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Question 1821Question →

While completing evening rounds, the nurse is approached by a client with borderline personality disorder. The client states, "You are the only person working here who actually understands me. The day shift nurse was completely heartless and refused to let me make a phone call." Which of the following is the most appropriate response by the nurse?

Show answer & explanation

Answer: The unit policy allows telephone access between 1900 and 2100. Let's review the schedule together.

Answer

The most appropriate response is to state the established unit rules regarding telephone privileges and review the schedule with the client.
The correct response sets firm, objective limits by redirecting the client to established unit policies. Clients with borderline personality disorder often use splitting (idealizing one person while devaluing another) to manipulate staff and test boundaries. A neutral, factual response that references universal rules prevents the client from successfully dividing the team and reinforces a safe, consistent therapeutic environment.

Step-by-Step Solution

1
Identify the psychiatric concept being demonstrated by the client.
The client, diagnosed with borderline personality disorder, is exhibiting 'splitting' by idealizing the current nurse while devaluing the previous nurse.
Recognizing this classic behavioral pattern is necessary to select a therapeutic and safe intervention.
2
Determine the primary nursing goal when managing splitting behavior.
The primary goal is to maintain consistent unit rules, avoid taking sides, and present a unified, objective staff approach.
Inconsistency or subjectivity allows the client to manipulate boundaries, which is detrimental to the therapeutic milieu.
3
Evaluate the given communication options against psychiatric nursing standards.
Redirecting the client to established unit policies maintains strict boundaries in a neutral, non-judgmental manner.
Alternative responses that defend staff, ask 'why', or grant special privileges are non-therapeutic and actively undermine the collaborative treatment plan.

Key Concept

Therapeutic Communication and Milieu Management for Splitting Behavior
Question 1822Question →

A nurse is monitoring a client admitted 6 hours ago with a complex pelvic fracture sustained from blunt force trauma. Which subtle trend in the client's assessment data is the most reliable early indicator of impending hemodynamic compromise?

Show answer & explanation

Answer: Blood pressure changing from 130/70 mm Hg to 114/84 mm Hg

Answer

The blood pressure changing from 130/70 mm Hg to 114/84 mm Hg is the most reliable early indicator.
Pelvic fractures carry a high risk for severe hemorrhage. A narrowing pulse pressure (the difference between systolic and diastolic pressure decreasing from 60 mm Hg to 30 mm Hg in this scenario) is a classic early sign of compensatory shock. As circulating blood volume drops, peripheral vasoconstriction raises or maintains the diastolic pressure while the systolic pressure begins to fall, resulting in a narrowed pulse pressure before overt hypotension occurs.

Step-by-Step Solution

1
Identify the primary physiological risk associated with a complex pelvic fracture.
The client is at extremely high risk for massive, hidden retroperitoneal hemorrhage and subsequent hypovolemic shock.
The pelvis houses major blood vessels, and fractures can lacerate these structures, leading to significant concealed blood loss.
2
Analyze the blood pressure trend provided in the correct option to determine the pulse pressure.
The initial pulse pressure (systolic minus diastolic) is 60 mm Hg (130 - 70). The subsequent pulse pressure is 30 mm Hg (114 - 84).
Calculating the pulse pressure is necessary to identify subtle hemodynamic shifts before gross hypotension occurs.
3
Evaluate the clinical significance of a narrowing pulse pressure.
The pulse pressure has narrowed significantly from 60 to 30 mm Hg, which is a key indicator of early compensated shock.
As circulating blood volume decreases, the sympathetic nervous system triggers peripheral vasoconstriction. This elevates or maintains diastolic pressure while systolic pressure begins to drift downward, creating a narrowed pulse pressure.
4
Differentiate this critical finding from expected or less definitive assessment data.
The other trends (urine output of 35 mL/hr, heart rate up to 96, and movement-related pain) are either expected or still within normal physiological limits.
Prioritizing the narrowing pulse pressure allows for immediate medical intervention before the client progresses to uncompensated shock.

Key Concept

Early recognition of hypovolemic shock via narrowing pulse pressure
Question 1823Question →

A nurse is preparing to insert a nasogastric (NG) tube for a client who requires enteral tube feedings. To reduce the risk of respiratory complications and aspiration, arrange the following nursing actions in the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first position the client upright, measure the correct length of the tube, safely advance the tube while the client swallows with their neck flexed, perform an initial bedside pH check, and finally verify placement with a radiograph before use.
Safe insertion of a nasogastric tube requires a systematic approach to prevent respiratory trauma and aspiration. The process begins with proper anatomical positioning (high Fowler's) and measuring the necessary length to reach the stomach. Advancing the tube with the neck flexed during swallowing protects the airway. Finally, while bedside methods like pH testing provide preliminary data, radiographic confirmation is mandatory before using the tube to eliminate the risk of administering feedings into the lungs.

Step-by-Step Solution

1
Place the client in a high Fowler's position.
The client is sitting upright.
This minimizes aspiration risk and uses gravity to assist with the tube's descent.
2
Measure the tube from the tip of the nose to the earlobe, and then to the xiphoid process.
The target insertion length is identified and marked on the tube.
This ensures the tube is advanced exactly to the stomach, preventing coiling or dangerous misplacement.
3
Instruct the client to flex their head toward their chest and swallow as the tube is advanced.
The tube passes the oropharynx and enters the esophagus.
Flexing the neck anatomically protects the airway by causing the epiglottis to cover the tracheal opening.
4
Secure the tube to the client's nose and aspirate gastric contents to test the pH.
Initial bedside verification indicates a highly acidic gastric environment.
A pH of less than 5 strongly suggests the tube is in the stomach rather than the respiratory tract or intestines.
5
Obtain a radiograph to definitively confirm tube placement before initiating feedings.
Absolute visual confirmation of placement is achieved.
This is the only definitive method to ensure the tube is not in the respiratory tract before administering anything through it, strictly reducing the risk of fatal pulmonary aspiration.

Key Concept

Nasogastric Tube Insertion Safety and Verification
Question 1824Question →

A 74-year-old client with mobility impairment is brought to an outpatient wound care clinic by a family caregiver. The client appears disheveled, has poor oral hygiene, and exhibits a new, unstageable sacral pressure injury. The caregiver loudly states, "I cannot deal with cleaning up these messes anymore; it is disgusting." The client avoids eye contact and remains silent. Which of the following nursing actions are appropriate? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Report the suspected neglect to Adult Protective Services or the appropriate state authority based on reasonable suspicion.; Document the caregiver's statements using direct quotes alongside objective descriptions of the client's physical condition.; Separate the client from the caregiver to conduct a private physical assessment and evaluate immediate safety.

Answer

The appropriate actions are to report the suspected neglect based on reasonable suspicion, objectively document the findings with direct quotes, and separate the client for a private assessment.
The priority in suspected abuse or neglect is ensuring client safety by conducting a private assessment away from the caregiver. Nurses are legally mandated to report reasonable suspicion of neglect to authorities immediately; waiting for definitive proof is a violation of this mandate. Furthermore, all documentation must be strictly objective, utilizing factual descriptions and exact quotes from the involved parties to ensure an accurate legal record.

Step-by-Step Solution

1
Analyze the clinical presentation and caregiver behavior.
The client shows signs of physical neglect (poor hygiene, severe pressure injury) and emotional distress, while the caregiver displays overt frustration and inappropriate verbalization.
Identifying red flags for dependent adult neglect is required to initiate proper safeguarding protocols.
2
Determine the immediate safety and assessment priorities.
The nurse must separate the client from the caregiver to conduct a thorough, private physical assessment.
A private assessment ensures the client can speak freely without intimidation and allows the nurse to fully evaluate for other signs of trauma.
3
Identify the legal and documentation responsibilities.
The nurse must report the reasonable suspicion of neglect to authorities and document the findings objectively, using direct quotes.
Nurses are mandated reporters and must act to protect the client legally, while maintaining a factual medical record.

Key Concept

Management and Mandatory Reporting of Elder Neglect
Question 1825Question →

An older adult client with a history of mild neurocognitive disorder is admitted to a bustling medical-surgical unit. During the chaotic shift change, the client becomes acutely agitated, yells that "strangers are attacking," and attempts to climb over the raised bed rails. The nurse recognizes the client is experiencing acute delirium exacerbated by sensory overload. Arrange the following nursing actions in the chronological priority order they should be performed.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct priority order is to first secure physical safety, second communicate therapeutically, third reduce environmental stimuli, fourth perform a physiological assessment, and finally document the event.
In any acute clinical scenario, the nursing prioritization framework dictates that immediate life safety and injury prevention come first. Stopping the client from falling over the bed rails addresses an immediate safety threat. Once the client is physically secure, de-escalation via therapeutic communication and environmental modification helps resolve the sensory overload causing the behavioral disturbance. Only after the crisis is stabilized should the nurse transition to investigating the underlying physiological causes (assessment) and completing administrative tasks (documentation).

Step-by-Step Solution

1
Intercept the client's attempt to climb out of bed.
The client's immediate risk of falling and sustaining a traumatic injury is neutralized.
According to Maslow's Hierarchy of Needs and basic survival principles, preventing imminent physical harm always takes absolute priority.
2
Address the client by name in a calm, reassuring voice.
The nurse establishes a non-threatening presence and begins reality orientation.
Once the physical fall is prevented, the nurse must immediately begin de-escalation techniques to manage the client's panic-level anxiety.
3
Decrease sensory stimuli (turn off TV, close door).
The chaotic environment exacerbating the client's sensory overload is minimized.
Sensory overload contributes heavily to agitation in clients with cognitive impairment; modifying the environment removes the trigger.
4
Perform a targeted physiological assessment (oxygenation, pain, elimination).
Potential reversible physiological causes for the acute delirium are identified.
Although assessment is typically the first step of the nursing process, emergency safety interventions supersede it. Once safe, the nurse must assess for root causes like hypoxia or infection.
5
Document the incident in the electronic health record.
The behavioral change and nursing interventions are legally and medically recorded.
Documentation is a vital nursing responsibility but must always follow direct client care and stabilization.

Key Concept

Prioritization of Nursing Care for Acute Delirium and Sensory Overload
Question 1826Question →

An older adult client is hospitalized after a severe bout of gastroenteritis with frequent liquid stools over the last three days. The laboratory reports the following arterial blood gas values: pH 7.297.29, PaCO2PaCO_2 42 mm Hg42\text{ mm Hg}, and HCO3−HCO_3^- 17 mEq/L17\text{ mEq/L}. Based on these results, which primary acid-base imbalance should the nurse identify?

Show answer & explanation

Answer: Metabolic acidosis

Answer

The client is experiencing metabolic acidosis.
The correct answer is metabolic acidosis because the arterial blood gas results show a low pH (7.297.29), indicating acidosis, paired with a low bicarbonate level (17 mEq/L17\text{ mEq/L}). The normal PaCO2PaCO_2 (42 mm Hg42\text{ mm Hg}) confirms that the primary disturbance is metabolic, which aligns with the clinical history of excessive lower gastrointestinal bicarbonate loss through severe diarrhea.

Step-by-Step Solution

1
Analyze the pH value to determine the primary state.
The pH is 7.297.29, which is less than the normal range of 7.357.35 to 7.457.45.
A pH below 7.357.35 defines acidemia (acidosis).
2
Analyze the PaCO2PaCO_2 value to check for respiratory involvement.
The PaCO2PaCO_2 is 42 mm Hg42\text{ mm Hg}, which is within the normal range of 3535 to 45 mm Hg45\text{ mm Hg}.
A normal PaCO2PaCO_2 rules out a primary respiratory disturbance as the cause of the acidosis.
3
Analyze the HCO3−HCO_3^- value to check for metabolic involvement.
The HCO3−HCO_3^- is 17 mEq/L17\text{ mEq/L}, which is less than the normal range of 2222 to 26 mEq/L26\text{ mEq/L}.
A decreased HCO3−HCO_3^- level directly corresponds with the acidic pH, confirming a metabolic origin.

Key Concept

Interpretation of uncompensated acid-base imbalances using arterial blood gas values.
Question 1827Question →

A nurse is managing the hygiene and comfort of an older adult client who is 24 hours post-operative following a right total hip arthroplasty (posterior approach). The client reports severe sacral and heel discomfort and requests assistance with a bed bath and repositioning. Which nursing intervention is the most appropriate to ensure safe basic care and comfort?

Show answer & explanation

Answer: Place an abduction wedge between the client's lower extremities, utilize assistance to turn the client onto the unaffected left side, and float the heels off the mattress using a pillow placed under the calves.

Answer

The correct intervention is to place an abduction wedge between the client's legs to maintain alignment, turn the client onto the unaffected side to relieve sacral pressure, and float the heels by placing a pillow underneath the calves.
Clients recovering from a posterior approach total hip arthroplasty are at a high risk for hip dislocation if the joint is flexed beyond 90 degrees, adducted, or internally rotated. Using an abduction wedge between the legs safely prevents adduction while turning and resting. Turning the client onto their unaffected (left) side offloads pressure from the sacrum and the surgical site. Furthermore, placing a pillow lengthwise under the calves effectively 'floats' the heels off the mattress, relieving pressure without causing tissue damage or compromising lower extremity circulation.

Step-by-Step Solution

1
Identify the surgical precautions for the client's specific procedure.
A posterior approach total hip arthroplasty requires preventing hip flexion greater than 90 degrees, hip adduction, and internal rotation.
Violating these precautions can cause an immediate and severe dislocation of the new hip prosthesis.
2
Evaluate the client's complaints of sacral and heel discomfort.
The discomfort is recognized as an early warning sign of tissue ischemia and potential pressure injury development.
Immobile, older adult clients are at a high risk for skin breakdown over bony prominences, requiring immediate pressure offloading.
3
Select the intervention that simultaneously addresses hygiene needs, pressure relief, and surgical safety.
Using an abduction wedge prevents adduction during turning, rolling to the unaffected side offloads the sacrum safely, and floating heels with a calf pillow relieves heel pressure.
This combination of actions satisfies all safety parameters while maximizing the client's basic care and comfort.

Key Concept

Postoperative Positioning and Pressure Injury Prevention
Estimated Time:2m 0s
Question 1828Question →

A client who recently experienced a cerebrovascular accident has residual right-sided weakness. The nursing staff is planning to assist the client from the bed into a wheelchair for the first time. Arrange the following steps in the correct chronological sequence to execute a safe stand-pivot transfer.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first position the wheelchair on the unaffected left side, then assist the client to sit and apply the transfer belt, brace the weak right leg, assist the client to stand and pivot on the strong left foot, and finally instruct the client to reach back with their left hand before sitting.
The correct sequence prioritizes client safety by leveraging their intact mobility. Placing the wheelchair on the unaffected (left) side ensures the client can bear weight and pivot safely on their strong leg. Once the environment is prepared, the client is brought to a seated position to safely apply the transfer belt. The nurse must then brace the hemiparetic right leg to prevent it from buckling during the standing phase. Finally, the client uses their strong left arm to reach for the armrest, which prevents them from falling abruptly into the chair.

Step-by-Step Solution

1
Position the wheelchair on the client's left side at a 45-degree angle to the bed and lock the wheels.
The destination is safely secured and accessible via the client's strong side.
Transferring toward the unaffected side allows the client to bear their own weight and assist with the movement.
2
Assist the client to sit on the edge of the bed with feet flat on the floor and apply a transfer belt.
The client is in a stable starting position with a secure grip point for the nurse.
A transfer belt must be applied while seated to ensure it is snug and will not slide up the rib cage during lifting.
3
Stand facing the client and brace their right knee and foot with your own knee and foot.
The hemiparetic leg is physically blocked from collapsing.
Clients with hemiparesis lack the muscle tone to keep the affected leg extended; bracing it provides essential joint stability.
4
Grasp the transfer belt, assist the client to a standing position, and guide them to pivot on their left foot.
The client successfully rotates their body toward the wheelchair.
Weight is borne primarily by the intact, strong leg during the pivot motion to prevent a fall.
5
Instruct the client to reach back with their left hand to grasp the wheelchair armrest before lowering into the seat.
The client safely and slowly sits down.
Using the strong arm provides stability and controls the speed of the descent, preventing the client from dropping abruptly.

Key Concept

During a bed-to-chair transfer for a client with hemiparesis, equipment must be placed on the unaffected side, and the nurse must brace the affected extremity to prevent buckling.
Question 1829Question →

An older adult client with a history of early-stage Alzheimer's disease is admitted with severe pneumonia. The client's respiratory status rapidly deteriorates, resulting in an altered level of consciousness and impending respiratory failure. The client's adult child, who is the designated durable power of attorney for healthcare (DPOA-HC), is at the bedside and demands the client be intubated immediately to save their life. However, the medical record contains a legally valid living will, executed by the client two years ago when fully competent, explicitly refusing intubation and mechanical ventilation. The attending physician verbally orders the nurse to prepare the equipment for immediate intubation, citing the proxy's demand. Which of the following is the most appropriate ethical and legal action for the nurse to take?

Show answer & explanation

Answer: Withhold the intubation equipment and immediately notify the physician that the client's documented living will legally supersedes the proxy's request.

Answer

The most appropriate action is to withhold the intubation equipment and immediately inform the physician that the client's documented living will supersedes the healthcare proxy's request.
The core ethical principle of autonomy dictates that an individual's documented wishes regarding healthcare must be honored. A living will is a legally binding advance directive that provides specific instructions about life-sustaining treatments. When a client becomes incapacitated, the designated durable power of attorney for healthcare (DPOA-HC) must make decisions based on the client's known wishes (substituted judgment). The DPOA-HC does not have the legal authority to override a valid, specific living will. Furthermore, the nurse acts as a client advocate (fidelity) and must intervene when a physician's order violates the client's established legal rights. Withholding the equipment and challenging the physician's order is the necessary action to prevent medical battery and uphold ethical practice.

Step-by-Step Solution

1
Analyze the legal standing of the available advance directives.
The client has a valid living will refusing intubation, and a designated DPOA-HC.
Understanding the hierarchy of advance directives is essential. A living will provides specific instructions, while a DPOA-HC makes decisions based on what the client would want.
2
Evaluate the conflict between the proxy's demand and the living will.
The proxy is demanding an intervention that the client explicitly refused in writing.
A DPOA-HC is legally obligated to use substituted judgment (following the client's known wishes). They do not have the authority to override a valid, specific living will.
3
Assess the physician's order in the context of ethical principles.
The physician's order to prepare for intubation violates the ethical principle of autonomy and constitutes potential medical battery.
Healthcare providers must honor competent clients' prior refusals of care, even in life-threatening emergencies.
4
Determine the required nursing advocacy action.
The nurse must refuse to participate in preparing for the intubation and clearly communicate the legal boundary to the physician.
The principle of fidelity requires the nurse to act as a steadfast advocate for the client's rights, intervening when other team members attempt to violate those rights.

Key Concept

Hierarchy of Advance Directives and Client Advocacy
Question 1830Question →

An adolescent client hospitalized for major depressive disorder has displayed severe anhedonia and psychomotor retardation for the past two weeks. Today, the client emerges from their room smiling, exhibiting unusually high energy, and gives a cherished guitar pick to another client. Which action is the priority for the nurse?

Show answer & explanation

Answer: Implement direct, continuous one-to-one observation of the client.

Answer

The nurse must implement direct, continuous one-to-one observation to ensure the client's immediate safety.
The correct action directly protects the client from self-harm. When a severely depressed client suddenly appears happy, energetic, and begins giving away personal belongings, it is a major red flag. It often indicates that the client has formulated a specific suicide plan and feels a sense of relief. Because the client now has the energy to carry out the act, the nurse must immediately institute continuous one-to-one observation to prevent a suicide attempt.

Step-by-Step Solution

1
Analyze the change in the client's clinical presentation.
The client shows a sudden, drastic improvement in mood and energy, alongside giving away a prized possession.
Recognizing abrupt shifts in behavior is essential in psychiatric nursing, as these changes often indicate a shift in risk level.
2
Correlate the behavioral change with potential risks.
The sudden lift in depression and giving away belongings strongly suggests the client has made a concrete suicide plan and now has the energy to execute it.
Clients with severe depression often lack the energy to commit suicide; an energy surge provides the means to act on suicidal ideation.
3
Determine the highest priority nursing intervention.
The immediate priority is maintaining a safe environment by initiating one-to-one observation.
According to Maslow's Hierarchy of Needs and basic safety principles, preserving the client's life supersedes all other assessments or documentation.

Key Concept

Suicide Risk Assessment and Safety Interventions
Estimated Time:1m 0s
Question 1831Question →

A client with a recent diagnosis of Guillain-Barré syndrome is being closely monitored on the medical-surgical unit. The nurse observes that the client is becoming increasingly lethargic, and their respiratory rate has decreased to 8 breaths per minute with weak chest wall movement. Based on these clinical findings, which of the following arterial blood gas (ABG) results should the nurse most anticipate?

Show answer & explanation

Answer: pH 7.25, PaCO2PaCO_2 62 mm Hg, HCO3−HCO_3^- 24 mEq/L

Answer

The ABG result showing pH 7.25, PaCO2PaCO_2 62 mm Hg, and HCO3−HCO_3^- 24 mEq/L, indicating acute respiratory acidosis.
The correct answer displays uncompensated respiratory acidosis. Guillain-Barré syndrome can lead to progressive neuromuscular weakness, eventually affecting the muscles of respiration. A respiratory rate of 8 breaths per minute with weak chest excursions indicates severe hypoventilation, which causes the body to retain carbon dioxide. This rapid accumulation of carbon dioxide (PaCO2PaCO_2 > 45 mm Hg) drives the blood pH down into an acidotic state (pH < 7.35). Because this is an acute change, the kidneys have not yet retained bicarbonate (HCO3−HCO_3^-) to compensate, leaving it within the normal range (22-26 mEq/L).

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has Guillain-Barré syndrome, is lethargic, and is hypoventilating with a respiratory rate of 8 breaths per minute and weak chest movement.
Understanding the physiological impact of the disease process helps predict the resulting acid-base imbalance.
2
Determine the physiological consequence of hypoventilation.
Inadequate ventilation leads to the retention of carbon dioxide (CO2CO_2) in the lungs and bloodstream.
CO2CO_2 acts as an acid in the body, so accumulating CO2CO_2 drives the blood pH lower.
3
Correlate the physiological change with expected ABG values.
The expected ABG will show a low pH (acidosis), an elevated PaCO2PaCO_2 (respiratory origin), and a normal HCO3−HCO_3^- since the kidneys have not had time to compensate.
This combination of values precisely defines uncompensated respiratory acidosis.

Key Concept

Arterial Blood Gas (ABG) Interpretation in Neuromuscular Respiratory Failure
Question 1832Question →

A clinical educator is evaluating a nursing student preparing to administer an intermittent intravenous (IV) antibiotic infusion into a patient's dedicated primary continuous IV line. Which actions by the student demonstrate correct application of parenteral therapy safety principles? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Cleansing the designated needleless connector on the primary tubing with an approved antiseptic wipe before attachment.; Confirming the physical and chemical compatibility of the prescribed antibiotic with the primary fluid prior to administration.; Suspending the secondary medication bag on the intravenous pole at a level higher than the primary fluid container.

Answer

The correct actions include cleansing the needleless connector before attachment, confirming fluid compatibility, and suspending the secondary bag higher than the primary fluid.
Safe parenteral therapy requires strict adherence to infection control (cleansing the connector), verification of chemical compatibility to prevent precipitation, and proper equipment setup (hanging the secondary bag higher to utilize gravity). These actions ensure the medication is delivered safely and effectively without compromising the patient's vascular access.

Step-by-Step Solution

1
Evaluate the requirement for infection control during IV administration.
Identify that scrubbing the needleless connector is essential to prevent central line-associated or peripheral bloodstream infections.
Maintaining aseptic technique is a fundamental safety principle in parenteral therapy.
2
Assess the principles of drug compatibility.
Determine that the nurse must verify the antibiotic is compatible with the continuous IV fluid.
Mixing incompatible solutions can cause dangerous precipitation in the IV line.
3
Analyze the mechanical setup of a secondary IV infusion.
Recognize that the secondary (piggyback) bag must be hung higher than the primary bag.
Gravity allows the higher bag to exert more hydrostatic pressure, infusing first.
4
Review the distractors for safety and delegation violations.
Eliminate options that involve infusing incompatible fluids, delegating initial assessments to UAP, or estimating pump rates.
These actions directly violate the nursing scope of practice and medication safety protocols.

Key Concept

Safe Parenteral Medication Administration Principles
Question 1833Question →

A nurse is completing the preoperative checklist for an adult client scheduled for a bilateral mastectomy the following morning. The client is crying quietly and states, "I do not know who I am going to be after this surgery. My partner says it does not matter, but I just cannot believe them."

Which response by the nurse is the most therapeutic?

Show answer & explanation

Answer: You are experiencing a lot of fear about how this physical change will impact who you are and your relationship.

Answer

The most therapeutic response reflects the client's feelings and validates their fear regarding their identity and relationship without offering false reassurance or judgment.
The correct response utilizes the therapeutic communication technique of reflection and validation. By restating the client's implicit concerns about identity and relationship security, the nurse acknowledges the client's emotional pain without judgment, encouraging further exploration of these profound fears.

Step-by-Step Solution

1
Analyze the client's statement and underlying emotional message.
The client is expressing deep-seated fears regarding loss of identity and relationship insecurity following a major body-altering surgery.
Therapeutic communication requires addressing the underlying emotional message rather than just the spoken words.
2
Evaluate the options for therapeutic communication techniques.
Look for responses that validate feelings, use open-ended exploration, or reflect the client's emotional state.
Effective therapeutic communication facilitates expression and helps the client process complex emotions.
3
Identify non-therapeutic barriers in the distractors.
Eliminate options that minimize feelings, offer false reassurance, give unwanted advice, or ask aggressive 'why' questions.
Non-therapeutic responses invalidate the client's experience and abruptly close the channels of communication.

Key Concept

Therapeutic Communication
Question 1834Question →

A 62-year-old client is in the progressive care unit 8 hours after a left pneumonectomy. The client appears lethargic and is receiving supplemental oxygen at 3 L/min via nasal cannula. During the assessment, the nurse observes the client lying in a right lateral decubitus position. The most recent arterial blood gas (ABG) values are as follows:

ParameterResult
pH7.28
PaCO2PaCO_258 mm Hg
HCO3−HCO_3^-25 mEq/L
PaO2PaO_264 mm Hg

Based on these clinical findings, what is the priority nursing action to reduce the risk of a life-threatening physiological complication?

Show answer & explanation

Answer: Assist the client into a supine or left lateral position to facilitate maximal expansion of the remaining lung.

Answer

Assist the client into a supine or left lateral position to facilitate maximal expansion of the remaining lung.
The client is experiencing acute uncompensated respiratory acidosis due to severe hypoventilation. Following a pneumonectomy, placing the client on the unoperated side (the right side, in this case) restricts the expansion of the sole functioning lung due to gravity and the weight of the mediastinum. To prevent a dangerous mediastinal shift and optimize gas exchange, the client must be positioned supine or on the operative side (left lateral). This allows the remaining functional lung to fully expand, which will improve ventilation and resolve the hypercapnia.

Step-by-Step Solution

1
Analyze the arterial blood gas (ABG) values.
The ABG reveals uncompensated respiratory acidosis (low pH of 7.28, high PaCO2PaCO_2 of 58 mm Hg) accompanied by hypoxemia.
An elevated PaCO2PaCO_2 indicates acute hypoventilation and CO2CO_2 retention.
2
Correlate the clinical findings with the surgical history.
The client had a left pneumonectomy, meaning the right lung is the only remaining functional lung in the thoracic cavity.
Understanding the anatomical alteration is necessary to pinpoint the mechanical cause of the hypoventilation.
3
Evaluate the physiological impact of the client's current physical position.
The client is in a right lateral decubitus position, which mechanically compresses the right lung due to gravity and body weight.
Positional restriction of the sole functioning lung is preventing adequate chest excursion, leading to the hypoventilation and resulting acidosis.
4
Determine the corrective priority action to reduce further risk.
Reposition the client to the supine or left lateral (operative) position.
This frees the non-operative lung to expand fully, thereby improving ventilation mechanics and reversing the life-threatening hypercapnia.

Key Concept

Post-pneumonectomy Positioning and Respiratory Acidosis
Question 1835Question →

A healthcare team is managing a 75-kg client who is on a continuous intravenous (IV) heparin drip for a pulmonary embolism. The infusion pump is currently set to deliver 20 units/kg/hr20 \text{ units/kg/hr}. Without warning, the client experiences profound hematemesis, epistaxis, and a sudden decline in consciousness. After stopping the heparin infusion, the nurse receives a stat prescription for intravenous protamine sulfate. The pharmacy dispenses protamine sulfate in vials with a concentration of 10 mg/mL10 \text{ mg/mL}. According to the facility's standard reversal protocol, 1 mg1 \text{ mg} of protamine sulfate neutralizes 100 units100 \text{ units} of heparin.

Based on the total amount of heparin the client received over the last hour, what is the exact volume in milliliters (mL) of protamine sulfate the nurse must administer (no rounding required), and what is a critical safety consideration during its administration?

Show answer & explanation

Answer: 1.5 mL; Administer the dose slowly over 1 to 3 minutes to minimize the risk of severe hypotension and bradycardia.

Answer

The correct volume is 1.5 mL, and the medication must be administered slowly over 1 to 3 minutes to prevent severe hypotension and bradycardia.
The client received 1,500 units1,500 \text{ units} of heparin in the last hour (75 kg×20 units/kg/hr75 \text{ kg} \times 20 \text{ units/kg/hr}). Since 1 mg1 \text{ mg} of protamine sulfate neutralizes 100 units100 \text{ units} of heparin, the client requires 15 mg15 \text{ mg} of protamine (1,500÷1001,500 \div 100). Using the dispensed concentration of 10 mg/mL10 \text{ mg/mL}, the required volume is 1.5 mL1.5 \text{ mL} (15 mg÷10 mg/mL15 \text{ mg} \div 10 \text{ mg/mL}). Furthermore, a critical pharmacological safety principle is that protamine sulfate must be administered slowly (no faster than 50 mg over 10 minutes) to prevent dangerous adverse effects, including sudden profound hypotension, bradycardia, and pulmonary hypertension.

Step-by-Step Solution

1
Calculate the total units of heparin administered in the last hour.
75 kg×20 units/kg/hr=1,500 units/hr75 \text{ kg} \times 20 \text{ units/kg/hr} = 1,500 \text{ units/hr}.
To determine the exact amount of circulating heparin that requires reversal.
2
Calculate the milligrams of protamine sulfate required.
1,500 units÷100 units/mg=15 mg1,500 \text{ units} \div 100 \text{ units/mg} = 15 \text{ mg}.
The protocol states that 1 mg of protamine neutralizes 100 units of heparin.
3
Calculate the final volume of protamine sulfate to administer.
15 mg÷10 mg/mL=1.5 mL15 \text{ mg} \div 10 \text{ mg/mL} = 1.5 \text{ mL}.
To determine the exact liquid volume to draw up from the dispensed vial.
4
Determine the safest rate of intravenous administration.
Administer slowly over 1 to 3 minutes.
Rapid IV push of protamine sulfate causes speed shock, which presents as severe hypotension, bradycardia, and anaphylactoid reactions.

Key Concept

Pharmacological and Parenteral Therapies - Antidote Administration and Medication Safety
Estimated Time:3m 0s
Question 1836Question →

A home hospice nurse is managing the care of a client in the final days of life. The client is unresponsive with Cheyne-Stokes respirations and peripheral mottling. The client's spouse is visibly distressed and demands, 'You must start an IV line for hydration. It is cruel to let him dehydrate to death.' Which of the following actions are appropriate for the nurse to take? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Educate the spouse that natural dehydration decreases respiratory secretions and can promote a more peaceful passing.; Elevate the head of the bed and position the client on their side to facilitate the drainage of oral secretions.; Apply artificial tears to the client's eyes and gently swab the oral cavity with moisture every few hours.

Answer

The appropriate actions are to educate the spouse about the benefits of natural dehydration, position the client to facilitate secretion drainage, and provide meticulous oral and eye care.
The correct nursing actions prioritize the client's physical comfort and the family's psychosocial needs. Educating the spouse that natural dehydration is a normal and beneficial part of the dying process helps reduce the 'death rattle' and promotes endorphin release. Physical comfort is maintained by positioning the client on their side with the head elevated to drain secretions and by providing regular eye and oral care to prevent drying and breakdown.

Step-by-Step Solution

1
Analyze the client's physiological state.
The client is in the active phase of dying, characterized by unresponsiveness, altered breathing patterns, and decreased peripheral perfusion.
Understanding the clinical phase determines the appropriate goals of care, which shift strictly to comfort rather than curative or life-prolonging measures.
2
Evaluate the spouse's request for artificial hydration.
Artificial hydration is contraindicated. As the body shuts down, it cannot process excess fluids, which leads to pulmonary edema, increased respiratory secretions (death rattle), and peripheral edema.
Natural dehydration stimulates endorphin release which promotes comfort, whereas IV fluids can cause significant physical distress.
3
Identify therapeutic nursing interventions.
The nurse must provide physical comfort (oral care, positioning) and psychological support (evidence-based education regarding the dying process) while avoiding non-therapeutic communication or inappropriate delegation.
Palliative and hospice care prioritize maximizing quality of life, managing symptoms, and supporting the family unit without accelerating or delaying death.

Key Concept

Management of physiological changes and family dynamics during the active phase of dying.
Question 1837Question →

A client is brought to the emergency department by law enforcement exhibiting extreme agitation, paranoia, severe diaphoresis, and aggressive behavior after a suspected ingestion of a synthetic stimulant. The client's initial tympanic temperature is 104.2°F (40.1°C). Arrange the following nursing actions in the most appropriate order of priority from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first secure the environment and obtain staff assistance, followed by administering a prescribed intramuscular benzodiazepine, initiating continuous cardiac monitoring, implementing rapid external cooling measures, and finally collecting diagnostic laboratory specimens.
The priority of care for a client experiencing severe synthetic stimulant toxicity follows the principles of safety, chemical restraint, physiological monitoring, and targeted symptom management. Securing the environment and gathering adequate staff is the absolute first step to ensure physical safety. Once safe, administering a benzodiazepine is the critical medical intervention to decrease the extreme agitation that is driving the life-threatening hyperthermia and metabolic demand. After the client is chemically sedated and compliant, the nurse can safely apply continuous cardiac monitoring to detect lethal arrhythmias. With monitoring in place, rapid cooling measures are applied to treat the critical hyperthermia (104.2°F). Finally, collecting diagnostic specimens is performed to guide ongoing treatment once the client is stabilized.

Step-by-Step Solution

1
Prioritize physical safety and containment.
Secure the immediate environment and request additional staff assistance.
Extreme agitation and paranoia from sympathomimetic toxicity pose an immediate physical threat to the client and the healthcare team. Physical safety must precede medical interventions.
2
Control the acute behavioral and physiological hyperactivity.
Administer a prescribed fast-acting intramuscular benzodiazepine.
Chemical sedation is urgently required to prevent self-harm, halt the progression of hyperthermia resulting from extreme muscle exertion, and allow for safe medical assessment and intervention.
3
Assess cardiovascular status.
Initiate continuous cardiac monitoring and continuous pulse oximetry.
Synthetic stimulants cause severe cardiovascular stress. Once the client is safely sedated, continuous monitoring must be established immediately to detect imminent myocardial ischemia or lethal arrhythmias.
4
Address the life-threatening hyperthermia.
Implement rapid external cooling measures.
A core temperature of 104.2°F (40.1°C) can rapidly lead to protein denaturation and multi-organ failure. Cooling is initiated once monitoring is in place to track physiological responses.
5
Investigate the underlying metabolic and toxicological state.
Collect blood and urine specimens for comprehensive toxicology and metabolic testing.
Laboratory results will guide definitive, longer-term medical management once the immediate life threats have been stabilized.

Key Concept

Prioritization of emergency nursing care for acute synthetic stimulant toxicity.
Question 1838Question →

A nurse is developing a plan of care for an older adult client admitted to a specialized burn unit with extensive facial and upper torso burns. The client's eyes and ears are covered with bulky antimicrobial dressings, resulting in acute sensory deprivation. The client has begun reporting feeling bugs crawling under their skin and hearing unfamiliar voices. Which of the following nursing interventions should be included in the plan of care to address these sensory and perceptual alterations? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Explain all nursing activities and identify environmental sounds to the client before initiating physical contact.; Provide structured, meaningful tactile stimulation by gently touching an unaffected area during interactions.; Establish a consistent daily routine and assign the same nursing staff to care for the client whenever possible.

Answer

The correct interventions are explaining all activities and sounds before physical contact, providing structured tactile stimulation, and establishing a consistent routine with consistent caregiver assignments.
The appropriate care for a client experiencing sensory deprivation and resulting perceptual alterations focuses on providing safe, meaningful stimulation and promoting environmental predictability. Explaining actions and sounds prevents startle responses and grounds the client. Gentle, appropriate tactile stimulation compensates for blocked visual and auditory pathways. Maintaining a consistent routine and staffing reduces confusion and fosters a sense of security.

Step-by-Step Solution

1
Analyze the clinical scenario to identify the primary etiology of the client's symptoms.
The client is experiencing acute sensory deprivation due to bulky dressings covering the eyes and ears, leading to tactile and auditory hallucinations.
Understanding the root cause (sensory deprivation versus sensory overload) dictates the appropriate environmental and behavioral interventions.
2
Evaluate the proposed interventions for therapeutic efficacy in treating sensory deprivation.
Providing grounding communication, offering safe and meaningful tactile stimulation, and ensuring environmental consistency will safely orient the client and compensate for lost sensory input.
These actions re-establish a connection with reality and reduce the brain's tendency to generate endogenous stimuli (hallucinations) when external stimuli are blocked.
3
Rule out options that represent unsafe practice or incorrect clinical judgment.
Delegating hallucination assessment to a UAP, arguing logically against the hallucinations, and misattributing acute perceptual changes to normal aging are all incorrect actions.
Assessment cannot be delegated, nontherapeutic communication exacerbates distress, and sudden cognitive changes require immediate clinical evaluation, not dismissal as a normal aging process.

Key Concept

Nursing management of acute sensory deprivation involves providing meaningful, structured sensory input, maintaining a consistent environment, and utilizing grounding communication techniques while avoiding nontherapeutic confrontation.
Question 1839Question →

A 72-year-old client is recovering in the outpatient care unit following a bronchoscopy performed with moderate sedation. Which of the following actions should the nurse take to reduce the client's risk of complications? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Keep the client nothing by mouth (NPO) until the gag reflex returns.; Assess respiratory rate, oxygen saturation, and lung sounds frequently.

Answer

The nurse should keep the client NPO until the gag reflex returns and frequently assess the client's respiratory rate, oxygen saturation, and lung sounds.
Following a bronchoscopy, the local anesthetic used in the throat suppresses the gag reflex, creating a high risk for aspiration. Keeping the client NPO until this reflex returns is an essential risk-reduction strategy. Additionally, moderate sedation can cause respiratory depression, making the frequent monitoring of oxygenation and lung sounds absolutely critical to detect and manage complications early.

Step-by-Step Solution

1
Identify the primary physiological risks associated with a bronchoscopy and moderate sedation.
The main risks are aspiration (due to topical anesthetics depressing the gag reflex) and respiratory depression/hypoxia (from the sedative medications).
Understanding procedure-specific risks dictates which focused nursing assessments and interventions are required.
2
Evaluate the correct interventions for airway and breathing protection.
Keeping the client NPO prevents aspiration, and frequent respiratory assessment detects hypoxia early.
Airway and breathing are the highest priorities in post-operative and post-procedure care.
3
Analyze the remaining options to identify unsafe practices or clinical errors.
Supine positioning increases aspiration risk, initial airway assessments cannot be delegated, and sudden confusion is a sign of hypoxia, not normal aging.
Recognizing unsafe actions prevents adverse client outcomes and legal/ethical delegation breaches.

Key Concept

Post-procedure care, airway protection, and complication monitoring following moderate sedation.
Question 1840Question →

A nurse is assessing a client who is recovering from a ruptured appendix. The client's temperature is 39.1°C (102.4°F), heart rate is 118 beats/min, respiratory rate is 24 breaths/min, and blood pressure is 100/60 mm Hg. The client's skin feels warm and is visibly flushed. These assessment findings most strongly indicate the early stages of which complication?

Show answer & explanation

Answer: Septic shock

Answer

Septic shock
The correct answer is septic shock because the client has a known source of infection (ruptured appendix) and is exhibiting the classic signs of the early, hyperdynamic ('warm') phase of this condition. During this phase, massive systemic vasodilation occurs, resulting in warm, flushed skin, accompanied by a high fever, tachycardia, and tachypnea.

Step-by-Step Solution

1
Analyze the client's history and vital signs.
The client has a source of infection (ruptured appendix) and presents with fever, tachycardia, tachypnea, and borderline low blood pressure.
Identifying systemic inflammatory responses is crucial for determining the underlying pathology.
2
Evaluate the specific skin assessment findings.
The skin is warm and flushed.
Skin temperature and color help differentiate between the types of shock (e.g., massive vasodilation vs. intense vasoconstriction).
3
Synthesize the findings to identify the complication.
The combination of an infection source, systemic inflammatory signs, and warm, flushed skin from vasodilation points to the hyperdynamic phase of septic shock.
Recognizing this specific triad of symptoms enables prompt, life-saving interventions.

Key Concept

Early indicators of septic shock (hyperdynamic phase)
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