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Question 141Question →

A nurse is caring for a client who is receiving a transfusion of packed red blood cells (PRBCs). Fifteen minutes into the transfusion, the client reports severe lower back pain, chills, and shortness of breath. Arrange the following nursing actions in the correct order of priority from first to last.

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Answer

The correct sequence is: Stop the transfusion, maintain the IV with normal saline using new tubing, assess the client's vital signs, notify the provider and blood bank, and return the blood materials to the blood bank.
In a suspected hemolytic blood transfusion reaction, the absolute first clinical priority is to stop the transfusion to prevent further exposure to incompatible blood. Next, the nurse must maintain intravenous access with 0.9% sodium chloride through new tubing to keep the vein open for emergency drugs without infusing the remaining blood in the old tubing. After stabilizing the IV line, the nurse assesses the client's vital signs and respiratory status to gather essential data. This data is then reported when notifying the healthcare provider and blood bank. Finally, the blood bag and tubing are returned to the blood bank for further investigation.

Step-by-Step Solution

1
Identify the type of emergency.
Severe lower back pain, chills, and dyspnea indicate an acute hemolytic transfusion reaction.
Recognizing the complication is the prerequisite for initiating the correct emergency protocol.
2
Stop the transfusion immediately.
The infusion of incompatible blood is halted.
Stopping the trigger limits the amount of antigen entering the body, minimizing further physiological deterioration.
3
Change the tubing and start normal saline.
Intravenous access is maintained without flushing more blood into the client.
A patent IV is essential for administering emergency medications and fluids to manage hypotension or shock.
4
Assess the client.
Vital signs and respiratory status are documented.
Provides a baseline of the client's current physiological compromise to communicate to the provider.
5
Notify the provider and blood bank, then send the equipment.
Further medical orders are obtained and the blood bank can investigate the reaction.
Ensures collaborative management and identifies the immunological cause of the adverse reaction.

Key Concept

Management of Acute Hemolytic Transfusion Reaction
Estimated Time:1m 30s
Question 142Question →

A client admitted with bacterial cellulitis is receiving a continuous primary infusion of normal saline at 125 mL/hr125\text{ mL/hr}. The nurse is ready to initiate a scheduled dose of intravenous ampicillin-sulbactam via a secondary piggyback line. Arrange the following steps in the correct order to safely set up the secondary infusion.

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Answer

The correct sequence is to first close the roller clamp on the secondary tubing, then spike the bag and prime the tubing. Next, cleanse the uppermost Y-site port of the primary tubing, attach the secondary tubing to this port, and finally lower the primary continuous intravenous fluid bag.
This sequence ensures patient safety, asepsis, and proper administration mechanics. Closing the clamp first prevents medication waste. Spiking and priming prepares the line and removes air. Cleansing the port maintains asepsis. Attaching to the upper Y-site ensures the pump controls the rate. Lowering the primary bag utilizes gravity to allow the piggyback to infuse entirely before the primary fluid resumes.

Step-by-Step Solution

1
Close the roller clamp on the secondary intravenous tubing.
The tubing is sealed off.
Prevents immediate uncontrolled flow of medication and rapid air entry when the IV bag is spiked.
2
Spike the secondary medication bag and prime the tubing.
The tubing is filled with the medication and purged of air.
Ensures the line is ready for connection without introducing air into the patient's vascular system.
3
Cleanse the uppermost Y-site port of the primary tubing with an antimicrobial swab.
The connection site is disinfected.
Prevents the introduction of pathogens into the central or peripheral bloodstream.
4
Attach the secondary tubing to the primary line.
The secondary line is securely connected to the infusion system.
Allows the secondary medication to be routed through the primary line so its rate can be regulated by the main infusion pump.
5
Suspend the primary intravenous fluid bag lower than the secondary medication bag.
The primary bag hangs physically lower than the secondary bag.
Hydrostatic pressure dictates that fluid from the higher bag (secondary) will infuse first. Once the secondary bag empties, the primary fluid will automatically resume.

Key Concept

Intravenous (IV) Piggyback Administration Setup
Question 143Question →

A nurse is caring for a client who is receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes after the transfusion begins, the client reports severe lower back pain, shortness of breath, and chills. Arrange the following nursing actions in the correct priority order from first to last.

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Answer

The correct sequence is to first stop the transfusion, then maintain IV access with normal saline using new tubing, followed by assessing the client, notifying the provider and blood bank, and finally sending the blood bag and tubing back to the blood bank.
According to prioritization principles, when a client experiences an adverse reaction to an infusion, the immediate priority is to stop the causative agent. Next, the nurse must maintain a patent IV line with normal saline using new tubing to ensure emergency medications can be given without flushing more of the reactive blood into the client. Only after these immediate safety measures are taken should the nurse conduct a full assessment, notify the provider, and handle the blood products.

Step-by-Step Solution

1
Identify the signs of an acute hemolytic transfusion reaction.
Recognize that lower back pain, shortness of breath, and chills require immediate intervention.
Early recognition is crucial for reducing risk potential and preventing severe physiological complications.
2
Determine the most critical priority action.
Select stopping the transfusion as the first step.
Removing the causative agent immediately prevents further harm to the client.
3
Sequence the remaining supportive and administrative actions.
Place securing IV access before assessment, followed by provider notification, and finally returning the equipment.
Airway and circulation support (IV access) precedes full assessment, and client stabilization precedes diagnostic follow-up.

Key Concept

Management of Acute Hemolytic Transfusion Reactions
Estimated Time:1m 30s
Question 144Question →

A nurse is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, pounding headache and blurred vision. The nurse notes profuse diaphoresis and flushing above the level of the injury. The client's blood pressure is 210/115 mm Hg, and the heart rate is 52 beats/min. Arrange the following nursing actions in the correct priority order.

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Answer

The correct priority sequence is to first elevate the head of the bed, then loosen clothing and check the bladder, assess for a fecal impaction, administer an antihypertensive medication if needed, and finally document the event.
In autonomic dysreflexia, the priority is preventing a stroke from severe hypertension. Elevating the head of the bed provides immediate orthostatic relief. The nurse then systematically assesses for and removes noxious stimuli below the level of the injury, starting with the bladder (most common) and then the bowel. Medications are a secondary intervention if trigger removal fails. Documentation is the final step after stabilization.

Step-by-Step Solution

1
Elevate the head of the bed to a high Fowler's position.
Induces an orthostatic decrease in blood pressure.
Autonomic dysreflexia causes severe, life-threatening hypertension. Sitting the client upright is the quickest non-pharmacological way to lower the blood pressure and prevent cerebral hemorrhage.
2
Loosen constrictive clothing and assess the urinary catheter for kinks.
Identifies and resolves the most common noxious stimulus.
The condition is a reflex response to stimuli below the level of injury. A distended bladder from a kinked catheter or full bladder is the leading cause.
3
Assess the client's rectum for a fecal impaction if the bladder is empty.
Identifies the second most common trigger.
If the bladder is ruled out, a bowel impaction is the next most likely noxious stimulus causing the sympathetic surge.
4
Administer a prescribed rapid-acting antihypertensive medication.
Pharmacologically lowers the blood pressure.
Medications are indicated only if identifying and removing the underlying noxious stimuli fails to resolve the hypertensive crisis.
5
Document the clinical event, the interventions implemented, and the client's response.
Provides an accurate medical record of the emergency.
Documentation should always occur after the client's immediate physiological needs have been met and stabilization is achieved.

Key Concept

Autonomic dysreflexia is a medical emergency in clients with spinal cord injuries at or above T6. Management prioritizes immediately lowering blood pressure through positioning (high Fowler's), followed by identifying and removing the triggering noxious stimulus (most commonly a full bladder or bowel).
Question 145Question →

A nurse is preparing to perform a sterile dressing change on a client's central venous catheter (CVC). To reduce the risk of a central line-associated bloodstream infection (CLABSI) and prevent catheter dislodgment, place the following steps in the correct chronological order.

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Answer

The correct sequence begins with donning a mask and directing the client's face away, followed by removing the old dressing. The nurse then transitions to sterile gloves, cleanses the site with chlorhexidine (allowing it to dry), and finally applies a new transparent occlusive dressing.
Changing a central line dressing requires strict adherence to sterile technique to prevent CLABSI. Masking protects the site from respiratory droplets. The old dressing is removed carefully toward the site to prevent dislodging the catheter. A sterile field is then established by donning sterile gloves. Chlorhexidine is applied with friction to destroy microorganisms and must dry completely to achieve its chemical antisepsis effect. Finally, a sterile occlusive dressing seals the site.

Step-by-Step Solution

1
Don a face mask and instruct the client to turn their head away.
Respiratory droplets are directed away from the vulnerable area.
Applying airborne precautions reduces the immediate risk of bacterial contamination from the respiratory tract before the protective dressing is even removed.
2
Remove the old dressing by pulling the edges toward the insertion site.
The insertion site is safely exposed.
Pulling away from the insertion site could snag the catheter and accidentally pull it out. This step utilizes clean technique.
3
Discard the old dressing and clean gloves, perform hand hygiene, and don sterile gloves.
The nurse successfully transitions to strict sterile technique.
Once the site is exposed, maximum sterile barrier precautions are required to touch the site and apply the new antiseptic and dressing.
4
Scrub the insertion site with chlorhexidine using friction and allow it to air dry.
Skin flora and potential pathogens are eradicated.
Friction helps the antiseptic penetrate the epidermis, and chlorhexidine must air dry completely to achieve its maximum antimicrobial efficacy.
5
Apply a new sterile transparent occlusive dressing over the insertion site.
The catheter site is securely sealed.
An occlusive transparent dressing prevents environmental contamination while allowing continuous visualization of the site for early signs of infection.

Key Concept

Central Venous Catheter (CVC) Infection Control and Dressing Change Sequencing
Question 146Question →

A nurse is preparing to administer prescribed intravenous (IV) push ondansetron to a client experiencing postoperative nausea. The client has a dedicated peripheral IV saline lock in place. Arrange the following actions in the correct sequence for safe administration.

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Answer

The correct sequence follows the SAS (Saline, Administer, Saline) method while maintaining asepsis and preventing catheter occlusion.
The correct sequence for administering an IV push medication through a saline lock is to first clean the port to maintain asepsis. Next, use the SAS method: check patency with normal saline (Saline), administer the medication at the proper rate (Administer), and flush again with normal saline to push the remaining medication at that exact same safe rate (Saline). Finally, clamp the line with positive pressure to prevent blood reflux and subsequent occlusion.

Step-by-Step Solution

1
Scrub the hub with antiseptic.
Port is disinfected.
Maintains asepsis and prevents catheter-associated bloodstream infections.
2
Aspirate and flush with normal saline.
Patency is confirmed.
Ensures the IV is properly located in the vein and clears the line.
3
Administer the IV push medication.
Medication is delivered safely.
Provides therapeutic intervention at the safe, prescribed administration rate.
4
Flush with normal saline at the same administration rate.
Medication is fully cleared from the extension tubing.
Ensures the entire dose reaches the client without inadvertently pushing a rapid bolus of the medication left in the tubing dead space.
5
Clamp while applying positive pressure.
System is sealed.
Prevents blood reflux into the catheter, avoiding occlusion.

Key Concept

Peripheral IV push medication administration (SAS method)
Question 147Question →

A nurse is caring for a client admitted with an exacerbation of heart failure. The client suddenly develops severe dyspnea, extreme anxiety, and begins coughing up pink, frothy sputum. Arrange the following nursing actions in the priority order they should be performed.

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Answer

The correct priority sequence is to first place the client in a high Fowler's position, followed by administering high-flow oxygen, obtaining vital signs, administering intravenous furosemide, and finally inserting an indwelling urinary catheter.
In acute pulmonary edema, the absolute priority is airway and breathing. Placing the client in a high Fowler's position immediately reduces venous return and eases breathing. Oxygen is applied next to treat hypoxia. Once ABCs are stabilized, baseline vital signs must be taken to safely administer medications. Intravenous furosemide is then given to pull fluid from the lungs, followed by the insertion of a urinary catheter to closely monitor the diuresis.

Step-by-Step Solution

1
Evaluate the immediate threat to life based on the presentation.
The client has developed acute pulmonary edema, compromising airway and breathing.
To determine the immediate ABC (Airway, Breathing, Circulation) priority.
2
Implement rapid mechanical intervention for breathing.
Place the client upright with dependent legs.
This physical action immediately decreases venous return to the heart and reduces pulmonary congestion and the work of breathing.
3
Treat the resultant hypoxemia.
Administer high-flow oxygen.
Improves alveolar gas exchange that has been severely impaired by fluid accumulating in the alveoli.
4
Establish a clinical baseline.
Assess vital signs and auscultate lung sounds.
Provides necessary hemodynamic data (such as blood pressure and heart rate) prior to medication administration.
5
Implement pharmacological treatment.
Administer intravenous furosemide.
Promotes rapid diuresis to decrease overall circulating blood volume and further relieve pulmonary congestion.
6
Monitor therapeutic response.
Insert an indwelling urinary catheter.
Allows accurate measurement of urine output to evaluate the effectiveness of the loop diuretic.

Key Concept

Prioritization of care in acute pulmonary edema focuses on the ABCs: optimizing breathing mechanics and oxygenation before proceeding to assessment and pharmacological interventions.
Question 148Question →

A nurse is preparing to perform open-system suctioning for a client with a tracheostomy tube. To reduce the risk of hypoxia and mucosal trauma, in which order should the nurse perform the following actions? Arrange the steps in the correct sequence from first to last.

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Answer

The correct sequence is to preoxygenate, insert without suction, withdraw slightly, apply suction while rotating outward, and finally reassess.
To reduce the risk of life-threatening complications such as hypoxemia, cardiac dysrhythmias, and mucosal trauma, the nurse must adhere to a strict procedural sequence. Preoxygenation provides a critical oxygen reserve. Inserting the catheter without suction protects the airway lining. Withdrawing the catheter slightly before applying suction prevents adherence to the carina, avoiding vagal stimulation. Applying suction only during withdrawal with a rotating motion safely removes secretions. Reassessing the client verifies the procedure's success and the client's stability.

Step-by-Step Solution

1
Preoxygenate the client.
Increases the client's arterial oxygenation levels.
Prevents hypoxemia during the procedure.
2
Insert the catheter without applying suction.
The catheter reaches the level of the carina or mainstem bronchi.
Applying suction during insertion causes severe tissue trauma and oxygen depletion.
3
Withdraw the catheter 1 to 2 centimeters.
The catheter tip is moved away from the sensitive carina.
Prevents direct vagal stimulation and localized tissue damage when suction is applied.
4
Apply intermittent suction while rotating and withdrawing.
Secretions are safely cleared from the airway.
Rotation prevents the catheter tip from continuously adhering to one area of the tracheal mucosa.
5
Reassess the client.
Post-procedure baseline is established.
Ensures the airway is patent and the client has not suffered adverse effects.

Key Concept

Safe tracheostomy suctioning sequence to minimize hypoxia and mucosal trauma.
Estimated Time:1m 0s
Question 149Question →

While monitoring a client receiving an initial unit of packed red blood cells, the nurse notes that 15 minutes into the infusion, the client abruptly reports severe lower back pain, chills, and a sensation of shortness of breath. The client's vital signs reveal a blood pressure of 90/60 mmHg, a heart rate of 116/min, a respiratory rate of 24/min, and a temperature of 101.2°F (38.4°C). Arrange the following nursing actions in the correct order of priority.

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Answer

1. Stop the blood transfusion.
2. Disconnect the blood tubing and initiate an infusion of normal saline using new tubing.
3. Assess the client's vital signs and respiratory status.
4. Notify the healthcare provider and the blood bank.
5. Send the remaining blood product and tubing to the blood bank for analysis.
In the event of a suspected acute hemolytic blood transfusion reaction, the absolute first priority is to stop the infusion to prevent further exposure to the incompatible antigen. Once the infusion is stopped, the nurse must maintain a patent IV line for emergency medications by infusing 0.9% sodium chloride using completely new tubing (to avoid pushing residual blood into the client). Next, the nurse performs a rapid physical assessment, including vital signs and respiratory status, to evaluate the severity of the physiological compromise. The nurse then notifies the healthcare provider to obtain emergency prescriptions and alerts the blood bank. Finally, the remaining blood, tubing, and labels are sent back to the blood bank for crossmatching and post-reaction analysis.

Step-by-Step Solution

1
Identify the complication occurring in the clinical scenario.
The client is experiencing a severe acute hemolytic transfusion reaction.
Lower back pain, chills, hypotension, and tachycardia shortly after starting a transfusion are hallmark physiological signs of an acute hemolytic reaction.
2
Determine the absolute first priority action.
Stop the blood transfusion.
The immediate priority in any adverse medication or blood reaction is to remove the causative agent to limit further physiological damage.
3
Determine the next action required to safely maintain venous access.
Disconnect the existing tubing and initiate normal saline using new tubing.
Venous access must be maintained for emergency interventions, but flushing the existing blood tubing would push more incompatible blood into the client.
4
Determine the next action to evaluate the client's condition.
Assess vital signs and respiratory status.
A rapid physiological assessment is necessary to determine the severity of the reaction and to prepare a complete, accurate report for the healthcare provider.
5
Determine the appropriate notification and follow-up protocol steps.
Notify the provider and blood bank, then send the remaining product to the laboratory.
The provider must prescribe emergency pharmacological interventions, and the blood bank must analyze the remaining product and tubing to confirm the reaction etiology.

Key Concept

Management Sequence for Acute Hemolytic Transfusion Reactions
Estimated Time:1m 30s
Question 150Question →

A nurse is assessing a client who had an exploratory laparotomy 3 days ago. While the nurse is in the room, the client sneezes forcefully and reports a sudden "popping" sensation. The nurse inspects the surgical site and observes a loop of bowel protruding through the incision. In what order should the nurse perform the following actions to reduce the risk of further complications? Arrange the actions in the correct sequence.

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Answer

The correct sequence is to first stay with the client and call for help, then position the client to reduce abdominal tension, cover the exposed organs with moist sterile dressings, assess vital signs for shock, and finally prepare for emergency surgery.
Wound evisceration is a life-threatening complication that requires immediate, prioritized nursing interventions to reduce the risk of tissue necrosis and shock. The nurse must first ensure safety by calling for help while staying with the client. Next, the nurse minimizes further damage by reducing intra-abdominal tension through positioning. The exposed tissue is then protected with sterile, moist dressings. Once the immediate anatomical threat is managed, the nurse assesses the systemic response by obtaining vital signs, and finally, completes preparations for definitive surgical repair.

Step-by-Step Solution

1
Stay with the client, call for immediate assistance, and instruct a colleague to notify the surgeon.
Assistance is secured without leaving the client alone.
Evisceration is a surgical emergency. The nurse must remain with the client to prevent further injury and manage the airway and hemodynamics while delegating the notification of the healthcare provider.
2
Place the client in a low Fowler's position with the knees flexed.
Intra-abdominal pressure is decreased.
This specific position relieves tension on the abdominal wall muscles, which reduces the risk of more bowel loops protruding through the open fascia.
3
Cover the protruding bowel with sterile dressings saturated in normal saline.
The exposed bowel is protected from dehydration and infection.
Internal organs will rapidly become necrotic if allowed to dry out. Sterile saline maintains moisture, and sterile technique prevents the introduction of environmental pathogens.
4
Obtain the client's vital signs and monitor for manifestations of shock.
The client's hemodynamic status is evaluated.
The sudden exposure of internal organs and potential fluid shifts can trigger shock. Baseline vital signs are necessary to guide fluid resuscitation and inform the surgeon.
5
Prepare the client for immediate surgical intervention.
The client is readied for definitive treatment.
The only definitive treatment for an evisceration is emergency surgical repair. The nurse prepares the client by ensuring patent intravenous access and maintaining NPO status.

Key Concept

Emergency Management of Wound Evisceration
Question 151Question →

A nurse is preparing to remove a non-tunneled central venous catheter (CVC) from a client's internal jugular vein. Place the following nursing actions in the correct chronological order to ensure client safety and prevent complications during the procedure.

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Answer

The correct sequence for removing a central venous catheter is to position the client supine, remove the dressing, instruct the client to bear down, withdraw the catheter, apply firm pressure, and finally inspect the catheter tip.
The safe removal of a central venous catheter prioritizes the prevention of an air embolism. The procedure begins by placing the client flat or in a slight Trendelenburg position to increase central venous pressure. After removing the dressing to free the catheter, the nurse instructs the client to bear down (Valsalva maneuver) to elevate intrathoracic pressure. The catheter is withdrawn exactly during this maneuver to ensure the vein remains under positive pressure. Immediate manual pressure is then applied to the site to achieve hemostasis and form an airtight seal over the tract. Finally, the nurse inspects the catheter tip to ensure no fragments were retained in the patient.

Step-by-Step Solution

1
Place the client in a supine or slight Trendelenburg position.
Central venous pressure is increased.
This positioning prevents an air embolism by keeping the venous pressure higher than atmospheric pressure.
2
Remove the transparent dressing and any securement devices.
The catheter is freed from the skin.
The site must be fully prepared before the client is instructed to alter their breathing pattern.
3
Instruct the client to take a deep breath and bear down.
Intrathoracic pressure is temporarily increased.
The Valsalva maneuver ensures positive pressure in the vein, further protecting against air entry.
4
Withdraw the catheter smoothly and continuously.
The catheter is completely removed from the jugular vein.
Removing the line while the client bears down minimizes the time the open tract is exposed to potential air intake.
5
Apply immediate, firm pressure to the insertion site using sterile gauze.
Hemostasis is achieved and the entry tract is sealed.
Firm pressure prevents bleeding and physically blocks air from entering the vein.
6
Inspect the distal tip of the removed catheter.
The physical integrity of the catheter is confirmed.
This verification ensures no pieces of the catheter have broken off into the client's bloodstream.

Key Concept

Safe removal of a central venous catheter requires strict adherence to procedural steps that prevent air embolism, primarily through patient positioning and the utilization of the Valsalva maneuver.
Question 152Question →

A nurse is caring for an adult client who is receiving a unit of packed red blood cells (PRBCs) for symptomatic anemia. Twenty minutes after the transfusion is initiated, the client reports sudden lower back pain and feeling unusually cold. The nurse notes the client is restless with a blood pressure of 88/52 mmHg. Arrange the following nursing actions in the correct order of priority. (Place the highest priority action first.)

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Answer

The correct order of interventions is to first stop the transfusion, then initiate normal saline with new tubing, assess the client's vital signs, notify the provider and blood bank, and finally send the blood product to the blood bank.
In the event of a suspected acute hemolytic transfusion reaction (indicated by lower back pain, chills, and hypotension), the absolute first priority is to stop the infusion to prevent further exposure to the offending antigen. The next step is to maintain patent IV access with normal saline using completely new tubing; using the old tubing would infuse more of the reactive blood. Once the source is stopped and access is secured, the nurse performs a rapid clinical assessment. This assessment data is then communicated to the healthcare provider to guide emergency pharmacological interventions. Finally, after the client is stabilized and acute actions are completed, the remaining blood product and tubing are sent to the blood bank for investigation.

Step-by-Step Solution

1
Recognize the signs of an acute hemolytic transfusion reaction and immediately stop the transfusion.
Further entry of incompatible blood into the client's circulation is halted.
Stopping the source of the harm is always the most critical first step to minimize the severity of the reaction and prevent further physiological deterioration.
2
Maintain intravenous access with new tubing and 0.9% sodium chloride.
A patent intravenous line is secured without infusing the remaining blood.
The client is hypotensive and will likely require emergency intravenous medications and fluid resuscitation. New tubing prevents pushing the remaining reactive blood into the client.
3
Perform a rapid clinical assessment of vital signs and respiratory status.
Current hemodynamic and respiratory data are obtained.
Accurate clinical data is required to determine the severity of the reaction and to provide a complete report to the healthcare provider.
4
Notify the healthcare provider and the blood bank.
The provider is informed of the reaction and assessment data.
The provider must prescribe emergency interventions (e.g., vasopressors, antihistamines), and the blood bank must initiate their adverse reaction protocol.
5
Return the blood product, tags, and tubing to the blood bank.
The physical evidence of the transfusion is sent for laboratory analysis.
The blood bank must analyze the remaining product and equipment to confirm the type and underlying cause of the adverse reaction.

Key Concept

Management of Acute Hemolytic Transfusion Reactions
Question 153Question →

A nurse is preparing to administer a prescribed intravenous (IV) push medication through a client's non-valved central venous catheter (CVC). Arrange the following steps in the correct order of execution. All steps must be used.

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Answer

The correct sequence for administering an IV push medication through a non-valved central venous catheter is: Scrub the connector, aspirate and flush with normal saline, administer the medication, flush with normal saline again using a push-pause technique, and finally instill the heparin flush.
The SASH sequence (Saline, Administer, Saline, Heparin) is the standard evidence-based practice for administering medications through a non-valved central venous catheter. Asepsis must be established first by scrubbing the hub. An initial saline flush with aspiration confirms placement. After medication administration, a second saline flush clears the drug. Finally, a heparin flush maintains patency.

Step-by-Step Solution

1
Scrub the needleless connector with an antimicrobial swab and allow it to dry completely.
The entry port is disinfected.
Prevents the introduction of microorganisms into the bloodstream, minimizing the risk of central line-associated bloodstream infections (CLABSI).
2
Attach a syringe of normal saline, aspirate for blood return, and flush the catheter.
Placement and patency are verified.
Aspiration ensures the catheter tip is appropriately situated in the vascular space, while the initial flush ensures there is no resistance or occlusion.
3
Administer the prescribed intravenous medication over the recommended duration.
The medication is delivered safely.
Administering at the correct rate prevents adverse reactions and toxicity.
4
Flush the catheter with normal saline using a push-pause technique.
The medication is cleared from the line.
Ensures the entire dose reaches the vascular system and clears the line to prevent incompatibility with subsequent infusions. The push-pause method creates turbulence to clean the catheter walls.
5
Instill the prescribed heparin flush solution into the catheter lumen.
The catheter is locked with heparin.
Maintains catheter patency in non-valved central lines by preventing blood coagulation inside the lumen between uses.

Key Concept

The SASH (Saline, Administer, Saline, Heparin) method ensures safe medication administration and maintains patency in non-valved central venous catheters.
Question 154Question →

A nurse is preparing to remove a client's non-tunneled central venous catheter (CVC). To minimize the risk of an air embolism and ensure client safety, arrange the following nursing actions in the correct chronological sequence.

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Answer

The correct sequence is to first place the client in a supine position, then instruct them to perform the Valsalva maneuver, followed by withdrawing the catheter, applying immediate firm pressure, and finally securing an occlusive dressing.
Removing a central venous catheter involves a significant risk of an air embolism if intrathoracic pressure falls below atmospheric pressure. By initially placing the client in a supine position and subsequently having them perform the Valsalva maneuver, the nurse artificially raises the central venous pressure. Withdrawing the catheter exclusively during this positive-pressure phase, immediately applying firm pressure to the site, and finally sealing the tract with an occlusive dressing effectively mitigates this life-threatening risk in the correct physiological sequence.

Step-by-Step Solution

1
Place the client in a supine position.
Central venous pressure is increased.
Supine positioning uses gravity to prevent a negative pressure gradient, reducing the risk of air being drawn into the vein.
2
Instruct the client to bear down (Valsalva maneuver).
Intrathoracic pressure increases significantly.
Creates a positive pressure environment in the central veins, blocking potential air entry.
3
Withdraw the catheter smoothly.
The catheter is removed safely.
The device is removed precisely while the protective positive pressure is actively maintained by the client.
4
Apply firm pressure to the site with sterile gauze.
Bleeding is controlled and the tract is compressed.
Promotes hemostasis and prevents any immediate air entry through the newly opened skin tract.
5
Apply an occlusive dressing over the insertion site.
An airtight seal is established.
Prevents delayed air entry as the internal tract fully closes.

Key Concept

Reduction of Risk Potential: Central Venous Catheter Removal
Estimated Time:1m 30s
Question 155Question →

A nurse is caring for a client with a T3 spinal cord injury who suddenly reports a severe, throbbing headache. The client presents with facial erythema, diaphoresis above the level of the lesion, and a blood pressure of 215/115 mmHg. Arrange the following nursing actions in the correct priority sequence from first to last.

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Answer

The correct priority sequence is: Position the client in a high-Fowler's position, then loosen restrictive clothing, followed by assessing the urinary catheter, and finally administering the antihypertensive medication.
Autonomic dysreflexia is a medical emergency characterized by uncontrolled hypertension in clients with spinal cord injuries at or above T6. The initial action is always to elevate the head of the bed to 90 degrees (high-Fowler's) to immediately decrease blood pressure through orthostasis. Next, constrictive clothing should be loosened to remove surface stimuli. The nurse then systematically assesses for and eliminates the noxious stimulus, starting with the most common cause: bladder distension or catheter obstruction. Finally, if conservative measures fail to lower the blood pressure, prescribed antihypertensives are administered.

Step-by-Step Solution

1
Position the client in a high-Fowler's position.
The client is sitting upright, utilizing gravity to induce orthostatic hypotension.
Extreme hypertension places the client at immediate risk for a cerebral hemorrhage. Sitting the client up is the fastest way to lower blood pressure before gathering equipment or conducting further assessments.
2
Loosen any restrictive clothing or tight devices.
Potential cutaneous triggers, such as a tight belt or restrictive blanket, are removed.
Cutaneous stimulation can trigger or exacerbate the sympathetic nervous system response. This is a rapid intervention performed immediately after positioning.
3
Assess the indwelling urinary catheter tubing for kinks or obstruction.
The nurse checks for the most common cause of autonomic dysreflexia.
A distended bladder is the leading cause of this condition. Identifying and eliminating the noxious stimulus is the primary definitive treatment to stop the sympathetic surge.
4
Administer the prescribed PRN rapid-acting antihypertensive medication.
Pharmacological management is initiated to control blood pressure.
If removing the noxious stimuli (such as clothing or bladder distension) does not quickly resolve the crisis, or if the cause cannot be immediately found, antihypertensive medications are required to protect the client.

Key Concept

Autonomic Dysreflexia Prioritization
Estimated Time:1m 30s
Question 156Question →

A nurse is preparing to draw a diagnostic blood specimen from a client's central venous catheter (CVC) using the syringe method. Arrange the following actions in the correct procedural sequence. All options must be used.

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Answer

The correct sequence is to disinfect the hub, flush the line to check patency, withdraw a waste sample, draw the actual specimen, and finally flush the line to clear residual blood.
When drawing blood from a central venous catheter, maintaining sterility and ensuring an uncontaminated sample are paramount. Scrubbing the hub is the first step to prevent central line-associated bloodstream infections. Flushing the line confirms patency. The critical step of withdrawing a waste sample ensures that the subsequent diagnostic sample is not diluted by the normal saline flush or residual medications. After obtaining the specimen, a larger volume flush is required to completely clear the lumen of blood, preventing fibrin buildup and occlusion.

Step-by-Step Solution

1
Scrub the needleless connector of the catheter with an appropriate antiseptic swab.
The entry point is disinfected.
This prevents the introduction of microorganisms into the client's bloodstream and reduces the risk of central line-associated bloodstream infections (CLABSI).
2
Flush the catheter lumen with 10 mL of preservative-free 0.9% sodium chloride.
Catheter patency is confirmed.
Flushing ensures the line is open and clears previously infused fluids that could mix with the blood.
3
Withdraw and discard a 5 mL waste sample of blood from the catheter lumen.
The flush solution is removed from the line.
Discarding the initial blood prevents dilution and contamination of the diagnostic specimen by the saline.
4
Attach a new sterile syringe and withdraw the required volume of blood for the specimen.
The diagnostic sample is obtained.
This sample will accurately reflect the client's physiological laboratory values without interference from flush solutions.
5
Flush the catheter vigorously with 10 to 20 mL of 0.9% sodium chloride using a pulsatile method.
Residual blood is cleared from the line.
A final flush prevents blood from pooling and clotting in the catheter, maintaining its long-term patency.

Key Concept

Central Venous Catheter Blood Specimen Collection Procedure
Question 157Question →

A client is receiving continuous bladder irrigation (CBI) following a transurethral resection of the prostate (TURP). The client suddenly reports severe lower abdominal cramping, and the nurse observes that the outflow drainage has significantly decreased. Arrange the following nursing actions in the correct priority sequence to manage this complication.

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Answer

The correct sequence is to first assess the tubing for kinks, then stop the irrigation fluid, manually irrigate the catheter to clear clots, administer antispasmodic medication, and finally reassess the client's response.
When managing a client with decreased CBI outflow and severe cramping, the nurse must follow a sequence prioritizing bladder safety. First, a non-invasive assessment of the tubing checks for easily fixable kinks. If the tubing is patent, the inflow must be stopped immediately to prevent further distension. Next, manual irrigation clears the likely cause, which is typically blood clots. Once the obstruction is cleared, pharmacological management of spasms is appropriate, followed by final evaluation of the interventions.

Step-by-Step Solution

1
Assess the catheter tubing for kinks or compression.
Rules out simple mechanical causes for the outflow obstruction.
Non-invasive assessment is the safest and most immediate first step when equipment appears to malfunction.
2
Stop the continuous bladder irrigation.
Prevents additional fluid from entering the bladder.
Decreased outflow with continued inflow rapidly leads to bladder overdistension and potential rupture.
3
Manually irrigate with sterile normal saline.
Dislodges any blood clots blocking the catheter.
Clots are the most common cause of internal obstruction following a TURP; manual irrigation directly clears the pathway.
4
Administer an antispasmodic medication.
Relieves bladder spasms.
Treats the underlying irritation and cramping once the physical blockage has been resolved.
5
Reassess pain and drainage characteristics.
Confirms the complication has been resolved.
Evaluation is the final step of the nursing process to ensure client safety and treatment efficacy.

Key Concept

Continuous Bladder Irrigation (CBI) Complication Management
Question 158Question →

A nurse is caring for a client who is receiving intravenous fluids via a central venous catheter. The nurse notices that the IV tubing has accidentally disconnected from the catheter hub. The client suddenly reports severe shortness of breath and exhibits cyanosis, tachycardia, and a loud, churning murmur over the precordium. Suspecting an air embolism, arrange the following nursing actions in the priority order they should be performed, from first to last.

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Answer

The correct sequence is to first clamp the central venous catheter, then place the client in a left lateral Trendelenburg position, followed by administering high-flow oxygen, activating the rapid response team, and finally monitoring and documenting the client's status.
In the event of an air embolism, prioritization follows the principle of stopping the cause, managing the immediate anatomical threat, supporting physiology, and then escalating care. Clamping the line directly stops the air entry. Left lateral Trendelenburg positioning anatomically traps the air, preventing a fatal pulmonary blockage. Oxygen supports the resulting hypoxia and helps dissolve the embolus. Only after these immediate bedside interventions should the nurse step away from direct care to call for the rapid response team, followed by ongoing monitoring.

Step-by-Step Solution

1
Clamp the central venous catheter.
Stops further air from entering the venous system.
Negative intrathoracic pressure can draw a lethal amount of air into an open central line within seconds, making this the most critical initial action.
2
Place the client in a left lateral Trendelenburg position.
Traps the air in the apex of the right atrium and ventricle.
This specific position (Durant's maneuver) uses gravity to prevent the air bubble from advancing into the pulmonary artery, where it would cause a complete right ventricular outflow tract obstruction.
3
Administer high-flow oxygen via a non-rebreather mask.
Treats hypoxia and reduces the size of the air embolus.
Breathing 100% oxygen increases the diffusion gradient for nitrogen to leave the bubble, accelerating its resorption while providing maximal oxygenation.
4
Activate the rapid response team and notify the healthcare provider.
Summons emergency medical assistance.
The client requires immediate medical evaluation and potential advanced interventions, such as aspiration of the air from the right ventricle.
5
Monitor vital signs and document the event.
Provides ongoing assessment of hemodynamic stability.
Continuous monitoring evaluates the effectiveness of the interventions and ensures a detailed clinical record for the healthcare team.

Key Concept

Management of a Central Line-Associated Air Embolism
Question 159Question →

A nurse is assessing a client who is 3 days postoperative following an abdominal laparotomy. The client coughs forcefully and suddenly states, "I feel like something just popped open." The nurse inspects the surgical site and observes a loop of bowel protruding through the incision. Arrange the following nursing actions in the correct priority order from first to last.

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Answer

The correct priority sequence for managing a surgical evisceration is: stay with the client and call for assistance, position the client in a low Fowler's position with bent knees, cover the exposed bowel with sterile moist dressings, assess vital signs, and then notify the surgeon.
Wound evisceration is a physiological emergency requiring swift, sequential action. The nurse must first ensure safety by staying with the client and calling for help. Next, reducing mechanical tension on the abdomen by placing the client in a low Fowler's position with bent knees prevents further organ protrusion. Protecting the exposed tissue with sterile, saline-soaked dressings is the next critical priority to prevent tissue necrosis and infection. Once the site is secured and protected, assessing vital signs is necessary to evaluate for shock. Finally, the provider is notified with all assessment data to arrange for immediate surgical repair.

Step-by-Step Solution

1
Ensure continuous presence and secure assistance.
Help is summoned without leaving the client unattended.
Evisceration is a critical emergency. Leaving the client risks further injury and severe anxiety. Help is needed to gather supplies and contact the provider.
2
Adjust the client's position to a low Fowler's position with knees flexed.
Abdominal wall tension is minimized.
This specific position relaxes the rectus abdominis muscles, which prevents additional abdominal contents from protruding through the opened incision.
3
Protect the exposed viscera with sterile, saline-moistened dressings.
The bowel is protected from the external environment and drying.
Exposed internal organs can quickly become necrotic if they dry out, and they are highly susceptible to severe infection. Sterile normal saline maintains tissue viability.
4
Obtain vital signs and assess perfusion.
The client's physiological stability is determined.
Evisceration can cause rapid fluid shifts and significant pain, leading to hypovolemic shock. Baseline vital signs are needed before calling the provider.
5
Communicate the critical situation to the surgical team.
Definitive surgical treatment is initiated.
Nursing interventions stabilize the client, but surgical repair in the operating room is the only definitive treatment for an evisceration.

Key Concept

Management of a postoperative abdominal evisceration requires immediate, sequential actions to reduce abdominal tension, protect the exposed viscera from necrosis and infection, and prepare the client for emergency surgery.
Question 160Question →

A nurse in the emergency department receives a client who sustained full-thickness thermal burns to the face, neck, and anterior chest from a house fire. Arrange the following nursing interventions in the priority order they should be performed. All options must be used.

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Answer

The correct priority order follows the primary and secondary survey framework (Airway, Breathing, Circulation). The nurse must first assess the airway, then administer oxygen, followed by establishing IV access, initiating fluids, and finally estimating the burn extent.
In the emergent phase of burn care, life-saving interventions must follow the ABCs of trauma. Securing a patent airway is the absolute first priority, especially for facial and neck burns that can rapidly swell. This is immediately followed by supporting breathing with 100% oxygen to counteract carbon monoxide and hypoxia. Once oxygenation is supported, the nurse addresses circulation by establishing large-bore IV access and initiating aggressive fluid resuscitation to prevent burn shock. Finally, during the secondary survey, the nurse calculates the total body surface area burned to refine the long-term fluid resuscitation plan.

Step-by-Step Solution

1
Prioritize Airway (A).
The nurse assesses the client's airway patency and respiratory effort.
Facial and neck burns carry a severe risk of inhalation injury and rapid airway occlusion from progressing edema.
2
Prioritize Breathing (B).
The nurse administers 100% humidified oxygen via a non-rebreather mask.
Clients exposed to house fires are at high risk for carbon monoxide poisoning and hypoxia, requiring immediate high-flow oxygen.
3
Prioritize Circulation (C).
The nurse inserts two large-bore intravenous catheters.
Severe burns cause massive capillary leak and fluid shifts. Vascular access must be secured before hypovolemic shock progresses.
4
Intervene for Circulation.
The nurse initiates fluid resuscitation with prescribed Lactated Ringer's solution.
Isotonic fluid replacement is critical to maintain cardiac output, organ perfusion, and prevent fatal burn shock.
5
Perform the Secondary Survey.
The nurse estimates the total body surface area burned using the Rule of Nines.
Once life-threatening ABC issues are stabilized, the nurse assesses the full extent of the injury to guide ongoing fluid administration calculations.

Key Concept

Emergent Management of Burn Injuries
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