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Question 1Question →

A client is brought to the emergency department by law enforcement due to severe agitation, paranoia, and physical aggression after ingesting synthetic cathinones ('bath salts'). Arrange the following nursing actions in the prioritized order of execution.

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Answer

The correct sequence prioritizes immediate staff safety and crisis de-escalation over physical assessment: Call for help, secure the scene, administer chemical restraint, perform physical assessment, and modify the environment.
When prioritizing care for a client exhibiting severe substance-induced violence, Maslow's hierarchy of needs and fundamental safety principles dictate that safety (for staff, the public, and the client) is the immediate priority. The nurse must first ensure adequate help is present and the scene is safe. Chemical de-escalation is then required before any hands-on physical assessment can safely occur. Finally, environmental modifications are made for ongoing management.

Step-by-Step Solution

1
Call for help.
Additional staff and security personnel respond to the location.
Managing a physically aggressive client requires a team approach to prevent injury to everyone involved.
2
Ensure scene safety.
Bystanders and hazards are safely removed from the immediate area.
Protects other vulnerable clients and removes items that could be used as weapons while waiting for the response team.
3
Administer chemical restraint.
The client receives a rapid-acting sedative (e.g., lorazepam or haloperidol).
Controls the violent behavior caused by the synthetic cathinone intoxication so that care can be provided.
4
Perform physical assessment.
Baseline vital signs and cardiac rhythm are successfully obtained.
Stimulant toxicity causes life-threatening cardiovascular complications, but assessment must wait until it is physically safe for the nurse to approach and touch the client.
5
Modify the environment.
The client is placed in a calm, low-stimulus room.
Decreasing sensory input helps reduce ongoing paranoia, agitation, and the risk of recurring aggression once the client is stable.

Key Concept

In psychiatric emergencies involving severe substance-induced aggression, the standard nursing process (assess first) is modified. Scene safety and securing adequate assistance take absolute priority over hands-on physical assessment.
Question 2Question →

A physician orders an intramuscular analgesic for a client in acute pain. The medication is dispensed by the pharmacy in a small glass ampule. Which sequence of actions should the nurse follow to safely extract the medication and prepare the syringe for injection?

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Answer

The correct sequence for preparing medication from an ampule begins with moving the fluid to the lower chamber, protecting the hands, breaking the glass safely, using a filter needle to withdraw the fluid, and finally changing the needle prior to injection.
Safely preparing a medication from an ampule requires a strict sequence to protect both the nurse and the client. Fluid must first be displaced from the neck. Then, the nurse must protect their hands with gauze and snap the ampule away from their body to prevent injury. A filter needle is essential to prevent drawing up glass shards, and this needle must be exchanged for a standard needle prior to injecting the client.

Step-by-Step Solution

1
Flick the upper stem of the ampule.
Medication moves to the lower chamber.
Ensures the entire dose is accessible for withdrawal and prevents spilling.
2
Wrap a sterile gauze pad around the ampule neck.
Fingers are shielded from the glass.
Prevents laceration injuries during the breaking process.
3
Snap the top section away from the body.
The ampule is opened safely.
Directs potential glass shards away from the nurse's face and body.
4
Withdraw medication using a filter needle.
Medication is drawn up without glass particles.
Filter needles catch microscopic glass fragments that inevitably fall into the liquid when the ampule is broken.
5
Replace the filter needle with an injection needle.
The syringe is ready for intramuscular administration.
Filter needles cannot be used to inject medication into a client's tissue.

Key Concept

Safe preparation of parenteral medications from a glass ampule
Question 3Question →

A client is admitted to the intensive care unit with severe diabetic ketoacidosis (DKA). The client is lethargic with a blood glucose of 680 mg/dL (37.7 mmol/L), a serum pH of 7.12, and a blood pressure of 82/48 mm Hg. Arrange the following collaborative nursing actions in the priority order they should be implemented.

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Answer

The correct sequence is: 1. Administer a rapid bolus of 0.9% sodium chloride to restore volume; 2. Evaluate the serum potassium level to ensure safety; 3. Initiate a continuous intravenous infusion of regular insulin to correct acidosis; 4. Incorporate 5% dextrose into the hydration fluids once glucose reaches 250 mg/dL to prevent hypoglycemia.
In the management of severe diabetic ketoacidosis (DKA), the immediate physiological priority is to address life-threatening hypovolemia and impaired tissue perfusion caused by osmotic diuresis; therefore, isotonic fluid resuscitation is the first step. Following the initiation of fluids, the nurse must verify the serum potassium level. Insulin therapy causes an intracellular shift of potassium, which can precipitate fatal cardiac arrhythmias if the client is already hypokalemic. Once a safe potassium level is confirmed (greater than 3.3 mEq/L), a continuous regular insulin infusion is started to halt ketone production and correct the acidosis. Finally, as the blood glucose decreases to approximately 250 mg/dL (13.9 mmol/L), dextrose must be added to the intravenous fluids to prevent hypoglycemia and to avoid rapid osmotic shifts that can lead to cerebral edema.

Step-by-Step Solution

1
Administer a rapid bolus of 0.9% sodium chloride.
Intravascular volume is restored, and tissue perfusion improves.
Severe osmotic diuresis in DKA leads to profound dehydration and hypovolemic shock (evidenced by the blood pressure of 82/48 mm Hg), which must be addressed immediately.
2
Evaluate the initial comprehensive metabolic panel for the serum potassium level.
Ensures the serum potassium is at least 3.3 mEq/L (3.3 mmol/L).
Insulin therapy drives potassium into the intracellular space. Administering insulin without confirming adequate potassium levels can trigger fatal arrhythmias.
3
Initiate a continuous intravenous infusion of regular insulin.
Ketone production is halted, and metabolic acidosis is corrected.
Once perfusion is improving and potassium is safe, regular insulin is required to reverse the underlying metabolic derangements of DKA.
4
Incorporate 5% dextrose into the intravenous hydration fluids.
Blood glucose slowly stabilizes without dropping too rapidly.
When blood glucose reaches 250 mg/dL (13.9 mmol/L), adding dextrose prevents iatrogenic hypoglycemia and protects against rapid osmotic changes that cause cerebral edema.

Key Concept

The physiological priority in Diabetic Ketoacidosis (DKA) is sequential management: fluid volume restoration, electrolyte verification, insulin administration, and hypoglycemia prevention.
Question 4Question →

A registered nurse is providing discharge instructions to a client with a right tibial fracture who must maintain strict non-weight-bearing status on the affected extremity. Arrange the following steps in the correct chronological sequence for safely ascending a flight of stairs using bilateral axillary crutches without the use of a handrail.

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Answer

The correct sequence for ascending stairs with crutches is to establish a tripod stance, transfer weight to the crutches, advance the unaffected leg up, shift weight to the unaffected leg, and finally bring the crutches and the affected leg up.
When ascending stairs with crutches, the fundamental principle is 'up with the good'. The client must first establish a stable tripod stance. Next, weight is shifted entirely to the upper body via the crutches so the strong, unaffected leg can be safely lifted onto the step. Once the strong leg is firmly planted on the step, the client shifts their weight onto that leg, using its strength to power the lift of the body. Finally, the client brings the crutches and the affected leg up together. This sequence ensures the injured extremity bears no weight and maximizes stability throughout the transfer.

Step-by-Step Solution

1
Assume a stable tripod stance facing the bottom of the staircase.
The client establishes a secure and balanced starting position.
A wide base of support prevents loss of balance before upward momentum is initiated.
2
Transfer body weight entirely onto the handgrips of the crutches.
The client's body weight is fully supported by the upper extremities.
This removes weight from the lower extremities, allowing the strong leg to be lifted safely without compromising balance.
3
Advance the unaffected left leg up onto the stair tread.
The strong leg is securely placed on the higher surface.
The strong leg must ascend first ('up with the good') to provide the necessary power to lift the rest of the body.
4
Shift body weight from the crutches onto the unaffected left leg.
The client's weight is now completely supported by the strong leg on the stair.
Transferring weight to the stable leg frees the upper body and crutches to be lifted.
5
Bring both crutches and the affected right leg up to the stair tread.
The client completes the step and returns to a stable tripod stance on the higher level.
The crutches and the non-weight-bearing leg follow the strong leg to prepare for the next step while maintaining the weight-bearing restriction.

Key Concept

Crutch Walking on Stairs (Ascending)
Question 5Question →

A nurse is preparing to administer an intermittent bolus enteral feeding to a client via a nasogastric (NG) tube. To reduce the risk of aspiration and maintain tube patency, arrange the following steps in the correct order. All options must be used.

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Answer

The correct sequence is: Elevate the head of the bed, verify tube placement and assess residual volume, flush the tube with water, administer the feeding, and finally flush the tube again.
The primary goal during enteral feeding is the reduction of risk potential, specifically preventing aspiration and tube occlusion. Therefore, the nurse must first elevate the head of the bed to physically protect the airway. Next, the nurse verifies the tube placement and checks gastric residual volume to ensure physiological readiness. Once airway safety and placement are confirmed, the nurse flushes the tube to establish patency, administers the feeding, and finally flushes the tube again to clear the formula and prevent mechanical clogging.

Step-by-Step Solution

1
Position the client appropriately.
The head of the bed is elevated to at least 30 to 45 degrees.
This physical intervention uses gravity to immediately reduce the risk of pulmonary aspiration during the procedure.
2
Confirm clinical safety parameters.
NG tube placement is verified and gastric residual volume is evaluated.
This guarantees the feeding is delivered into the gastrointestinal tract safely without overloading the stomach.
3
Establish and verify tube patency.
The tube is flushed with 30 mL of water.
This clears the tube of any previous contents and confirms it is not blocked prior to infusing a thick formula.
4
Deliver prescribed nutrition.
The enteral formula is administered to the client.
Provides the therapeutic nutritional support ordered by the healthcare provider.
5
Maintain equipment function.
The tube is flushed again with water.
This clears the internal lumen of the tube, preventing the formula from coagulating and causing an occlusion.

Key Concept

Enteral Feeding Safety and Aspiration Precautions
Question 6Question →

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

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Answer

The correct priority sequence is to stop the transfusion first, maintain IV access with normal saline using new tubing, assess the client's vital signs, notify the provider and blood bank, and finally send the remaining blood and tubing to the blood bank.
In any emergency where a therapeutic intervention causes severe harm (such as a hemolytic transfusion reaction), the absolute first priority is to stop the offending agent. Once stopped, preserving IV access with normal saline and new tubing ensures a route for emergency medications without infusing residual blood. The nurse must then assess the client to gather necessary clinical data before notifying the healthcare provider. Administrative tasks, such as returning the blood bag to the laboratory, are performed only after the client is physiologically stabilized and primary interventions are complete.

Step-by-Step Solution

1
Stop the blood transfusion immediately.
The infusion of potentially incompatible blood is halted.
This is the most critical first step to minimize the amount of antigen entering the bloodstream, directly reducing the risk of a severe or fatal hemolytic reaction.
2
Infuse normal saline through new IV tubing.
Intravenous access is maintained without infusing residual blood.
The client will likely need emergency medications. New tubing is crucial because flushing the old tubing would push the remaining incompatible blood into the client.
3
Assess the client's vital signs and respiratory status.
Objective clinical data regarding hemodynamic and respiratory stability is gathered.
The nurse must know the client's current status before calling the provider to ensure appropriate emergency orders can be given.
4
Notify the primary healthcare provider and the blood bank.
The medical team is informed and the facility's transfusion reaction protocol is initiated.
The provider must prescribe emergency interventions based on the assessment, and the blood bank must prepare for an investigation.
5
Send the remaining blood product and tubing to the blood bank.
The physical evidence of the reaction is transported for analysis.
This allows the laboratory to retype and crossmatch the blood and test for hemolysis, which is a post-stabilization priority.

Key Concept

Management of Acute Hemolytic Transfusion Reaction
Question 7Question →

A nurse is providing care for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache. Upon assessment, the nurse notes profuse diaphoresis on the client's face and neck, severe facial flushing, a blood pressure of 218/114 mm Hg, and a heart rate of 52 beats/min. The client has an indwelling urinary catheter in place. Arrange the following nursing interventions in the correct order of priority, from first to last.

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Answer

The correct sequence of actions for managing autonomic dysreflexia is: elevate the head of the bed, loosen restrictive clothing, assess the urinary catheter for kinks, administer a prescribed antihypertensive medication if symptoms persist, and finally document the event.
In autonomic dysreflexia, a massive uncompensated cardiovascular reaction occurs mediated by the sympathetic nervous system. The immediate priority is to lower the blood pressure to prevent a stroke, which is achieved first by utilizing gravity (elevating the head of the bed). Following this immediate safety measure, the nurse systematically removes potential triggers, starting with quick external checks (loosening clothing) and then checking the most common internal cause (bladder distention). Medical intervention with antihypertensives follows if these steps fail, and administrative tasks like documentation always come last.

Step-by-Step Solution

1
Elevate the head of the bed to a sitting or high Fowler's position.
Induces orthostatic hypotension.
This is the most rapid way to lower the blood pressure and prevent a catastrophic complication like a stroke.
2
Loosen any constrictive clothing or devices.
Removes superficial noxious stimuli.
Tight clothing can act as a trigger for the exaggerated sympathetic response.
3
Assess the urinary system by checking the indwelling catheter for kinks.
Identifies and resolves potential bladder distention.
Bladder distention is the leading cause of autonomic dysreflexia. Restoring urine flow removes the primary noxious stimulus.
4
Administer a rapid-acting antihypertensive medication.
Pharmacologically reduces blood pressure.
This is indicated if conservative measures (removing stimuli) fail to resolve the hypertensive crisis.
5
Document the event and response.
Creates a formal clinical record.
Documentation is essential but must be deferred until the life-threatening crisis is managed.

Key Concept

Management of Autonomic Dysreflexia (Hyperreflexia)
Question 8Question →

The nurse is preparing to administer a large-volume cleansing enema to an adult client. Arrange the following procedural steps in the correct chronological order.

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Answer

The correct sequence is to first position the client, then lubricate the tubing, insert the tubing into the rectum, elevate the container to the correct height, and finally unclamp the tubing to instill the solution.
The chronological sequence prioritizes client safety and procedural efficacy. First, the client must be anatomically positioned to receive the fluid. Next, the equipment is prepared for insertion by lubricating the tip. The tube is then carefully inserted into the rectum. After placement is secured, the container is elevated to create the correct hydrostatic pressure before unclamping the flow.

Step-by-Step Solution

1
Assist the client into the left lateral Sims' position with the right knee flexed.
The client's descending colon is positioned lower than the rectum.
This utilizes gravity to help the enema solution flow deeper into the colon.
2
Lubricate the distal 2 to 3 inches (5 to 7.5 cm) of the enema tubing.
The tip of the tube becomes slick.
Lubrication reduces friction, preventing mucosal injury during insertion.
3
Direct the tubing toward the umbilicus and gently insert it 3 to 4 inches (7.5 to 10 cm).
The tube enters the rectum without meeting resistance.
This angle follows the anatomical curvature of the lower bowel, ensuring safe and effective placement.
4
Elevate the enema container 12 to 18 inches (30 to 45 cm) above the client's anus.
Hydrostatic pressure is established.
This height provides a safe flow rate. Holding it higher could cause rapid instillation and painful cramping.
5
Unclamp the tubing to allow the solution to flow slowly into the rectum.
The solution enters the bowel.
This initiates the therapeutic intervention once all safety measures are in place.

Key Concept

Safe administration of a large-volume enema requires a systematic approach prioritizing anatomical alignment, prevention of tissue trauma, and controlled fluid pressure.
Question 9Question →

A registered nurse on a medical-surgical unit receives the morning handoff report for four assigned clients. In which order should the nurse assess these clients? Arrange the clients from highest priority (first) to lowest priority (last).

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Answer

The correct sequence prioritizes the airway threat (myasthenia gravis), followed by the acute circulation threat (heparin bleeding), then the expected abnormal systemic finding (heart failure), and finally the expected localized chronic symptom (ulcerative colitis).
The prioritization follows the ABCs and the acute vs. chronic framework. The client with myasthenia gravis has a new, acute threat to their airway (bulbar weakness), making them the highest priority. The client with spontaneous bleeding on a heparin drip represents an acute circulation threat and is the second priority. The client with heart failure has abnormal but expected findings (crackles, elevated BNP) for their condition, placing them third. The client with ulcerative colitis has expected symptoms (bloody stools) without life-threatening systemic compromise, making them the lowest priority.

Step-by-Step Solution

1
Evaluate the clients for imminent life-threatening airway or breathing conditions.
The client with myasthenia gravis has difficulty swallowing and a weak cough, indicating a potential loss of airway.
Airway takes the highest priority in the ABCs triage framework.
2
Identify acute circulation or hemorrhagic risks among the remaining clients.
The client with a heparin infusion is experiencing spontaneous epistaxis.
Circulatory collapse from active bleeding is the next highest priority after airway and breathing issues are addressed.
3
Differentiate between acute, unexpected findings and expected disease manifestations for the remaining clients.
Both the heart failure client and the ulcerative colitis client are experiencing expected manifestations of their admitted diagnoses.
Expected findings take a lower priority than acute, unstable, or unexpected physiological changes.
4
Prioritize between the remaining stable clients based on physiological impact.
The heart failure client's fluid overload is a systemic cardiopulmonary issue, whereas the ulcerative colitis client's symptom is localized and highly typical for the disease process.
Systemic cardiopulmonary issues generally require closer monitoring and precedence over localized, stable chronic symptoms.

Key Concept

Prioritizing client care using the ABCs (Airway, Breathing, Circulation) and Acute vs. Chronic frameworks.
Estimated Time:1m 30s
Question 10Question →

A nurse is preparing to telephone the healthcare provider to report a client's abnormal laboratory result. Arrange the nurse's planned statements in the correct sequence using the SBAR (Situation, Background, Assessment, Recommendation) communication tool. (Place the first statement at the top and the last statement at the bottom.)

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Answer

The correct sequence follows the standard SBAR framework: Situation (reporting the low potassium), Background (heart failure and furosemide use), Assessment (current heart rate and concern for dysrhythmias), and Recommendation (requesting potassium replacement).
The SBAR tool is a standardized framework for communicating critical information between healthcare team members. The correct order ensures that the provider immediately knows why the nurse is calling (Situation), the context of the issue (Background), the current clinical status (Assessment), and the proposed intervention (Recommendation).

Step-by-Step Solution

1
Identify the Situation (S).
The statement introducing the nurse, the client, and the low potassium level is placed first.
The SBAR framework begins by clearly stating the immediate reason for the communication.
2
Identify the Background (B).
The statement detailing the admission for heart failure and furosemide administration is placed second.
After stating the problem, the nurse must provide the historical clinical context that led up to it.
3
Identify the Assessment (A).
The statement describing the client's current heart rate and the nurse's clinical concern is placed third.
The nurse shares current findings and their analysis of the patient's present state.
4
Identify the Recommendation (R).
The statement requesting a potassium supplement and repeat lab work is placed last.
The communication concludes with a specific request or proposed action plan for the provider.

Key Concept

Structured Interprofessional Communication (SBAR)
Question 11Question →

During the mid-morning peak on a high-acuity step-down unit, an experienced registered nurse (RN) team leader is coordinating care with a licensed practical/vocational nurse (LPN/VN), a newly licensed RN, and an unlicensed assistive personnel (UAP). Several matters are brought to the team leader's attention simultaneously.

Arrange the following actions in the order the RN should perform them, prioritizing from the most urgent (first) to the least urgent (last).

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Answer

The correct sequence prioritizes immediate airway/breathing threats (BiPAP agitation), followed by active circulation crises (unresolved chest pain), high-risk prophylactic interventions (critical hypokalemia), assessment of potential iatrogenic harm (PICC line compression), and finally, routine supervision (CVC flush).
The RN must use clinical judgment to prioritize care delivery and supervision.

1. First (Airway/Breathing): The client on BiPAP who is agitated and removing their mask is demonstrating classic signs of severe hypoxia. This is an immediate threat to life.
2. Second (Circulation - Active): The client with unresolved chest pain after nitroglycerin is actively experiencing myocardial ischemia. This symptomatic circulatory crisis must be evaluated immediately after securing the airway.
3. Third (Circulation - Potential): A potassium level of 2.8 mEq/L is a critical value that places the client at high risk for fatal dysrhythmias. The RN must initiate IV replacement promptly, but since the client is currently asymptomatic, this follows the active crises.
4. Fourth (Assessment of Harm): The UAP's error of inflating a blood pressure cuff over a PICC line requires the RN to assess for localized complications (thrombosis, catheter damage). This potential injury takes precedence over routine tasks.
5. Fifth (Routine Supervision): Providing observation for a newly licensed RN performing a routine central venous catheter flush involves a stable client and a maintenance task. This is the lowest acuity situation and can be safely delayed.

Step-by-Step Solution

1
Identify the immediate threat to life using the Airway, Breathing, Circulation (ABC) framework.
The client on BiPAP who is agitated and removing their mask is experiencing severe airway/breathing compromise.
Agitation is an early clinical sign of hypoxia. Removing the BiPAP mask will cause rapid respiratory deterioration, making this the highest priority.
2
Evaluate the remaining situations for active, unstable circulatory issues.
The client with continuing chest pain despite nitroglycerin is experiencing active myocardial ischemia.
Unrelieved chest pain is an acute circulatory emergency (potential myocardial infarction) that must be addressed immediately after airway and breathing are secured.
3
Prioritize critical but currently asymptomatic physiological threats.
The client with a serum potassium of 2.8 mEq/L requires prompt intravenous electrolyte replacement.
Severe hypokalemia can trigger lethal dysrhythmias. The RN must initiate IV replacement soon, but active symptomatic crises take precedence over prophylactic interventions.
4
Assess potential risks for localized harm caused by delegation errors.
The client whose blood pressure was taken on a PICC line arm requires a vascular and catheter assessment.
The UAP's error created a risk for thrombosis or catheter damage. The RN must evaluate this, but it is a localized issue rather than a systemic emergency.
5
Schedule routine administrative or supervisory tasks.
The newly licensed RN needs supervision for a routine central venous catheter flush.
The client is stable and the task is standard maintenance. This can safely wait until all urgent client needs are met.

Key Concept

When managing a nursing team, the RN must prioritize client assessments and interventions using the ABCs (Airway, Breathing, Circulation) and Maslow's Hierarchy of Needs, addressing active systemic crises before prophylactic interventions, localized assessments, or routine supervision.
Question 12Question →

A nurse is coordinating the transition of care for a client recovering from a complex bowel resection with a newly placed colostomy who is being discharged to a home health agency. To ensure a safe and effective interprofessional transition, arrange the following nursing actions in the correct chronological order.

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Answer

The correct sequence begins with the nursing assessment, followed by securing specialist consultations, facilitating an interdisciplinary care conference, partnering with the social worker to finalize resources, and concluding with a structured SBAR handoff report.
Care coordination must logically progress from data collection to collaborative planning, implementation, and final transition. Assessment identifies the client's needs, which prompts specific interdisciplinary referrals. Once specialists provide their input, a care conference synthesizes these recommendations into a unified strategy. The social worker then finalizes the logistical arrangements of this strategy. Finally, the nurse executes an SBAR handoff to safely transfer care to the receiving agency.

Step-by-Step Solution

1
Perform a comprehensive assessment.
Identifies the client's specific clinical and functional deficits.
The nursing process dictates that assessment must occur prior to planning or intervening.
2
Secure consultations with the WOCN and clinical pharmacist.
Engages appropriate allied health professionals.
Specialists require the initial assessment data to target their specific discipline's evaluations.
3
Facilitate a multidisciplinary family care conference.
Synthesizes the individual specialist recommendations.
A cohesive discharge strategy cannot be formulated until all team members have evaluated the client.
4
Partner with the medical social worker to authorize community resources.
Operationalizes the established discharge strategy.
Logistical arrangements and agency selection are based directly on the outcomes of the care conference.
5
Execute a standardized handoff report utilizing the SBAR framework.
Transfers clinical accountability to the receiving facility.
The transition of care report is the final step, ensuring the receiving team understands the synthesized plan.

Key Concept

Effective interprofessional care coordination requires sequencing actions according to the nursing process: assessment, referral, synthesis of the plan, logistical implementation, and final transfer of accountability via structured communication (SBAR).
Question 13Question →

A nurse on a medical-surgical unit realizes that a client has inadvertently received the wrong medication. Arrange the following nursing actions in the correct priority order, from first to last.

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Answer

The correct sequence is to first assess the client, then notify the healthcare provider, implement any new orders, and finally complete the incident report.
When a medication error occurs, the nurse's absolute first priority is client safety. According to the nursing process, the nurse must assess the client and obtain vital signs before taking any other action. Once the client's physiological condition is known, the nurse contacts the healthcare provider with the pertinent assessment data. After receiving and implementing any new orders from the provider to stabilize or treat the client, the nurse completes the facility incident report as a final administrative step.

Step-by-Step Solution

1
Assess the client for adverse reactions and obtain vital signs.
The client's physiological stability and current status are determined.
Assessment is always the first step in the nursing process to ensure immediate client safety.
2
Notify the primary healthcare provider about the medication error.
The provider is made aware of the error and the client's current condition.
The provider needs the assessment data to make informed decisions about necessary counteractive treatments.
3
Implement any new orders prescribed by the provider.
Medical interventions are applied to counteract or monitor the effects of the wrong medication.
Prompt execution of new orders is critical to mitigate potential harm from the error.
4
Complete an objective facility incident report.
The error is formally documented according to facility policy.
Administrative documentation is important for quality improvement but must wait until the client is safe and stable.

Key Concept

Prioritization of Care and Error Management
Question 14Question →

A registered nurse is caring for an adult client admitted with a deep vein thrombosis. The client suddenly becomes frustrated, packs their belongings, and states, 'I am leaving this hospital right now, no matter what.' The client is alert, oriented, and legally competent. Arrange the following nursing actions in the correct sequence to ensure the client's legal rights are protected while minimizing facility liability. (Place the first action at the top and the final action at the bottom.)

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Answer

The correct sequence prioritizes client advocacy and assessment first, followed by chain-of-command notification, ensuring an informed refusal, obtaining legal documentation, and finally comprehensively documenting the event.
The legally sound process for an Against Medical Advice (AMA) discharge requires the nurse to first act as an advocate by assessing the client's concerns. If the issue cannot be resolved, the nurse must notify the provider. Next, the client must be educated on the risks to ensure an 'informed refusal.' Only after risks are explained should the AMA signature be requested. Finally, the nurse must document the entire objective sequence in the medical record to protect against liability.

Step-by-Step Solution

1
Assess the client's reasons for wanting to leave and attempt to resolve their concerns.
The nurse identifies the root cause of the client's frustration.
Advocacy and problem resolution are the primary nursing responsibilities before accepting an AMA discharge.
2
Notify the attending healthcare provider regarding the client's intent to leave against medical advice.
The healthcare provider is made aware of the situation.
The provider must be informed so they can intervene, discuss risks directly with the client, or provide necessary discharge prescriptions.
3
Ensure the client is informed of the specific medical risks and potential complications of leaving the facility.
The client understands the consequences of their decision.
A legal 'informed refusal' requires that the client fully understands the risks of leaving without completing treatment.
4
Request that the client sign the official facility Against Medical Advice (AMA) form.
The facility obtains legal documentation of the client's refusal.
The signed form provides legal protection by acknowledging that the client was informed of risks and chose to leave anyway.
5
Document the client's departure, the education provided, and the refusal of treatment in the medical record.
A permanent, objective record of the event is created.
Comprehensive documentation is the final legal safeguard to protect the nurse and the healthcare facility from liability.

Key Concept

Against Medical Advice (AMA) Procedure and Legal Liability
Question 15Question →

A registered nurse (RN) on a surgical step-down unit plans to delegate a sterile wound dressing change to a licensed practical/vocational nurse (LPN/VN). Place the RN's actions in the correct chronological order according to the National Council of State Boards of Nursing (NCSBN) delegation process.

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Answer

The correct sequence is: Assess the client, verify competency, provide specific instructions, observe/supervise periodically, and finally evaluate outcomes and provide feedback.
According to the NCSBN National Guidelines for Nursing Delegation, the delegation process follows a systematic sequence: 1) Assess and plan (evaluating client stability), 2) Communicate (providing clear directions to a competent delegatee), 3) Surveillance and supervision (monitoring the performance), and 4) Evaluation and feedback (reviewing the outcomes). Verifying competency is a critical component that immediately follows client assessment to ensure the 'Right Person' is chosen before providing instructions.

Step-by-Step Solution

1
Assess the client
Determines client stability and task appropriateness.
Delegation must always begin with an assessment of the client's current needs.
2
Verify competency
Confirms the delegatee is legally and institutionally permitted to perform the task.
The RN is responsible for ensuring the right person is assigned the right task.
3
Provide instructions
Establishes clear expectations and communication parameters.
The delegatee needs to know exactly what to do and when to report back (Right Direction/Communication).
4
Supervise periodically
Ensures the task is being executed safely and correctly.
The RN retains accountability and must provide appropriate surveillance (Right Supervision).
5
Evaluate and give feedback
Closes the delegation loop by reviewing outcomes and performance.
Evaluation is an exclusive RN responsibility that cannot be delegated.

Key Concept

NCSBN Delegation Process
Question 16Question →

A nurse is preparing to enter the room of a client placed on airborne and contact precautions. The nurse has gathered the necessary personal protective equipment (PPE). In what order should the nurse don the PPE? Arrange the steps in the correct sequence from first to last.

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Answer

The correct sequence is: 1. Perform hand hygiene, 2. Don the isolation gown, 3. Apply the N95 respirator, 4. Place the face shield or goggles, and 5. Don clean gloves.
The Centers for Disease Control and Prevention (CDC) guidelines establish a specific sequence for donning personal protective equipment (PPE) to maximize protection and minimize the risk of cross-contamination. Hand hygiene is universally performed first. The isolation gown is applied next because it provides foundational body coverage. The N95 respirator is applied and seal-checked before eyewear so the straps do not interfere with the goggles. Eye protection follows. Finally, gloves are donned last so they can be pulled securely over the gown's cuffs, establishing a continuous protective barrier.

Step-by-Step Solution

1
Identify the first priority before handling clean PPE.
Perform hand hygiene.
Hand hygiene removes existing pathogens from the hands and ensures the clean PPE remains uncontaminated during the donning process.
2
Select the piece of PPE that provides core body coverage.
Don the isolation gown.
The gown covers the torso and arms and must be tied securely behind the neck and waist to prevent shifting during patient care.
3
Apply respiratory protection.
Apply the N95 respirator.
The respirator must be fitted directly to the face before applying eye protection to ensure the straps are positioned correctly and the seal is completely intact.
4
Apply eye protection.
Place the face shield or goggles.
Eye protection sits over or adjacent to the respirator, providing droplet and splash protection for the mucous membranes of the eyes without interfering with the respirator.
5
Apply the final barrier.
Don clean gloves.
Gloves are placed last so they can be stretched over the edges of the gown cuffs, sealing the wrists and completing the continuous barrier.

Key Concept

Personal Protective Equipment (PPE) Donning Sequence
Question 17Question →

A nurse in a gastrointestinal outpatient clinic is instructing a client with a new colostomy on how to independently change their one-piece ostomy pouching system at home. In what order should the client be taught to perform these actions? Arrange the steps in the correct sequence.

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Answer

The correct sequence is: remove the used pouch, cleanse and dry the stoma and skin, measure the stoma, cut the opening on the new barrier, and apply the new skin barrier.
When changing an ostomy pouch, the client must first carefully remove the old appliance. The peristomal area is then cleaned with warm water and dried completely to ensure a healthy, residue-free skin surface. Next, the stoma is measured, as its size decreases over time. The client then cuts the skin barrier to fit the measurement, leaving a small gap (about 1/8 inch) to avoid strangulating the stoma. Finally, the protective backing is removed, and the appliance is pressed firmly onto the skin to create a secure, leak-free seal.

Step-by-Step Solution

1
Remove the used pouch and skin barrier.
The old appliance is detached without trauma.
Pushing the skin away from the adhesive prevents mechanical skin stripping.
2
Cleanse the stoma and surrounding skin.
The skin is free of effluent and old adhesive.
Warm water is sufficient; soaps can leave residue. The skin must be completely dry for the new barrier to adhere properly.
3
Measure the stoma using the template.
The exact current size of the stoma is determined.
Stoma size fluctuates, especially in the first few months, requiring measurement before each change.
4
Cut the opening on the new skin barrier.
A custom hole is prepared for the stoma.
The hole should be about 1/8 inch larger than the stoma to prevent constriction while protecting the peristomal skin.
5
Apply the new skin barrier firmly.
The new appliance is securely attached.
Pressing firmly ensures a proper seal, which prevents leaks and skin breakdown.

Key Concept

Ostomy Self-Care and Appliance Management
Question 18Question →

While a unit of packed red blood cells (PRBCs) is infusing, the client suddenly develops severe lower back pain, dyspnea, and visible shivering. The nurse suspects an acute hemolytic transfusion reaction. Arrange the following nursing interventions in the correct chronological order of priority. (Place the first action at the top and the last action at the bottom.)

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Answer

The correct sequence is to first stop the transfusion, then disconnect the blood tubing, attach new tubing primed with 0.9% sodium chloride, assess the client's status, notify the provider and blood bank, and finally send the equipment to the blood bank for testing.
The correct sequence prioritizes immediate patient safety by stopping the administration of the offending agent, physically disconnecting it, and securing venous access with a new line. Only after these lifesaving actions are complete should the nurse gather assessment data to communicate with the medical team, and finally preserve the evidence for laboratory investigation.

Step-by-Step Solution

1
Stop the blood transfusion.
The infusion of the potentially incompatible blood product is halted.
This is the most critical first step to prevent further physiological harm to a client experiencing an acute hemolytic reaction.
2
Disconnect the blood administration set from the intravenous hub.
The source of the incompatible blood is physically separated from the client's vascular access.
This prevents inadvertently pushing the remaining blood in the tubing into the client during the subsequent flush.
3
Attach a new intravenous tubing primed with 0.9% sodium chloride.
A patent intravenous line is secured with a compatible isotonic fluid.
Intravenous access must be maintained for potential emergency interventions, fluid resuscitation, and blood pressure support.
4
Assess the client's vital signs and clinical status.
Objective data regarding the severity of the reaction is gathered.
The nurse must evaluate the client's respiratory, hemodynamic, and neurological status to provide accurate and current information to the healthcare provider.
5
Notify the primary healthcare provider and the blood bank.
The medical team is alerted, and further emergency orders can be obtained.
The provider needs the assessment data to prescribe interventions (e.g., epinephrine, vasopressors, antihistamines), and the blood bank must initiate a reaction investigation.
6
Send the discontinued blood bag and administration set to the blood bank.
The suspected blood product is transported for laboratory analysis.
Testing the remaining blood and tubing is required to confirm the type of reaction, such as an ABO incompatibility.

Key Concept

Management of Acute Hemolytic Transfusion Reaction
Estimated Time:2m 0s
Question 19Question →

A registered nurse has completed wound care for a client placed on contact and droplet precautions. The nurse is wearing a disposable gown, non-sterile gloves, a face shield, and a surgical mask. Arrange the steps for removing the personal protective equipment (PPE) in the correct chronological sequence according to standard infection control guidelines.

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Answer

The correct sequence for removing (doffing) PPE is: remove gloves first, then the face shield, followed by the gown, the surgical mask, and finally perform hand hygiene.
According to standard Centers for Disease Control and Prevention (CDC) guidelines for PPE removal (doffing), the most contaminated items should be removed first to minimize the risk of self-contamination. Gloves are removed first, followed by eye protection (face shield or goggles). The gown is then removed, followed by the mask or respirator. Hand hygiene is absolutely required as the final step after all PPE has been removed.

Step-by-Step Solution

1
Remove the contaminated gloves.
Hands are freed from the most highly contaminated item.
Prevents cross-contamination to the face, eyes, or clean areas of the body during subsequent removal steps.
2
Remove the face shield by the headband or ear pieces.
Eye and face protection is safely discarded.
The outside of the shield is contaminated; handling only the back straps prevents pathogen transfer to the bare hands.
3
Remove the disposable gown by pulling it away from the neck and shoulders.
Body protection is safely discarded.
The front and sleeves are heavily contaminated. Rolling it outward traps pathogens on the inside of the bundle.
4
Remove the surgical mask by grasping the ties or elastics.
Respiratory protection is safely discarded.
The mask is removed last to maintain respiratory and mucous membrane protection until all other contaminated items have been safely disposed of.
5
Perform hand hygiene with an alcohol-based rub or soap and water.
Hands are completely sanitized.
Eradicates any transient pathogens that may have inadvertently transferred to the hands during the doffing process.

Key Concept

Standard doffing sequence to prevent self-contamination
Question 20Question →

An older adult client with acute delirium secondary to urosepsis is repeatedly grasping at their central venous catheter. The nurse must implement safety measures to prevent line dislodgement. Arrange the following interventions in the correct order of implementation, from the first initial action (least restrictive) to the final emergency measure (most restrictive).

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Answer

The correct sequence is: (1) Assess for reversible causes of agitation, (2) Camouflage the central venous catheter, (3) Relocate the client near the nurses' station and activate alarms, (4) Assign a continuous one-to-one sitter, and (5) Apply soft wrist restraints as a last resort.
The standard of care for patient safety and restraint application mandates an escalation from the least restrictive to the most restrictive interventions. The sequence must logically begin with an assessment to identify any physiological or reversible causes for the agitation. Once these are ruled out, the nurse attempts simple environmental changes, such as hiding the medical device. If the behavior continues, the nurse escalates to increased monitoring via alarms and relocating the client. If passive monitoring is insufficient, continuous direct human supervision is deployed. Only when all non-physical alternatives have failed to protect the client's safety may physical restraints be applied, and they must be secured safely to a movable bed frame part to prevent injury.

Step-by-Step Solution

1
Assess the client for physiological drivers of agitation.
Rules out or treats easily reversible causes like hypoxia or pain.
The nursing process dictates that assessment must precede intervention; resolving the root cause is the least invasive way to ensure safety.
2
Implement simple environmental modifications, such as camouflaging the line.
Removes the visual trigger causing the client to pull at the catheter.
This is a direct, non-restrictive intervention that maintains the client's full freedom of movement while promoting safety.
3
Increase passive monitoring by moving the client's room and utilizing alarms.
Enhances nursing awareness of the client's movements without physical restriction.
When basic modifications fail, escalating to heightened surveillance is required before requesting additional human resources or applying restraints.
4
Implement direct, continuous human supervision (1:1 sitter).
Provides immediate verbal redirection and physical blocking of attempts to pull the line.
Direct human supervision is the most restrictive non-physical intervention and must be attempted and documented as a failure before physical restraints can be legally justified.
5
Apply soft wrist restraints to the movable portion of the bed frame.
Physically prevents the client's hands from reaching the central venous catheter.
Physical restraints are an emergency measure of absolute last resort, to be used only when all other alternatives have been exhausted and the risk to the client's safety is imminent.

Key Concept

Hierarchy of least restrictive safety interventions and the nursing process
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