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Question 1241Question →

A nurse is caring for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache and blurred vision. The nurse observes profuse facial diaphoresis and records a blood pressure of 215/115 mm Hg. In what order should the nurse perform the following interventions? Arrange from first to last action.

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Answer

The correct sequence of interventions is: 1) Elevate the head of the bed, 2) Loosen constrictive clothing, 3) Inspect the urinary catheter, 4) Administer antihypertensive medication, and 5) Document the event.
In the management of autonomic dysreflexia, the nurse must prioritize actions that immediately reduce the risk of a catastrophic complication, such as a hemorrhagic stroke. Elevating the head of the bed is the fastest and most effective first step to lower blood pressure orthostatically. Subsequent steps focus on systematically removing noxious stimuli, starting with quick external fixes (loosening clothing) followed by assessing internal causes (bladder distention). Pharmacological intervention is reserved for refractory hypertension, and documentation occurs only after complete stabilization.

Step-by-Step Solution

1
Elevate the head of the bed to a high Fowler's position.
The client's upper body is raised to a 90-degree angle.
This is the most critical first step because it leverages gravity to induce orthostatic hypotension, rapidly pooling blood in the lower extremities to lower the dangerously high systemic blood pressure and protect the brain.
2
Loosen any constrictive clothing or tight abdominal binders.
External physical pressure on the client's body is relieved.
Tactile or physical restrictions below the level of the spinal cord injury act as noxious stimuli that trigger the reflex. Removing them quickly helps mitigate the autonomic response.
3
Inspect the indwelling urinary catheter tubing for kinks and ensure dependent drainage.
The primary internal trigger for the dysreflexic episode is evaluated and resolved if present.
Bladder distention is the most frequent cause of autonomic dysreflexia. Ensuring patency of the urinary catheter removes this internal noxious stimulus.
4
Administer the prescribed PRN rapid-acting intravenous antihypertensive medication.
Pharmacological agents are introduced into the bloodstream to lower blood pressure.
If mechanical interventions (positioning, loosening clothing, bladder/bowel management) do not resolve the severe hypertension, medications must be given to prevent life-threatening complications.
5
Document the clinical presentation, interventions performed, and the client's physiological response.
The event is permanently recorded in the client's electronic health record.
Documentation is critical but is always performed last, after the acute, life-threatening emergency has been fully managed and the client is safe.

Key Concept

Prioritization of care for a client experiencing autonomic dysreflexia, focusing on immediate reduction of blood pressure followed by the elimination of noxious stimuli.
Question 1242Question →

During a surgical procedure under general anesthesia, the intraoperative monitor reveals a sudden, rapid rise in end-tidal carbon dioxide (ETCO2). Simultaneously, the client develops generalized muscle rigidity and unexpected severe sinus tachycardia. Recognizing a malignant hyperthermia crisis, in which order must the nurse execute or assist with the following collaborative interventions? Arrange the actions from highest priority (first) to lowest priority (last).

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Answer

The correct sequence prioritizes removing the causative agent first, followed by supporting airway/breathing, administering the definitive antidote, treating the hyperthermia symptomatically, and finally establishing monitoring for secondary complications.
In any acute emergency, the nursing process and prioritization frameworks dictate that removing the immediate life-threatening cause is paramount. For malignant hyperthermia, this means stopping the triggering anesthetics immediately. Following the ABC framework, the next priority is to support ventilation and oxygenation (Breathing) because the hypermetabolic state creates extreme oxygen demand and CO2 production. Once ventilation is supported, circulation and pharmacological reversal take precedence via the administration of dantrolene, the definitive antidote. Only after these immediate life-saving measures are taken should the team focus on symptom management (active cooling) and ongoing assessment for secondary complications (urinary catheterization for rhabdomyolysis).

Step-by-Step Solution

1
Discontinue the administration of volatile inhaled anesthetics and succinylcholine.
The causative pharmacologic triggers are removed from the client's system.
Halting the trigger is the absolute first step in malignant hyperthermia to stop the unregulated release of calcium from the sarcoplasmic reticulum.
2
Hyperventilate the client with 100% oxygen at a high flow rate.
Hypoxemia is prevented and excess carbon dioxide is rapidly eliminated.
The hypermetabolic state causes severe oxygen consumption and CO2 production; aggressive ventilation (Breathing) immediately follows securing the trigger.
3
Administer reconstituted intravenous dantrolene sodium.
Muscle relaxation occurs and the hypermetabolic crisis is pharmacologically reversed.
Dantrolene is the only specific antidote for malignant hyperthermia and must be given promptly after airway and breathing are managed.
4
Initiate active surface cooling measures and infuse chilled intravenous fluids.
The client's rapidly rising core body temperature is systematically lowered.
Hyperthermia is a severe but secondary symptom of the metabolic crisis; cooling measures prevent brain damage but follow ABCs and antidote administration.
5
Insert an indwelling urinary catheter to monitor hourly urine output.
Urine output and color (monitoring for myoglobinuria) are continuously assessed.
Assessing for complications such as acute kidney injury secondary to rhabdomyolysis is vital but represents a lower-acuity monitoring intervention compared to acute resuscitation.

Key Concept

Prioritization of care during a malignant hyperthermia crisis strictly follows immediate removal of the triggering agent, followed by the ABCs (Airway, Breathing, Circulation/Antidote).
Question 1243Question →

A hospitalized client is receiving a continuous infusion of a maintenance fluid through a single-lumen peripheral venous catheter. The healthcare provider has prescribed a scheduled intravenous (IV) bolus medication that is physically incompatible with the current infusion. Arrange the following actions in the correct chronological order to safely deliver the medication.

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Answer

The correct sequence for administering an incompatible IV bolus medication through a continuous infusion line is to first stop the continuous infusion, flush the line with normal saline, administer the medication, flush the line again with normal saline at the same rate the medication was given, and finally restart the continuous infusion.
When administering an IV bolus medication that is incompatible with a continuous infusion through the same line, the nurse must prevent the two fluids from mixing. This is achieved using the SAS (Saline-Administer-Saline) method. The nurse stops the continuous infusion and flushes the line with a compatible solution (like 0.9% sodium chloride) to clear the tubing. After administering the medication over the prescribed time, the nurse flushes the line again to clear the medication before restarting the incompatible continuous infusion. This prevents precipitation in the line and ensures safe drug delivery.

Step-by-Step Solution

1
Stop the continuous intravenous infusion.
The flow of the incompatible maintenance fluid is halted.
Prevents the incompatible fluid from mixing with the medication in the intravenous line.
2
Flush the catheter with 10 mL of 0.9% sodium chloride.
The intravenous line is cleared of the incompatible maintenance fluid.
Creates a safe, neutral barrier in the tubing prior to medication administration.
3
Administer the prescribed intravenous bolus medication.
The medication is delivered to the client.
Provides the therapeutic intervention over the safe, recommended duration.
4
Flush the catheter again with 10 mL of 0.9% sodium chloride at the same administration rate.
The medication is completely cleared from the tubing.
Ensures the full dose is received and prevents rapid infusion of residual medication.
5
Restart the continuous maintenance fluid infusion.
The original fluid therapy is resumed.
Maintains the client's prescribed fluid requirements after the medication has been safely delivered.

Key Concept

Administration of an incompatible IV bolus medication via an existing continuous infusion line requires the Saline-Administer-Saline (SAS) technique to prevent drug precipitation and ensure patient safety.
Question 1244Question →

A nurse is preparing to perform an abdominal assessment on a client who is receiving continuous nasogastric (NG) tube suctioning for a bowel obstruction. Which action should the nurse take to ensure an accurate physical assessment?

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Answer: Temporarily turn off the nasogastric tube suction before auscultating for bowel sounds.

Answer

Temporarily turn off the nasogastric tube suction before auscultating for bowel sounds.
When assessing the abdomen of a client with an active nasogastric tube connected to suction, the nurse must temporarily turn off the suction before auscultation. If the suction is left on, the sound of the stomach contents and air moving through the tube can mimic normal or hyperactive bowel sounds, making it impossible to accurately assess the client's true gastrointestinal status.

Step-by-Step Solution

1
Identify the standard sequence for an abdominal assessment.
The correct sequence is inspect, auscultate, percuss, and palpate.
Performing palpation or percussion before auscultation can alter natural bowel activity.
2
Consider the impact of the client's continuous NG tube suctioning.
The mechanical sound of the suction device can be transmitted through the abdominal wall.
Suction noises can easily be mistaken for hyperactive bowel sounds or obscure hypoactive sounds.
3
Determine the correct nursing intervention for accurate auscultation.
The suction must be temporarily paused while listening with the diaphragm of the stethoscope.
This isolates the client's physiological sounds from the mechanical equipment.

Key Concept

Abdominal Assessment Techniques and Sequence
Question 1245Question →

Following a therapeutic right-sided thoracentesis to relieve a pleural effusion, a client on the medical-surgical unit suddenly exhibits acute agitation, tachypnea, and sharp right-sided chest pain. To mitigate the risk of severe physiological compromise, which actions must the nurse perform immediately? (Select all that apply.)

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Answer: Place the client in an upright, seated posture to optimize respiratory mechanics.; Alert the rapid response team and the primary healthcare provider.; Coordinate with the radiology department for a stat portable chest x-ray.

Answer

The correct actions are to place the client in an upright posture, alert the rapid response team, and coordinate a stat portable chest x-ray.
The client's presentation of acute agitation, tachypnea, and sharp chest pain following a thoracentesis is highly suspicious for a pneumothorax, a potentially life-threatening complication. Immediate risk reduction involves supporting the airway and breathing by placing the client in an upright position. Because this is a medical emergency, the nurse must activate the rapid response team to bring advanced critical care support to the bedside. Additionally, coordinating a stat portable chest x-ray is essential to confirm the diagnosis and guide definitive life-saving interventions, such as chest tube insertion.

Step-by-Step Solution

1
Analyze the clinical presentation.
The sudden onset of agitation, tachypnea, and sharp chest pain following a thoracentesis strongly suggests a pneumothorax.
Recognizing signs of life-threatening procedural complications is the first step in physiological risk reduction.
2
Prioritize interventions based on the ABCs (Airway, Breathing, Circulation).
Positioning the client upright maximizes lung expansion and immediately improves respiratory mechanics.
Airway and breathing are the highest priorities during an acute clinical deterioration.
3
Identify the need for collaborative care and rapid diagnostics.
The rapid response team is notified for advanced support, and a chest x-ray is requested to confirm the complication.
A pneumothorax requires definitive medical intervention, such as chest tube insertion, which must be guided by diagnostic imaging.

Key Concept

Post-thoracentesis complications and physiological risk reduction.
Question 1246Question →

A nurse is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, pounding headache. The nurse notes profuse diaphoresis on the client's face and neck, and a blood pressure reading of 210/115 mm Hg. Arrange the following nursing actions in the correct priority order from first to last.

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Answer

The correct sequence of actions for managing autonomic dysreflexia is to first elevate the head of the bed, then check for bladder distention, followed by checking for bowel impaction, administering antihypertensive medication if unresolved, and finally documenting the event.
Autonomic dysreflexia is a medical emergency characterized by severe hypertension triggered by a noxious stimulus below the level of the spinal cord injury. The immediate priority is to lower the blood pressure mechanically by placing the client in a high-Fowler's position. Next, the nurse must locate and remove the triggering stimulus, starting with the most common cause (bladder distention) followed by the next most common (bowel impaction). If these non-pharmacological interventions fail, antihypertensive medications are administered. Documentation occurs last, after the client is stabilized.

Step-by-Step Solution

1
Elevate the head of the bed to a high-Fowler's position.
The client's upper body is raised to a 90-degree angle.
This immediately induces orthostatic pooling of blood in the lower extremities, helping to lower the dangerously high blood pressure.
2
Check the urinary catheter tubing for kinks or assess the bladder for distention.
The most common trigger for autonomic dysreflexia is evaluated.
Removing the noxious stimulus is the primary treatment; bladder issues are the most frequent cause.
3
Examine the client for signs of fecal impaction.
The second most common trigger is evaluated.
If the bladder is not the source, the bowel is the next logical system to assess for a noxious stimulus.
4
Administer the prescribed rapid-acting antihypertensive medication.
Medication is delivered to artificially lower the blood pressure.
This is necessary if the stimulus cannot be removed or if the blood pressure remains dangerously high despite removing the stimulus.
5
Document the event, the interventions provided, and the client's response.
The medical record is updated with accurate information.
Administrative and legal requirements are fulfilled after the client is safe and stable.

Key Concept

Management of Autonomic Dysreflexia
Question 1247Question →

A nurse is changing the administration set for a client's central venous catheter. The client suddenly gasps, reports sharp chest pain, and becomes profoundly dyspneic and tachycardic. Suspecting a central line-associated air embolism, arrange the following nursing actions in the correct priority sequence to minimize physiological risk.

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Answer

The correct sequence is to first clamp the catheter, then position the client in a left lateral Trendelenburg position, followed by administering high-flow oxygen, notifying the Rapid Response Team, and finally assessing continuous vital signs.
In the event of a suspected air embolism, the nurse must prioritize immediate actions that physically stop the embolism from worsening. Clamping the line prevents more air from entering. The left lateral Trendelenburg position traps the existing air in the right atrium/ventricle. Oxygen administration supports tissue perfusion and shrinks the nitrogen bubble. Only after these life-saving nursing interventions are applied should the nurse escalate the situation to the medical team and proceed with ongoing monitoring.

Step-by-Step Solution

1
Clamp the central venous catheter tubing immediately.
Further air entry into the central circulation is halted.
Source control is the most critical first step to prevent a fatal volume of air from entering the vascular system.
2
Place the client in a left lateral Trendelenburg position.
The air embolus is localized to the right side of the heart.
This positioning prevents the air from migrating into the pulmonary artery and causing right ventricular outflow tract obstruction.
3
Administer high-flow oxygen via a non-rebreather mask.
Systemic oxygenation is supported and nitrogen absorption is accelerated.
High-flow oxygen reduces hypoxia-induced tissue damage and decreases the size of the air embolus.
4
Notify the Rapid Response Team and the healthcare provider.
Emergency medical personnel are dispatched to the client's room.
Medical intervention, such as aspiration of the air from the right ventricle, may be required.
5
Assess continuous vital signs and prepare for potential cardiopulmonary resuscitation.
The client's hemodynamic status is closely monitored for deterioration.
An air embolism can rapidly lead to cardiovascular collapse, requiring immediate resuscitation efforts.

Key Concept

Management of a central venous catheter air embolism requires immediate source control and specific client positioning to prevent circulatory collapse.
Question 1248Question →

A nurse is caring for a client who is receiving a continuous transfusion of packed red blood cells (PRBCs) through a primary peripheral intravenous (IV) catheter. The client's latest laboratory results reveal a critically low serum potassium level of 2.3 mEq/L, and the healthcare provider prescribes a dose of 40 mEq of IV potassium chloride. A second, saline-locked peripheral IV access is available on the client's other arm. Which of the following is the safest nursing action to implement?

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Answer: Connect a pre-mixed potassium chloride infusion to the saline-locked IV access and administer it via an electronic pump at a maximum rate of 10 mEq per hour.

Answer

Connect a pre-mixed potassium chloride infusion to the saline-locked IV access and administer it via an electronic pump at a maximum rate of 10 mEq per hour.
The safest and standard practice for administering intravenous potassium chloride is to use a pre-mixed solution (to avoid mixing errors) and administer it via an electronic infusion pump. For a peripheral intravenous line, the maximum safe infusion rate is 10 mEq per hour to prevent burning at the site and to avoid life-threatening cardiac arrhythmias.

Step-by-Step Solution

1
Evaluate the prescribed medication and the client's current intravenous access.
The client requires a high-alert medication (40 mEq of IV potassium chloride). One IV line is infusing blood products, and a second line is saline-locked and available for use.
Identifying available access points is essential to prevent medication incompatibilities and ensure safe delivery.
2
Determine the safe administration rate and method for intravenous potassium chloride.
Potassium chloride must be properly diluted and administered via an infusion pump. The rate must not exceed 10 mEq per hour through a peripheral line.
Rapid infusion or direct IV push of potassium causes fatal cardiac arrhythmias.
3
Identify contraindications related to the current blood transfusion and delegation rules.
Potassium cannot be mixed with blood products, and the RN must personally assess the IV site for complications during the infusion.
Blood products are only compatible with 0.9% sodium chloride. Furthermore, assessing an IV site for vesicant extravasation requires nursing clinical judgment and cannot be delegated.

Key Concept

Intravenous potassium chloride administration safety, compatibility, and nursing delegation.
Question 1249Question →

A client in the emergency department is experiencing a severe panic attack and is visibly hyperventilating. Which of the following assessment findings and laboratory values indicate the client is developing respiratory alkalosis? Select all that apply.

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Answer: Arterial blood pH of 7.52; Partial pressure of arterial carbon dioxide (PaCO2) of 28 mm Hg; Client reports tingling and numbness in the hands

Answer

The findings that indicate respiratory alkalosis are an arterial blood pH of 7.52, a PaCO2 of 28 mm Hg, and client reports of tingling and numbness in the hands.
Hyperventilation, common during severe panic attacks, leads to the excessive "blowing off" of carbon dioxide. Because carbon dioxide functions as an acid in the bloodstream, its rapid depletion causes the blood pH to rise above the normal upper limit of 7.45 (alkalosis) and the PaCO2 to fall below the normal lower limit of 35 mm Hg. Additionally, an alkalotic state increases the binding of circulating calcium to albumin, resulting in a functional hypocalcemia. This drop in ionized calcium triggers neuromuscular excitability, which frequently presents as tingling and numbness in the extremities.

Step-by-Step Solution

1
Identify the primary physiological impact of hyperventilation.
Hyperventilation causes the rapid elimination of carbon dioxide (CO2) from the lungs.
Carbon dioxide acts as an acid in the body; losing it shifts the blood pH toward alkalinity.
2
Determine the expected Arterial Blood Gas (ABG) values for this condition.
The ABG will show a decreased PaCO2 (below 35 mm Hg) and an elevated pH (above 7.45).
The decreased PaCO2 is the primary respiratory disturbance, which directly causes the systemic alkalosis (high pH).
3
Identify common clinical manifestations associated with systemic alkalosis.
Neuromuscular excitability, such as tingling, numbness, and tetany, are expected findings.
Alkalosis causes a temporary drop in ionized serum calcium, leading to the clinical signs of hypocalcemia.

Key Concept

Respiratory alkalosis occurs when hyperventilation causes excessive elimination of carbon dioxide, leading to a decreased PaCO2, an elevated pH, and secondary hypocalcemia causing neuromuscular symptoms.
Estimated Time:1m 0s
Question 1250Question →

A mental health clinic nurse evaluates a client who recently experienced a traumatic home eviction. The client paces the examination room, wrings their hands, and states, "I have nowhere to go. I am a complete failure as a provider." Which of the following responses by the nurse demonstrate therapeutic communication? Select all that apply.

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Answer: You are feeling overwhelmed and unsure of where to go next.; This must be an incredibly difficult situation for you to face.; Let us sit down together and talk about what happened.

Answer

The correct responses are those that utilize restatement ('feeling overwhelmed'), demonstrate empathy ('incredibly difficult situation'), and offer self ('sit down together').
Therapeutic communication focuses on validating the client's feelings, exploring their emotional state, and establishing a trusting nurse-client relationship. Restating the client's feelings, offering empathy, and offering one's presence (offering self) are all established therapeutic techniques. These approaches encourage the client to express their emotions openly without feeling judged, which is the immediate priority during a psychological crisis.

Step-by-Step Solution

1
Analyze the client's emotional state and the scenario.
The client is experiencing acute anxiety and feelings of worthlessness secondary to a major life stressor (eviction).
Identifying the emotional baseline is required to select communication techniques that will de-escalate anxiety rather than increase it.
2
Evaluate each nursing response for therapeutic versus non-therapeutic techniques.
Identify validating and explorative statements while discarding statements that advise, judge, or provide false reassurance.
The NCLEX requires nurses to differentiate between responses that facilitate client-led dialogue and those that create communication blocks.
3
Select all options that use active listening, empathy, and reflection.
The responses focusing on the client's current feelings, offering presence, and validating the struggle are correctly identified as therapeutic.
These techniques empower the client, promote emotional safety, and form the foundation of psychiatric nursing care.

Key Concept

Therapeutic Communication Techniques
Question 1251Question →

A nurse is caring for a client admitted with acute pancreatitis. Which of the following assessment findings should the nurse identify as indicators that the client is developing systemic inflammatory response syndrome (SIRS)? Select all that apply.

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Answer: Heart rate of 112 beats/min; Respiratory rate of 28 breaths/min; White blood cell count of 16,500/mm³

Answer

The indicators of SIRS in this scenario include a heart rate of 112 beats/min, a respiratory rate of 28 breaths/min, and a white blood cell count of 16,500/mm³.
Systemic inflammatory response syndrome (SIRS) is a widespread inflammatory response to an insult, such as severe pancreatitis. It is defined by two or more of the following: temperature greater than 38.0°C or less than 36.0°C, heart rate greater than 90 beats/min, respiratory rate greater than 20 breaths/min (or PaCO2 < 32 mm Hg), and a white blood cell count greater than 12,000/mm³ or less than 4,000/mm³. The options presenting a heart rate of 112 beats/min, a respiratory rate of 28 breaths/min, and a WBC of 16,500/mm³ all exceed these thresholds and are clear indicators of SIRS.

Step-by-Step Solution

1
Recall the diagnostic criteria for systemic inflammatory response syndrome (SIRS).
SIRS is identified by the presence of two or more of the following: Temperature > 38.0°C or < 36.0°C, Heart rate > 90 beats/min, Respiratory rate > 20 breaths/min or PaCO2 < 32 mm Hg, and WBC > 12,000/mm³, < 4,000/mm³, or > 10% bands.
Accurate identification of SIRS is essential for recognizing early physiological decompensation.
2
Evaluate the client's vital signs and laboratory values against the SIRS criteria.
The heart rate of 112 beats/min, respiratory rate of 28 breaths/min, and WBC count of 16,500/mm³ all meet the criteria for SIRS.
Comparing client data to established clinical thresholds determines the presence of the syndrome.
3
Analyze the remaining options to confirm they do not meet SIRS criteria.
The temperature of 37.6°C is not > 38.0°C, the PaCO2 of 42 mm Hg is not < 32 mm Hg, and the urine output of 45 mL/hr is normal.
Eliminating distractors ensures that only true indicators of systemic inflammation are selected.

Key Concept

Systemic Inflammatory Response Syndrome (SIRS) Criteria
Question 1252Question →

While caring for a client with a deep vein thrombosis, the registered nurse prepares to administer a scheduled dose of intravenous levofloxacin. The client has a single peripheral venous catheter currently infusing continuous intravenous heparin. What is the priority action the nurse must perform before proceeding?

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Answer: Consult a medication reference resource to confirm that levofloxacin and heparin can be safely mixed in the same line.

Answer

Consult a medication reference resource to confirm that levofloxacin and heparin can be safely mixed in the same line.
Before administering multiple intravenous medications through a single access site, the nurse must verify that the drugs are physically and chemically compatible. Failure to do so can result in crystallization, precipitation, or inactivation of the drugs, which can cause severe harm to the client, such as an embolus or loss of venous access.

Step-by-Step Solution

1
Identify that two different medications are planned to infuse through a single venous access site.
Recognized a potential risk for drug-drug incompatibility in the intravenous tubing.
Different chemical compounds can form precipitates or inactivate each other when mixed together.
2
Determine the safest intervention prior to mixing the fluids.
Selected the action of checking a drug compatibility reference.
Verifying compatibility is a required safety standard before administering any secondary intravenous medication into an active line.

Key Concept

Intravenous Medication Compatibility
Question 1253Question →

A nurse is preparing to administer a large-volume cleansing enema to an adult client. In what order should the nurse perform the following actions? Arrange the steps from first to last.

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Answer

The correct procedural sequence is to first position the client in the left lateral Sims position, then lubricate the enema tubing, carefully insert the tubing into the rectum, and finally raise the container to begin the infusion.
Administering a cleansing enema safely requires a logical, step-by-step approach. The nurse must first place the client in the left lateral Sims position to align with the anatomy of the lower GI tract. Next, the equipment is readied by lubricating the tubing tip. The tube is then carefully inserted. Only after the tube is securely in the rectum should the nurse raise the bag to allow the fluid to flow via gravity.

Step-by-Step Solution

1
Assist the client into the left lateral Sims position.
The client is in the safest and most effective anatomical position.
The left lateral Sims position utilizes gravity to help the fluid flow down into the sigmoid and descending colon.
2
Lubricate the tip of the enema tubing.
The tubing is prepared for safe insertion.
Lubrication minimizes tissue friction, preventing pain or damage to the sensitive rectal mucosa.
3
Insert the tubing 3 to 4 inches into the rectum.
The tube passes the internal sphincter and rests safely in the rectum.
Inserting the tube 3 to 4 inches in an adult, directed toward the umbilicus, ensures the fluid will be delivered appropriately without risking bowel wall perforation.
4
Raise the enema container and open the clamp.
Fluid begins to instill into the colon at a controlled rate.
The height of the bag controls the pressure and flow rate of the instillation. Raising it only after secure placement prevents spills and ensures a controlled, safe procedure.

Key Concept

Basic Care and Comfort: Enema Administration
Question 1254Question →

Upon returning to the inpatient mental health facility from a supervised community outing, a client with a history of substance use disorder walks briskly toward the dormitory area. The registered nurse notices the client keeping their right hand tightly concealed inside their jacket pocket. When approached, the client avoids eye contact, turns away, and says, "Leave me alone, I'm just exhausted." Which action should the nurse take to best maintain the safety of the therapeutic environment?

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Answer: Maintain a safe physical distance, calmly request the client to stop, and ask them to reveal the pocket's contents while signaling for staff assistance.

Answer

The nurse should maintain a safe physical distance, calmly request the client to stop, and ask them to reveal the pocket's contents while signaling for staff assistance.
The correct answer effectively balances the immediate need to secure the therapeutic environment against potential contraband with the ethical requirement to use the least restrictive intervention. By maintaining a safe distance and calling for backup, the nurse protects personal safety. By calmly asking the client to reveal the item, the nurse attempts verbal de-escalation before resorting to more restrictive measures.

Step-by-Step Solution

1
Identify the primary clinical concern based on the client's behavior.
The client's concealment of their hand after an off-unit outing indicates a high risk of smuggling contraband (such as drugs or weapons) into the unit, threatening milieu safety.
Recognizing potential environmental hazards is the first step in protecting all clients and staff on a psychiatric unit.
2
Determine the appropriate level of intervention required.
The situation requires immediate action before the client enters the general population, but does not yet meet the criteria for physical restraints.
Interventions must balance the immediate safety of the therapeutic environment with the client's right to the least restrictive care.
3
Select the nursing action that manages the risk safely and therapeutically.
Maintaining distance, using calm verbal directives, and coordinating with other staff provides a safe, structured approach to assessing the concealed item.
This prevents premature escalation while ensuring that the nurse is not isolated if the client becomes aggressive.

Key Concept

Maintaining a safe therapeutic milieu requires prompt identification of potential contraband using the least restrictive, safely coordinated interventions.
Question 1255Question →

A nurse is caring for a postpartum client who is tearful in her room. The client states, "I am a terrible mother. I cannot even produce enough milk to feed my own baby." Which of the following responses by the nurse are therapeutic? Select all that apply.

Select all that apply

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Answer: I will just sit here with you for a while.; You are feeling inadequate because feeding your baby is not going as you had planned.; Tell me more about what being a good mother means to you.

Answer

The therapeutic responses are offering to sit with the client, reflecting her feelings of inadequacy, and encouraging her to explore what being a good mother means.
The correct responses utilize established therapeutic communication techniques. Offering to sit with the client provides a supportive, non-demanding presence. Reflecting the client's feelings of inadequacy validates her emotional experience without judgment. Asking the client to tell more about her definition of a good mother uses the technique of exploration, encouraging her to process her thoughts and feelings out loud.

Step-by-Step Solution

1
Analyze the client's statement to identify her emotional state and core concern.
The client is experiencing guilt, feelings of inadequacy, and distress over her inability to breastfeed.
Understanding the emotion is necessary to select a response that validates rather than minimizes her feelings.
2
Evaluate each nursing response for therapeutic communication principles.
Identify statements that use active listening, reflection, exploration, and offering self.
Therapeutic communication aims to facilitate emotional expression and empower the client.
3
Identify and eliminate non-therapeutic barriers in the remaining options.
Eliminate options that offer false reassurance, give unwanted advice, minimize feelings, or ask confrontational 'why' questions.
These communication blocks close off the conversation and invalidate the client.

Key Concept

Therapeutic Communication Techniques
Question 1256Question →

A nurse in a palliative care unit is caring for a terminally ill client who has entered the active phase of dying. The client suddenly becomes highly restless, pulls at the bed linens, and converses with deceased relatives. The client's adult child is visibly distressed and pleads with the nurse, 'Please tell my mother she is in the hospital and her parents are not here.' Which is the priority nursing action?

Show answer & explanation

Answer: Assess the client for physiological sources of discomfort, such as urinary retention, and educate the family to avoid forcing reality orientation.

Answer

The priority nursing action is to assess the client for physiological sources of discomfort, such as urinary retention, and to educate the family to avoid forcing reality orientation.
In the active phase of dying, clients frequently experience terminal delirium or severe agitation. Following the nursing process, assessment is always the initial priority action. The nurse must first rule out and treat underlying, reversible physical causes of agitation, such as uncontrolled pain, a distended bladder, or constipation. Concurrently, psychosocial support is essential; the nurse must educate the distressed family that attempting to orient the client to reality is counterproductive and heightens the client's anxiety, whereas joining the client's reality or simply offering calm presence promotes comfort and peace.

Step-by-Step Solution

1
Analyze the clinical scenario.
The client is in the active phase of dying and exhibiting signs of terminal delirium, including severe restlessness and interacting with deceased loved ones.
Recognizing the physiological and psychological changes at the end of life is essential for determining appropriate interventions.
2
Apply the principles of prioritizing nursing care.
The nursing process requires assessment prior to intervention. The priority is to rule out and address any reversible physical causes for the sudden agitation.
Unrelieved pain, urinary retention, or fecal impaction are common, highly treatable causes of agitation in dying clients that must be addressed before resorting to pharmacological sedation.
3
Evaluate the psychosocial needs of the client and the distressed family.
Educating the family that reality orientation increases the client's distress is critical. Therapeutic communication involves validating the family's emotions while guiding them to participate in the client's reality.
Providing a peaceful, symptom-free environment and supporting the family's coping mechanisms are the primary goals of end-of-life palliative care.

Key Concept

Terminal Delirium Management and Therapeutic Communication
Estimated Time:1m 30s
Question 1257Question →

A 68-year-old client is being monitored in the progressive care unit two hours after undergoing a bedside left-sided thoracentesis for a pleural effusion. The client suddenly becomes restless, diaphoretic, and has a respiratory rate of 34 breaths/min. The nurse observes diminished breath sounds on the left side and asymmetrical chest expansion. An arterial blood gas (ABG) reveals a pH of 7.49, PaCO2 of 29 mm Hg, PaO2 of 56 mm Hg, and HCO3 of 23 mEq/L. Which action should the nurse implement first to reduce the risk of severe physiological decompensation?

Show answer & explanation

Answer: Apply high-flow supplemental oxygen and immediately notify the rapid response team for a suspected pneumothorax.

Answer

Apply high-flow supplemental oxygen and immediately notify the rapid response team for a suspected pneumothorax.
The client is exhibiting classic signs of an acute pneumothorax, a known high-risk complication of a thoracentesis. The asymmetrical chest expansion, diminished breath sounds, severe hypoxemia, and compensatory tachypnea require immediate escalation to a rapid response team and high-flow oxygen administration to prevent impending hemodynamic collapse.

Step-by-Step Solution

1
Analyze the client's clinical presentation and the diagnostic ABG data.
The client exhibits signs of a left-sided pneumothorax (diminished breath sounds, asymmetric chest expansion, restlessness). The ABG shows uncompensated respiratory alkalosis driven by critical hypoxemia (PaO2 56 mm Hg).
A thoracentesis carries a significant risk of puncturing the visceral pleura, leading to air entering the pleural space.
2
Determine the priority intervention using the ABC (Airway, Breathing, Circulation) framework.
The client has an acute, life-threatening breathing and oxygenation deficit that takes absolute precedence over other assessments.
Immediate oxygenation and advanced medical intervention are required to prevent the development of a tension pneumothorax and subsequent cardiopulmonary arrest.
3
Select the nursing action that directly mitigates the physiological threat.
Applying high-flow oxygen and activating the rapid response team is the safest and most urgent intervention.
This ensures immediate life-saving support and prepares the team for potential emergency chest tube insertion.

Key Concept

Post-procedure complication recognition and prioritization (Airway, Breathing, Circulation)
Question 1258Question →

A client arrives at the medical-surgical unit after undergoing a flexible bronchoscopy with a transbronchial biopsy under conscious sedation. To reduce the risk of potential physiological complications, which actions should the nurse include in the client's immediate care plan? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Withhold all oral food and fluids until the return of the client's gag and swallow reflexes is clinically verified.; Monitor for sudden onset of pleuritic chest pain, asymmetrical chest wall expansion, and tracheal deviation.; Assess for signs of laryngeal edema, such as inspiratory stridor or increasing hoarseness, which may threaten airway patency.

Answer

The correct actions are to withhold oral intake until the gag reflex returns, monitor for signs of a pneumothorax (chest pain, asymmetrical expansion), and assess for laryngeal edema (stridor, hoarseness).
The correct interventions focus on protecting the airway and identifying life-threatening complications early. Verifying the gag reflex prevents aspiration, as topical anesthetics numb the throat. Monitoring for pleuritic chest pain and asymmetrical expansion detects a pneumothorax, a known severe complication of a transbronchial biopsy. Assessing for stridor and hoarseness ensures early recognition of laryngeal edema, which can rapidly compromise the airway.

Step-by-Step Solution

1
Identify the procedure and its associated physiological risks.
The client underwent a bronchoscopy with a transbronchial biopsy under conscious sedation. Primary risks include aspiration (due to topical anesthetics), pneumothorax (due to the biopsy puncturing the pleura), and airway edema (due to instrumentation trauma).
Understanding procedure-specific risks is essential for prioritizing focused post-operative assessments.
2
Evaluate the options related to airway protection.
Withholding oral intake until the gag reflex returns actively prevents aspiration. Assessing for stridor detects impending airway compromise. Positioning the client flat is contraindicated as it increases aspiration risk and limits diaphragmatic excursion.
Airway patency is always the highest clinical priority following procedures involving the respiratory tract.
3
Evaluate the options related to breathing and gas exchange.
Monitoring for asymmetrical chest expansion identifies a pneumothorax, a major complication of a transbronchial biopsy. Interpreting a PaCO2 of 42 mm Hg as an emergency is incorrect, as this is a normal physiological value.
Breathing complications must be quickly identified, but normal baseline findings must be recognized to prevent inappropriate interventions.
4
Evaluate the option related to delegation and care management.
Delegating initial post-procedure lung auscultation to a UAP is outside their scope of practice.
The Registered Nurse must perform initial assessments to establish a clinical baseline and exercise nursing judgment.

Key Concept

Post-Bronchoscopy Complication Prevention and Monitoring
Question 1259Question →

An adult client is receiving scheduled enteral nutrition through a percutaneous endoscopic gastrostomy tube. Which intervention should the nurse implement to decrease the risk of aspiration?

Show answer & explanation

Answer: Maintain the client's upper body in a semi-Fowler's position during the administration.

Answer

Maintain the client's upper body in a semi-Fowler's position during the administration.
Elevating the upper body into a semi-Fowler's position uses gravity to keep the administered formula inside the stomach, which directly decreases the likelihood of regurgitation and aspiration into the lungs.

Step-by-Step Solution

1
Identify the primary complication associated with enteral feedings.
The most significant severe risk is aspiration of stomach contents into the respiratory tract.
Formula introduced into the stomach can reflux into the esophagus if not properly managed.
2
Determine the physiological principle that prevents this complication.
Gravity assists in keeping gastric contents in the stomach and promotes downward emptying.
Elevating the upper body prevents fluid from traveling upward toward the airway.
3
Select the nursing action that applies this principle.
Positioning the client in a semi-Fowler's position elevates the upper body appropriately.
This specific position effectively reduces the risk of aspiration during and after the feeding.

Key Concept

Aspiration Precautions for Enteral Feedings
Estimated Time:45s
Question 1260Question →

A nurse is caring for a client with post-traumatic stress disorder (PTSD) on an inpatient mental health unit. Following a loud argument between two other clients in the dayroom, the client retreats to a corner, begins hyperventilating, covers their ears, and screams, "Don't touch me! Keep away!" The client is trembling, visually scanning the room, and clenching their fists. Which initial nursing action is the priority?

Show answer & explanation

Answer: Clear the immediate area of other individuals, maintain a distance of at least two arm's lengths, and address the client in a low, calm voice.

Answer

The priority initial action is to clear the immediate area of other individuals, maintain a distance of at least two arm's lengths, and address the client in a low, calm voice.
The client is exhibiting signs of severe anxiety, hypervigilance, and a potential flashback related to PTSD. The priority intervention is to ensure safety through de-escalation using the least restrictive means. Clearing the area reduces environmental stimuli, while maintaining distance and using a calm voice prevents the client from feeling cornered or threatened, thereby facilitating emotional regulation.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client is exhibiting hypervigilance, defensive posturing, and severe fear, which indicates an acute trauma response or PTSD flashback triggered by the milieu disruption.
Accurate assessment of the underlying cause of the agitation is required to select the appropriate de-escalation strategy.
2
Evaluate the proposed interventions against the principle of the least restrictive environment.
Verbal de-escalation and environmental modification are the least restrictive measures. Physical touch, close staff proximity, and seclusion are highly restrictive and potentially escalating.
Nursing standards mandate attempting the least restrictive interventions first to preserve client autonomy and prevent unnecessary psychological trauma.
3
Select the priority action that ensures immediate safety while minimizing perceived threats to the client.
The action of clearing the area, maintaining a safe physical distance, and speaking calmly is selected.
This combination effectively reduces sensory overload, respects the client's urgent need for physical boundaries, and safely initiates therapeutic de-escalation.

Key Concept

Verbal De-escalation and Least Restrictive Environment
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