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Question 1381Question →

A nurse is planning care for a client who has just returned to the medical-surgical unit following a lumbar puncture. Which of the following positions should the nurse maintain for this client immediately after the procedure?

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Answer: Supine with the head of the bed flat

Answer

Supine with the head of the bed flat
Following a lumbar puncture, the client should be maintained in a flat, supine position for a prescribed period (typically 4 to 8 hours). This position minimizes the pressure on the dural puncture site, preventing the leakage of cerebrospinal fluid (CSF) and significantly reducing the risk of a post-dural puncture headache.

Step-by-Step Solution

1
Identify the procedure the client underwent.
The client had a lumbar puncture, which involves puncturing the dura mater to access cerebrospinal fluid (CSF).
Specific post-operative complications are associated with different procedures.
2
Recall the potential complications of a lumbar puncture.
A major complication is a CSF leak from the puncture site, leading to a severe spinal headache.
Understanding the risk guides the primary nursing intervention.
3
Determine the appropriate position to prevent this complication.
Keeping the client flat distributes CSF pressure evenly and minimizes hydrostatic pressure at the dural puncture site.
Gravity exacerbates CSF leakage if the head is elevated.

Key Concept

Post-procedure positioning to prevent complications (Lumbar Puncture)
Estimated Time:45s
Question 1382Question →

A client arrives at the medical unit after undergoing a diagnostic lumbar puncture. Which positioning instruction is the most appropriate for the nurse to provide?

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Answer: Remain completely flat in bed for the duration prescribed by the provider.

Answer

The client should remain completely flat in bed for the duration prescribed by the provider.
Following a lumbar puncture, the standard of care requires the client to remain flat (supine) in bed for a specified duration, typically 1 to 8 hours depending on provider orders. This flat position minimizes hydrostatic pressure at the dural puncture site, significantly reducing the risk of cerebrospinal fluid (CSF) leakage and the development of a post-dural puncture headache.

Step-by-Step Solution

1
Identify the procedure the client just underwent.
The client had a diagnostic lumbar puncture.
Different procedures require specific post-operative or post-procedure positioning to prevent complications.
2
Determine the primary risk following a lumbar puncture.
The main risk is leakage of cerebrospinal fluid (CSF) from the dural puncture site, which causes a severe spinal headache.
Understanding the complication guides the appropriate nursing intervention.
3
Select the position that minimizes this risk.
Lying completely flat reduces pressure on the dural tear, preventing CSF leakage.
Gravity exacerbates the pressure on the puncture site when the head is elevated.

Key Concept

Post-Lumbar Puncture Positioning
Question 1383Question →

A client is admitted to the observation unit with atypical chest pain. Following a negative cardiac workup, the client remains visibly tense, exhibits rapid and shallow breathing, and tells the nurse, "I just cannot catch my breath when I think about all the debt I owe." What is the priority nursing action for this client?

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Answer: Guide the client through slow, deep-breathing exercises.

Answer

The priority nursing action is to guide the client through slow, deep-breathing exercises.
The client is experiencing an acute physical manifestation of stress and anxiety, indicated by rapid, shallow breathing. According to Maslow's Hierarchy of Needs, physiological needs and immediate physical stabilization take precedence. Guiding the client through deep-breathing exercises directly addresses the physiological symptom, promotes relaxation, and restores a normal respiratory pattern.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has a negative cardiac workup but is exhibiting rapid, shallow breathing and expressing severe psychological distress related to finances.
To identify the immediate clinical problem and rule out physiological cardiac emergencies.
2
Apply Maslow's Hierarchy of Needs to prioritize care.
The immediate physiological symptom (rapid, shallow breathing due to acute anxiety) takes precedence over long-term psychosocial or educational needs.
To determine which nursing intervention must occur first to ensure client stability.
3
Select the intervention that addresses the highest priority need.
Guiding the client through deep-breathing exercises is selected to restore a normal respiratory pattern and reduce sympathetic nervous system arousal.
To stabilize the client's immediate physical condition before addressing the underlying psychosocial stressors.

Key Concept

Prioritization of interventions for acute stress and anxiety
Question 1384Question →

An adult client with a history of alcohol use disorder and major depressive disorder is admitted to a medical unit for the treatment of severe pneumonia. On the third day of hospitalization, the client, who previously exhibited profound sadness and psychomotor retardation, suddenly appears peaceful and states, "I finally figured out how to solve all my problems. I will not be a burden to my family anymore." The nurse also notes that the client is diaphoretic and has visible bilateral hand tremors. Which of the following nursing actions are appropriate to include in the immediate plan of care? Select all that apply.

Select all that apply

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Answer: Ask the client directly if they are having thoughts of self-harm or suicide.; Initiate continuous, one-to-one observation of the client.; Implement environmental seizure precautions.

Answer

The correct actions include asking the client directly about suicidal thoughts, initiating continuous one-to-one observation, and implementing environmental seizure precautions.
The client is simultaneously experiencing two life-threatening emergencies. First, the sudden shift from deep depression to a peaceful state, combined with the statement about not being a burden, is a classic warning sign of impending suicide. This necessitates asking the client directly about self-harm and placing them on continuous 1:1 observation. Second, diaphoresis and hand tremors on the third day of hospitalization in a client with alcohol use disorder indicate severe alcohol withdrawal. Because this can rapidly progress to delirium tremens and seizures, implementing seizure precautions is a critical safety priority.

Step-by-Step Solution

1
Analyze the client's psychiatric risk factors and statements.
The client has major depressive disorder and shows a sudden, unexplained shift from profound sadness to a peaceful state, accompanied by a statement about no longer being a burden.
Sudden mood improvement often indicates the client has finalized a suicide plan and feels relief. This requires immediate direct assessment of suicidal intent and implementation of 1:1 safety observation.
2
Analyze the client's medical history and physical assessment findings.
The client has a history of alcohol use disorder, is on day 3 of hospitalization (72 hours since last drink), and is exhibiting diaphoresis and bilateral hand tremors.
These factors strongly indicate progressing acute alcohol withdrawal, which peaks around 48-72 hours. The client is at imminent risk for delirium tremens and withdrawal seizures, requiring immediate seizure precautions.
3
Evaluate the nursing actions for safety and scope of practice.
Therapeutic communication must address the suicide risk rather than validating the calm mood. Assessment of withdrawal severity must remain with the RN.
Delegating complex assessments to UAPs or providing false reassurance compromises patient safety and violates established standards of psychiatric and medical-surgical nursing care.

Key Concept

Prioritizing physiological and psychological safety in clients with dual diagnoses (Alcohol Withdrawal Syndrome and Suicidal Ideation).
Question 1385Question →

A pediatric unit nurse is organizing care for a 6-year-old client who is one day postoperative following a tonsillectomy. The client's condition has remained stable throughout the night. Which specific task is most appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)?

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Answer: Recording the exact amount of clear liquids the client consumes

Answer

Recording the exact amount of clear liquids the client consumes
The correct answer involves measuring and documenting intake and output. This is a standard, routine task with a predictable outcome that does not require nursing judgment, making it entirely legally and clinically appropriate to delegate to a UAP when caring for a stable client.

Step-by-Step Solution

1
Identify the client's status and the personnel involved.
The client is a clinically stable 6-year-old, one day postoperative. The personnel being assigned a task is a UAP.
Delegation decisions depend heavily on the client's stability and the scope of practice of the team member.
2
Apply the core principles of delegation.
Registered nurses cannot delegate tasks that involve nursing assessment, clinical judgment, or primary teaching (often remembered by the acronym EAT: Evaluate, Assess, Teach).
These functions require a valid nursing license and specialized clinical education.
3
Evaluate each option against the scope of practice for a UAP.
Inspecting the throat is an assessment; instructing parents is teaching; determining medication needs is clinical judgment. Recording fluid intake is a routine, non-complex task.
Routine tasks with predictable outcomes are safe and legally appropriate to delegate to a UAP for a stable client.

Key Concept

Delegation to Unlicensed Assistive Personnel (UAP)
Question 1386Question →

A client is receiving a continuous intravenous (IV) infusion of unfractionated heparin. The nurse must administer a scheduled dose of an IV push medication that is chemically incompatible with heparin. The client has a single peripheral IV access line. Arrange the following actions in the correct sequence to safely administer the medication.

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Answer

The correct sequence is to first stop the continuous infusion pump, then clamp the tubing above the lowest port and flush with normal saline, followed by administering the IV push medication. After administration, flush again with normal saline at the same rate the medication was given, and finally unclamp and restart the continuous infusion.
When administering an IV push medication through a single peripheral line with an incompatible continuous infusion, the nurse must first stop the pump to halt the primary fluid. The tubing must be clamped immediately above the lowest injection port (closest to the client) to prevent retrograde flow. A pre-flush of normal saline clears the line of the incompatible drug to avoid precipitation. The medication is then administered at the prescribed rate. Crucially, the post-flush must also be administered at the exact same slow rate as the medication because the lower tubing still contains the active drug. Rapid flushing would push the residual drug into the client too quickly, risking speed shock. Finally, the tubing is unclamped and the continuous infusion is restarted.

Step-by-Step Solution

1
Stop the continuous heparin infusion.
The flow of the incompatible medication is temporarily halted.
This prevents the incompatible medications from mixing in the line during the procedure.
2
Clamp the primary tubing and flush the lowest injection port with normal saline.
The line below the port and the IV catheter are cleared of heparin.
Clamping prevents the flush from traveling retrogradely up the line. Flushing clears the physical space of the incompatible drug to prevent dangerous precipitation.
3
Administer the IV push medication.
The medication is delivered into the cleared IV line.
The medication is given at the prescribed rate to ensure safety and therapeutic effect.
4
Flush the line with normal saline at the same rate the medication was administered.
The remaining medication in the dead space of the IV tubing and catheter is safely delivered.
Flushing too quickly would result in rapid bolus delivery (speed shock) of the residual medication still present in the tubing.
5
Unclamp the tubing and restart the continuous infusion.
The primary heparin infusion resumes.
This restores the continuous therapeutic delivery of the primary medication.

Key Concept

Safe administration of an IV push medication through a line with an incompatible continuous infusion requires isolating the injection site, adequately clearing the line before and after administration, and carefully controlling flush rates to prevent speed shock.
Question 1387Question →

A nurse is instructing a client on the proper procedure for a 24-hour urine collection for creatinine clearance. In what chronological order should the nurse instruct the client to perform the following steps? Arrange the steps in the correct sequence.

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Answer

The correct sequence is to first discard the initial void, document the start time, collect all subsequent urine for 24 hours, void one final time at the 24-hour mark, and finally transport the specimen to the laboratory.
For a 24-hour urine collection, the bladder must first be emptied and that urine discarded so the collection period begins with an empty bladder. The exact time is then recorded as the start time. All subsequent urine voided over the next 24 hours is saved in a designated container, which is typically kept on ice or refrigerated. Exactly 24 hours after the start time, the client voids one last time and adds it to the container to complete the collection. Finally, the complete specimen is transported to the laboratory.

Step-by-Step Solution

1
Empty the bladder completely into the toilet and discard this initial urine.
The bladder is emptied.
Ensures the collected urine only reflects what is produced from the start time onward.
2
Document the exact time of the discarded void as the official start time.
The start time is recorded.
Establishes the precise beginning of the 24-hour timeframe.
3
Collect all subsequent urine voids in the designated refrigerated specimen container.
Urine is continuously collected and preserved.
Captures all urine produced during the collection period while maintaining specimen integrity.
4
Void one final time exactly 24 hours after the start time and add it to the container.
The 24-hour collection is completed.
Ensures the total volume represents exactly one full day of urine production.
5
Transport the completed collection container to the laboratory.
The specimen is delivered for testing.
Allows the laboratory to analyze the complete 24-hour sample.

Key Concept

Diagnostic Test Preparation and Specimen Collection
Estimated Time:1m 0s
Question 1388Question →

A 55-year-old female client visits an ambulatory care clinic for an annual well-woman examination. The nurse is coordinating the client's health promotion and preventive care plan. Arrange the following nursing actions in the most appropriate chronological sequence.

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Answer

The correct sequence follows the nursing process: gathering comprehensive assessment data, analyzing the data to identify necessary secondary prevention screenings, assessing the client's readiness and knowledge regarding those specific tests, implementing tailored education, and finally coordinating the logistics and follow-up for the procedures.
This sequence strictly adheres to the nursing process (ADPIE) and the principles of effective client education. The nurse must first assess the client's overall health history to determine which secondary prevention screenings are clinically indicated. Once the necessary screenings are identified, the nurse must assess the client's specific knowledge and feelings about those exact tests before delivering targeted education. Finally, after the client is fully informed, the practical steps of scheduling and establishing follow-up are completed.

Step-by-Step Solution

1
Identify the initial phase of the nursing process for health promotion.
Collect a comprehensive health history, including dates of previous preventive screenings and multi-generational family health patterns.
Comprehensive assessment must precede any clinical decision-making or planning. Accurate risks cannot be identified without a complete history.
2
Determine the next logical action after collecting baseline data.
Determine the client's eligibility for age- and risk-appropriate secondary prevention measures, such as mammography and bone densitometry.
The nurse analyzes the assessment data against evidence-based guidelines to identify which secondary prevention screenings are clinically indicated for this specific client.
3
Identify the prerequisite action before conducting client education.
Evaluate the client's baseline knowledge and beliefs regarding the specifically recommended screening procedures.
Effective health teaching requires assessing the client's current understanding, readiness to learn, and potential barriers before delivering new information.
4
Select the appropriate implementation phase action.
Deliver tailored education to address identified knowledge gaps and mitigate any expressed anxieties about the tests.
Once learning readiness is established, the nurse provides targeted education to ensure the client can make an informed decision and to alleviate fears.
5
Determine the final logistical step in the sequence.
Coordinate the scheduling of the required diagnostic appointments and establish a timeline for reviewing the results.
After the client is fully educated and agreeable to the plan, the nurse finalizes practical arrangements and ensures continuity of care through appropriate follow-up.

Key Concept

Nursing Process in Health Promotion and Client Education
Question 1389Question →

A 74-year-old client is admitted to the progressive care unit with a large acute pulmonary embolism and is receiving a continuous intravenous (IV) heparin infusion. The nurse is creating a plan of care to monitor for and reduce the risk of potential physiological complications. Which of the following actions should the nurse include in the plan of care? Select all that apply.

Select all that apply

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Answer: Establish a secondary peripheral intravenous access site for the administration of other prescribed intermittent medications.; Monitor the client for early physiological indicators of hemodynamic compromise, such as a narrowing pulse pressure and unexplained tachycardia.; Ensure that the specific antidote, protamine sulfate, is readily available on the unit.

Answer

The correct interventions are establishing a secondary IV access for other medications, monitoring for early signs of shock like a narrowing pulse pressure, and ensuring protamine sulfate is available on the unit.
Establishing a secondary peripheral IV line is necessary because continuous heparin infusions must run on a dedicated line to prevent inadvertent bolusing and medication incompatibilities. Monitoring for a narrowing pulse pressure and tachycardia allows for the early detection of obstructive shock, a life-threatening complication of a large pulmonary embolism. Ensuring protamine sulfate is available is a crucial safety measure to rapidly reverse heparin in the event of severe hemorrhage.

Step-by-Step Solution

1
Analyze the client's diagnosis and current treatments.
The client has a pulmonary embolism (high risk for hypoxemia and obstructive shock) and is on a continuous heparin infusion (high risk for hemorrhage and drug incompatibilities).
Identifying the primary physiological threats guides the selection of targeted risk reduction strategies.
2
Evaluate each intervention for its ability to safely mitigate these physiological risks.
Maintaining a dedicated heparin line, securing the antidote, and closely monitoring for early shock indicators (tachycardia, narrowing pulse pressure) directly reduce the risk of mortality and medication errors.
These actions prioritize airway, breathing, circulation, and medication safety.
3
Identify and eliminate contraindicated or unsafe actions.
Placing the dyspneic client supine, delegating complex nursing assessments to a UAP, and dismissing altered mental status as normal aging are dangerous missteps.
A supine position impairs breathing, UAPs cannot perform clinical evaluations, and confusion indicates severe, acute hypoxemia.

Key Concept

Risk reduction in clients with pulmonary embolism focuses on maintaining oxygenation (high-Fowler's position), preventing hemorrhage (dedicated heparin line, readily available antidotes), and early detection of hemodynamic compromise or hypoxemia (recognizing subtle vital sign changes and altered mental status).
Question 1390Question →

An adult client admitted with a fractured femur received a dose of intravenous morphine 20 minutes ago. The orthopedic surgeon arrives, explains the necessity of an urgent open reduction and internal fixation (ORIF) to the client, and asks the registered nurse to witness the surgical consent signature. Which of the following actions by the nurse are appropriate? Select all that apply.

Select all that apply

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Answer: Inform the surgeon that the client cannot legally sign the consent document at this time.; Request that the surgeon contact the client's medical power of attorney or legal next of kin.; Document the time of the opioid administration and the client's current inability to sign.

Answer

The correct actions are to inform the surgeon that the client cannot legally sign, request that a surrogate decision-maker be contacted, and thoroughly document the situation.
Clients who have received central nervous system depressants, such as opioids, within the prior several hours lack the legal competence to provide informed, voluntary consent. In such situations, the nurse acts as a client advocate by intervening, preventing the client from signing, and advising the provider to contact the designated medical power of attorney or legal next of kin. Thorough documentation of the medication administration and the client's legal incapacity is also required.

Step-by-Step Solution

1
Assess the client's legal competence to sign the consent form.
The client received intravenous morphine 20 minutes ago.
Opioids are central nervous system depressants that alter cognitive function and automatically invalidate legal capacity for consent.
2
Determine the appropriate legal pathway for obtaining consent.
A surrogate decision-maker must be contacted by the provider.
When a client is temporarily incapacitated by medication, a designated proxy or next of kin assumes decision-making rights.
3
Identify the nurse's scope of practice regarding the consent process.
The nurse must advocate for the client by stopping the signature and documenting the event.
The nurse's role is to ensure consent is voluntary and competent, not to obtain it or bypass safety protocols.

Key Concept

Legal competence and the nurse's advocacy role in the informed consent process for sedated clients.
Question 1391Question →

While organizing the morning workflow on a general medical unit, the nurse considers which tasks can be safely assigned to the unlicensed assistive personnel (UAP). Which task is appropriate for the nurse to delegate to the UAP?

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Answer: Assisting a client who is two days post-appendectomy with ambulation in the hallway.

Answer

Assisting a client who is two days post-appendectomy with ambulation in the hallway.
The correct answer involves a routine, standard task for a clinically stable client. Assisting a client with ambulation two days after a simple appendectomy is a predictable intervention that falls entirely within the UAP's scope of practice. It does not require independent nursing judgment, physiological assessment, or patient education.

Step-by-Step Solution

1
Identify the scope of practice for Unlicensed Assistive Personnel (UAP).
UAPs are permitted to perform routine, standard care tasks for stable clients.
The National Council of State Boards of Nursing (NCSBN) strictly dictates delegation parameters for safe patient care.
2
Evaluate each option against the 'EAT' acronym (Do not delegate Evaluation, Assessment, or Teaching).
Three options involve patient teaching, physiological assessment, or clinical judgment.
These actions require the specialized knowledge and application of the nursing process, which cannot be delegated to unlicensed personnel.
3
Select the task that falls within the UAP's allowed duties.
Ambulation of a stable, postoperative client is selected.
It is a standard, predictable procedure that does not require independent nursing judgment.

Key Concept

Delegation to Unlicensed Assistive Personnel (UAP)
Question 1392Question →

A home health registered nurse (RN) is evaluating the self-care capacity of a 68-year-old client with early-stage Alzheimer's disease and poorly controlled type 2 diabetes mellitus. The client lives with their adult child, who works outside the home during the day. The nurse is developing a management plan to promote the client's maximum independence while ensuring clinical safety. Which action represents the most appropriate integration of self-care principles for this client?

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Answer: Utilizing a system where the adult child pre-fills a daily medication organizer and programs an automated voice alarm to prompt the client's self-administration.

Answer

The most appropriate action is utilizing a system where the adult child pre-fills a daily medication organizer and programs an automated voice alarm to prompt the client's self-administration.
For a client with early-stage Alzheimer's disease, the primary nursing goal is to maximize independence while mitigating the profound safety risks associated with memory deficits. Having a cognitively intact caregiver (the adult child) manage the complex task of sorting and dosing medications, combined with a technological memory aid (the automated voice alarm) to prompt the actual administration, creates an optimal balance. This intervention allows the client to actively participate in their daily self-care routines without exposing them to the high risk of medication errors (such as missing a dose or double-dosing insulin/oral hypoglycemics).

Step-by-Step Solution

1
Analyze the client's clinical profile and social determinants.
The client has early-stage cognitive impairment (Alzheimer's) and a complex chronic illness (diabetes), but is alone during the day.
Identifying cognitive and physical barriers is the foundational step in formulating a safe, individualized self-care plan.
2
Evaluate the proposed self-care support strategy.
Pre-filling the organizer by a competent caregiver removes the cognitive burden of medication sorting, while the alarm provides the necessary memory cue.
This strategy safely bridges the gap between the client's cognitive deficits and their need for independence in self-care.
3
Analyze the incorrect clinical judgments presented in the scenario.
Sudden confusion indicates acute delirium (a medical emergency), UAPs cannot evaluate learning, and foot inspections represent secondary/tertiary prevention.
Ruling out unsafe, improperly delegated, or clinically inaccurate interventions ensures the chosen plan meets professional nursing standards.

Key Concept

Adaptive strategies for cognitive impairment in self-care management
Estimated Time:1m 30s
Question 1393Question →

A client in the pre-operative holding area is informed that a scheduled tissue biopsy has been postponed due to an unexpected laboratory issue. The client begins pacing rapidly, clenching their fists, and loudly states, 'I cannot handle this! The waiting is agonizing!' Which responses by the nurse utilize appropriate stress management and de-escalation techniques? Select all that apply.

Select all that apply

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Answer: It sounds like you are feeling incredibly overwhelmed and frustrated by this sudden delay.; Let us walk over to this quiet area and practice some slow, focused breathing.; Can you tell me what has helped you manage sudden disappointments in the past?

Answer

The therapeutic responses involve reflecting the client's feelings, directing them to a quieter space for deep breathing, and exploring their past adaptive coping mechanisms.
The correct nursing actions prioritize therapeutic communication to directly manage the client's acute stress. Acknowledging the client's frustration builds trust and helps de-escalate the emotional intensity. Offering to move to a quiet area and practice focused breathing provides an immediate, actionable strategy to reduce physiological hyperarousal. Finally, asking about past coping strategies empowers the client to draw on their own resilience and shifts their focus toward adaptive problem-solving.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client is exhibiting signs of acute situational stress and hyperarousal, evidenced by rapid pacing, clenched fists, and statements indicating an inability to cope.
Understanding the client's current psychological state determines the immediate nursing priorities.
2
Identify the primary goals of the nursing intervention.
The immediate goals are to establish a therapeutic connection, safely de-escalate the physical agitation, and promote adaptive coping strategies.
Effective stress management during a crisis requires both physiological regulation and psychosocial support.
3
Evaluate each response option against established therapeutic communication principles.
Select the options that validate feelings, offer concrete relaxation techniques, and encourage problem-solving. Reject options that use non-therapeutic blocks such as giving advice, false reassurance, or asking 'why'.
Therapeutic communication is the primary tool for managing acute client stress in a clinical setting.

Key Concept

Therapeutic Communication and Acute Stress Management
Question 1394Question →

A registered nurse on a high-acuity cardiac step-down unit is evaluating assessment data for a group of assigned clients. Which of the following client presentations require immediate intervention by the nurse? Select all that apply.

Select all that apply

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Answer: A client 3 hours post-percutaneous coronary intervention via the right femoral artery who reports a new onset of severe lower back pain; A client receiving a continuous intravenous furosemide infusion who exhibits new-onset frequent premature ventricular contractions; A client recovering from a thoracic aneurysm repair whose pulse pressure has narrowed from 45 mm Hg to 20 mm Hg over the last hour

Answer

The correct selections are the client with back pain post-PCI, the client with new premature ventricular contractions on furosemide, and the client with a narrowing pulse pressure.
In prioritization triage, acute, unexpected changes that threaten Airway, Breathing, or Circulation take the highest priority. Severe lower back pain following a femoral percutaneous coronary intervention is a cardinal sign of retroperitoneal bleeding, a life-threatening circulatory complication. New-onset premature ventricular contractions in a client receiving a loop diuretic like furosemide strongly suggest hypokalemia, which can rapidly degenerate into lethal ventricular tachycardia or fibrillation. A narrowing pulse pressure is a critical early compensatory mechanism in shock states, reflecting falling cardiac output. All three of these clients require immediate, life-saving nursing and medical interventions.

Step-by-Step Solution

1
Analyze each client's clinical presentation to determine if the findings are acute and unexpected or chronic and expected.
Three clients show unexpected, acute changes, while two clients show stable, expected baseline data.
Prioritization requires distinguishing between physiological adaptation to chronic disease and acute pathological deterioration.
2
Evaluate the acute findings against the Airway, Breathing, Circulation (ABC) prioritization framework.
The back pain post-PCI (hemorrhage), the PVCs on furosemide (electrolyte-induced dysrhythmia), and the narrowing pulse pressure (shock) all represent critical threats to Circulation.
Identifying immediate life threats determines which clients require the highest priority of nursing care.

Key Concept

Prioritization of acute circulatory instability and life-threatening dysrhythmias over stable, expected chronic physiological adaptations.
Question 1395Question →

A nurse on an acute mental health unit responds to a sudden commotion in the common area. A client experiencing substance-induced psychosis is hurling chairs at the reinforced windows and shouting, "The gas is coming through the vents!" Verbal de-escalation attempts have completely failed, and the client is now attempting to lift a heavy wooden table. Which actions should the nurse implement? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Evacuate all other clients and visitors from the common area immediately.; Activate the facility's designated psychiatric emergency response team.; Prepare to administer a prescribed short-acting intramuscular antipsychotic medication.

Answer

The nurse should evacuate bystanders from the area, activate the psychiatric emergency response team, and prepare a short-acting intramuscular antipsychotic medication.
In a psychiatric emergency involving imminent violence and the failure of verbal de-escalation, the nurse must prioritize physical safety and follow the hierarchy of least restrictive interventions. Evacuating bystanders immediately removes them from physical danger. Activating the emergency response team provides necessary backup, as managing an armed, violent client requires a coordinated team approach. Preparing a short-acting intramuscular antipsychotic is the correct next clinical step; chemical interventions are less restrictive than mechanical restraints and are explicitly indicated for acute agitation with psychosis when the client poses a danger to themselves or others.

Step-by-Step Solution

1
Assess the immediate environment for physical safety threats.
The nurse identifies that the client is actively violent, armed with heavy furniture, and unresponsive to verbal de-escalation.
Safety of the client, peers, and staff is the absolute highest priority in any psychiatric emergency.
2
Remove vulnerable individuals from the immediate vicinity.
Other clients and visitors are evacuated from the common area.
This minimizes the risk of collateral injury and removes potential stimuli that could be exacerbating the client's paranoia.
3
Summon additional trained personnel.
The psychiatric emergency response team is activated.
A coordinated team is required to safely manage a violent client, providing a 'show of force' that can sometimes prompt voluntary de-escalation.
4
Select the next least restrictive intervention to manage the behavior.
The nurse prepares a short-acting intramuscular antipsychotic medication.
Because verbal de-escalation has failed and violence is occurring, chemical restraint (medication) is the next appropriate step before resorting to seclusion or mechanical restraints.

Key Concept

Crisis Intervention and the Principle of Least Restrictive Environment
Question 1396Question →

A nurse is preparing to administer an intravenous loading dose of phenytoin to an adult client who was recently admitted for status epilepticus. The client is currently stable but requires the medication to prevent recurrent seizure activity. The client has a continuous peripheral intravenous (IV) infusion of 5% dextrose in water5\% \text{ dextrose in water} (D5WD_5W) running at 75 mL/hr75\text{ mL/hr}. Which of the following nursing actions is essential for the safe administration of this medication?

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Answer: Stop the primary infusion, flush the line with 0.9% sodium chloride0.9\% \text{ sodium chloride}, and administer the phenytoin at a maximum rate of 50 mg/min50\text{ mg/min}.

Answer

Stop the primary infusion, flush the line with 0.9% sodium chloride, and administer the phenytoin at a maximum rate of 50 mg/min.
Phenytoin is physically incompatible with all dextrose solutions and will form a dangerous precipitate if they are mixed. Because the client is receiving a continuous D5WD_5W infusion, the nurse must pause the primary infusion and flush the line completely with normal saline (0.9% sodium chloride0.9\% \text{ sodium chloride}) before and after administration. Furthermore, to prevent severe cardiovascular toxicity including profound hypotension and dysrhythmias, intravenous phenytoin must be administered slowly, never exceeding a rate of 50 mg/min50\text{ mg/min} in adult clients.

Step-by-Step Solution

1
Review the prescribed medication and its compatibility with the current continuous intravenous fluid.
Phenytoin is highly incompatible with dextrose solutions like D5WD_5W and will precipitate.
Verifying IV fluid compatibility is essential to prevent crystallization in the catheter, which could lead to an embolism or loss of IV access.
2
Determine the correct procedure for administration through a line running an incompatible fluid.
The primary D5WD_5W infusion must be paused, and the line must be flushed thoroughly with 0.9% sodium chloride0.9\% \text{ sodium chloride} (normal saline) both before and after giving the drug.
Normal saline is the only compatible IV fluid for flushing and diluting phenytoin.
3
Identify the safe administration rate and necessary patient monitoring.
The medication must be administered at a rate no faster than 50 mg/min50\text{ mg/min} by the registered nurse.
Rapid infusion causes cardiovascular collapse, and the required complex assessments cannot be delegated to a UAP.

Key Concept

Safe administration parameters for intravenous phenytoin
Question 1397Question →

An oriented and competent client with progressive amyotrophic lateral sclerosis (ALS) is receiving palliative care and continuous non-invasive positive pressure ventilation. The client tells the nurse, "I am exhausted from fighting this. I want to take off this mask and let nature take its course." The client's adult children are at the bedside, visibly distraught, and state, "He is just having a bad day and is depressed. You cannot take it off, he will not survive the night!" There are no advance directives on file. Which action should the nurse take first?

Show answer & explanation

Answer: Request the family members to step out of the room temporarily to privately explore the client's feelings and verify voluntariness.

Answer

The nurse should ask the family to step out of the room temporarily to privately explore the client's request.
The priority action is to assess the client's request privately. A competent adult has the right to refuse life-sustaining treatment, but the nurse must ensure this decision is made voluntarily and is not being influenced by the family's presence or distress. Assessing the client alone allows for open, therapeutic communication about their exhaustion and end-of-life wishes.

Step-by-Step Solution

1
Analyze the clinical situation and identify the conflict.
A competent client is requesting withdrawal of life-sustaining treatment, but the family is actively opposing it due to emotional distress.
Understanding the competing interests (client autonomy vs. family grief) is essential for prioritizing the next nursing action.
2
Apply the nursing process (Assessment first).
The nurse determines that more information is needed directly from the client regarding their request.
Before intervening, the nurse must ensure the client's decision is informed, consistent, and voluntary.
3
Establish an appropriate environment for assessment.
The nurse decides to separate the client from the family temporarily.
The family's acute distress can inadvertently coerce the client or suppress their true wishes; a private assessment guarantees the voluntariness of the client's decision.

Key Concept

Client Autonomy and Private Assessment in End of Life Care
Question 1398Question →

A nurse is preparing to administer a prescribed intravenous (IV) infusion of potassium chloride to a client who has a serum potassium level of 2.9 mEq/L and is experiencing premature ventricular contractions (PVCs). Which actions are safe and appropriate for the nurse to implement? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Ensure the potassium chloride solution is administered using an electronic infusion pump.; Verify that the client has a urine output of at least 30 mL/hr before initiating the infusion.; Set the peripheral IV infusion rate to deliver a maximum of 10 mEq of potassium per hour.

Answer

The safe and appropriate actions are to administer the solution using an electronic infusion pump, verify adequate urine output prior to the infusion, and limit the peripheral infusion rate to a maximum of 10 mEq per hour.
Intravenous potassium chloride is a high-alert medication. Safe administration requires using an electronic infusion pump to prevent accidental boluses. Because potassium is excreted by the kidneys, the nurse must verify adequate urine output (at least 30 mL/hr) prior to administration to prevent hyperkalemia. Additionally, to avoid cardiac toxicity and severe vein irritation, the infusion rate through a peripheral line should never exceed 10 mEq per hour.

Step-by-Step Solution

1
Analyze the prescribed medication and the client's clinical presentation.
The client has severe hypokalemia (2.9 mEq/L) with cardiac manifestations (PVCs) and requires intravenous potassium chloride, which is a high-alert medication.
Identifying high-alert medications is critical for determining the required safety protocols for administration.
2
Evaluate the safe administration parameters for intravenous potassium chloride.
Safe parameters include always using an infusion pump, ensuring a maximum peripheral rate of 10 mEq/hr, and confirming renal function (urine output >30 mL/hr).
Adhering to strict administration parameters prevents fatal arrhythmias and hyperkalemia.
3
Identify and reject unsafe practices from the available options.
Rapid infusion rates and failing to check IV compatibility are identified as severe safety risks and are rejected.
Potassium given too quickly directly causes cardiac arrest, and incompatible IV medications can cause dangerous precipitation in the line.

Key Concept

Safe administration protocols for high-alert intravenous medications, specifically potassium chloride.
Question 1399Question →

A nurse is monitoring a client receiving a transfusion of packed red blood cells. Fifteen minutes after the infusion begins, the client suddenly develops severe lower back pain, chills, and dyspnea. Suspecting an acute hemolytic transfusion reaction, arrange the following nursing actions in the correct priority sequence from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first stop the transfusion, then replace the tubing to infuse normal saline, assess the client, notify the provider and blood bank, and finally send the materials to the lab.
In any acute medical emergency caused by an external agent, the first priority is to remove or stop the causative agent. Therefore, stopping the transfusion is step one. Maintaining IV access with normal saline using new tubing is step two, ensuring a lifeline is available without worsening the reaction. Step three is assessing the client to determine the exact physiological impact. Step four is notifying the provider using the gathered assessment data. Step five, the final administrative and diagnostic step, is sending the materials to the lab.

Step-by-Step Solution

1
Identify the primary source of harm and intervene immediately.
The blood transfusion is stopped.
Continuing the transfusion, even for a few more seconds, exacerbates the acute hemolytic reaction.
2
Maintain vascular access without administering more of the offending agent.
New IV tubing is attached and normal saline is infused.
Using the existing blood tubing would push the remaining blood into the client. Normal saline maintains line patency for emergency drugs.
3
Determine the client's physiological baseline following the insult.
Vital signs and respiratory status are assessed.
Objective data is required to communicate the client's status to the provider and anticipate necessary interventions (e.g., oxygen, epinephrine, diuretics).
4
Communicate the crisis to the interdisciplinary team.
The healthcare provider and blood bank are notified.
The provider must prescribe medical interventions, and the blood bank must initiate their internal investigation protocols.
5
Facilitate diagnostic investigation.
Blood bag, tubing, and client samples are sent to the laboratory.
This confirms the type of reaction and determines if a systemic error occurred, but it is the lowest priority compared to client stabilization.

Key Concept

Priority Management of Suspected Transfusion Reactions
Estimated Time:1m 30s
Question 1400Question →

A client in the cardiac intensive care unit requires a continuous intravenous infusion of dobutamine at 10 \mug/kg/min10\text{ \mu g/kg/min} for severe ventricular dysfunction. The client currently has only one functioning peripheral venous access site. After assessing new-onset bilateral crackles and an oxygen saturation of 88%88\%, the healthcare provider prescribes an immediate 80 mg80\text{ mg} intravenous bolus of furosemide. Which of the following actions is the safest and most appropriate method to administer the prescribed diuretic?

Show answer & explanation

Answer: Establish a second peripheral intravenous access site and administer the diuretic steadily over 4 minutes.

Answer

The safest action is to establish a second peripheral IV site and administer the furosemide slowly over 4 minutes.
The correct action addresses three critical pharmacology and safety principles simultaneously: dobutamine cannot be paused due to its short half-life and the risk of hemodynamic collapse, furosemide is highly incompatible with dobutamine and will precipitate if mixed, and a high dose of furosemide (80 mg80\text{ mg}) must be pushed slowly over at least 4 minutes (maximum 20 mg/minute20\text{ mg/minute}) to prevent permanent ototoxicity. Establishing a second line is the only action that fulfills all of these safety requirements.

Step-by-Step Solution

1
Analyze the physical compatibility of the two medications.
Furosemide and dobutamine are physically incompatible and will immediately precipitate if mixed in the same IV tubing.
Administering incompatible medications together can cause catheter occlusion and life-threatening emboli, requiring separation of the medications.
2
Determine the pharmacokinetics of the continuous vasoactive infusion.
Dobutamine has an extremely short half-life of approximately 2 minutes.
Pausing the dobutamine infusion for a flush-push-flush sequence would cause a rapid, dangerous drop in cardiac output and systemic perfusion.
3
Calculate the safe administration rate for the intravenous bolus of furosemide.
The maximum safe rate for intravenous furosemide is 20 mg/minute20\text{ mg/minute}. An 80 mg80\text{ mg} dose must be administered over at least 4 minutes.
Rapid administration of high-dose loop diuretics significantly increases the risk of permanent ototoxicity.
4
Synthesize the findings to determine the priority nursing action.
Because the medications cannot be mixed, the continuous infusion cannot be safely paused, and the diuretic must be pushed slowly, a second IV line is absolutely necessary.
Establishing a second line ensures that the client receives the critical diuretic at the safe rate without interrupting life-sustaining cardiac support.

Key Concept

Parenteral therapy safety requires simultaneous evaluation of drug compatibility, safe administration rates, and the hemodynamic consequences of interrupting continuous vasoactive infusions.
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