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Question 1841Question →

A critical care nurse is managing a mechanically ventilated client equipped with a triple-lumen central venous catheter. The three lumens are continuously delivering norepinephrine, total parenteral nutrition (TPN), and a lipid-based propofol emulsion. The client's cardiac monitor suddenly displays atrial fibrillation with a ventricular response of 152 beats per minute, and the provider orders an emergent intravenous bolus of diltiazem. After verifying that diltiazem is incompatible with both the vasopressor and the sedative, which action is the most appropriate for the nurse to take?

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Answer: Initiate a new peripheral intravenous access site to administer the prescribed calcium channel blocker

Answer

Initiate a new peripheral intravenous access site to administer the prescribed calcium channel blocker.
When a client requires an emergent intravenous medication but all existing central venous catheter lumens are occupied by continuous infusions that cannot be safely interrupted or are incompatible, the nurse must establish a new peripheral intravenous access. Norepinephrine is a life-sustaining vasoactive drip that must never be paused or flushed, as flushing would deliver a dangerous bolus of the vasopressor. Total parenteral nutrition (TPN) requires a strictly dedicated line due to high risks of central line infection and drug incompatibility. Propofol is incompatible with the prescribed medication and provides necessary continuous sedation for mechanical ventilation. Therefore, securing a new peripheral line is the only safe method to administer the diltiazem bolus without compromising the client's hemodynamic or respiratory stability.

Step-by-Step Solution

1
Evaluate the existing continuous intravenous infusions.
Identified norepinephrine, TPN, and propofol infusing simultaneously in the three central lumens.
To determine if any current intravenous access lines can be safely utilized for an emergent intravenous push medication.
2
Analyze the compatibility and safety constraints of each continuous infusion.
Determined that norepinephrine cannot be flushed, TPN requires a strictly dedicated line, and propofol is incompatible with the ordered medication.
To prevent life-threatening adverse drug reactions, loss of airway sedation, or severe hemodynamic collapse.
3
Determine the safest route of administration for the emergent bolus.
Decided to start a new peripheral intravenous line.
When all central lines are occupied by incompatible or dedicated continuous infusions, establishing a new access site is required to safely administer the medication without compromising client stability.

Key Concept

Management of multiple continuous intravenous infusions and drug compatibility in critical care
Question 1842Question →

An emergency department nurse is caring for a client who recently experienced a devastating house fire. The client is trembling, disorganized, and repeatedly states, "Everything is gone. I should have just stayed in the house." Arrange the following crisis intervention steps in the correct order from first to last.

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Answer

The correct order is to first assess the risk for self-harm, establish a therapeutic relationship, explore the client's perception of the event, identify supports and coping mechanisms, and finally collaborate on a short-term action plan.
In crisis intervention, the nurse must follow a structured approach to ensure client safety and promote stabilization. According to established crisis intervention models, the first priority is always a lethality and safety assessment, particularly when the client expresses thoughts of wishing they were dead. Once safety is confirmed, the nurse establishes therapeutic rapport to build trust. Following this, the nurse assesses the client's perception of the precipitating event (the problem) and then explores available situational supports and coping mechanisms. Finally, the nurse and client collaborate to formulate a concrete, short-term action plan to restore equilibrium.

Step-by-Step Solution

1
Determine the highest priority need.
The client made a statement implying they wished they had died in the fire.
Client safety and lethality assessment is always the first step in crisis intervention.
2
Identify the next foundational step for therapeutic interaction.
Establishing rapport and a therapeutic relationship.
A trusting relationship is required for the client to openly share their feelings and engage in problem-solving.
3
Sequence the assessment of the crisis components.
Explore the perception of the event, followed by assessing available supports.
Understanding what the event means to the client must occur before the nurse can help identify appropriate coping resources.
4
Determine the final acute intervention.
Develop a short-term action plan.
After all assessments and resource identification, a concrete plan for the immediate future restores a sense of control.

Key Concept

Crisis Intervention Sequencing
Question 1843Question →

A nurse is responding to a client on an inpatient psychiatric unit who is pacing the hallway, speaking loudly, and visibly clenching their fists. Arrange the following therapeutic communication and de-escalation interventions in the correct chronological order from first to last.

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Answer

The correct sequence for therapeutic de-escalation is to first approach calmly, then acknowledge feelings, offer choices, set limits if necessary, and finally explore triggers when calm.
The correct order follows the evidence-based principles of therapeutic crisis intervention. Safety and non-verbal posture must be established first. This is followed by empathetic validation to build trust. Once acknowledged, offering choices helps the client self-regulate. If this fails, clear limits protect the milieu. Finally, processing the event can only happen when the client is neurologically capable of reasoning, which is after they have calmed down.

Step-by-Step Solution

1
Identify the initial priority in a crisis scenario.
The nurse must first ensure safety and establish a non-threatening presence.
Approaching with a calm posture and safe distance sets the foundation for a therapeutic interaction without increasing the client's anxiety.
2
Determine the first verbal intervention.
The nurse should acknowledge the client's emotional state.
Brief, empathetic reflection validates the client's feelings and begins the de-escalation process.
3
Select the next step to promote client stabilization.
The nurse offers a simple, concrete choice.
Agitated clients feel out of control; offering a choice helps them regain autonomy and redirects their focus.
4
Decide on the intervention if agitation escalates.
The nurse must establish firm, non-threatening limits.
Limit setting is required when earlier de-escalation attempts are ineffective and safety boundaries must be maintained.
5
Identify the final phase of the intervention.
The nurse explores triggers once the client is calm.
Processing the event and discussing coping strategies can only occur when the client has returned to their baseline emotional state.

Key Concept

Therapeutic De-escalation Sequence
Question 1844Question →

A nurse is administering a newly prescribed intravenous antibiotic. Ten minutes into the infusion, the client reports severe shortness of breath, a tight feeling in the throat, and dizziness. The client's blood pressure is 82/5082/50 mm Hg and heart rate is 128128 bpm. Arrange the following nursing interventions in the correct order of priority.

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Answer

The correct sequence is to stop the triggering agent, secure the airway and provide oxygen, administer the first-line medication (epinephrine), support circulation with positioning and fluids, and finally administer adjunctive medications.
In any medical emergency involving a continuous intravenous triggering agent, the first and most critical action is to stop the infusion. Following this, the nurse must adhere to the ABC (Airway, Breathing, Circulation) framework. Ensuring a patent airway and providing oxygen addresses the most immediate threat to life (laryngeal edema and hypoxia). Once the airway is supported, intramuscular epinephrine is the absolute priority pharmacological intervention, as it directly reverses bronchospasm and severe vasodilation. After epinephrine administration, circulatory support is provided through leg elevation and rapid isotonic fluid boluses to treat distributive shock. Finally, adjunctive medications such as antihistamines and corticosteroids are administered to alleviate ongoing symptoms and prevent biphasic allergic reactions.

Step-by-Step Solution

1
Identify the immediate threat and remove the cause.
The intravenous antibiotic infusion is stopped immediately.
Halting the exposure to the allergen prevents the anaphylactic reaction from rapidly worsening.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework.
A patent airway is maintained, and high-flow oxygen is administered.
Hypoxia and complete airway occlusion from laryngeal edema represent the most immediate threats to life.
3
Administer life-saving primary pharmacotherapy.
Intramuscular epinephrine is administered into the vastus lateralis.
Epinephrine directly counteracts anaphylaxis by causing rapid bronchodilation and vasoconstriction, thereby improving the airway and blood pressure.
4
Manage the profound distributive shock (Circulation).
The lower extremities are elevated, and a rapid intravenous fluid bolus is initiated.
Anaphylaxis causes massive vasodilation and capillary leak. Positioning and volume replacement help restore adequate venous return and systemic perfusion.
5
Administer secondary supportive treatments.
Intravenous diphenhydramine and corticosteroids are administered.
These adjunctive medications block further histamine release and reduce inflammation, helping to prevent a delayed biphasic reaction.

Key Concept

Prioritization of clinical interventions in acute anaphylactic shock utilizing the ABC framework.
Question 1845Question →

A rapid response code is called in the psychiatric emergency department for a client demonstrating imminent physical violence. The provider verbally orders immediate four-point mechanical restraints. Arrange the following nursing actions in the correct chronological sequence of implementation.

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Answer

The correct sequence is: 1) Assemble a team of at least five personnel, 2) Designate a leader to communicate with the client, 3) Secure restraints to the bed frame, 4) Assess peripheral circulation, and 5) Document the precipitating behaviors.
Applying mechanical restraints is a high-risk, last-resort intervention requiring a strict chronological protocol to ensure safety and legal compliance. First, a sufficient team (minimum of 5) must be assembled. Second, a single leader must explain the action to the client to maintain therapeutic communication and minimize trauma. Third, the restraints are physically applied using safe techniques (quick-release knots attached to the non-moving bed frame). Fourth, immediate physiological assessment (circulation and skin integrity) is required to prevent neurovascular damage. Finally, once the client is safe and secured, comprehensive documentation of the emergency and the failed alternatives is completed.

Step-by-Step Solution

1
Identify the primary nursing priority in an acute psychiatric emergency requiring restraints.
The priority is physical safety for both the client and the staff through proper preparation.
Approaching a violent client without adequate support can result in severe injury.
2
Determine the first chronological action to ensure safety.
Assemble a coordinated team of at least five trained personnel.
Standard protocol requires five staff members (one for each limb and one for the head) to safely physically manage a violent client.
3
Identify the immediate next step before physical contact is initiated.
Designate a single team leader to communicate the reason for the intervention.
Having one person speak calmly prevents sensory overload and respects the client's rights by explaining the procedure, even in an emergency.
4
Select the action related to the physical application of the intervention.
Secure the restraint straps to the non-moving parts of the bed frame using quick-release knots.
Restraints must be tied to a stable part of the bed (not side rails) with a knot that can be untied instantly in case of a medical emergency.
5
Determine the most critical nursing assessment immediately following application.
Assess the client's peripheral pulses, skin temperature, and capillary refill in all extremities.
Mechanical restraints pose a significant risk of neurovascular compromise; circulation must be verified immediately.
6
Identify the final administrative step once the situation is physically stabilized.
Document the precipitating behaviors and the specific alternative interventions that failed.
Legal and ethical standards require comprehensive documentation of the rationale and the failure of less restrictive measures, which is completed after the client is safe.

Key Concept

Psychiatric Emergency Restraint Protocol
Question 1846Question →

A registered nurse in a pediatric clinic is evaluating a 4-year-old child during a routine visit. The nurse observes symmetric, well-demarcated burn marks on both of the child's calves. The parent states, 'He was running around and accidentally backed into our space heater.' Which of the following is the priority nursing action?

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Answer: Initiate clinic protocols to separate the child from the parent to ensure immediate safety while completing the assessment.

Answer

Initiate clinic protocols to separate the child from the parent to ensure immediate safety while completing the assessment.
When physical abuse is suspected, the nurse's primary responsibility is to ensure the client's immediate physical safety. Separating the child from the suspected perpetrator prevents further harm and allows the healthcare team to conduct a thorough physical and psychosocial assessment without the child feeling intimidated or coached.

Step-by-Step Solution

1
Analyze the clinical findings against the reported history.
Symmetric, well-demarcated burns are classic signs of inflicted (non-accidental) injury, which strongly conflicts with the parent's history of an accidental bump.
Identifying inconsistencies between the physical evidence and the caregiver's explanation establishes a reasonable suspicion of abuse.
2
Determine the immediate priority of care using safety principles.
Protecting the vulnerable client from further potential harm becomes the highest priority.
According to Maslow's hierarchy of needs and fundamental safety principles, a client must be secured from immediate threats before further interventions can occur.
3
Select the best initial nursing action.
Separating the child from the suspected perpetrator is chosen as the first action.
Separation ensures immediate physical safety, de-escalates the environment, and allows the healthcare team to conduct a full assessment and mandatory reporting procedures safely.

Key Concept

Prioritizing Immediate Safety in Suspected Abuse
Estimated Time:1m 0s
Question 1847Question →

A 65-year-old client admitted with heart failure reports acute, severe nausea. The client's current vital signs include a blood pressure of 118/74 mmHg and a heart rate of 82 bpm. The healthcare provider prescribes 4 mg of ondansetron to be administered via intravenous (IV) push through an existing intermittent peripheral IV catheter (saline lock). Arrange the following steps in the correct chronological order for safely administering this parenteral medication.

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Answer

The correct sequence for administering an IV push medication via a saline lock is to clean the port, assess patency with a saline flush, clean the port again, administer the medication, and perform a final saline flush at the medication's administration rate.
The standard sequence for administering medication via an intermittent IV lock utilizes the SAS method (Saline, Administer, Saline) while prioritizing infection control and patient safety. The nurse must scrub the hub before every connection. First, patency is verified with a saline flush. Next, the medication is administered at the appropriate rate. Finally, a post-administration flush clears the line, which must be given at the same rate as the medication to prevent a rapid bolus of the residual drug.

Step-by-Step Solution

1
Clean the injection port of the intermittent IV catheter with an antimicrobial swab.
The port is effectively disinfected.
Prevents the introduction of microorganisms from the environment into the client's bloodstream.
2
Attach a syringe containing normal saline, aspirate for a blood return, and flush the line.
Intravenous catheter patency is confirmed.
Ensures the IV catheter is properly located in the vein and has not infiltrated before administering a potentially irritating medication.
3
Clean the injection port again with a new antimicrobial swab and attach the medication syringe.
The port is re-disinfected prior to medication attachment.
Maintains strict asepsis, as the port was exposed when the previous saline syringe was removed.
4
Administer the prescribed ondansetron slowly over the recommended amount of time.
The medication is safely delivered into the bloodstream.
Pushing medication at the correct rate prevents adverse reactions such as speed shock or hemodynamic instability.
5
Clean the injection port and flush the catheter with normal saline at the same rate the medication was administered.
The medication is completely cleared from the tubing and the lock is maintained.
Flushing clears the medication line. Pushing the final flush at the same rate as the medication ensures that any residual drug in the catheter is not inadvertently delivered as a rapid bolus.

Key Concept

Safe administration of intravenous push medications via an intermittent peripheral IV lock requires strict aseptic technique, verification of catheter patency, and proper flushing protocols.
Question 1848Question →

A nurse on a surgical rehabilitation unit is caring for a client who is 48 hours post-operative following a right above-the-knee amputation. Which intervention should the nurse implement?

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Answer: Assist the client into a prone position for 20 to 30 minutes every 3 to 4 hours.

Answer

Assist the client into a prone position for 20 to 30 minutes every 3 to 4 hours.
The correct action is to assist the client into a prone position multiple times a day. This position allows the hip joint to extend completely, counteracting the natural tendency of the hip flexor muscles to shorten and form a contracture following a lower extremity amputation. Preventing a contracture is crucial for successful prosthetic training.

Step-by-Step Solution

1
Identify the client's procedure and the current post-operative timeframe.
The client is 48 hours post-operative for a right above-the-knee amputation.
The timeframe determines the appropriate clinical interventions, as immediate post-op care differs from care provided after the initial 24 hours.
2
Recall the primary mobility and anatomical complications associated with an above-the-knee amputation.
Hip flexion contractures are a major risk due to muscle imbalance and prolonged periods of sitting or limb elevation.
Contractures can severely impair the client's future ability to be fitted for and successfully use a prosthesis.
3
Evaluate each nursing intervention for its effect on hip alignment and safe care practices.
Prone positioning actively extends the hip joint. Elevation or high-Fowler's positioning flexes the hip joint. Delegation of an evaluation is an unsafe practice.
Interventions must promote joint extension to counteract the risk of contractures, and assessments must remain the responsibility of the registered nurse.

Key Concept

Prevention of flexion contractures following lower extremity amputation
Question 1849Question →

A client is prescribed a scheduled dose of intravenous (IV) phenytoin to manage seizure activity. The client currently has a continuous peripheral IV infusion of 5% dextrose in water (D5W) infusing. Which action must the nurse implement to administer this medication safely?

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Answer: Flush the intravenous line with 0.9% sodium chloride before and after the administration.

Answer

The correct action is to flush the intravenous line with 0.9% sodium chloride before and after administering the medication.
Phenytoin is highly incompatible with dextrose-containing solutions such as 5% dextrose in water (D5W). If mixed, the medication will quickly precipitate and form crystals. To safely administer the drug through the existing intravenous line, the nurse must clear the dextrose from the tubing by flushing it with a compatible solution—specifically 0.9% sodium chloride (normal saline)—both before and immediately after the medication push.

Step-by-Step Solution

1
Analyze the compatibility of the prescribed medication with the existing intravenous fluid.
Phenytoin is highly incompatible with dextrose-containing solutions like D5W.
Mixing these two substances causes the phenytoin to form solid precipitates (crystals) in the tubing, which can lead to catheter occlusion or an embolus.
2
Determine the appropriate compatible diluent or flush solution.
Normal saline (0.9% sodium chloride) is the standard and required compatible solution for phenytoin.
Phenytoin remains stable and soluble only in normal saline.
3
Formulate a safe administration sequence using the existing intravenous access.
The nurse must pause the D5W, flush the line with normal saline, administer the drug at the correct rate, and flush again with normal saline before resuming the D5W.
This creates a physical barrier of normal saline between the incompatible medication and the dextrose fluid.

Key Concept

Intravenous medication compatibility and safe administration principles.
Question 1850Question →

A nurse is evaluating a client with severe hepatic cirrhosis who recently underwent a therapeutic bedside paracentesis with the removal of 5 liters of ascitic fluid. Twenty minutes after the procedure, the client reports feeling dizzy and nauseous. The nurse observes that the client's heart rate has increased from 78 to 118 beats per minute, and the blood pressure has decreased from 132/82 mm Hg to 94/56 mm Hg. Which of the following actions should the nurse perform first to mitigate the risk of severe hemodynamic collapse?

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Answer: Initiate the prescribed intravenous infusion of albumin.

Answer

The most critical action is to initiate the prescribed intravenous infusion of albumin.
The removal of large volumes of ascitic fluid decreases abdominal pressure, leading to splanchnic vasodilation and a massive shift of intravascular fluid back into the peritoneal cavity. The client's symptoms of dizziness, accompanied by tachycardia and hypotension, are classic indicators of impending hypovolemic shock. Administering a colloid volume expander, such as intravenous albumin, increases intravascular oncotic pressure. This pulls fluid back into the bloodstream, restoring cardiac output and mitigating the risk of cardiovascular collapse.

Step-by-Step Solution

1
Analyze the client's vital sign trends and reported symptoms following the invasive procedure.
The acute onset of dizziness, marked tachycardia, and significant hypotension indicate a severe decrease in intravascular volume.
Large-volume paracentesis decreases intra-abdominal pressure, causing rapid vasodilation and a massive shift of fluid from the intravascular space into the peritoneal cavity.
2
Identify the immediate priority to prevent profound hypovolemic shock.
The primary goal is to restore intravascular volume and maintain organ perfusion.
Without intervention, the fluid shift will lead to progressive hemodynamic collapse and potential organ failure.
3
Select the specific intervention that addresses the underlying pathophysiological mechanism.
Administering intravenous albumin is the correct choice.
Albumin acts as a colloid, increasing plasma oncotic pressure to pull fluid back into the vascular space, effectively reversing the procedure-induced hypovolemia.

Key Concept

Post-paracentesis hypovolemic shock recognition and volume replacement
Estimated Time:1m 15s
Question 1851Question →

A nurse receives a client who has just returned to the medical unit following a percutaneous liver biopsy. To minimize the risk of post-procedure bleeding, which of the following positions should the nurse assist the client into?

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Answer: Right side-lying position with a small towel or pillow under the puncture site

Answer

The correct action is to assist the client into a right side-lying position with a small towel or pillow under the puncture site.
The correct position applies the client's own body weight against the bed to create direct pressure on the liver, which is located in the right upper quadrant. This localized pressure is crucial for achieving hemostasis and preventing post-procedure hemorrhage.

Step-by-Step Solution

1
Identify the anatomical location of the procedure.
The liver is located in the right upper quadrant of the abdomen.
Knowing the organ's location is essential for determining how to apply pressure to the procedural site.
2
Determine the primary post-procedure risk.
Bleeding or hemorrhage is the most significant risk following a highly vascular procedure like a liver biopsy.
Risk reduction relies on anticipating and preventing specific procedural complications.
3
Select the position that mitigates this risk.
The right side-lying position applies the client's body weight over the site.
Direct pressure promotes hemostasis at the puncture site.

Key Concept

Post-procedure positioning to prevent hemorrhage
Estimated Time:1m 0s
Question 1852Question →

A nurse in an orthopedic rehabilitation clinic is providing discharge teaching to a client with a fractured left tibia. The client is prescribed strict non-weight-bearing status for the left leg and is learning to use axillary crutches. When evaluating the client's understanding of how to safely descend a flight of stairs, which statement by the client indicates correct technique?

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Answer: I will move my crutches down to the lower step first, keep my left foot off the ground, and then step down with my right leg.

Answer

The statement describing moving the crutches down first, keeping the left foot off the ground, and then stepping down with the right leg demonstrates correct understanding.
When descending stairs with axillary crutches, the correct sequence is to lead with the crutches and the affected extremity ('down with the bad'). The client should first advance the crutches to the lower step while keeping the injured (left) leg lowered but completely off the ground to maintain non-weight-bearing status. The client supports their body weight using their hands on the crutch grips and then steps down with the strong, unaffected (right) leg. This technique ensures a stable base of support is established before the body moves downward.

Step-by-Step Solution

1
Identify the client's prescribed mobility status and affected extremity.
The client is strictly non-weight-bearing on the left tibia and must use axillary crutches.
Determining the affected side and weight-bearing status dictates the correct crutch-walking technique and precautions.
2
Determine the correct biomechanical sequence for descending stairs with crutches.
The correct sequence is to lead with the crutches and the affected leg ('down with the bad').
Moving the crutches down first establishes a wide base of support on the lower step before the body's center of gravity shifts downward.
3
Evaluate the safety principles of axillary crutch use.
Body weight must always be supported by the handgrips, never by resting the axillae (armpits) on the crutch pads.
Bearing weight on the axillae compresses the brachial plexus, leading to severe nerve damage.
4
Analyze each statement to identify the correct descending sequence and safe technique.
Only the statement describing lowering the crutches first, maintaining non-weight-bearing status on the left leg, and avoiding axillary pressure is correct.
This option strictly adheres to both the correct sequential technique and the safe biomechanical principles of crutch ambulation.

Key Concept

Assistive Device Ambulation: Stair Descent with Axillary Crutches
Question 1853Question →

A client, age 82, with advanced emphysema and cor pulmonale is receiving treatment for hospital-acquired pneumonia. The client is currently prescribed continuous supplemental oxygen at 4 L/min via nasal cannula. During an assessment, the nurse finds the client somnolent, difficult to arouse, and taking 9 shallow breaths per minute. The most recent arterial blood gas analysis reveals a pH of 7.24, PaCO2 of 74 mm Hg, PaO2 of 56 mm Hg, and HCO3 of 32 mEq/L. Based on these clinical findings, which immediate intervention should the nurse implement?

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Answer: Activate the rapid response team and prepare to initiate manual positive-pressure ventilation.

Answer

The most appropriate action is to activate the rapid response team and prepare to initiate manual positive-pressure ventilation.
The client is exhibiting classic signs of CO2 narcosis (somnolence, bradypnea) and acute respiratory failure, as evidenced by the severe respiratory acidosis on the ABG analysis. In clients with advanced COPD, excessive supplemental oxygen (such as 4 L/min) can eliminate their hypoxic drive to breathe. The immediate priority is to secure the airway, assist ventilation to eliminate excess carbon dioxide, and summon emergency assistance.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client is somnolent with bradypnea (9 breaths/min) and shallow breathing.
Identifying these signs is crucial as they indicate a life-threatening airway and breathing compromise.
2
Interpret the arterial blood gas (ABG) values.
pH 7.24, PaCO2 74 mm Hg, and HCO3 32 mEq/L indicates acute-on-chronic uncompensated respiratory acidosis.
This confirms severe hypercapnia, which is causing the decreased level of consciousness known as CO2 narcosis.
3
Evaluate the current interventions in the context of the client's disease process.
The client is receiving 4 L/min of oxygen.
In advanced emphysema, excessive supplemental oxygen can blunt the hypoxic drive to breathe, directly causing or worsening CO2 retention.
4
Determine the priority risk reduction action.
The client requires immediate manual ventilation and emergency assistance.
Positive-pressure ventilation is necessary immediately to blow off excess carbon dioxide and restore adequate oxygenation while the rapid response team arrives.

Key Concept

Hypercapnic Respiratory Failure and CO2 Narcosis in COPD
Question 1854Question →

A 55-year-old client is 3 days postoperative following an exploratory laparotomy. During a forceful coughing episode, the client reports a sudden "popping" sensation in the abdomen. The nurse inspects the surgical site and observes an abdominal evisceration. Place the following nursing interventions in the correct priority order to minimize the risk of severe physiological complications. (Arrange the steps from first to last.)

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Answer

The correct priority sequence is: 1) Call for immediate assistance, 2) Position the client in a low Fowler's position with flexed knees, 3) Cover the viscera with sterile moist dressings, 4) Assess vital signs, and 5) Prepare the client for emergency surgery.
In the event of an abdominal evisceration, the overarching goal is to reduce the risk of bowel ischemia, infection, and shock. The nurse must first call for immediate assistance to obtain sterile supplies and alert the surgeon, ensuring they do not leave the unstable client. Before supplies arrive, placing the client in a low Fowler's position with flexed knees immediately relaxes the abdominal musculature, minimizing further organ protrusion. Once the sterile saline and dressings arrive, the nurse covers the exposed viscera to maintain moisture and viability. After securing the physical defect, the nurse evaluates the client's hemodynamic status by checking vital signs to detect early hypovolemic shock. Finally, the nurse verifies intravenous access and prepares the client for the definitive treatment, which is emergency surgical closure.

Step-by-Step Solution

1
Call for immediate assistance and instruct a colleague to bring sterile supplies and notify the surgeon.
The nurse secures additional help and necessary supplies without leaving the client's bedside.
An evisceration is a surgical emergency. The nurse cannot leave the client alone to gather supplies, so mobilizing the team is the first necessary action.
2
Position the client in a low Fowler's position with the hips and knees flexed.
Intra-abdominal pressure is rapidly reduced.
Flexing the knees and raising the head of the bed slightly relaxes the abdominal muscles, reducing tension on the wound and preventing further organ protrusion while waiting for supplies to be brought to the room.
3
Cover the protruding viscera with sterile dressings moistened with sterile normal saline.
The exposed internal organs are protected from the external environment.
Moist, sterile dressings prevent the viscera from drying out, which could lead to severe ischemia and necrosis, while also reducing the risk of bacterial contamination.
4
Assess the client's vital signs and monitor for clinical indicators of shock.
The client's hemodynamic status is systematically evaluated.
Evisceration can lead to rapid fluid shifts and hypovolemic shock. Once the physical wound is stabilized, assessing vital signs is the next critical priority.
5
Verify peripheral intravenous access and prepare the client for emergency surgery.
The client is readied for definitive surgical management.
The only resolution for an evisceration is surgical repair. Ensuring patent IV access allows for fluid resuscitation and administration of preoperative medications.

Key Concept

Abdominal Evisceration Emergency Management Sequence
Question 1855Question →

A 54-year-old client is admitted to the medical unit with an acute exacerbation of heart failure. The client's current vital signs are blood pressure 158/96 mm Hg, heart rate 108/min, and temperature 37.6°C (99.7°F). The client appears mildly agitated and is frequently picking at the bed linens. During the admission assessment, the client states, "I drink a half-liter of vodka every day, but I haven't had a drink since yesterday morning. Please do not tell my healthcare provider; I do not want them to judge me." Which action is the most appropriate for the nurse to take?

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Answer: Explain to the client that the healthcare provider must be informed to ensure safe medical care and immediately initiate alcohol withdrawal precautions.

Answer

Explain to the client that the healthcare provider must be informed to ensure safe medical care and immediately initiate alcohol withdrawal precautions.
The client is at high risk for complicated alcohol withdrawal, including seizures and delirium tremens, as it has been over 24 hours since their last drink. Furthermore, the client is already exhibiting early signs of autonomic hyperactivity (hypertension, tachycardia) and neurological irritability (agitation, picking at linens). The nurse must prioritize client safety by communicating this critical information to the healthcare provider to obtain appropriate prescriptions and immediately implementing withdrawal and seizure precautions. The nurse should communicate this necessity to the client therapeutically, validating their feelings of fear while maintaining firm safety boundaries.

Step-by-Step Solution

1
Analyze the client's vital signs and behavior in conjunction with their self-reported history.
The client has hypertension, tachycardia, mild agitation, and tactile disturbances (picking at linens), and their last heavy alcohol intake was over 24 hours ago.
Recognizing early physiological and behavioral indicators of withdrawal is critical to preventing life-threatening complications like status epilepticus or delirium tremens.
2
Evaluate the client's request for confidentiality regarding their substance use.
The nurse determines that keeping this secret would directly endanger the client's life, as pharmacological intervention is necessary.
Patient safety supersedes the request for confidentiality when the withheld information poses a direct and immediate threat to the client's well-being.
3
Determine the priority nursing action based on the assessment and ethical principles.
The nurse must therapeutically inform the client that the provider will be notified, and immediately implement withdrawal and seizure precautions.
Immediate action ensures the provider can prescribe appropriate medical management (e.g., benzodiazepines) while keeping the client in a safe, monitored environment.

Key Concept

Management and Prioritization of Acute Alcohol Withdrawal
Question 1856Question →

During a night shift on a medical-surgical unit, an 82-year-old client with profound presbycusis and dense bilateral cataracts suddenly becomes highly agitated. The client, who is in a private room with the door closed for contact precautions, points to a dark corner and insists, 'Those men in the shadows are whispering and planning to hurt me!' The client's vital signs are within normal limits, and oxygen saturation is 97% on room air. Based on principles of sensory and perceptual alterations, which nursing action is the most appropriate priority?

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Answer: Turn on the room lights, insert the client's functioning hearing aids, and calmly provide reality orientation by identifying oneself.

Answer

The correct action is to turn on the room lights, insert the client's functioning hearing aids, and calmly provide reality orientation.
This client is experiencing perceptual alterations (illusions or hallucinations) stemming from severe sensory deprivation. The combination of visual and auditory deficits (cataracts and presbycusis), coupled with a dark, isolated environment, drastically reduces meaningful sensory input. The brain may compensate for this lack of stimuli by creating hallucinations or misinterpreting shadows as threats. The most effective initial action is to restore adequate sensory stimulation. By turning on the lights and ensuring the client's hearing aids are in place, the nurse increases meaningful environmental input, which directly addresses the root cause of the perceptual alteration and facilitates reality orientation.

Step-by-Step Solution

1
Analyze the client's risk factors.
The client has significant visual (cataracts) and auditory (presbycusis) deficits, and is placed in an environment with minimal meaningful stimuli (private room, night shift, closed door).
Identifying these factors points to sensory deprivation as the underlying cause of the acute perceptual alterations (hallucinations or illusions).
2
Evaluate the client's physical stability.
Vital signs are stable and oxygen saturation is normal.
This rules out immediate physiological emergencies like hypoxia as the primary cause of the sudden agitation, allowing focus on the sensory environment.
3
Determine the priority nursing intervention.
The priority is to correct the sensory deficit by modifying the environment and utilizing assistive devices.
Turning on the lights and using hearing aids increases meaningful sensory input, which directly treats the sensory deprivation and helps reorient the client.

Key Concept

Mitigating Sensory Deprivation
Question 1857Question →

A nurse is preparing to administer an intravenous (IV) infusion of amphotericin B deoxycholate to a client diagnosed with a severe systemic fungal infection. Which of the following nursing actions are appropriate when managing this parenteral therapy? Select all that apply.

Select all that apply

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Answer: Administer prescribed prophylactic acetaminophen and diphenhydramine 30 minutes prior to the infusion.; Monitor the client's serum creatinine and blood urea nitrogen (BUN) levels closely throughout therapy.; Evaluate the intravenous insertion site frequently for signs of phlebitis and extravasation.

Answer

The correct actions are to administer prescribed prophylactic medications prior to the infusion, monitor renal function (BUN and creatinine) closely, and evaluate the IV site frequently for complications.
Amphotericin B is associated with severe infusion reactions (fever, chills, rigors), making pre-medication with acetaminophen and diphenhydramine a standard safety practice. Because it is highly nephrotoxic, meticulous monitoring of BUN and creatinine levels is required to prevent acute kidney injury. Furthermore, it is a known vesicant and chemical irritant, requiring frequent assessment of the IV site to prevent severe tissue necrosis from extravasation.

Step-by-Step Solution

1
Analyze the medication profile of amphotericin B deoxycholate.
Identified high potential for severe adverse effects including 'shake and bake' infusion reactions, nephrotoxicity, and phlebitis.
Understanding the drug's toxicity profile is required to determine the necessary nursing interventions.
2
Evaluate the options related to preparation and infusion mechanics.
Determined that the medication must be diluted in D5W (not normal saline) and infused slowly over 2 to 4 hours (not rapidly).
Saline causes precipitation, and rapid infusion can lead to fatal cardiovascular collapse.
3
Evaluate the options related to physiological monitoring and safety.
Confirmed the need for pre-medication, renal lab monitoring, and IV site assessment, while identifying that the drug causes hypokalemia, not hyperkalemia.
Proactive monitoring and symptom management prevent irreversible organ damage and severe discomfort.

Key Concept

Amphotericin B is a highly toxic antifungal medication requiring strict administration protocols: dilution in D5W only, slow infusion over 2-4 hours, pre-medication to prevent infusion reactions, and vigilant monitoring for nephrotoxicity, hypokalemia, and phlebitis.
Question 1858Question →

A nurse is preparing to discontinue a client's peripheral intravenous (IV) catheter. Place the following steps in the correct chronological order from first to last.

Drag items to arrange them in the correct order

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Answer

The correct sequence is: perform hand hygiene and don gloves, clamp tubing and remove dressing, withdraw the catheter, apply firm pressure, and finally inspect the catheter tip.
The correct sequence ensures patient safety, infection control, and proper hemostasis during the discontinuation of a peripheral IV line. Standard precautions must be taken first. Then, the site is freed from securement devices so the catheter can be withdrawn smoothly without causing trauma. Once removed, immediate direct pressure prevents bleeding and hematoma formation. Finally, inspecting the catheter ensures that no fragments have broken off into the patient's circulatory system.

Step-by-Step Solution

1
Initiate standard precautions by performing hand hygiene and applying gloves.
The nurse is protected, and the patient is safe from contamination.
Infection control is the foundational first step for any procedure involving potential blood exposure.
2
Stop the flow of fluids by clamping the tubing and remove the adhesive dressing.
The IV catheter is no longer secured to the patient's skin.
The dressing must be removed before the catheter can be physically withdrawn.
3
Pull the catheter out of the vein in a smooth, straight motion.
The catheter is completely removed from the patient's arm.
Removing it parallel to the skin prevents injury to the vein wall.
4
Immediately place a sterile gauze pad over the site and hold firm pressure.
Bleeding stops and a clot begins to form.
Direct pressure is required to achieve hemostasis and prevent a hematoma.
5
Look closely at the tip of the removed IV catheter.
The nurse confirms the entire catheter was removed.
A missing tip indicates a catheter embolus, which is a medical emergency requiring immediate intervention.

Key Concept

Discontinuation of a Peripheral Intravenous (IV) Catheter
Question 1859Question →

A 68-year-old client is admitted to the medical unit with a history of recurrent syncope, dehydration, and the recent initiation of a new antihypertensive medication. The healthcare provider prescribes orthostatic vital sign measurements. To ensure accurate assessment and reduce the risk of a potential fall, arrange the following procedural steps in the correct chronological order.

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Answer

The correct sequence requires obtaining a resting supine baseline, then measuring vital signs in the supine position, followed by standing the client, waiting for a brief period, and taking the final standing measurements.
Measuring orthostatic vital signs is a key diagnostic procedure to reduce the risk of syncope and falls in vulnerable clients. The correct sequence ensures standard baseline measurements are obtained while supine, followed by a controlled position change, an appropriate delay for the body's physiological response, and a final measurement to identify significant hemodynamic changes.

Step-by-Step Solution

1
Establish a resting baseline state.
The client is placed in a supine position for 5 to 10 minutes.
This allows hemodynamics to stabilize before any initial measurements are taken.
2
Obtain baseline vital signs.
Blood pressure and heart rate are measured and recorded.
This provides the critical comparison values for subsequent position changes.
3
Change the client's position to induce an orthostatic challenge.
The client is assisted to a standing position.
Gravity causes blood to pool in the lower extremities, challenging the cardiovascular system's compensatory mechanisms.
4
Allow time for physiological compensation.
The nurse waits 1 to 3 minutes.
This provides time for baroreceptors to detect the drop in blood pressure and attempt to increase heart rate and vascular resistance.
5
Reassess vital signs.
Blood pressure and heart rate are measured again.
This allows identification of a drop in systolic blood pressure of 20 mm Hg or more, or a diastolic drop of 10 mm Hg or more.

Key Concept

Orthostatic Vital Sign Assessment Sequence
Question 1860Question →

A nurse is preparing to draw a blood specimen from a client's central venous catheter (CVC). To maintain catheter patency, prevent infection, and ensure accurate laboratory results, arrange the following steps in the correct chronological sequence.

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Answer

The correct sequence is to disinfect the hub, flush to confirm patency, draw and discard the waste blood, obtain the required diagnostic specimen, and finally perform a thorough flush to prevent line occlusion.
Following this exact sequence ensures three critical risk reduction goals: preventing infection by scrubbing first, ensuring accurate diagnostics by clearing the line of fluids before sampling, and maintaining the integrity of the device by flushing away residual blood to prevent thrombosis.

Step-by-Step Solution

1
Disinfect the access hub.
Microorganisms are removed from the connector surface.
Prevents the direct introduction of pathogens into the central circulation.
2
Flush the catheter with normal saline.
Line patency is verified.
Ensures the line is functioning properly and clears residual medications.
3
Aspirate and discard the initial volume of blood.
Mixed blood and saline is removed from the catheter.
Prevents laboratory results from being falsely altered by fluid dilution.
4
Withdraw the required blood specimen.
A pure, undiluted blood sample is collected.
Provides an accurate sample for necessary diagnostic laboratory analysis.
5
Perform a final flush of the catheter.
Residual blood is completely cleared from the line.
Prevents blood from clotting inside the catheter, maintaining patency for future use.

Key Concept

Reduction of risk potential during central venous catheter blood sampling involves strict aseptic technique, proper clearing of line fluids to ensure accurate diagnostics, and thorough flushing to prevent catheter occlusion.
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