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Question 161Question →

A client on the cardiac step-down unit suddenly develops severe dyspnea, audible wheezing, and expectorates pink, frothy sputum. The vital signs monitor shows an oxygen saturation of 84% on room air and a heart rate of 122 beats/min. Arrange the following nursing interventions in the most appropriate sequential order from first to last.

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Answer

First, position the client upright with legs dangling. Second, provide supplementary oxygen. Third, administer the intravenous loop diuretic. Finally, place an indwelling urinary catheter.
The correct sequence relies on the ABCs and prioritization principles for acute physiological decompensation. In acute pulmonary edema, positional changes (high-Fowler's with legs dangling) represent the fastest, most effective non-pharmacological method to reduce preload and improve lung expansion. This is immediately followed by oxygen therapy to directly address the 84% oxygen saturation. Once basic airway and breathing mechanics are supported, pharmacological reduction of the fluid volume is initiated. Lastly, placing a catheter allows the nurse to monitor the therapeutic response to the diuretic.

Step-by-Step Solution

1
Elevate the head of the bed to high-Fowler's and dangle the client's legs.
Decreases venous return to the right atrium and drops pulmonary venous pressure.
Positional changes are the fastest interventions to relieve respiratory distress in acute heart failure.
2
Apply high-flow oxygen via a non-rebreather mask.
Increases alveolar oxygen concentration.
The client is experiencing severe hypoxemia (84%) due to fluid in the alveoli, requiring immediate respiratory support.
3
Administer an intravenous loop diuretic.
Initiates rapid diuresis and provides mild venodilation.
Treats the underlying physiological fluid overload driving the acute pulmonary edema.
4
Insert an indwelling urinary catheter.
Allows for strict, continuous monitoring of urine output.
Required to safely evaluate the therapeutic effectiveness of the loop diuretic and monitor hemodynamic status.

Key Concept

Prioritization in Acute Pulmonary Edema
Question 162Question →

A nurse is preparing to perform a routine scheduled dressing change for a client's central venous catheter (CVC). In what order should the nurse perform the following actions? Arrange the steps in the correct chronological sequence.

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Answer

The correct sequence is: place mask on client -> remove old dressing -> don sterile gloves -> scrub with chlorhexidine -> allow to air dry -> apply new sterile dressing.
A central venous catheter dressing change is a sterile procedure that requires strict adherence to infection control principles. Protecting the site from respiratory droplets is the first priority. The old dressing is then carefully removed with clean gloves to avoid dislodgement. To maintain asepsis, the nurse must change to sterile gloves before cleansing the site. Chlorhexidine requires a back-and-forth friction scrub and must dry completely to be effective. Finally, the site is covered with a new sterile transparent dressing to maintain a protective barrier.

Step-by-Step Solution

1
Place a surgical mask on the client and turn their head.
The client's respiratory droplets are directed away from the site.
Prevents contamination of the CVC site with airborne flora when the old dressing is removed.
2
Remove the existing transparent dressing.
The insertion site is exposed.
The old dressing must be removed using clean gloves, pulling toward the site to prevent dislodgement.
3
Remove clean gloves, perform hand hygiene, and don sterile gloves.
The nurse's hands are prepared for a sterile procedure.
Maintaining strict asepsis is critical before touching the exposed insertion site or using sterile cleansing supplies.
4
Scrub the insertion site with chlorhexidine.
The skin around the insertion site is disinfected.
Friction and the antiseptic properties of chlorhexidine reduce microbial count on the skin.
5
Allow the cleansed area to air dry.
The chlorhexidine achieves maximum efficacy.
Chemical disinfectants require adequate contact and drying time to destroy pathogens.
6
Apply a new sterile transparent dressing.
The CVC site is securely covered.
Provides a barrier against microorganisms while allowing nurses to monitor for infection.

Key Concept

Central Venous Catheter (CVC) Sterile Dressing Change Procedure
Estimated Time:1m 30s
Question 163Question →

A nurse is administering a prescribed intravenous medication to a client via an electronic infusion pump. Shortly after the medication is initiated, the client suddenly reports a severe headache, a tight feeling in the chest, and dizziness. The nurse observes intense facial flushing and notes a rapid, irregular pulse. Recognizing these manifestations as speed shock, in what chronological order should the nurse perform the following interventions? Arrange the actions from first to last.

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Answer

The correct sequence for managing speed shock is: Stop the medication infusion -> Disconnect the tubing and attach a new administration set primed with saline -> Obtain a complete set of vital signs -> Report the findings to the healthcare provider -> Document the event in the health record.
The correct sequence prioritizes immediate client safety by stopping the infusion first. Crucially, the nurse must change the entire tubing setup before running normal saline to prevent flushing residual medication into the client. Assessment follows to gather objective data, which is then communicated to the provider. Documentation occurs last, only after the client has been stabilized.

Step-by-Step Solution

1
Stop the medication infusion immediately to halt further drug delivery.
Prevents additional concentrated medication from rapidly entering the client's bloodstream.
Speed shock is a systemic reaction caused by the rapid accumulation of a drug in the circulation; stopping the source is the immediate life-saving priority.
2
Disconnect the medication tubing and attach a new administration set primed with 0.9% sodium chloride.
Maintains patent intravenous access for potential emergency medications while completely eliminating the source of the offending drug.
Flushing the existing tubing would push a concentrated bolus of the residual medication into the client, severely exacerbating the speed shock reaction.
3
Obtain a complete set of vital signs and evaluate the client's cardiopulmonary status.
Provides objective clinical data regarding the severity of the client's hemodynamic compromise.
Accurate assessment data is required to determine the client's immediate stability and to formulate an effective SBAR communication for the healthcare provider.
4
Report the adverse reaction and current assessment findings to the healthcare provider.
Facilitates collaborative emergency care and the acquisition of new pharmacological prescriptions.
The provider must be informed of the adverse event, equipped with recent vital signs, to direct further medical management appropriately.
5
Document the event, interventions provided, and the client's physiological response in the health record.
Creates an accurate legal and medical record of the adverse drug event.
Documentation is critical but should always occur after the client is stabilized and immediate life-saving interventions are complete.

Key Concept

Management of Intravenous Speed Shock and Safe Parenteral Infusion Practices
Question 164Question →

A nurse is preparing to witness a client's signature on an informed consent document for a scheduled lumbar laminectomy. The nurse places the document on the bedside table and hands the client a pen. The client hesitates and states, "The doctor said this will fix my back, but I am terrified of being paralyzed. Maybe I should just try physical therapy instead." Arrange the following nursing actions in the correct chronological sequence.

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Answer

The correct sequence is to first stop the client from signing, assess their specific concerns, notify the surgeon of the knowledge deficit, verify the surgeon has addressed these concerns, and finally witness the signature once the client is ready.
Informed consent requires the client to fully understand the risks, benefits, and alternatives of a procedure before signing. When a client expresses doubt or asks about alternatives, the nurse's immediate priority is to stop the signing process. Next, the nurse assesses the specific concerns to communicate them effectively. Because explaining medical risks and alternatives is outside the RN scope of practice, the nurse must advocate by notifying the surgeon. Once the surgeon has fulfilled their legal duty to re-educate the client, the nurse can safely resume their role as a witness and authenticate the voluntary signature.

Step-by-Step Solution

1
Halt the consent process.
The client does not sign the document prematurely.
Ensures the client's legal rights are protected and prevents the execution of an invalid informed consent.
2
Assess the client's understanding.
The nurse gathers specific information about the client's fears and knowledge gaps.
Provides the necessary clinical context to effectively communicate the problem to the healthcare provider.
3
Notify the surgeon.
The surgeon is made aware of the client's hesitation and need for further discussion.
Fulfills the nurse's role as a client advocate, as nurses cannot legally explain surgical risks or alternatives.
4
Verify provider education.
The surgeon discusses risks and alternatives with the client.
Ensures the legal requirement for the provider to obtain informed consent is met before proceeding.
5
Witness the signature.
The consent form is legally finalized.
Validates that the signature is authentic, voluntary, and provided by a competent, fully informed client.

Key Concept

The nurse's role in informed consent is to act as an advocate and witness, halting the process and notifying the provider if the client demonstrates a lack of understanding or expresses a desire for alternative treatments.
Question 165Question →

A nurse is caring for a client who is 15 minutes into a packed red blood cell (PRBC) transfusion. The client suddenly reports acute lower back pain, severe shortness of breath, and a feeling of impending doom. Arrange the following nursing interventions in the correct prioritized sequence. (Place the first action at the top and the final action at the bottom).

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Answer

The correct sequence prioritizes immediate cessation of the antigen, followed by maintaining intravenous access with a new line, assessing the client, notifying the provider, and finally sending the equipment for diagnostic analysis.
In any acute medical emergency, especially an acute hemolytic transfusion reaction, the absolute priority is to stop the offending agent. Once stopped, the nurse must ensure a patent circulation route (by maintaining an IV line with normal saline using completely new tubing) before gathering further objective data (vital signs). Notification of the provider requires this assessment data to secure appropriate orders, and administrative/diagnostic tasks (returning the bag to the lab) are consistently completed last.

Step-by-Step Solution

1
Stop the transfusion immediately.
Halts the delivery of the incompatible blood product.
Continuing the transfusion, even for a few seconds, increases the severity of the acute hemolytic reaction and the risk of mortality.
2
Disconnect the tubing and initiate normal saline with a new line.
Maintains patent venous access without administering more blood.
A patent IV is critical for administering emergency medications. New tubing must be used so that residual blood in the old tubing is not inadvertently flushed into the client.
3
Perform a focused assessment, including vital signs.
Provides objective clinical data regarding the client's hemodynamic and respiratory status.
The healthcare provider will require current vital signs to prescribe the appropriate emergency interventions (e.g., vasopressors, fluids, corticosteroids).
4
Notify the healthcare provider and the blood bank.
Initiates collaborative medical management and the institutional transfusion reaction protocol.
The provider must intervene to manage shock, and the blood bank must prepare for a clinical and laboratory investigation.
5
Send the blood bag, tubing, and a client blood sample to the laboratory.
Facilitates direct antiglobulin testing and hemolysis analysis.
This confirms the specific etiology of the reaction (e.g., ABO incompatibility) after the client has been hemodynamically stabilized.

Key Concept

Prioritization of Care: Acute Hemolytic Transfusion Reaction Management
Question 166Question →

A client is scheduled for a below-the-knee amputation due to severe and progressive peripheral arterial disease. The client signed the informed consent document the previous day. Today, as the nurse approaches to administer the prescribed preoperative intravenous midazolam, the client withdraws their arm and states, "I cannot go through with this. I would rather die with my leg attached." Arrange the following nursing actions in the correct order of priority from first to last.

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Answer

First, withhold the preoperative sedative. Second, assess the client's reasons for refusal. Third, notify the surgeon and operating room. Fourth, ensure the surgeon discusses the consequences of refusal. Finally, document the event.
The correct sequence strictly follows the nursing process and legal principles of client advocacy. The absolute first priority is safety and preserving the client's legal rights; withholding the sedative prevents chemical impairment and potential battery. Next, the nurse assesses the client's rationale to gather data. Once assessed, the nurse notifies the provider and surgical team of the revocation. The nurse then advocates for the client by ensuring the surgeon discusses the life-threatening consequences of refusal (establishing informed refusal). Finally, after the clinical situation is safely addressed, the nurse documents the entire event in the medical record.

Step-by-Step Solution

1
Withhold the preoperative intravenous midazolam.
The client's legal competence and right to refuse are protected.
Administering a sedative after a client expresses refusal constitutes battery and chemically impairs their ability to make a legally binding informed refusal.
2
Explore the reasons behind the client's decision.
The nurse gathers pertinent assessment data regarding the client's fears and rationale.
The nursing process requires assessment before intervention. This data is necessary to provide a complete and accurate report to the provider.
3
Notify the surgeon and operating room staff.
The surgical team is alerted to the change in status and preparations are halted.
The provider must be informed immediately after assessment to manage the medical implications of the cancellation and adjust the surgical schedule.
4
Collaborate with the surgeon to facilitate informed refusal.
The client receives a direct medical explanation of the risks of not having the surgery.
It is solely the provider's responsibility to explain medical risks, while the nurse acts as an advocate to ensure this legal and ethical discussion occurs.
5
Document the entire sequence of events.
A legal record of the client's decision and the healthcare team's response is created.
Comprehensive documentation must occur after the immediate clinical situation has been managed to ensure accuracy and continuity of care.

Key Concept

When a client revokes consent, the nurse's priority is to halt any interventions that would impair competence (like sedation), assess the rationale, notify the provider, advocate for informed refusal, and thoroughly document.
Estimated Time:2m 0s
Question 167Question →

A client with severe alcohol withdrawal syndrome is experiencing tactile hallucinations and repeatedly attempting to pull out their continuous bladder irrigation (CBI) catheter. After alternative de-escalation measures have failed, the primary healthcare provider prescribes bilateral soft wrist restraints. Arrange the following nursing actions in the correct chronological order.

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Answer

The correct sequence is to first explain the procedure to the client, apply the cuffs checking for a two-finger fit, secure the straps to the movable bed frame, assess distal neurovascular status, and finally document the intervention.
The correct chronological order ensures optimal client safety, preserves neurovascular integrity, and maintains strict legal and protocol compliance. Verbal communication and explanation must always precede physical contact. The physical application of the cuffs must occur before securing the ties to the bed. A comprehensive neurovascular assessment is required immediately after the restraints are fully secured to ensure the anchoring process did not inadvertently compromise circulation. Finally, thorough documentation serves as the essential concluding step, officially recording the completed intervention and initial assessment findings.

Step-by-Step Solution

1
Communicate with the client regarding the intervention.
The client receives an explanation of the temporary safety measure.
Ethical nursing practice requires informing the client prior to physical interventions, even when cognitive impairment or hallucinations are present.
2
Apply the restraint cuffs to the wrists.
The restraints are positioned with enough space to allow two fingers underneath.
Ensures the restraints are secure enough to be effective but loose enough to prevent friction and circulatory compromise.
3
Secure the straps to the bed.
The restraints are anchored to the movable portion of the bed frame.
Securing to the movable frame ensures the straps will not tighten or pull the client's extremities if the head of the bed is raised or lowered.
4
Perform a neurovascular assessment.
Radial pulses, capillary refill, and skin temperature are verified as normal.
Confirms that the process of anchoring and tying the straps did not inadvertently tighten the cuffs and occlude peripheral blood flow.
5
Document the intervention.
The electronic health record is updated with all required clinical and legal data.
Provides a legal record of compliance with strict restraint protocols, including the failure of prior alternatives and the initial safety assessment.

Key Concept

Safe Application and Monitoring of Physical Restraints
Question 168Question →

A nurse discovers a small fire in a client's wastebasket. In which order should the nurse perform the following actions? Arrange the steps from first to last.

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Answer

The correct sequence follows the RACE protocol: Rescue the client, Activate the alarm, Confine the fire, and Extinguish the fire.
The RACE acronym stands for Rescue, Alarm, Confine, and Extinguish/Evacuate. This evidence-based protocol dictates that healthcare professionals must prioritize human life first (Rescue), followed by system-wide notification (Alarm), limiting the hazard (Confine), and finally attempting to put out the fire (Extinguish) only after all other steps are complete.

Step-by-Step Solution

1
Rescue the client from the room.
The client is moved out of immediate danger.
Life safety is the highest priority in any fire emergency.
2
Activate the fire alarm.
The facility and emergency services are notified.
Early notification ensures additional help arrives quickly.
3
Close the client's room door.
The fire and smoke are contained to a smaller area.
Confinement slows the spread of the fire and protects the rest of the facility.
4
Use the fire extinguisher.
The small fire is addressed.
Extinguishing is only attempted after securing life safety, alerting others, and containing the area.

Key Concept

RACE Fire Response Protocol
Question 169Question →

A nurse is caring for a client receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes into the transfusion, the client reports sudden chills, severe lower back pain, and shortness of breath. In what chronological order should the nurse perform the following actions to reduce the risk of further physiological deterioration? Arrange the actions from first to last.

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Answer

The correct sequence is: Stop the transfusion, replace the IV tubing with normal saline, assess the client, notify the provider and blood bank, and finally return the blood products to the blood bank.
In any severe adverse reaction, the immediate priority is to stop the offending agent. Following cessation, maintaining vascular access with new tubing and normal saline ensures the client can receive emergency treatments without receiving more blood. Only after stabilizing the line should the nurse assess the client fully to gather data for the provider. Notification follows assessment, and administrative tasks (returning the bag for investigation) are completed last.

Step-by-Step Solution

1
Stop the blood transfusion immediately.
The flow of incompatible blood into the client is halted.
This is the most critical first step to minimize the severity of the acute hemolytic reaction and prevent further physiological deterioration.
2
Replace the IV tubing and infuse 0.9% sodium chloride.
Intravenous access is maintained without administering additional blood.
Flushing the existing tubing would push more blood into the client. New tubing ensures safety while keeping the vein open for emergency medications.
3
Assess the client's vital signs and clinical status.
Current physiological data (blood pressure, oxygenation, heart rate) is obtained.
The nurse needs accurate, up-to-date assessment data to effectively communicate the client's condition to the healthcare provider.
4
Notify the primary healthcare provider and the blood bank.
The medical team is alerted and treatment orders can be obtained.
The provider must prescribe interventions (e.g., oxygen, fluids, diuretics, vasopressors) to manage the systemic reaction.
5
Return the blood bag and tubing to the blood bank.
The blood products are prepared for investigation.
The blood bank must analyze the remaining blood, tubing, and records to determine the exact cause of the adverse reaction.

Key Concept

Management of acute hemolytic transfusion reactions prioritizes immediately stopping the causative agent, maintaining hemodynamic stability, and communicating findings.
Question 170Question →

A nurse is inserting a nasogastric (NG) tube for enteral nutrition in an alert adult client. Arrange the following procedural steps in the exact chronological sequence to ensure safe insertion and minimize the risk of tracheal intubation.

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Answer

The correct sequence for nasogastric tube insertion is: measuring the tube length (NEX method), positioning the neck in hyperextension for initial nasal insertion, flexing the neck forward once the oropharynx is reached, advancing the tube during active swallowing, and finally securing the tube and confirming placement via radiograph.
The correct sequence prioritizes anatomical alignment and airway protection. Measurement (NEX method) establishes the depth baseline. Initial neck hyperextension aligns the nasal passage for the tube's entry. Once the tube hits the posterior pharynx (oropharynx), switching to neck flexion (chin-to-chest) is critical as it closes the epiglottis, shielding the trachea. Advancing specifically during swallowing capitalizes on natural esophageal peristalsis. Finally, securing the tube and obtaining an x-ray is the universal standard for verifying safe gastric placement before use.

Step-by-Step Solution

1
Measure the tube from the tip of the nose to the earlobe, and then to the xiphoid process.
The target insertion depth is established.
Determining the correct length ensures the tube reaches the stomach rather than remaining in the esophagus or coiling.
2
Instruct the client to extend their neck backward as the tube is inserted into the naris.
The tube passes smoothly through the nasal cavity.
Neck hyperextension straightens the nasopharyngeal pathway, reducing resistance and mucosal trauma.
3
Stop advancement at the oropharynx and instruct the client to bring their chin to their chest.
The epiglottis closes over the larynx.
Forward flexion physically blocks the airway (trachea), directing the tube toward the posterior esophagus.
4
Advance the tube steadily while the client swallows small sips of water.
The tube reaches the predetermined measurement mark.
Swallowing peristalsis pulls the tube downward while the elevated larynx further protects the airway.
5
Secure the tube and prepare for an abdominal radiograph.
The procedure is safely concluded pending confirmation.
Radiographic confirmation is the only definitive method to ensure gastric, rather than pulmonary, placement before feeding.

Key Concept

Safe anatomical insertion of a nasogastric (NG) tube utilizes specific dynamic client head positions—initial hyperextension followed by flexion—to bypass the airway and safely access the gastrointestinal tract.
Estimated Time:1m 30s
Question 171Question →

A nurse is caring for a client who is receiving intravenous fluids through a central venous catheter. The client suddenly develops severe dyspnea, chest pain, and a feeling of impending doom. The nurse suspects a central line-associated air embolism. In what order should the nurse take the following actions to reduce the risk of a life-threatening complication? Arrange the steps from first to last.

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Answer

The correct order is: 1) Clamp the catheter, 2) place the client in a left lateral Trendelenburg position, 3) administer oxygen, 4) notify the healthcare provider, and 5) remain with the client.
When an air embolism is suspected, the nurse must rapidly intervene using the 'stop, position, oxygenate' approach to reduce the risk of a fatal pulmonary obstruction. The absolute first priority is to stop more air from entering by clamping the line. The second step is to trap the existing air in the right atrium by placing the client in the left lateral Trendelenburg position. Following this, administering 100% oxygen treats hypoxia and helps absorb the air bubble. Finally, the nurse calls for medical assistance and provides continuous monitoring.

Step-by-Step Solution

1
Clamp the central venous catheter.
The source of air entry is physically blocked.
The most critical initial action during an adverse event is to stop the causative agent or source.
2
Place the client in a left lateral Trendelenburg position.
The client is positioned on their left side with their head lower than their feet.
This specific position traps the air bubble in the apex of the right atrium, preventing it from migrating into the pulmonary artery and causing a right ventricular outflow tract obstruction.
3
Administer high-flow oxygen via a non-rebreather mask.
The client receives 100% oxygen.
High-concentration oxygen relieves hypoxia and creates a diffusion gradient that helps reduce the size of the air embolus by encouraging nitrogen to exit the bubble.
4
Notify the healthcare provider and the rapid response team.
Advanced medical support is summoned.
Once immediate independent life-saving measures are implemented, the provider must be contacted for advanced interventions.
5
Remain with the client and continuously monitor vital signs.
Continuous observation of the client's status is maintained.
The client is critically unstable and requires continuous monitoring for potential cardiopulmonary arrest.

Key Concept

The emergency management of a suspected central venous catheter air embolism requires stopping further air entry, properly positioning the client to prevent pulmonary obstruction, and providing oxygenation.
Question 172Question →

A client with end-stage renal disease misses two dialysis sessions and presents to the emergency department with profound muscle weakness. The initial serum potassium level is 7.6 mEq/L7.6\text{ mEq/L} (7.6 mmol/L7.6\text{ mmol/L}), and the 12-lead electrocardiogram (ECG) reveals absent P waves, a widened QRS complex, and tall, peaked T waves. The healthcare provider prescribes several emergency interventions. Arrange the following nursing actions in the correct priority order from first to last.

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Answer

The correct priority sequence is: 1) Administer intravenous calcium gluconate, 2) Administer an intravenous bolus of regular insulin and 50% dextrose, 3) Administer oral sodium polystyrene sulfonate, 4) Draw a follow-up serum potassium level.
The correct priority for treating symptomatic hyperkalemia follows the principle of protecting the heart first, shifting potassium second, and eliminating potassium third. Calcium gluconate acts in 1 to 3 minutes to stabilize the myocardium and prevent lethal arrhythmias. Regular insulin with dextrose shifts potassium into cells over 15 to 30 minutes, providing a temporary reduction in serum levels. Sodium polystyrene sulfonate is then administered to permanently bind and excrete potassium from the gastrointestinal tract. Finally, drawing a follow-up serum potassium level evaluates the effectiveness of these treatments.

Step-by-Step Solution

1
Identify the life-threatening physiological abnormality.
The client has severe hyperkalemia (7.6 mEq/L7.6\text{ mEq/L}) accompanied by significant ECG changes (widened QRS, peaked T waves).
Recognizing impending cardiac arrest dictates the immediate need for myocardial stabilization over potassium reduction.
2
Select the intervention for immediate myocardial stabilization.
Intravenous calcium gluconate is administered first.
Calcium directly antagonizes the membrane effects of hyperkalemia. Without it, the client is at imminent risk for ventricular fibrillation.
3
Select the intervention for rapid intracellular potassium shifting.
Intravenous regular insulin and 50%50\% dextrose are administered second.
This quickly lowers the serum potassium level temporarily, buying time for permanent elimination therapies to take effect.
4
Select the intervention for total body potassium elimination.
Oral sodium polystyrene sulfonate is administered third.
This permanently removes potassium from the body via the gastrointestinal tract but has a delayed onset of action (hours).
5
Select the evaluation step.
A follow-up serum potassium level is drawn last.
After administering all acute emergency treatments, the nurse must assess the therapeutic response.

Key Concept

In the setting of severe hyperkalemia with electrocardiographic changes, myocardial stabilization with intravenous calcium is the absolute first priority, preceding any interventions designed to lower the serum potassium level.
Question 173Question →

A nurse is preparing to discontinue a non-tunneled central venous catheter (CVC) located in the right subclavian vein of a 68-year-old client who has completed a course of intravenous antibiotics for osteomyelitis. To strictly reduce the risk of a life-threatening physiological complication during this procedure, in what order should the nurse perform the following actions? Arrange the steps from first to last.

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Answer

The correct sequence is to position the client flat, remove the dressing, instruct the Valsalva maneuver, withdraw the catheter, and immediately apply pressure.
Removing a central venous catheter carries a high risk of air embolism. The procedure must be precisely sequenced to maximize intrathoracic and central venous pressure before the catheter is withdrawn. Positioning the client flat or in Trendelenburg must occur first to raise central venous pressure. Only then should the nurse remove the dressing to prepare the site. Immediately before pulling the catheter, the client performs the Valsalva maneuver to further spike intrathoracic pressure. The catheter is then swiftly removed during this maneuver, followed by the immediate application of firm pressure to seal the tract.

Step-by-Step Solution

1
Position the client in a flat, supine or Trendelenburg position.
Central venous pressure is increased in the upper body.
This creates a positive pressure gradient that is the fundamental baseline requirement to reduce the risk of an air embolism.
2
Remove the existing transparent dressing while stabilizing the catheter.
The insertion site is safely exposed.
Performing this step after positioning ensures the client is already hemodynamically safe in the event of accidental catheter dislodgement during dressing removal.
3
Instruct the client to take a deep inhalation, hold it, and bear down.
Intrathoracic pressure is acutely elevated.
The Valsalva maneuver strictly prevents air entry into the venous system during the high-risk moment when the vein communicates with the atmosphere.
4
Withdraw the catheter completely in a swift, continuous motion.
The catheter is removed from the vascular space.
Swift removal during the Valsalva maneuver minimizes the duration the venous tract remains open.
5
Apply immediate firm pressure to the site with sterile gauze.
Hemostasis is achieved and air tracking is prevented.
Direct pressure physically blocks air from entering the venous tract and controls bleeding until an occlusive dressing is applied.

Key Concept

Central Venous Catheter Discontinuation and Air Embolism Prevention
Question 174Question →

A nurse is preparing to administer an intermittent intravenous (IV) piggyback medication using the backpriming method through an existing continuous primary IV infusion. Assuming hand hygiene and medication verification have been completed, place the following steps in the correct sequence for setting up the IV piggyback.

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Answer

The correct sequence is: 1) Close the clamp and spike the bag, 2) Scrub the primary port, 3) Attach and lower the secondary bag, 4) Open the clamp to backprime, and 5) Close the clamp, hang the bag, and program the pump.
The correct sequence ensures patient safety, maintains asepsis, and prevents medication waste. By closing the clamp before spiking, the system remains closed. Scrubbing the hub is a mandatory aseptic step before any connection. Lowering the secondary bag below the primary bag creates the necessary hydrostatic pressure gradient. When the clamp is opened, the primary fluid flows backward, clearing air from the secondary line without wasting medication. Finally, closing the clamp and hanging the bag high allows the medication to infuse first when the pump is programmed.

Step-by-Step Solution

1
Close the roller clamp on the secondary IV tubing and spike the secondary medication bag.
The medication is secured in a closed system.
Closing the clamp prevents medication waste and air entry during spiking.
2
Scrub the needleless connector on the primary IV tubing located above the infusion pump.
The Y-site is disinfected.
Strict aseptic technique is required to prevent catheter-related bloodstream infections.
3
Attach the secondary IV tubing to the cleansed primary port and lower the secondary bag below the primary fluid bag.
The secondary set is connected and positioned for gravity backflow.
Lowering the secondary bag creates hydrostatic pressure that allows primary fluid to flow backward into the secondary line.
4
Open the secondary roller clamp to allow primary IV fluid to flow backward into the secondary tubing until the drip chamber is half full.
The secondary tubing and drip chamber fill with primary fluid.
Backpriming displaces air in the secondary tubing without losing any of the ordered medication.
5
Close the secondary roller clamp, hang the secondary bag higher than the primary bag, and program the infusion pump.
The IV piggyback is ready to infuse.
Hanging the secondary bag higher ensures it will infuse first, and programming the pump ensures the correct administration rate.

Key Concept

Intravenous Piggyback (IVPB) Backpriming Procedure
Estimated Time:1m 30s
Question 175Question →

A nurse is preparing a client with ascites for a bedside abdominal paracentesis. In which order should the nurse perform the following actions to ensure the client's safety and reduce the risk of physiological complications? Arrange the actions in the correct chronological sequence.

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Answer

The correct sequence is to first verify informed consent, then instruct the client to void, followed by obtaining baseline measurements, and finally positioning the client upright for the procedure.
Preparing a client for a paracentesis requires a deliberate, sequential approach focused on risk reduction. First, the nurse must ensure legal consent is obtained. Next, instructing the client to void is the most critical physiological safety step to prevent accidental bladder injury. Once the bladder is empty, accurate baselines (vital signs, dry weight, abdominal girth) are recorded to later assess fluid shifts and signs of hemodynamic instability. Finally, positioning the client upright uses gravity to safely pool fluid in the lower abdomen, keeping floating bowel loops and the decompressed bladder away from the insertion site.

Step-by-Step Solution

1
Verify informed consent
Legal requirements and client understanding are confirmed.
Consent must be verified before any procedure-specific physical preparation begins.
2
Instruct the client to void
The bladder is fully decompressed.
An empty bladder minimizes the physiological risk of an iatrogenic bladder puncture when the trocar is inserted into the abdomen.
3
Obtain baseline measurements
Vital signs, dry weight, and abdominal girth are recorded.
Baselines taken after voiding provide accurate clinical data to evaluate the volume of fluid removed and to monitor for post-procedure hypovolemic shock.
4
Position the client upright
Ascitic fluid pools in the dependent areas of the abdomen.
An upright position uses gravity to concentrate fluid safely away from major abdominal organs, reducing the risk of accidental bowel perforation.

Key Concept

Prioritization of safety and risk reduction interventions during preparation for an invasive procedure (paracentesis).
Question 176Question →

A nurse is assisting with a vaginal delivery. Following the delivery of the fetal head, the head retracts tightly against the maternal perineum. Arrange the following nursing actions in the correct sequence of priority.

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Answer

The correct sequence is: stop pushing and call for help, perform the McRoberts maneuver, apply suprapubic pressure, assist with internal maneuvers, and assess the newborn for trauma.
Shoulder dystocia is a critical emergency requiring immediate sequential actions. First, pushing must cease to prevent further impaction, and additional help is summoned (including neonatal staff). Next, the McRoberts maneuver (hyperflexion of legs) is performed to widen the pelvic outlet. If unsuccessful, suprapubic pressure is applied to manually dislodge the anterior shoulder. If these external maneuvers fail, the nurse prepares to assist the provider with internal maneuvers. Finally, after delivery, the newborn is at high risk for trauma (e.g., fractured clavicle, brachial plexus injury) and must be thoroughly assessed.

Step-by-Step Solution

1
Identify the complication.
The retraction of the fetal head (turtle sign) indicates shoulder dystocia.
Recognizing the emergency dictates the immediate algorithm for intervention.
2
Initiate emergency protocols.
Instruct the client to stop pushing and call for help.
Pushing further impacts the shoulder. Additional staff, including the neonatal resuscitation team, are necessary for maneuvers and potential newborn distress.
3
Implement first-line physical maneuvers.
Perform the McRoberts maneuver (hyperflexing the maternal legs).
This non-invasive maneuver changes the maternal pelvic geometry and resolves many cases of shoulder dystocia.
4
Add secondary pressure maneuvers.
Apply suprapubic pressure.
Suprapubic pressure aims to dislodge the anterior shoulder from behind the pubic bone. Fundal pressure must never be used.
5
Progress to advanced obstetric interventions.
Assist with internal rotational maneuvers.
If external maneuvers fail, the provider will need to manually rotate the fetus or deliver the posterior arm.
6
Perform post-delivery evaluation.
Assess the newborn for birth trauma.
Shoulder dystocia carries a high risk for clavicular fractures, brachial plexus injuries (such as Erb's palsy), and hypoxia.

Key Concept

Management of shoulder dystocia follows a specific algorithmic sequence prioritizing non-invasive maneuvers to safely dislodge the fetal shoulder and prevent birth trauma or hypoxia.
Question 177Question →

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

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Answer

The correct sequence is: assist the client into the left lateral Sims position, lubricate the tubing tip, insert the tubing 3 to 4 inches, elevate the container 12 to 18 inches, and finally open the roller clamp.
Administering a cleansing enema requires a systematic and safe procedural flow. The nurse must first place the client in the left lateral Sims position to align the anatomy with gravity for optimal fluid flow. Next, the tubing tip is lubricated to prevent mucosal trauma. The tube is then gently inserted 3 to 4 inches into the rectum. After secure insertion, the container is elevated 12 to 18 inches to establish safe hydrostatic pressure, preventing rapid infusion and cramping. Finally, the clamp is opened to initiate the slow flow of the solution.

Step-by-Step Solution

1
Position the client appropriately.
The client is in the left lateral Sims position.
This specific position exposes the anus and uses gravity to help the fluid flow naturally into the descending and sigmoid colon.
2
Prepare the equipment for insertion.
The enema tube tip is lubricated.
Lubrication is necessary immediately prior to insertion to prevent tissue injury and ensure a smooth entry.
3
Insert the tube into the rectum.
The tube is inserted 3 to 4 inches.
This depth passes the internal and external anal sphincters safely. Inserting it further could damage the intestinal wall.
4
Set the appropriate hydrostatic pressure.
The enema bag is elevated 12 to 18 inches above the anus.
Holding the bag too high causes the fluid to infuse too rapidly, which can trigger severe cramping and premature expulsion of the fluid.
5
Begin the infusion.
The roller clamp is opened.
Once all safety measures (position, insertion depth, and pressure head) are established, the fluid can be safely administered.

Key Concept

Safe administration of a large-volume cleansing enema (Hygiene and Elimination)
Estimated Time:1m 30s
Question 178Question →

An acute care facility experiences a sudden hospital-wide cyberattack, resulting in a complete failure of the electronic health record (EHR) system. The incident command center declares a system downtime emergency. Arrange the following response actions in the correct chronological sequence.

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Answer

The correct chronological sequence is: 1. Conduct a rapid assessment of clients; 2. Retrieve the unit's emergency downtime box; 3. Distribute paper flowsheets and MARs; 4. Initiate the use of manual paper requisition slips; 5. Enter the clinical data back into the EHR after the system is restored.
During an emergency response to a cyberattack or EHR downtime, the nursing process and safety principles dictate a specific operational flow. The nurse must first ensure immediate client safety, as network outages can sometimes affect interconnected medical devices. Second, the nurse secures the means to document care by retrieving the downtime box. Third, the nurse empowers the staff by distributing the forms. Fourth, the nurse coordinates care across the facility using manual requisitions. Finally, the nurse participates in the recovery phase by retroactively entering data once the system is online.

Step-by-Step Solution

1
Conduct a rapid assessment of clients and life-sustaining equipment.
Immediate client safety and physiological stability are verified.
Direct client safety is universally the highest priority during any facility emergency, including technological infrastructure failures.
2
Retrieve the emergency downtime box.
Essential paper forms and downtime protocols are available for the unit.
Nurses require the appropriate physical tools to transition smoothly from electronic to manual documentation.
3
Distribute paper flowsheets and MARs to the staff.
Clinical staff are equipped to document care immediately.
This step ensures the continuity of legal and clinical documentation on the unit during the outage.
4
Initiate manual requisition processes for ancillary departments.
New orders, laboratory tests, and pharmacy needs can be processed.
Maintaining external communication and workflow with other departments is essential once internal documentation is secure.
5
Retroactively enter data into the EHR once it is restored.
The electronic health record is fully updated and complete.
This completes the emergency response cycle by transitioning back to normal operations and restoring the permanent legal record.

Key Concept

Electronic Health Record (EHR) Downtime Emergency Response Protocol
Question 179Question →

A nurse is preparing to administer an intermittent intravenous (IV) piggyback antibiotic to a client. The client currently has a continuous primary IV infusion of 0.9% sodium chloride running via an electronic infusion pump. In what order should the nurse perform the following actions? Arrange the steps from first to last.

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Answer

The correct sequence is to first verify medication compatibility, prepare the secondary tubing by spiking and priming, cleanse the primary line access port, attach the tubing while lowering the primary bag, and finally open the clamp and program the infusion pump.
The safe and effective administration of an intravenous piggyback (IVPB) medication follows a strict sequence prioritizing safety, asepsis, and fluid dynamics. First, the nurse must verify compatibility between the secondary medication and the primary infusion to prevent precipitation. Next, the nurse prepares the equipment by closing the clamp, spiking the bag, and priming the tubing to remove air. Once the equipment is ready, the nurse cleanses the uppermost access port (above the pump) immediately before connection to maintain strict asepsis. The nurse then attaches the secondary tubing and uses an extension hook to lower the primary bag; this utilizes hydrostatic pressure to ensure the secondary medication infuses first. Finally, the nurse opens the clamp and programs the infusion pump to deliver the medication safely.

Step-by-Step Solution

1
Verify the compatibility of the secondary antibiotic with the primary 0.9% sodium chloride infusion.
Ensures the two fluids will not react adversely when mixed in the primary tubing.
Incompatible medications can form crystals or precipitates, which can occlude the line or cause a fatal embolism in the client.
2
Close the secondary tubing roller clamp, spike the antibiotic bag, and prime the tubing.
The secondary line is filled with medication and all air is expelled.
Preparing the tubing before accessing the patient's line minimizes the time the access port is left open and prevents air from entering the circulatory system.
3
Cleanse the uppermost access port on the primary intravenous tubing with an antimicrobial swab.
The connection site is thoroughly disinfected.
Scrubbing the hub with friction removes microorganisms and prevents catheter-related bloodstream infections. This must be done immediately prior to connection.
4
Attach the secondary tubing to the primary line and use an extension hook to lower the primary fluid bag.
The secondary bag is positioned higher than the primary bag in the IV setup.
Because standard infusion pumps draw fluid from the highest source of hydrostatic pressure, hanging the secondary bag higher ensures the antibiotic infuses first rather than the primary fluid.
5
Open the secondary tubing roller clamp, program the infusion pump, and initiate the secondary infusion.
The antibiotic administration begins at the prescribed rate.
The electronic pump controls the precise delivery rate, and the clamp must be open to allow fluid flow and prevent occlusion alarms.

Key Concept

Safe administration of intravenous piggyback (IVPB) medications requires verifying compatibility, maintaining strict asepsis, and utilizing hydrostatic pressure to ensure the correct medication infuses.
Estimated Time:1m 0s
Question 180Question →

A nurse enters the room of a client receiving internal radiation therapy (brachytherapy) for cervical cancer. The nurse discovers that the intracavitary radioactive applicator has accidentally dislodged and is resting on the client's bed linens. To safely reduce the risk of harmful radiation exposure, arrange the following nursing actions in the correct priority sequence.

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Answer

The correct sequence is: 1) Clear the room and keep the client still, 2) Don a lead apron, 3) Use long-handled forceps, 4) Place the implant in a lead-lined container, and 5) Notify the radiation safety officer and provider.
The correct sequence prioritizes the ALARA (As Low As Reasonably Achievable) radiation safety principles: Time, Distance, and Shielding. The immediate priority is to use distance to protect unshielded visitors by evacuating them and keeping the client still to prevent the source from falling. Next, the nurse must apply personal shielding (lead apron) before approaching the hazard. To minimize exposure time and maintain distance, the nurse uses long-handled forceps to retrieve the source and immediately secures it in a lead-lined container. Only after the acute physical hazard is contained should the nurse leave the bedside to notify the radiation safety officer and provider.

Step-by-Step Solution

1
Instruct the client to remain completely still and direct all visitors to exit the room.
Unshielded individuals are removed from the radiation field.
Distance is the most effective immediate protection against radiation exposure. Keeping the client still prevents the source from falling to the floor, which would widen the contamination area.
2
Put on a lead-lined apron to ensure personal shielding.
The nurse's core organs are protected from gamma radiation.
ALARA principles dictate that personnel must utilize appropriate shielding before closely approaching an active radiation source.
3
Grasp the dislodged radioactive implant using long-handled forceps.
The radioactive source is retrieved safely.
Radioactive materials must never be touched directly with hands. Forceps provide necessary distance between the radiation source and the nurse's hands.
4
Place the radioactive implant into the lead-lined containment pig located in the room.
The radiation source is fully shielded and contained.
Placing the source in the designated lead pig immediately terminates the acute radiation exposure hazard in the environment.
5
Notify the radiation safety officer and the healthcare provider of the dislodgement.
Specialized personnel are alerted to the incident.
Once the immediate danger is neutralized, specialists must evaluate the client for potential tissue damage, sweep the room for residual radiation, and adjust the cancer treatment plan.

Key Concept

ALARA Principles and Internal Radiation Safety Protocols
Estimated Time:1m 30s
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