratory rate: 26 breaths/min
- Central Venous Pressure (CVP): 15 mmHg (baseline was 6 mmHg)
- Arterial Blood Gas (ABG): pH 7.30, PaCO2PaCO_2 32 mmHg, PaO2PaO_2 82 mmHg, HCO3−HCO_3^- 15 mEq/L
- Assessment: Heart sounds are muffled, and the client is increasingly restless.

Based on the interpretation of this clinical data, which of the following actions should the nurse take FIRST to reduce the risk of severe physiological decompensation?

Show answer & explanation

Answer: Prepare the client for an immediate echocardiogram and anticipate an emergency pericardiocentesis.

Answer

The correct action is to prepare the client for an immediate echocardiogram and anticipate an emergency pericardiocentesis.
The client is exhibiting classic signs of cardiac tamponade (Beck's triad: hypotension, muffled heart sounds, elevated central venous pressure) combined with a sudden cessation of chest tube drainage. This represents obstructive shock requiring immediate echocardiography to confirm, followed by pericardiocentesis or sternotomy to relieve the pressure.

Step-by-Step Solution

1
Analyze the vital signs and physical assessment findings.
The client has a narrowed pulse pressure (86 - 68 = 18 mmHg), tachycardia, an elevated CVP, and muffled heart sounds.
Identifying these specific hemodynamic changes is necessary to recognize Beck's triad, a cardinal indicator of cardiac tamponade.
2
Evaluate the change in chest tube drainage.
Drainage dropped abruptly from 120 mL/hr to 10 mL/hr.
Sudden cessation of drainage after open-heart surgery suggests a clot has formed in the tube, causing blood to accumulate in the pericardial space.
3
Interpret the Arterial Blood Gas (ABG) results.
pH is 7.30 (acidosis), HCO3−HCO_3^- is 15 mEq/L (metabolic cause), and PaCO2PaCO_2 is 32 mmHg (partial respiratory compensation).
This confirms partially compensated metabolic acidosis, likely secondary to poor tissue perfusion (lactic acidosis) from reduced cardiac output.
4
Determine the highest priority intervention to prevent arrest.
Prepare for an emergency echocardiogram and pericardiocentesis.
Cardiac tamponade is an acute obstructive shock that requires immediate mechanical decompression to restore ventricular filling and cardiac output.

Key Concept

Early recognition and emergency management of cardiac tamponade post-cardiac surgery.
Question 1083Question →

A client diagnosed with paranoid schizophrenia is brought to the emergency department triage area experiencing an acute psychotic episode. The client is pacing rapidly, intensely scanning the room, and shouting, 'They planted a device in my chest! I have to cut it out before it detonates!' The client grabs a hard plastic pen from the registration desk and holds the point firmly against their chest. Which action should the nurse take FIRST?

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Answer: Maintain a safe distance, clear bystanders from the immediate area, and activate the behavioral emergency response team.

Answer

The correct action is to maintain a safe distance, clear the area of bystanders, and activate the behavioral emergency response team.
In an acute psychiatric emergency where a client is armed and actively threatening self-harm due to a delusion, the nurse's highest priority is immediate safety. Maintaining a safe distance prevents staff injury, clearing bystanders protects others and reduces sensory stimulation, and activating a specialized team ensures sufficient resources are present to safely manage the crisis.

Step-by-Step Solution

1
Assess the immediate safety of the environment.
The nurse identifies that an acutely agitated, psychotic client armed with a potential weapon poses a high, immediate risk to self and others.
Safety assessment is the first step in crisis management before attempting any direct intervention.
2
Prioritize milieu and personal safety.
The nurse maintains a safe, non-threatening distance and evacuates bystanders from the immediate triage area.
This prevents collateral injury, reduces environmental stimulation that feeds the client's agitation, and protects the nurse from physical harm.
3
Activate specialized facility resources.
The nurse calls for the behavioral emergency response team.
A coordinated team approach ensures sufficient trained personnel are present to safely manage the crisis using established de-escalation protocols and the least restrictive effective measures.

Key Concept

Management of Acute Psychiatric Emergencies and Milieu Safety
Question 1084Question →

A 68-year-old client is receiving care on a surgical unit 48 hours following a bowel resection. The nurse observes the client exhibiting profound diaphoresis, coarse bilateral tremors, a heart rate of 138 beats/minute, and severe agitation. The client points to the corner of the room, frantically stating that spiders are crawling up the walls. The client's spouse casually mentions, "I forgot to bring the anxiety pills they take every day at home... alprazolam, I think." Which of the following nursing actions are appropriate to include in the client's immediate plan of care? (Select all that apply.)

Select all that apply

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Answer: Implement seizure precautions by padding the side rails and ensuring suction equipment is readily available.; Administer prescribed intravenous lorazepam based on a symptom-triggered assessment scale.; Maintain a low-stimulation environment by dimming the room lights, closing the door, and limiting unnecessary interruptions.

Answer

The appropriate nursing actions are to implement seizure precautions, administer a prescribed benzodiazepine taper, and maintain a low-stimulation environment.
The client is exhibiting classic manifestations of severe sedative-hypnotic (benzodiazepine) withdrawal, which typically peaks 24 to 72 hours after the abrupt cessation of a short-acting agent like alprazolam. Symptoms include profound autonomic hyperactivity (tachycardia, diaphoresis), coarse tremors, severe agitation, and perceptual disturbances such as visual hallucinations. This constitutes a life-threatening medical emergency due to the high risk of withdrawal seizures. The most appropriate nursing actions address both immediate safety and the underlying physiological deficit. Implementing strict seizure precautions (padding side rails, ensuring suction is available) is essential for physical safety. Administering a prescribed substitution taper with a long-acting benzodiazepine (such as lorazepam) based on a symptom-triggered assessment scale is the pharmacological standard of care to safely manage neuro-excitability. Finally, maintaining a low-stimulation environment significantly reduces sensory triggers that could exacerbate agitation or lower the seizure threshold.

Step-by-Step Solution

1
Analyze the client's clinical presentation and recent history.
The client presents with autonomic hyperactivity (tachycardia, diaphoresis), tremors, agitation, and visual hallucinations 48 hours post-operation, compounded by the abrupt cessation of daily alprazolam.
Accurately identifying the clinical syndrome is necessary to differentiate acute substance withdrawal from standard postoperative delirium or infection.
2
Determine the pathophysiological risk and prioritize interventions.
The client is experiencing severe sedative-hypnotic (benzodiazepine) withdrawal, which carries an imminent risk of status epilepticus and cardiovascular collapse.
Benzodiazepine withdrawal is a life-threatening medical emergency requiring immediate pharmacological stabilization and environmental safety measures.
3
Select the evidence-based nursing and medical interventions.
The correct actions include initiating seizure precautions, administering a substitution taper (like lorazepam), and reducing environmental stimuli.
These specific actions address physical safety, correct the underlying pharmacological deficit, and minimize neuro-excitability.
4
Eliminate contraindicated or unsafe actions from the plan of care.
Reject the options involving haloperidol, delegating to the UAP, and attributing symptoms to normal aging.
Haloperidol lowers the seizure threshold; UAPs cannot assess unstable clients; and dismissing pathological withdrawal as expected aging delays life-saving care.

Key Concept

Sedative-Hypnotic Withdrawal Management and Prioritization
Question 1085Question →

A nurse is caring for a 4-year-old client who is hospitalized with an acute respiratory infection. The child tearfully tells the nurse, "I got sick because I was mean to my little sister yesterday." Based on the cognitive development of a preschooler, which response by the nurse is most appropriate?

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Answer: You did not get sick because you were mean. A tiny germ made you sick.

Answer

The most appropriate response is to explicitly tell the child that they did not get sick because they were mean, and explain that a germ caused the illness.
Preschool-aged children (3 to 5 years old) are in Piaget's preoperational stage of cognitive development. They often exhibit 'magical thinking,' believing that their thoughts, wishes, or bad behaviors can cause external events, such as an illness. The correct response directly addresses this misconception using simple, concrete language that the child can understand, explicitly reassuring them that they are not to blame.

Step-by-Step Solution

1
Identify the client's developmental stage and associated cognitive characteristics.
The client is a 4-year-old preschooler. According to Piaget, preschoolers are in the preoperational stage and commonly exhibit "magical thinking."
Understanding the developmental stage is required to interpret the child's statement correctly.
2
Analyze the child's statement.
The child believes their bad behavior caused the illness, which is a classic example of magical thinking and egocentrism.
Identifying the root of the child's fear allows the nurse to formulate a targeted therapeutic response.
3
Evaluate the options based on age-appropriate communication.
The best response uses simple, concrete language to correct the misconception without validating the magical thinking or using overly abstract logic.
Therapeutic communication must align with the child's cognitive ability to be effective and reassuring.

Key Concept

Magical Thinking in Preschoolers
Question 1086Question →

A nurse is caring for a client who is receiving internal radiation therapy (brachytherapy) with a sealed implant for cervical cancer. Upon entering the room, the nurse discovers that the radioactive implant has become dislodged and is lying on the client's bed linens. Which of the following is the nurse's priority action?

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Answer: Use long-handled forceps to retrieve the implant and place it in a lead-lined container.

Answer

The nurse should use long-handled forceps to pick up the dislodged radioactive implant and place it in the lead-lined container.
When a sealed radioactive implant becomes dislodged, the utmost priority is to limit radiation exposure to the client and staff based on the safety principles of time, distance, and shielding. The correct action is to use long-handled forceps (which increases distance) to retrieve the implant and immediately place it into a lead-lined container (which provides shielding). This emergency equipment must be kept in the client's room at all times during internal radiation therapy. Only after securing the radiation source should the nurse notify the radiation safety officer and the healthcare provider.

Step-by-Step Solution

1
Identify the immediate hazard.
The dislodged radioactive implant presents an immediate, unshielded radiation exposure risk to the client and healthcare staff.
Recognizing the risk dictates the application of radiation safety principles: time, distance, and shielding.
2
Implement appropriate safe handling procedures without leaving the client.
The nurse uses long-handled forceps to pick up the implant and places it inside a lead-lined container.
Long-handled forceps provide critical distance from the radiation source, and the lead container provides the necessary shielding to contain the hazard safely.
3
Determine subsequent notifications.
After the immediate radiation hazard is secured, the nurse notifies the radiation safety officer and the primary healthcare provider.
Once the environment is safe, the specialized medical team must be informed so they can evaluate the client and adjust the treatment plan.

Key Concept

Safe handling of a dislodged sealed radioactive implant (brachytherapy) requires maximizing distance (using long-handled forceps) and utilizing shielding (lead-lined container) to minimize radiation exposure.
Question 1087Question →

A pediatric clinic nurse is providing anticipatory guidance to the parents of a 30-month-old toddler. The parents are expecting their second child in two months. Which of the following instructions should the nurse include to support the toddler's developmental transition and promote a safe environment? Select all that apply.

Select all that apply

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Answer: Transition the toddler from a crib to a youth bed at least one month before the newborn's arrival.; Delay the initiation of toilet training until the family routine has stabilized after the birth.; Provide the toddler with a baby doll to practice caregiving and role-playing activities.

Answer

The correct interventions are transitioning to a youth bed a month early, delaying toilet training, and providing a baby doll for role-playing.
Supporting a toddler through the arrival of a sibling requires minimizing concurrent stressors and fostering developmentally appropriate coping mechanisms. Transitioning the toddler to a youth bed well before the birth prevents feelings of displacement. Delaying toilet training is recommended because major transitions often cause stress and regression, making it an inappropriate time to introduce a new, demanding skill. Providing a baby doll encourages symbolic play, which aligns with Piaget's preoperational stage and allows the toddler to safely process the transition through imitation.

Step-by-Step Solution

1
Analyze the client's developmental stage.
The 30-month-old client is in Erikson's Autonomy vs. Shame and Doubt stage and Piaget's early Preoperational stage.
Understanding baseline developmental milestones is required to formulate an appropriate care plan.
2
Evaluate the impact of the upcoming family transition.
The arrival of a newborn introduces significant stress, often leading to feelings of displacement and regressive behaviors in toddlers.
Anticipatory guidance must address the psychological impact of sibling arrival.
3
Review each option against developmental safety and psychosocial principles.
Interventions that introduce changes gradually, utilize symbolic play, and minimize concurrent stressors are appropriate. Punitive measures or unrealistic expectations are incorrect.
Nursing interventions must be developmentally safe and promote healthy coping mechanisms.

Key Concept

Toddler Psychosocial Development and Sibling Adaptation
Estimated Time:1m 30s
Question 1088Question →

A 32-year-old client is brought to the emergency department by police after being found standing on a bridge ledge. The client experienced a sudden job loss and eviction earlier in the day. While pacing in the triage room, the client stops, appears suddenly calm, smiles faintly, and states, 'It's okay now. I finally feel peaceful knowing the struggle will be over tonight.' The client is physically uninjured. Which of the following nursing interventions are the priority during this acute crisis phase? (Select all that apply)

Select all that apply

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Answer: Implement continuous one-to-one direct nursing observation of the client.; Ask the client directly if they have a specific plan and means to end their life.; Remove all unnecessary medical equipment, tubing, and personal belongings from the client's room.

Answer

The priority interventions are to implement continuous one-to-one observation, directly assess the client's suicide plan, and remove all potential environmental hazards.
The absolute priority in crisis intervention, especially with suspected suicidal ideation, is client safety. The client's sudden shift to calmness and the statement about the struggle being 'over tonight' strongly indicate a finalized suicide plan and a high risk for imminent self-harm. The correct actions prioritize immediate safety by initiating continuous 1:1 direct observation, explicitly assessing the details of the suicide plan, and removing any potential environmental hazards to prevent injury.

Step-by-Step Solution

1
Analyze the client's clinical presentation and verbal statements.
The client has experienced a severe situational crisis and is exhibiting a sudden, paradoxical shift from agitation to profound calmness, accompanied by a statement implying an imminent end to their struggle.
Identifying subtle behavioral shifts is crucial. A sudden sense of peace in a previously frantic or deeply depressed client is a major red flag indicating they may have made a definitive decision to commit suicide.
2
Prioritize nursing interventions based on immediate safety risks.
Immediate physical safety and suicide prevention become the absolute highest priorities, overriding routine assessments or long-term coping strategies.
According to Maslow's Hierarchy of Needs and emergency protocols, preserving life and preventing self-harm take precedence over all other psychosocial interventions during an acute crisis.
3
Evaluate each intervention option against the immediate safety priority.
Actions that secure the environment, directly assess lethality, and establish continuous monitoring are correct. Actions that delegate initial assessment, misinterpret symptoms, or use false reassurance are incorrect.
Therapeutic crisis intervention requires direct action to maintain safety, validate the severity of the client's emotional pain without minimizing it, and utilize appropriate RN clinical judgment.

Key Concept

During an acute crisis, a sudden shift from severe agitation or depression to calmness often indicates a finalized suicide plan, requiring immediate, direct safety interventions.
Question 1089Question →

A public health nurse is facilitating a health education workshop for caregivers of pre-adolescent clients. The nurse outlines the predictable sequence of physiological changes marking female puberty. Arrange the following developmental milestones in the typical chronological order of their onset, from earliest to latest.

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Answer

The correct chronological sequence is: Appearance of breast buds, followed by Growth of initial pubic hair, followed by Attainment of peak height velocity, and finally Onset of the first menstrual period.
The predictable sequence of female pubertal development begins with thelarche (breast budding), followed by pubarche (pubic hair development). As puberty progresses, the adolescent experiences a rapid growth spurt (peak height velocity), which is ultimately followed by menarche (the onset of menstruation) as a late stage of development.

Step-by-Step Solution

1
Identify the earliest sign of female puberty.
Appearance of breast buds (thelarche) is recognized as the first physiological change.
Thelarche marks the beginning of physical maturation and the onset of puberty.
2
Determine the subsequent developmental milestone.
Growth of initial pubic hair (pubarche) follows thelarche.
Pubarche typically occurs within months after breast budding begins.
3
Place the growth spurt in the sequence.
Attainment of peak height velocity is positioned third.
The rapid growth spurt happens during mid-puberty, after initial primary and secondary sex characteristics have started but before full reproductive maturity.
4
Identify the final developmental marker in this sequence.
Onset of the first menstrual period (menarche) is placed last.
Menarche is a late pubertal event, signaling the later stages of physical maturation, typically occurring about 2 years after thelarche.

Key Concept

Sequence of female pubertal development
Question 1090Question →

A nurse is caring for a 45-year-old client who is 4 hours post-operative following an abdominal hysterectomy. Over the last hour, the client's blood pressure has trended from 124/76124/76 mm Hg to 110/84110/84 mm Hg, and the heart rate has increased from 7878 to 115115 beats/min. The client's arterial blood gas (ABG) results on room air are: pH 7.387.38, PaCO2 4040 mm Hg, HCO3 2424 mEq/L, and PaO2 9292 mm Hg. The client reports mild incisional pain. Which of the following actions should the nurse take first?

Show answer & explanation

Answer: Administer prescribed intravenous fluids and notify the healthcare provider.

Answer

The nurse should first administer prescribed intravenous fluids and notify the healthcare provider to manage early compensatory shock.
The client is demonstrating early signs of hypovolemic shock, evidenced by a significantly increased heart rate and a narrowing pulse pressure (the difference between systolic and diastolic blood pressure has decreased from 4848 mm Hg to 2626 mm Hg). In the compensatory stage of shock, the sympathetic nervous system causes systemic vasoconstriction, which raises the diastolic pressure while the systolic pressure drops or remains stable, resulting in a narrow pulse pressure. Immediate administration of intravenous fluids and provider notification are critical to prevent further physiological decompensation and restore adequate perfusion.

Step-by-Step Solution

1
Analyze the client's vital sign trends over the last hour.
The pulse pressure has narrowed from 4848 mm Hg (124−76124 - 76) to 2626 mm Hg (110−84110 - 84), and the heart rate has increased significantly to 115115 beats/min.
Identifying subtle changes in vital signs is crucial for detecting early physiological decompensation.
2
Evaluate the arterial blood gas (ABG) results.
The pH (7.387.38), PaCO2 (4040 mm Hg), HCO3 (2424 mEq/L), and PaO2 (9292 mm Hg) are all completely within normal limits.
This rules out respiratory or metabolic acid-base imbalances as the cause of the client's changing condition.
3
Synthesize the assessment data to determine the highest physiological risk.
The combination of tachycardia and a narrowing pulse pressure in a post-operative client indicates early (compensatory) hypovolemic shock, likely due to internal hemorrhage.
Early recognition of shock allows for immediate intervention before irreversible tissue damage occurs.
4
Select the most appropriate nursing intervention.
Administering prescribed intravenous fluids and immediately notifying the healthcare provider is the priority.
Fluid resuscitation increases intravascular volume to support blood pressure and perfusion while the provider determines the source of bleeding.

Key Concept

Early recognition and management of hypovolemic shock in the post-operative period.
Question 1091Question →

A nurse is caring for a postoperative client who has a continuous epidural infusion for analgesia, a peripheral intravenous (IV) catheter, and an enteral feeding tube. The nurse is preparing to administer a prescribed IV push antibiotic. To prevent a catastrophic tubing misconnection error, which action is the most critical for the nurse to perform?

Show answer & explanation

Answer: Physically trace the tubing from the peripheral IV catheter insertion site on the client's body up to the intended injection port.

Answer

The nurse must physically trace the tubing starting from the client's peripheral IV insertion site up to the injection port before administering the medication.
Tubing misconnections are a critical, often fatal, medical error. To prevent administering an intravenous medication into an epidural or enteral line, the evidence-based safety standard is to physically trace the tubing starting directly from the patient's insertion site (the peripheral IV) up to the port where the medication will be injected. Relying on memory, labels, or the presence of an infusion pump is insufficient and dangerous.

Step-by-Step Solution

1
Identify all access lines currently attached to the client.
The client has multiple distinct access routes: an epidural, an enteral tube, and a peripheral IV.
Recognizing the presence of multiple lines highlights a high risk for potentially fatal tubing misconnections.
2
Select the correct physiological route for the prescribed medication.
The antibiotic is prescribed via the intravenous route.
Administering an intravenous medication via an epidural or enteral route can lead to severe neurotoxicity, paralysis, or death.
3
Verify the correct line through physical tracing.
The nurse traces the tubing from the peripheral IV site on the client's body directly up to the injection port.
Tracing from the patient to the port is the only evidence-based standard to ensure the medication enters the correct vascular system.

Key Concept

Prevention of Tubing Misconnections
Estimated Time:1m 30s
Question 1092Question →

A nurse is coordinating the care plan for a 78-year-old client recovering from urosepsis. The client is hemodynamically stable but exhibits new-onset confusion, intermittent agitation, and a refusal to eat. The client has a continuous intravenous (IV) infusion and an indwelling urinary catheter. Which actions represent appropriate interdisciplinary collaboration and safe care management? Select all that apply.

Select all that apply

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Answer: Request a medication review by the clinical pharmacist to identify any pharmacological causes for the acute confusion.; Consult with the registered dietitian to assess the client's nutritional requirements and recommend targeted interventions for the food refusal.; Collaborate with the physical therapist to establish a safe, progressive mobility plan to prevent functional decline.

Answer

The appropriate collaborative actions are requesting a medication review by the clinical pharmacist, consulting the registered dietitian for a nutritional assessment, and collaborating with the physical therapist for a progressive mobility plan.
Effective interdisciplinary collaboration involves utilizing the specialized expertise of various healthcare professionals to optimize client outcomes. The clinical pharmacist evaluates potential polypharmacy or adverse drug reactions contributing to delirium. The registered dietitian is the appropriate expert to address the client's nutritional deficits. The physical therapist provides targeted interventions to maintain mobility and prevent deconditioning in older adults recovering from acute illness.

Step-by-Step Solution

1
Analyze the client's acute clinical presentation.
The client is experiencing new-onset confusion, agitation, and refusal to eat, alongside a risk for deconditioning.
Identifying the specific clinical challenges determines which interdisciplinary team members are required.
2
Evaluate the need for pharmacological expertise.
The clinical pharmacist is identified as the appropriate team member to review the IV medications and overall regimen for causes of acute confusion.
Pharmacists are the experts in drug interactions and toxicities.
3
Evaluate the need for nutritional and physical therapy expertise.
The registered dietitian is identified for the refusal to eat, and the physical therapist is identified to manage mobility.
These team members operate within their specific scopes of practice to address the client's deficits.
4
Analyze the remaining options against safety and delegation principles.
The remaining options are rejected because they involve attributing acute pathology to normal aging, improperly delegating assessments to a UAP, and prematurely utilizing restraints.
Effective interdisciplinary collaboration requires adherence to legal, ethical, and safety standards.

Key Concept

Collaboration with Interdisciplinary Team
Question 1093Question →

A client with acute delirium is placed in bilateral soft wrist restraints to prevent the removal of a central venous catheter after less restrictive measures were unsuccessful. Which of the following nursing actions are appropriate when caring for this client? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Assess the peripheral pulses, skin temperature, and capillary refill of the hands.; Release the restraints at least every 2 hours to provide skin care and range-of-motion exercises.; Attach the restraint straps to the movable portion of the bed frame using a quick-release tie.

Answer

The appropriate nursing actions are to assess the peripheral pulses and skin temperature, release the restraints at least every 2 hours for range-of-motion exercises, and attach the restraint straps to the movable portion of the bed frame using a quick-release tie.
Appropriate restraint management requires the nurse to ensure patient safety and prevent complications. Assessing peripheral circulation prevents ischemic injury. Releasing the restraints every 2 hours allows for skin care and prevents joint contractures. Attaching the straps to the movable portion of the bed frame with a quick-release tie ensures the restraints move with the client when the bed's head or foot is adjusted, and allows the restraints to be immediately removed in a medical emergency.

Step-by-Step Solution

1
Identify the safety principles required for a client in physical restraints.
The nurse must prioritize circulation, skin integrity, legal guidelines, and emergency safety.
Restraints pose significant risks of injury, ischemia, and entrapment if applied or monitored incorrectly.
2
Evaluate each proposed nursing action against standard restraint guidelines.
Neurovascular checks, regular removal for range-of-motion, and tying to a movable bed frame with quick-release knots are correct and necessary safety practices.
These actions prevent circulatory compromise, maintain joint mobility, and allow for rapid restraint removal in an emergency.
3
Identify the unsafe or illegal practices among the options.
Tying restraints to side rails, using square knots, obtaining PRN prescriptions, and delegating assessment to a UAP are incorrect.
These actions violate safety standards, legal regulations regarding PRN orders, and the registered nurse's scope of practice.

Key Concept

Safe application, legal requirements, and monitoring of physical restraints
Question 1094Question →

During a pediatric clinical rotation, a nursing instructor is reviewing the proposed care plan of a nursing student assigned to a 4-year-old client. The client is admitted with suspected *Haemophilus influenzae* type b (Hib) epiglottitis and a draining sacral wound that is positive for *Acinetobacter baumannii*. Which of the following interventions proposed by the student indicate a correct understanding of transmission-based precautions and safe care? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Don a standard surgical mask prior to providing direct care to the client.; Keep dedicated, disposable medical equipment, such as a stethoscope, inside the client's room.; Remove the isolation gown and gloves inside the room and perform hand hygiene before exiting.

Answer

The correct interventions include donning a standard surgical mask prior to care, keeping dedicated disposable medical equipment inside the room, and removing the isolation gown and gloves inside the room followed by hand hygiene before exiting.
The client requires concurrent Droplet Precautions (due to Hib epiglottitis) and Contact Precautions (due to the Acinetobacter baumannii wound infection). Droplet precautions require healthcare workers to wear a standard surgical mask when providing direct care. Contact precautions mandate the use of dedicated, disposable medical equipment to prevent cross-contamination. Furthermore, to contain the contact pathogen, healthcare workers must remove their gown and gloves inside the client's room and perform hand hygiene immediately before crossing the threshold to exit.

Step-by-Step Solution

1
Identify the transmission pathways for the specific pathogens involved in the clinical scenario.
Hib epiglottitis requires Droplet Precautions. Acinetobacter baumannii in a draining wound requires Contact Precautions.
Accurate identification of the isolation tiers dictates the specific personal protective equipment (PPE) and environmental controls needed.
2
Apply the protocols for Contact Precautions.
The nurse must use a gown and gloves upon entry, dedicate patient-care equipment to that single client, and doff the gown and gloves inside the room before performing hand hygiene.
These measures prevent the physical transfer of multidrug-resistant organisms to other clients or environmental surfaces outside the room.
3
Apply the protocols for Droplet Precautions.
The nurse must wear a surgical mask when in close contact. If transport is necessary, the client must wear a surgical mask as source control.
Droplet Precautions protect against large-particle respiratory droplets generated by coughing, sneezing, or talking.
4
Evaluate the proposed delegation of tasks.
Airway assessment is a critical nursing responsibility that cannot be delegated.
Regardless of infection control protocols, the registered nurse retains the responsibility for all initial and critical assessments, especially in a life-threatening condition like epiglottitis.

Key Concept

Concurrent Application of Droplet and Contact Precautions
Estimated Time:1m 30s
Question 1095Question →

Match each clinical presentation with the appropriate category of infection control precautions required.

Click a left item, then click its matching right item

Items

Active pulmonary tuberculosis
MRSA wound infection with excessive drainage
Seasonal influenza
Routine care for an asymptomatic, uninfected client

Matches

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Answer

Active pulmonary tuberculosis pairs with Airborne Precautions. MRSA wound infection pairs with Contact Precautions. Seasonal influenza pairs with Droplet Precautions. Routine care pairs with Standard Precautions.
Each pathogen or clinical situation has a specific mechanism of transmission that dictates the appropriate tier of precautions to prevent the spread of infection within healthcare settings. Applying the correct tier is essential for patient and staff safety.

Step-by-Step Solution

1
Identify the mode of transmission for pulmonary tuberculosis.
Tuberculosis is transmitted via small airborne particles.
This determines the need for Airborne Precautions.
2
Identify the mode of transmission for MRSA in a draining wound.
MRSA is transmitted through direct or indirect physical contact.
This determines the need for Contact Precautions.
3
Identify the mode of transmission for seasonal influenza.
Influenza spreads via large respiratory droplets.
This determines the need for Droplet Precautions.
4
Determine precautions for an uninfected client.
All clients require baseline infection control measures.
Standard Precautions apply universally to all patient care activities.

Key Concept

Understanding the modes of transmission for common pathogens to apply the correct category of isolation precautions.
Question 1096Question →

A nurse is caring for a 65-year-old client admitted with a heart failure exacerbation and a suspected systemic infection. The client has a continuous peripheral intravenous (IV) infusion of Lactated Ringer's solution running at 75 mL/hr. The client's current vital signs are blood pressure 138/85 mmHg, heart rate 92 beats/min, and respiratory rate 18 breaths/min. The healthcare provider has prescribed several new IV medications to manage the client's condition. Which of the following actions by the nurse demonstrate safe pharmacological and parenteral therapy principles? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Verifying Y-site compatibility in an approved drug reference prior to administering an intravenous push dose of ondansetron for nausea.; Administering a prescribed intravenous push dose of furosemide slowly at a rate not exceeding 20 mg per minute.; Flushing the intravenous catheter with preservative-free 0.9% sodium chloride before and after administering an incompatible medication.

Answer

The correct actions include verifying Y-site compatibility, administering furosemide slowly to prevent ototoxicity, and flushing the intravenous line with 0.9% sodium chloride before and after giving incompatible medications.
Safe parenteral therapy requires strict adherence to administration guidelines to prevent life-threatening complications. Verifying Y-site compatibility is an essential pre-administration assessment to prevent adverse interactions in the intravenous tubing. Administering intravenous furosemide slowly (not exceeding 20 mg/minute) is necessary to prevent speed shock and ototoxicity. When administering an incompatible medication through an existing line, the nurse must adequately flush the catheter with 0.9% sodium chloride before and after the dose to ensure the incompatible drugs do not mix.

Step-by-Step Solution

1
Analyze the compatibility of prescribed medications with the continuous Lactated Ringer's infusion.
Recognize that ceftriaxone is strictly incompatible with calcium-containing Lactated Ringer's, while the compatibility of other medications like ondansetron must be verified before administration.
Preventing fatal intravenous precipitates is a critical priority in parenteral therapy.
2
Evaluate the safe administration rates for high-alert intravenous medications.
Determine that potassium chloride must not exceed 10 mEq/hr peripherally, and furosemide must be pushed slowly at a maximum rate of 20 mg/min.
Rapid administration of potassium causes life-threatening cardiac dysrhythmias, and rapid furosemide causes ototoxicity.
3
Determine the appropriate scope of practice regarding intravenous therapy monitoring.
Identify that assessing an intravenous site for complications like phlebitis or infiltration requires clinical judgment.
The registered nurse remains accountable for patient assessment and cannot delegate this task to unlicensed assistive personnel.

Key Concept

Safe Parenteral Therapy and Medication Administration Principles
Question 1097Question →

A clinical nurse evaluates a client who is 88 hours post-operative following a laparoscopic Roux-en-Y gastric bypass. Which of the following nursing actions or clinical judgments are appropriate to reduce the risk of physiological decompensation? (Select all that apply.)

Select all that apply

Show answer & explanation

Answer: Administering a prescribed intravenous analgesic 3030 minutes before assisting the client with incentive spirometry.; Notifying the rapid response team if the client develops sudden restlessness, mild tachycardia, and a narrowing pulse pressure.; Assisting the client with early ambulation in the unit hallway to promote pulmonary expansion and venous return.

Answer

The appropriate actions are administering analgesics before spirometry, notifying the rapid response team for early signs of shock, and assisting with early ambulation.
Clients recovering from major bariatric surgery are at elevated risk for cardiopulmonary complications and anastomotic leaks. Providing intravenous analgesia before pulmonary hygiene (incentive spirometry) ensures the client can tolerate deep diaphragmatic breathing. Early ambulation is a core standard of care to prevent deep vein thrombosis and promote gastrointestinal motility. Furthermore, acute restlessness paired with a narrowing pulse pressure and mild tachycardia are classic early, subtle indicators of compensatory shock (often due to hemorrhage or sepsis from an internal leak), which necessitates immediate escalation to a rapid response team.

Step-by-Step Solution

1
Evaluate post-operative respiratory care principles for bariatric clients.
Pain control prior to incentive spirometry is essential to allow deep diaphragmatic excursion. Early ambulation is also critical to prevent atelectasis and venous stasis.
Bariatric clients are at extremely high risk for pulmonary complications due to restricted chest wall expansion and abdominal pain.
2
Analyze the significance of the presented arterial blood gas (ABG) values.
A pH of 7.287.28 combined with a PaCO2\text{PaCO}_2 of 5858 mm Hg indicates acute, uncompensated respiratory acidosis.
This is a pathological state of hypoventilation that signals impending respiratory failure, not a benign residual effect of anesthesia.
3
Identify clinical signs of severe postoperative complications such as anastomotic leak or hemorrhage.
Restlessness, tachycardia, and a narrowing pulse pressure are early compensatory mechanisms for shock. Unrelieved left shoulder pain (Kehr's sign) indicates phrenic nerve irritation from peritonitis or intra-abdominal bleeding.
Recognizing early physiological deterioration prevents progression to irreversible shock or systemic sepsis.
4
Determine the correct client positioning requirements.
The client must be placed in a semi-Fowler's position, not completely supine.
Semi-Fowler's position utilizes gravity to pull abdominal adipose tissue away from the diaphragm, improving lung expansion and reducing tension on the gastrointestinal anastomosis.

Key Concept

Early recognition of subtle physiological deterioration and application of appropriate post-operative pulmonary/hemodynamic interventions reduces risk potential.
Question 1098Question →

A nurse educator is conducting a compliance audit on a medical-surgical unit regarding the safe use of safety devices and restraints. Which implemented intervention meets the legal criteria for a physical restraint and requires the nurse to immediately obtain a formal healthcare provider prescription?

Show answer & explanation

Answer: Fastening a locking lap tray to the wheelchair of a client with severe right-sided hemiplegia who is physically incapable of unlatching the device independently.

Answer

Fastening a locking lap tray to the wheelchair of a client with severe right-sided hemiplegia who is physically incapable of unlatching the device independently.
The defining characteristic of a physical restraint is any device or method that restricts a client's freedom of movement and cannot be easily removed by the client. Because the client with hemiplegia lacks the physical ability to unlatch the lap tray, it effectively immobilizes them in the wheelchair. This meets the strict legal criteria for a restraint, mandating a specific provider prescription, informed consent, and rigorous monitoring.

Step-by-Step Solution

1
Define the legal criteria for a physical restraint.
A physical restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a client to move their arms, legs, body, or head freely.
Understanding the precise definition is required to differentiate between restraints, medical devices, and safety alternatives.
2
Evaluate the intent and the client's ability to remove the device in the correct option.
The locking lap tray restricts the client's mobility (keeps them in the chair). Because the client has hemiplegia and cannot unlatch it, they cannot remove it independently, making it a restraint.
If a client can easily remove a device (e.g., untying an untethered mitt), it acts as an enabler. If they cannot remove it, it becomes a physical restraint.
3
Analyze the distractors for regulatory exemptions to the restraint definition.
Orthopedic braces (structural support), low beds with mats (fall alternatives), and human sitters (observation) do not restrict freedom of movement in a manner legally classified as a restraint.
Recognizing legal exemptions prevents the inappropriate categorization of standard medical treatments or safety care as restraints.

Key Concept

Identifying Legal Boundaries and Definitions of Physical Restraints
Estimated Time:1m 30s
Question 1099Question →

A nurse is caring for a client who was recently diagnosed with a terminal illness. The client tells the nurse, "The laboratory must have mixed up my test results with someone else's. I feel perfectly healthy and I am returning to work tomorrow." Which of the following defense mechanisms is the client demonstrating?

Show answer & explanation

Answer: Denial

Answer

Denial
The correct answer is denial because the client is completely rejecting the objective reality of the clinical diagnosis and test results to protect themselves from the overwhelming anxiety associated with a terminal illness.

Step-by-Step Solution

1
Analyze the client's statement and behavior in response to the stressful event (terminal diagnosis).
The client states the results must belong to someone else and insists they are healthy.
Identifying the specific reaction is necessary to determine which coping mechanism is being utilized.
2
Match the observed behavior to the definitions of common psychological defense mechanisms.
The behavior matches the definition of denial, which is the refusal to accept reality or fact.
This confirms the correct conceptual term for the client's coping strategy.

Key Concept

Defense Mechanisms: Denial
Question 1100Question →

A nurse is preparing to perform a physical assessment on a client's abdomen. Which sequence of examination techniques should the nurse follow?

Show answer & explanation

Answer: Inspection, auscultation, percussion, and palpation

Answer

The nurse should follow the sequence of inspection, auscultation, percussion, and palpation.
The correct sequence for an abdominal assessment is inspection, auscultation, percussion, and palpation. Auscultating immediately after inspection ensures that the bowel sounds heard are accurate and have not been artificially stimulated or altered by the physical pressure of palpation or percussion.

Step-by-Step Solution

1
Identify the body system being assessed.
The system to be assessed is the gastrointestinal system (abdomen).
Different body systems require specific modifications to the general physical assessment sequence.
2
Recall the standard physical assessment sequence versus the abdominal assessment sequence.
Standard sequence is inspect, palpate, percuss, auscultate. Abdominal sequence is inspect, auscultate, percuss, palpate.
Manipulating the abdomen through palpation or percussion before listening can stimulate bowel motility and create false bowel sounds.

Key Concept

Abdominal Assessment Sequence
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