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A hospitalized client requires an intravenous dose of phenytoin for seizure management. The client's continuous intravenous fluids consist of 5% dextrose in water infusing at $100\text{ mL/hr}$ through a single-lumen peripheral catheter. Which action represents the safest method for the nurse to administer this medication?

Connect the medication syringe to the lowest Y-site port on the primary tubing and administer it concurrently with the active infusion to dilute the drug.

Dilute the prescribed dose in a

50\text{ mL}

bag of 5% dextrose in water and administer it as a secondary piggyback infusion over thirty minutes.

Pause the continuous intravenous fluids, flush the catheter with 0.9% sodium chloride, administer the medication at a maximum rate of

50\text{ mg/min}

, and flush again with 0.9% sodium chloride.

Flush the catheter with sterile water, inject the medication rapidly over one minute to quickly halt seizure activity, and follow with a final sterile water flush.

Show answer & explanation

Answer: Pause the continuous intravenous fluids, flush the catheter with 0.9% sodium chloride, administer the medication at a maximum rate of $50\text{ mg/min}$ , and flush again with 0.9% sodium chloride.

Answer

Pause the continuous intravenous fluids, flush the catheter with 0.9% sodium chloride, administer the medication at a maximum rate of

50\text{ mg/min}

, and flush again with 0.9% sodium chloride.

The correct action involves pausing the dextrose infusion and flushing the line with 0.9% sodium chloride (normal saline) before and after administration. Phenytoin is highly incompatible with dextrose solutions and will form a precipitate if they come into contact. Furthermore, intravenous phenytoin must be administered slowly, not exceeding

50\text{ mg/min}

, to prevent cardiovascular toxicity such as severe hypotension and arrhythmias.

Step-by-Step Solution

Identify the primary intravenous fluid currently infusing.

The client is receiving 5% dextrose in water.

Compatibility must be established before administering any intravenous medication.

Determine the compatibility of phenytoin with the infusing fluid.

Phenytoin is incompatible with dextrose solutions and will form a precipitate.

Mixing incompatible drugs can cause crystal formation, leading to catheter occlusion or emboli.

Determine the correct administration protocol for the medication.

The line must be flushed with normal saline before and after the dose, and the medication must be pushed slowly (max

50\text{ mg/min}

Normal saline clears the line of dextrose, and a slow administration rate prevents cardiovascular toxicity.

Key Concept

Phenytoin is highly incompatible with dextrose solutions and must be administered slowly (no faster than

50\text{ mg/min}

) using 0.9% sodium chloride to prevent precipitation and cardiovascular adverse effects.

Question 1222Question →

A primary nurse is developing a care plan for an adolescent client with viral encephalitis. The client exhibits severe agitation and has bilateral soft wrist restraints in place to prevent the dislodgment of a peripherally inserted central catheter (PICC). Which actions are appropriate for the nurse to include in the plan of care? Select all that apply.

Select all that apply

Fasten the restraint straps to the movable part of the bed frame using quick-release slip knots.

Release the restraints temporarily every two hours to perform range-of-motion exercises and check skin integrity.

Obtain a standing, as-needed prescription from the attending provider to reapply the restraints if the agitation worsens.

Direct the assistive personnel to evaluate the peripheral pulses and capillary refill in the client's hands.

Attach the restraint straps directly to the side rails of the bed to facilitate rapid removal in an emergency.

Ensure that two fingers can be easily inserted between the restraint padding and the client's wrist.

Show answer & explanation

Answer: Fasten the restraint straps to the movable part of the bed frame using quick-release slip knots.; Release the restraints temporarily every two hours to perform range-of-motion exercises and check skin integrity.; Ensure that two fingers can be easily inserted between the restraint padding and the client's wrist.

Answer

The nurse should fasten straps to the movable bed frame with quick-release knots, release restraints every two hours for care and assessment, and ensure two fingers fit under the restraint padding.

Appropriate care for a client in restraints includes ensuring safety and maintaining circulation. Fastening straps to the movable portion of the bed frame using quick-release knots prevents injury when adjusting the bed and allows for emergency removal. Removing the restraints every two hours is mandatory to assess the skin, promote circulation, and provide range of motion. Ensuring two fingers can fit between the restraint and the client's wrist confirms that the device will not impede blood flow or cause nerve compression.

Step-by-Step Solution

Analyze the client situation and the indication for restraints.

The client has soft wrist restraints for a non-violent, medical-surgical reason (preventing PICC line dislodgment).

Identifying the type of restraint indication (medical-surgical vs. behavioral/violent) determines the required frequency of monitoring and documentation.

Evaluate each option against established safety standards and legal guidelines for restraint use.

Safe practices include quick-release knots, tying to movable bed frames, 2-hour releases, and 2-finger tightness. Unsafe practices include PRN orders, tying to side rails, and delegating assessments.

Applying regulatory standards ensures the client's physical safety, protects their legal rights, and maintains proper nursing delegation.

Select all interventions that represent safe, evidence-based nursing care.

The options involving quick-release knots on the movable frame, 2-hour care intervals, and appropriate fit verification are selected.

These interventions mitigate the risks associated with physical restraints, such as nerve damage, impaired circulation, and strangulation/injury from bed movement.

Key Concept

The safe application, monitoring, and legal documentation requirements for physical restraints in a clinical setting.

Question 1223Question →

A nurse is caring for an $80\text{ kg}$ adult client experiencing status epilepticus. The healthcare provider prescribes a loading dose of intravenous (IV) phenytoin at $15\text{ mg/kg}$ . The client currently has a continuous infusion of $5\%\text{ dextrose in water (D5W)}$ running at $50\text{ mL/hr}$ via a 22-gauge peripheral IV catheter in the right dorsal hand. Based on the pharmacological properties of phenytoin, which of the following is the most appropriate action by the nurse?

Prioritize rapid termination of the seizure by administering the medication undiluted via IV push over 5 minutes to quickly achieve therapeutic serum levels.

Dilute the medication in

250\text{ mL}

5\%\text{ dextrose in water (D5W)}

and administer via a secondary infusion over 45 minutes.

Establish a new 18-gauge IV access in a large proximal vein, dilute the dose in

0.9\%\text{ sodium chloride}

, and infuse over at least 30 minutes.

Pause the D5W infusion, flush the existing 22-gauge IV catheter with

0.9\%\text{ sodium chloride}

, and administer the dose via IV push over 15 minutes.

Show answer & explanation

Answer: Establish a new 18-gauge IV access in a large proximal vein, dilute the dose in $0.9\%\text{ sodium chloride}$ , and infuse over at least 30 minutes.

Answer

Establish a new 18-gauge IV access in a large proximal vein, dilute the dose in

0.9\%\text{ sodium chloride}

, and infuse over at least 30 minutes.

Intravenous phenytoin requires strict adherence to multiple safety parameters. The total dose is

1200\text{ mg}

(

80\text{ kg} \times 15\text{ mg/kg}

). Because the maximum safe administration rate is

50\text{ mg/min}

, the absolute minimum infusion time is 24 minutes. Infusing over 30 minutes achieves a safe rate of

40\text{ mg/min}

. Furthermore, phenytoin precipitates in dextrose and requires dilution in

0.9\%\text{ sodium chloride}

. Because it is a known vesicant that can cause 'purple glove syndrome' (severe localized ischemia and edema), it must be administered through a large-bore catheter (18- or 20-gauge) in a large proximal vein, avoiding small distal veins like those in the hand.

Step-by-Step Solution

Calculate the total required dose based on the client's weight.

80\text{ kg} \times 15\text{ mg/kg} = 1200\text{ mg}

of phenytoin.

Accurate weight-based dosing is critical for determining the total medication volume and subsequent infusion parameters.

Determine the minimum safe infusion time based on the maximum allowable rate.

1200\text{ mg} \div 50\text{ mg/min} = 24\text{ minutes}

Phenytoin has a strict maximum administration rate of

50\text{ mg/min}

in adults to prevent severe hypotension and lethal dysrhythmias.

Evaluate the current IV access and fluid compatibility.

The current 22-gauge IV is too small for a vesicant, and the continuous D5W infusion is incompatible with phenytoin.

Phenytoin precipitates in dextrose and is highly irritating to veins, risking purple glove syndrome if given in small distal veins.

Select the intervention that meets all safety criteria: dose rate, compatibility, and vascular access.

Inserting a new 18-gauge IV in a large vein, diluting with normal saline, and infusing over 30 minutes (

40\text{ mg/min}

) is the only completely safe option.

This comprehensively addresses the pharmacological constraints and safety requirements for IV phenytoin administration.

Key Concept

Safe administration of intravenous phenytoin requires synthesis of weight-based dosing, rate calculation (max

50\text{ mg/min}

), fluid compatibility (only

0.9\%\text{ NaCl}

), and vesicant precautions.

Question 1224Question →

A nurse is assigned to care for a client who requires a transfusion of packed red blood cells (PRBCs) due to symptomatic anemia. Which of the following actions must the nurse perform to ensure safe administration of the blood product? Select all that apply.

Select all that apply

Obtain and document the client's baseline vital signs immediately prior to initiating the transfusion.

Verify the client's identity and the blood product information with a second registered nurse at the bedside.

Check the client's medical record to confirm that a signed informed consent document is present.

Prime the Y-type blood administration tubing with a continuous infusion of 5% dextrose in water (D5W).

Delegate the initial 15-minute vital sign assessment to the unlicensed assistive personnel (UAP).

Program the infusion pump rate so that the unit of packed red blood cells infuses over a 6-hour period.

Show answer & explanation

Answer: Obtain and document the client's baseline vital signs immediately prior to initiating the transfusion.; Verify the client's identity and the blood product information with a second registered nurse at the bedside.; Check the client's medical record to confirm that a signed informed consent document is present.

Answer

The nurse must obtain baseline vital signs, verify the client and blood product with a second registered nurse, and confirm that informed consent is signed in the medical record.

Safe blood transfusion administration requires strict adherence to core safety protocols. Verifying the client and product with a second nurse prevents catastrophic incompatibility. Taking baseline vital signs establishes a reference point to detect adverse reactions early. Finally, ensuring informed consent is signed protects the client's legal rights and confirms they understand the procedure's risks.

Step-by-Step Solution

Review the prescribed orders and the client's medical record.

The nurse confirms the prescription for PRBCs and verifies that a signed informed consent is present.

Blood transfusions carry significant risks, and legal consent must be documented prior to starting the procedure.

Prepare the necessary equipment and perform pre-transfusion assessments.

The nurse primes the blood tubing exclusively with 0.9% sodium chloride and obtains baseline vital signs.

Normal saline is the only compatible fluid for blood transfusions. Baseline vital signs are required to quickly identify any deviations indicating a transfusion reaction.

Verify the blood product at the client's bedside.

The nurse and a second registered nurse confirm the client's identity, blood type, and the donor unit numbers.

A two-nurse independent verification is a mandatory safety standard to prevent fatal ABO incompatibility reactions.

Key Concept

Safe administration protocols for blood products

Question 1225Question →

An admission assessment reveals that a newly arrived client has right-sided hemiparesis due to a recent stroke. The client is documented as a high fall risk. Which nursing action is most appropriate to ensure a safe environment and prevent injury?

Place the call light, water pitcher, and personal belongings on the client's left side.

Raise all four side rails on the bed to keep the client from getting up unassisted.

Instruct the unlicensed assistive personnel (UAP) to complete the admission fall risk assessment.

Initiate contact precautions immediately to minimize the risk of environmental cross-contamination.

Show answer & explanation

Answer: Place the call light, water pitcher, and personal belongings on the client's left side.

Answer

Place the call light, water pitcher, and personal belongings on the client's left side.

Placing frequently used items on the client's unaffected (left) side ensures they can easily reach for what they need without overextending, losing their balance, or attempting to get out of bed unsafely, thereby directly reducing the risk of a fall.

Step-by-Step Solution

Evaluate the client's specific physical deficits and safety risks.

The client has right-sided hemiparesis (weakness) and is at a high risk for falling.

Identifying specific physical limitations is required to implement targeted, individualized safety measures.

Determine the safest environmental setup based on the deficit.

Frequently used items must be placed on the unaffected (left) side.

Ensuring items are easily reachable by the client's strong hand prevents overreaching, loss of balance, and subsequent falls.

Key Concept

Environmental modification for fall prevention in clients with unilateral weakness.

Estimated Time:45s

Question 1226Question →

A nurse is preparing to admit a client who has a draining wound infected with methicillin-resistant *Staphylococcus aureus* (MRSA). Which of the following infection control measures should the nurse implement? Select all that apply.

Select all that apply

Put on a single-use gown before providing direct care to the client.

Assign the client to a private room or cohort them with another client who has an active MRSA infection.

Wear a fit-tested N95 respirator mask when assessing the client's breath sounds.

Leave dedicated non-critical care equipment, such as a stethoscope, inside the client's room.

Maintain the client in a negative-pressure isolation room with the door continuously closed.

Take off all personal protective equipment in the hallway immediately after leaving the client's room.

Show answer & explanation

Answer: Put on a single-use gown before providing direct care to the client.; Assign the client to a private room or cohort them with another client who has an active MRSA infection.; Leave dedicated non-critical care equipment, such as a stethoscope, inside the client's room.

Answer

The correct infection control measures for a client with MRSA include assigning a private room or cohorting with another MRSA-positive client, putting on a single-use gown before direct care, and leaving dedicated non-critical equipment inside the room.

Methicillin-resistant *Staphylococcus aureus* (MRSA) is transmitted via direct and indirect contact. Contact Precautions require placing the client in a private room (or cohorting with another client with the same active infection), using a gown and gloves when interacting with the client or their environment, and dedicating non-critical care equipment (such as a stethoscope or blood pressure cuff) to the client's room to prevent cross-contamination.

Step-by-Step Solution

Identify the pathogen and its mode of transmission based on the clinical scenario.

MRSA is primarily transmitted through direct physical contact or indirect contact with contaminated surfaces.

Determining the transmission route is necessary to select the correct tier of transmission-based precautions.

Determine the appropriate isolation category.

Contact Precautions are required for MRSA.

Standard precautions alone are insufficient for multidrug-resistant organisms spread by contact.

Select the specific interventions that align with Contact Precautions.

A private room, a gown and gloves for patient contact, and dedicated non-critical equipment are required. N95 respirators and negative-pressure rooms are not indicated.

These specific measures prevent the physical transfer of the pathogen to healthcare workers, the environment, and other clients.

Key Concept

Contact Precautions for Multidrug-Resistant Organisms

Question 1227Question →

A nurse is preparing to perform Leopold maneuvers on a client at 36 weeks of gestation to determine fetal presentation and position. Arrange the following steps of the procedure in the correct chronological order, from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct chronological sequence begins with client preparation (emptying the bladder), followed by the first maneuver (palpating the fundus), the second maneuver (palpating the lateral sides), the third maneuver (grasping the lower uterine segment), and concludes with the fourth maneuver (facing the client's feet to palpate the lower abdomen).

Leopold maneuvers must be performed in a specific, systematic sequence to accurately determine fetal position, presentation, and attitude. The client must first empty their bladder to ensure accurate palpation and prevent discomfort. The first maneuver involves palpating the fundus to identify fetal lie. The second maneuver involves palpating the lateral sides of the uterus to locate the smooth fetal back and the irregular extremities. The third maneuver involves grasping the lower uterine segment to confirm the presenting part and assess for engagement. Finally, the fourth maneuver requires the nurse to change positioning and face the client's feet to palpate the lower abdomen, assessing the cephalic prominence and fetal attitude.

Step-by-Step Solution

Identify the necessary preparation before performing abdominal palpation.

Instruct the client to empty their bladder before the assessment.

Ensures client comfort and accuracy of the examination by preventing a full bladder from displacing the uterus.

Determine the first maneuver of Leopold's assessment.

Palpate the uterine fundus to determine which fetal part is located in the upper pole.

Identifies fetal lie and the presenting part in the fundus.

Determine the second maneuver.

Palpate the lateral sides of the abdomen to locate the fetal back and extremities.

Locates the fetal back for optimal placement of the fetal monitor and auscultation of the fetal heart rate.

Determine the third maneuver.

Grasp the lower uterine segment just above the symphysis pubis to confirm the presenting part.

Confirms the presenting part and determines if the fetal head has engaged in the pelvic inlet.

Determine the fourth maneuver.

Face the client's feet and palpate the lower abdomen to assess the cephalic prominence.

Evaluates fetal attitude and the degree of head flexion, which requires a shift in the nurse's positioning.

Key Concept

Leopold Maneuvers Sequence

Question 1228Question →

A nurse is caring for an alert and oriented client with diabetes mellitus who suddenly reports sweating, palpitations, and feeling hungry. Arrange the following nursing actions in the correct order to manage this acute situation.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first assess the blood glucose, then administer 15 grams of a fast-acting carbohydrate, reassess the blood glucose in 15 minutes, and finally provide a snack with complex carbohydrates and protein.

The correct sequence follows the standard protocol for managing acute hypoglycemia in a conscious client. The nurse first assesses the blood glucose to confirm the condition. Next, 15 grams of a fast-acting carbohydrate is given for rapid absorption. After 15 minutes, the nurse reassesses to evaluate the intervention's effectiveness. Finally, once the glucose level is stable, a complex carbohydrate and protein snack is provided to prevent a secondary hypoglycemic event.

Step-by-Step Solution

Confirm the client's condition.

The capillary blood glucose level is assessed to verify hypoglycemia.

Assessment must precede intervention to ensure the correct protocol is followed.

Provide rapid treatment.

15 grams of a fast-acting simple carbohydrate is administered.

A simple carbohydrate quickly absorbs into the bloodstream to rapidly raise the blood glucose level.

Evaluate the treatment's effectiveness.

The blood glucose level is reassessed 15 minutes after the fast-acting carbohydrate is given.

Monitoring is required to determine if the blood glucose is rising to a safe level or if the initial treatment needs to be repeated.

Sustain the blood glucose level.

A snack containing a complex carbohydrate and protein is provided.

Complex carbohydrates and proteins take longer to digest, which helps maintain the blood glucose level and prevents another sudden drop.

Key Concept

The 15/15 Rule for Acute Hypoglycemia Management

Question 1229Question →

A young adult client undergoing a hematopoietic stem cell transplant is maintained in a windowless protective isolation room with a constantly humming high-efficiency particulate air (HEPA) filter. On the eighth day of isolation, the client retreats to the corner of the room, points at the ceiling vent, and screams, "They are pumping toxic gas in here to suffocate me! The hissing is getting louder!" Vital signs reveal a heart rate of 124 bpm and respirations of 26 breaths/minute. Which action is most appropriate for the nurse to take?

Ask the client, "Why do you believe that someone would want to pump toxic gas into your room while you are recovering from your transplant?"

Temporarily deactivate the HEPA filtration system and dim the overhead room lighting in an effort to minimize environmental overstimulation and help the client relax.

State, "I understand you are terrified, but I do not smell any gas. That hissing sound is the air filtration system. Let's examine the machine together."

Direct the unlicensed assistive personnel to remain inside the room and closely monitor the client's behavior while the nurse steps out to page the physician.

Show answer & explanation

Answer: State, "I understand you are terrified, but I do not smell any gas. That hissing sound is the air filtration system. Let's examine the machine together."

Answer

The nurse should validate the client's fear while presenting reality, explaining that the hissing sound comes from the air filtration system, and encourage the client to examine the machine together.

The correct action simultaneously addresses the client's emotional state and the underlying sensory alteration. By stating 'I understand you are terrified,' the nurse validates the client's feelings without validating the delusion itself. By clarifying that there is no gas and identifying the hissing as the air filter, the nurse presents reality and corrects the illusion. Walking to the machine introduces meaningful physical and visual stimuli, which helps counteract the sensory deprivation that is causing the perceptual disturbance.

Step-by-Step Solution

Analyze the client's presentation based on the environment.

The client is in a windowless room with a constant, monotonous humming sound. This environment creates sensory deprivation, which often leads to perceptual alterations such as illusions (misinterpreting the filter's hissing) and delusions.

Identifying the root cause (sensory deprivation vs. sensory overload) is essential for selecting the correct therapeutic intervention.

Evaluate the safety and physiological stability of the client.

The client's elevated heart rate and respiratory rate indicate an acute panic response to the hallucination/delusion, but they are hemodynamically stable. The primary safety risk involves the psychiatric crisis and maintaining the integrity of the protective isolation.

Prioritization requires ensuring immediate physical safety and infection control before addressing psychosocial needs.

Select the most appropriate therapeutic communication and behavioral intervention.

The nurse must verbally validate the client's emotion (fear) without validating the false belief, present reality clearly, and introduce meaningful, concrete sensory stimulation (examining the machine) to break the cycle of sensory deprivation.

Effective management of sensory deprivation requires reorienting the client and replacing monotonous stimuli with interactive, purposeful stimuli.

Key Concept

Management of sensory deprivation and perceptual alterations in isolation environments.

Question 1230Question →

A pediatric client weighing $44\text{ lb}$ is admitted with a severe lower respiratory tract infection. The healthcare provider prescribes intravenous cefotaxime $50\text{ mg/kg/dose}$ every 12 hours. The pharmacy dispenses a reconstituted cefotaxime solution with a concentration of $200\text{ mg/mL}$ . How many milliliters ( $\text{mL}$ ) should the nurse administer per dose?

2.5

Show answer & explanation

Answer: 5

Answer

The nurse should administer

5\text{ mL}

for each dose.

To determine the correct volume, the weight must first be converted to kilograms (

44 \div 2.2 = 20\text{ kg}

). Then, calculate the required dose in milligrams by multiplying the weight by the prescribed dosage (

20\text{ kg} \times 50\text{ mg/kg} = 1000\text{ mg}

). Finally, divide the required dose by the concentration of the available solution (

1000\text{ mg} \div 200\text{ mg/mL} = 5\text{ mL}

). Since the order specifies '

50\text{ mg/kg/dose}

', no further division for administration frequency is needed.

Step-by-Step Solution

Convert the client's weight from pounds to kilograms.

44\text{ lb} \div 2.2\text{ lb/kg} = 20\text{ kg}

Medication dosages are calculated based on metric weight (kilograms).

Calculate the prescribed dose in milligrams (

\text{mg}

20\text{ kg} \times 50\text{ mg/kg/dose} = 1000\text{ mg/dose}

The prescription specifies the amount of medication per kilogram for each individual dose.

Calculate the volume in milliliters (

\text{mL}

) to administer.

1000\text{ mg} \div 200\text{ mg/mL} = 5\text{ mL}

This determines how much of the available solution provides the required milligram dose.

Key Concept

Pediatric weight-based intravenous medication dosage calculation

Alternative Method

Dimensional analysis can solve this in a single equation:

X\text{ mL} = \frac{1\text{ mL}}{200\text{ mg}} \times \frac{50\text{ mg}}{1\text{ kg}} \times \frac{1\text{ kg}}{2.2\text{ lb}} \times 44\text{ lb} = 5\text{ mL}

Estimated Time:1m 30s

Question 1231Question →

An adult client is transferred back to the medical-surgical unit immediately following a percutaneous liver biopsy. To minimize the risk of post-procedure hemorrhage, which of the following positions should the nurse assist the client into?

Right side-lying position with a small rolled towel under the puncture site

Left side-lying position with the knees flexed toward the chest

Supine position with the head of the bed elevated 45 degrees

Prone position with a small pillow placed under the abdomen

Show answer & explanation

Answer: Right side-lying position with a small rolled towel under the puncture site

Answer

The right side-lying position with a small rolled towel under the puncture site is the most appropriate position for a client following a liver biopsy.

Following a percutaneous liver biopsy, the client must be placed in a right side-lying position for several hours. Because the liver is a highly vascular organ, this position utilizes the client's own body weight (often supplemented with a small pillow or rolled towel placed under the puncture site) to apply direct, continuous pressure to the liver capsule against the chest wall. This external pressure promotes hemostasis and significantly reduces the risk of post-procedure hemorrhage.

Step-by-Step Solution

Identify the primary complication associated with the procedure.

The liver is a highly vascular organ, making hemorrhage the most significant immediate post-biopsy complication.

Understanding the risks of a percutaneous liver biopsy directs the immediate post-procedure nursing care.

Determine the anatomical location of the liver and the puncture site.

The liver is located in the right upper quadrant of the abdomen, and the biopsy is typically performed through the right lower rib cage.

Knowing the location is essential to apply targeted pressure to the correct site.

Select the position that applies direct pressure to the anatomical site.

Placing the client on their right side with a rolled towel under the puncture site compresses the liver against the chest wall.

Direct pressure promotes hemostasis and minimizes the risk of internal bleeding.

Key Concept

Post-Procedure Positioning for Hemostasis

Estimated Time:1m 0s

Question 1232Question →

A client with severe hypokalemia is prescribed an intravenous (IV) infusion of $40\text{ mEq}$ of potassium chloride (KCl) diluted in $100\text{ mL}$ of normal saline. Which of the following actions by the nurse is essential for the safe administration of this therapy?

Program the intravenous pump to deliver the medication at a maximum rate of

10\text{ mEq/hr}

Calculate the drip rate to infuse the entire

100\text{ mL}

volume over

15\text{ minutes}

using gravity tubing.

Connect the secondary medication tubing to the Y-site of an infusing total parenteral nutrition (TPN) line.

Delegate the hourly inspection of the intravenous insertion site for signs of infiltration to the unlicensed assistive personnel (UAP).

Show answer & explanation

Answer: Program the intravenous pump to deliver the medication at a maximum rate of $10\text{ mEq/hr}$ .

Answer

The correct action is to program the intravenous pump to deliver the medication at a maximum rate of 10 mEq/hr.

Intravenous potassium chloride is a high-alert medication that can cause fatal cardiac arrhythmias if administered too rapidly. The standard maximum safe rate for a peripheral IV line is

10\text{ mEq/hr}

. It must always be administered using an electronic infusion pump to ensure precise rate control and prevent accidental boluses.

Step-by-Step Solution

Identify the high-alert status of the medication.

Recognize that intravenous potassium chloride (KCl) is a high-alert electrolyte.

Rapid or uncontrolled administration of potassium chloride can lead to fatal cardiac arrhythmias and cardiac arrest.

Determine safe administration protocols for the medication.

Identify that the medication must be diluted, administered via an electronic infusion pump, and infused at a strictly controlled rate.

Gravity tubing or rapid IV push methods are strictly contraindicated because they cannot guarantee a precise, slow delivery rate.

Establish the maximum safe infusion rate.

Determine that the standard maximum safe infusion rate for IV potassium chloride through a peripheral line is 10 mEq/hr.

Rates exceeding this limit significantly increase the risk of phlebitis, burning at the IV site, and systemic cardiac toxicity.

Evaluate the safety of the alternative actions provided.

Rule out the other options by recognizing that TPN requires a dedicated line and IV site assessment cannot be delegated to a UAP.

Maintaining fundamental safety principles for parenteral therapies ensures the correct action is solely focused on the safe infusion rate.

Key Concept

Safe administration of intravenous high-alert medications (Potassium Chloride)

Question 1233Question →

A nurse is developing a feeding and basic care plan for a geriatric client who has right-sided hemiparesis and severe dysphagia following an ischemic stroke. Which specific intervention should the nurse include to promote safe swallowing and minimize the risk of aspiration?

Instruct the client to flex their chin slightly downward toward the chest when swallowing.

Maintain the client in a semi-Fowler's position at a 30-degree angle during meal consumption.

Delegate the continuous monitoring of the client's initial meal to the unlicensed assistive personnel (UAP).

Document the client's frequent coughing during oral intake as an expected, age-related decline in the gag reflex.

Show answer & explanation

Answer: Instruct the client to flex their chin slightly downward toward the chest when swallowing.

Answer

Instruct the client to flex their chin slightly downward toward the chest when swallowing.

The correct intervention utilizes the chin-tuck maneuver, a vital compensatory strategy for clients with dysphagia. Flexing the chin downward toward the chest physically narrows the opening to the airway (larynx) and widens the vallecular space. This structural shift helps prevent food or liquid from passively falling into the trachea and causing aspiration, ensuring basic safety and comfort during nutrition intake.

Step-by-Step Solution

Analyze the client's clinical presentation and risks.

The client has right-sided weakness and severe dysphagia post-stroke, placing them at an exceptionally high risk for airway compromise (aspiration) during meals.

Identifying specific neurological deficits allows the nurse to prioritize targeted, evidence-based feeding interventions over routine care.

Evaluate standard basic care interventions for dysphagia and aspiration prevention.

Safe feeding protocols require maximum upright positioning (90 degrees), placing food on the unaffected side of the mouth, avoiding thin liquids/straws, and using compensatory swallowing techniques.

Evidence-based practice guidelines dictate specific positional and mechanical strategies to actively protect the airway when physiological reflexes are impaired.

Select the option that correctly implements a protective swallowing strategy.

The chin-tuck maneuver is identified as the correct physiological intervention to prevent aspiration.

Tucking the chin downward physically narrows the airway entrance (larynx), directing the food bolus safely backward into the esophagus rather than down the trachea.

Key Concept

Aspiration Precautions and Dysphagia Management

Question 1234Question →

A client who was admitted for diabetic ketoacidosis (DKA) now has a closed anion gap and a blood glucose of $180 \text{ mg/dL}$ ( $10.0 \text{ mmol/L}$ ). The healthcare provider prescribes transitioning the client from the continuous intravenous regular insulin infusion to a subcutaneous insulin regimen. To reduce the risk of physiological decompensation, in what order should the nurse perform the following actions? Arrange the actions from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Confirm the meal is at the bedside, administer the subcutaneous insulin, assist the client to eat, maintain the IV insulin for 1 to 2 hours, and finally discontinue the IV insulin.

When transitioning a client with resolved diabetic ketoacidosis (DKA) from intravenous (IV) to subcutaneous (SQ) insulin, the primary risk reduction goal is preventing a relapse of DKA while avoiding hypoglycemia. Because IV regular insulin has a half-life of only minutes, stopping it abruptly causes immediate insulin deficiency. The nurse must first ensure food is present, give the SQ insulin, have the client eat, and then crucially maintain the IV infusion for an overlap period of

1

2

hours. This allows the SQ insulin to reach a therapeutic level before the IV supply is removed.

Step-by-Step Solution

Assess the client's readiness to eat and ensure the meal is physically present at the bedside.

Hypoglycemia risk is mitigated before administering rapid-acting insulin.

Subcutaneous rapid-acting insulin has an onset of

10

15

minutes. Administering it without guaranteed immediate oral intake risks severe hypoglycemia.

Administer the prescribed subcutaneous dose of insulin.

The subcutaneous insulin depot is created.

This initiates the transition process, but the subcutaneous insulin will take time to absorb and reach therapeutic blood levels.

Instruct the client to consume the meal.

Carbohydrate absorption matches the onset of the rapid-acting insulin.

Provides glucose to prevent hypoglycemia as the insulin begins to peak.

Maintain the continuous intravenous regular insulin infusion for

1

2

hours.

Continuous insulin coverage is maintained during the subcutaneous absorption phase.

Intravenous regular insulin has a half-life of only minutes. An overlap period is required to prevent a critical gap in insulin coverage, which would cause rapid rebound hyperglycemia and potentially reopen the anion gap.

Discontinue the intravenous regular insulin infusion.

The transition to subcutaneous insulin is safely completed.

The subcutaneous insulin has now reached a therapeutic level, making the intravenous infusion unnecessary and preventing late hypoglycemia.

Key Concept

Diabetic Ketoacidosis (DKA) Intravenous to Subcutaneous Insulin Transition Protocol

Question 1235Question →

A nurse is assisting a client during the second stage of labor. After the fetal head is delivered, it immediately retracts firmly against the maternal perineum. Arrange the following nursing actions in the correct order of priority from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for managing shoulder dystocia is to first call for help, then instruct the client to stop pushing, followed by assisting with the McRoberts maneuver, applying suprapubic pressure, and finally documenting the event.

When shoulder dystocia occurs (indicated by the 'turtle sign' where the head retracts), the immediate priority is to summon help, often remembered by the 'H' in the HELPERR mnemonic. Next, the nurse must prevent further impaction by instructing the client not to push. The first-line physical intervention is the McRoberts maneuver, which resolves a large percentage of dystocias by altering pelvic angles. If this fails, suprapubic pressure is applied to manually push the shoulder under the pubic bone. Finally, after the newborn is delivered and the acute emergency is managed, meticulous documentation of the timing of the head delivery and all maneuvers is required.

Step-by-Step Solution

Summon additional help.

Obstetric and neonatal teams are notified of the emergency.

Shoulder dystocia requires a coordinated team approach for maternal maneuvers and potential neonatal resuscitation.

Halt maternal pushing efforts.

The client stops bearing down.

Pushing worsens the impaction of the fetal shoulder against the maternal pelvis.

Implement the McRoberts maneuver.

The client's thighs are hyperflexed to the abdomen.

This alters the maternal pelvic geometry, straightening the sacrum and opening the pelvic outlet.

Apply suprapubic pressure.

Downward pressure is applied over the symphysis pubis.

This helps manually dislodge the anterior fetal shoulder from behind the pubic bone.

Record the sequence of events.

Times and specific maneuvers are documented.

Meticulous documentation is required for the medical record, but only after the acute crisis is managed.

Key Concept

Nursing priorities during an obstetric emergency (Shoulder Dystocia)

Question 1236Question →

A clinical nurse is guiding a client with generalized deconditioning on how to safely transfer from a seated position in a standard armchair to a standing position using a rolling walker. Place the following instructions and actions in the correct sequential order to prevent injury.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first apply the transfer belt, have the client scoot to the edge of the chair, place their hands on the chair's armrests, push up to a standing position, and finally grasp the walker handles once balanced.

Safe transferring with a walker requires strict adherence to biomechanics and device safety rules. The nurse must first apply a transfer belt to ensure client safety during the movement. Next, the client must scoot to the edge of the chair to bring their center of gravity forward. Crucially, the client must push up from the chair's armrests rather than pulling on the walker. Pulling on a wheeled walker can cause it to tip or roll, leading to a severe fall. Once the client has pushed up, is standing upright, and has established equilibrium, they can safely transfer their hands one at a time to the walker.

Step-by-Step Solution

Apply the transfer belt.

The nurse has a secure handhold on the client.

Applying the belt first ensures safety is established before initiating any movement.

Instruct the client to scoot to the edge of the chair.

The client's center of gravity is brought forward.

This reduces the distance the client must lift their body weight and prepares them for an efficient transfer.

Direct the client to place hands on the chair armrests.

The client's arms are positioned to provide upward thrust.

Using the stable chair for leverage prevents the dangerous mistake of pulling on the lightweight walker.

Have the client push up to stand.

The client transitions from sitting to full standing.

Combining the forward lean with arm and leg extension safely elevates the client against gravity.

Instruct the client to grasp the walker handles.

The client is fully stabilized with the assistive device.

Waiting until balance is achieved ensures the client does not rely on the walker while in a vulnerable, off-balance position.

Key Concept

Assistive Device Safety and Proper Transfer Biomechanics

Estimated Time:1m 0s

Question 1237Question →

A nurse on a medical-surgical unit is reviewing the morning laboratory results for four assigned clients. To reduce the risk of a life-threatening complication, which client's result requires the most immediate intervention?

A client receiving a continuous intravenous heparin infusion who has a platelet count of

42,000/\text{mm}^3

(

42 \times 10^9/\text{L}

A client with severe chronic obstructive pulmonary disease (COPD) who has an arterial blood gas PaCO

_2

54 \text{ mm Hg}

A client who is two days postoperative following an open appendectomy with a white blood cell count of

12,000/\text{mm}^3

(

12.0 \times 10^9/\text{L}

A client prescribed daily oral furosemide for heart failure who has a serum potassium level of

4.2 \text{ mEq/L}

(

4.2 \text{ mmol/L}

Show answer & explanation

Answer: A client receiving a continuous intravenous heparin infusion who has a platelet count of $42,000/\text{mm}^3$ ( $42 \times 10^9/\text{L}$ ).

Answer

The client receiving intravenous heparin with a platelet count of

42,000/\text{mm}^3

A platelet count of

42,000/\text{mm}^3

(normal is

150,000

400,000/\text{mm}^3

) in a client receiving an intravenous anticoagulant is critically low. This places the client at imminent risk for spontaneous, severe hemorrhage or indicates the development of Heparin-Induced Thrombocytopenia (HIT). The nurse must immediately stop the infusion and notify the provider to reduce the risk of a fatal bleeding event.

Step-by-Step Solution

Analyze the normal reference ranges for the provided laboratory values.

Normal platelets:

150,000

400,000/\text{mm}^3

. Normal PaCO

_2

35

45 \text{ mm Hg}

. Normal WBC:

5,000

10,000/\text{mm}^3

. Normal Potassium:

3.5

5.0 \text{ mEq/L}

Establishing baseline normal values is required before identifying abnormalities.

Evaluate the clinical context for each abnormal finding.

The COPD client's elevated PaCO

_2

is an expected chronic condition. The postoperative client's slightly elevated WBC is expected inflammation. The client on heparin has critically low platelets.

Context determines whether an abnormal value is an expected chronic state, a normal physiological response, or an acute emergency.

Prioritize the finding that poses the most immediate, life-threatening risk to the client.

The severe thrombocytopenia (platelets

42,000/\text{mm}^3

) while on a high-alert anticoagulant poses a massive risk for internal bleeding.

Nurses must prioritize interventions that prevent imminent harm and rapidly mitigate severe risks.

Key Concept

Prioritization and Risk Reduction in Laboratory Interpretation

Question 1238Question →

An adult client with a history of schizophrenia is brought to the emergency department from a residential care facility. The client exhibits "lead-pipe" muscle rigidity, a core body temperature of $104.2^\circ\text{F}$ ( $40.1^\circ\text{C}$ ), profuse diaphoresis, and a fluctuating level of consciousness. The client's daily medication regimen includes haloperidol and fluoxetine. Based on this clinical presentation, which of the following nursing actions should be prioritized? (Select all that apply.)

Select all that apply

Withhold all scheduled doses of haloperidol and notify the healthcare provider immediately.

Prepare to administer intravenous dantrolene sodium as prescribed.

Initiate active external cooling measures such as cooling blankets and ice packs.

Delegate the ongoing assessment of the client's vital signs and neurological status to the unlicensed assistive personnel (UAP).

Administer the scheduled dose of haloperidol to rapidly manage the client's altered mental status and severe agitation.

Administer prescribed intravenous emergency medications via secondary piggyback into the client's continuous total parenteral nutrition (TPN) line.

Show answer & explanation

Answer: Withhold all scheduled doses of haloperidol and notify the healthcare provider immediately.; Prepare to administer intravenous dantrolene sodium as prescribed.; Initiate active external cooling measures such as cooling blankets and ice packs.

Answer

The correct actions are to withhold all scheduled doses of haloperidol, prepare to administer intravenous dantrolene sodium, and initiate active external cooling measures.

Neuroleptic malignant syndrome (NMS) is a rare but life-threatening pharmacological emergency caused by antipsychotic medications (like haloperidol). It is characterized by severe autonomic instability, extreme hyperpyrexia, altered mental status, and 'lead-pipe' muscle rigidity. The immediate nursing and medical priorities are discontinuing the offending medication, administering specific antidotes such as dantrolene (a muscle relaxant) to halt the muscular hypermetabolism, and aggressively treating the hyperpyrexia with external cooling measures.

Step-by-Step Solution

Analyze the client's clinical presentation and medication history.

The combination of haloperidol use, lead-pipe rigidity, extreme hyperpyrexia, and autonomic instability identifies Neuroleptic Malignant Syndrome (NMS).

Recognizing the specific toxidrome is required to implement the correct pharmacological and physiological interventions.

Determine the immediate pharmacological priorities.

The offending drug (haloperidol) must be stopped immediately, and specific antidotes/relaxants (dantrolene) must be prepared.

Continuing the causative agent will worsen the life-threatening reaction, while dantrolene directly counteracts the extreme muscle contraction.

Identify physiological safety and supportive care needs.

External cooling is required for hyperpyrexia, the RN must maintain direct assessment of the unstable client, and safe IV administration rules (avoiding the TPN line) must be upheld.

Supportive care prevents mortality in NMS, and strict adherence to scope of practice and IV compatibility ensures patient safety during an emergency.

Key Concept

Pharmacological Management of Neuroleptic Malignant Syndrome (NMS) and Intravenous Safety

Estimated Time:1m 30s

Question 1239Question →

A nurse is monitoring a client who is receiving an intravenous transfusion of packed red blood cells (PRBCs). Ten minutes into the transfusion, the client develops sudden, severe lower back pain, tachycardia, and hypotension. Place the following nursing actions in the correct priority order to manage this complication.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Stop the transfusion, disconnect the blood tubing, attach new saline tubing, assess the client, notify the healthcare provider and blood bank, and return the blood product to the blood bank.

In the event of a severe transfusion reaction, the priority is minimizing harm. The sequence follows the nursing process adapted for emergencies: intervene to stop harm (stop transfusion, disconnect tubing, maintain access with new saline), assess the impact (vital signs), communicate for further orders (notify HCP), and perform follow-up diagnostics (return product to blood bank).

Step-by-Step Solution

Stop the continuous flow of the packed red blood cells.

The client receives no further incompatible or contaminated blood.

Lower back pain, tachycardia, and hypotension are classic signs of a life-threatening acute hemolytic transfusion reaction. Immediate cessation is the most critical intervention.

Disconnect the existing blood administration set from the IV hub.

The source of the reaction is physically separated from the client's vascular access.

Leaving the tubing connected risks inadvertently pushing more of the reactant into the bloodstream during subsequent flushes.

Connect a new IV tubing setup primed with normal saline.

Intravenous access is maintained for emergency medications and volume expansion.

Normal saline must be infused through new tubing to prevent clotting of the IV site and to treat the resulting hypotension.

Perform a focused physiological assessment.

Baseline data during the reaction is obtained.

The nurse needs current vital signs, airway status, and hemodynamic parameters to accurately report the client's condition.

Communicate with the healthcare provider and blood bank.

Emergency medical orders are obtained and the facility's reaction protocol is activated.

Medical intervention (such as vasopressors, antihistamines, or diuretics) is required, and the blood bank must investigate the cause.

Package and send the blood bag, tubing, and required lab specimens.

Diagnostic testing can determine the exact cause of the reaction.

Analyzing the remaining product and the client's post-reaction blood and urine is necessary for root-cause analysis.

Key Concept

Management of Acute Hemolytic Transfusion Reactions

Question 1240Question →

Following shift report on a progressive care unit, the registered nurse establishes the initial rounding order for assigned clients. Which client requires immediate evaluation?

A client admitted with a heart failure exacerbation who is newly restless and has a blood pressure of 90/76 mm Hg.

A client 3 days post-myocardial infarction who reports sharp chest pain that worsens with deep inspiration and improves when leaning forward.

A client with a deep vein thrombosis receiving a continuous intravenous heparin infusion who has an activated partial thromboplastin time (aPTT) of 75 seconds.

A client with chronic atrial fibrillation scheduled for a cardioversion who has an international normalized ratio (INR) of 2.6.

Show answer & explanation

Answer: A client admitted with a heart failure exacerbation who is newly restless and has a blood pressure of 90/76 mm Hg.

Answer

The client admitted with a heart failure exacerbation who is newly restless and has a blood pressure of 90/76 mm Hg requires immediate evaluation.

The correct answer describes a client exhibiting early signs of cardiogenic shock. New-onset restlessness is a highly sensitive early indicator of hypoxia and decreased cerebral perfusion. Furthermore, a blood pressure of 90/76 mm Hg reveals a severely narrowed pulse pressure of 14 mm Hg. A normal pulse pressure is typically 30 to 50 mm Hg; a significantly narrow pulse pressure in a heart failure client indicates the left ventricle is failing to generate adequate stroke volume. This client is highly unstable and requires immediate life-saving intervention.

Step-by-Step Solution

Analyze the clinical presentation of the client with a heart failure exacerbation.

The client has new-onset restlessness and a blood pressure of 90/76 mm Hg, which yields a pulse pressure of 14 mm Hg.

Identifying acute changes in neurological status and vital sign trends is essential for detecting early clinical deterioration.

Evaluate the physiological significance of the narrowed pulse pressure.

A pulse pressure under 25 to 30 mm Hg indicates severely decreased stroke volume and failing left ventricular function.

In the context of heart failure, a narrow pulse pressure combined with restlessness (a sign of cerebral hypoxia) strongly suggests the development of life-threatening cardiogenic shock.

Compare the stability and acuity of the remaining clients.

The other clients exhibit an expected, non-life-threatening complication of a myocardial infarction (pericarditis) and expected therapeutic laboratory values (aPTT of 75 seconds; INR of 2.6).

Safe prioritization requires the nurse to evaluate the client with the most acute, unexpected, and hemodynamically unstable condition first.

Key Concept

In prioritization, sudden neurological changes (restlessness) and vital sign trends indicating decreased cardiac output (narrowing pulse pressure) signal impending shock and demand immediate intervention.

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