Physiological Integrity

1960 questions

All types1,960 Multiple choice1,004 Multiple select425 Numeric102 Ordering429

An adult client is transferred back to the medical-surgical unit immediately following a percutaneous liver biopsy. To minimize the risk of post-procedure hemorrhage, which of the following positions should the nurse assist the client into?

Right side-lying position with a small rolled towel under the puncture site

Left side-lying position with the knees flexed toward the chest

Supine position with the head of the bed elevated 45 degrees

Prone position with a small pillow placed under the abdomen

Show answer & explanation

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

Answer

The right side-lying position with a small rolled towel under the puncture site is the most appropriate position for a client following a liver biopsy.

Following a percutaneous liver biopsy, the client must be placed in a right side-lying position for several hours. Because the liver is a highly vascular organ, this position utilizes the client's own body weight (often supplemented with a small pillow or rolled towel placed under the puncture site) to apply direct, continuous pressure to the liver capsule against the chest wall. This external pressure promotes hemostasis and significantly reduces the risk of post-procedure hemorrhage.

Step-by-Step Solution

Identify the primary complication associated with the procedure.

The liver is a highly vascular organ, making hemorrhage the most significant immediate post-biopsy complication.

Understanding the risks of a percutaneous liver biopsy directs the immediate post-procedure nursing care.

Determine the anatomical location of the liver and the puncture site.

The liver is located in the right upper quadrant of the abdomen, and the biopsy is typically performed through the right lower rib cage.

Knowing the location is essential to apply targeted pressure to the correct site.

Select the position that applies direct pressure to the anatomical site.

Placing the client on their right side with a rolled towel under the puncture site compresses the liver against the chest wall.

Direct pressure promotes hemostasis and minimizes the risk of internal bleeding.

Key Concept

Post-Procedure Positioning for Hemostasis

Estimated Time:1m 0s

Question 822Question →

A client with severe hypokalemia is prescribed an intravenous (IV) infusion of $40\text{ mEq}$ of potassium chloride (KCl) diluted in $100\text{ mL}$ of normal saline. Which of the following actions by the nurse is essential for the safe administration of this therapy?

Program the intravenous pump to deliver the medication at a maximum rate of

10\text{ mEq/hr}

Calculate the drip rate to infuse the entire

100\text{ mL}

volume over

15\text{ minutes}

using gravity tubing.

Connect the secondary medication tubing to the Y-site of an infusing total parenteral nutrition (TPN) line.

Delegate the hourly inspection of the intravenous insertion site for signs of infiltration to the unlicensed assistive personnel (UAP).

Show answer & explanation

Answer: Program the intravenous pump to deliver the medication at a maximum rate of $10\text{ mEq/hr}$ .

Answer

The correct action is to program the intravenous pump to deliver the medication at a maximum rate of 10 mEq/hr.

Intravenous potassium chloride is a high-alert medication that can cause fatal cardiac arrhythmias if administered too rapidly. The standard maximum safe rate for a peripheral IV line is

10\text{ mEq/hr}

. It must always be administered using an electronic infusion pump to ensure precise rate control and prevent accidental boluses.

Step-by-Step Solution

Identify the high-alert status of the medication.

Recognize that intravenous potassium chloride (KCl) is a high-alert electrolyte.

Rapid or uncontrolled administration of potassium chloride can lead to fatal cardiac arrhythmias and cardiac arrest.

Determine safe administration protocols for the medication.

Identify that the medication must be diluted, administered via an electronic infusion pump, and infused at a strictly controlled rate.

Gravity tubing or rapid IV push methods are strictly contraindicated because they cannot guarantee a precise, slow delivery rate.

Establish the maximum safe infusion rate.

Determine that the standard maximum safe infusion rate for IV potassium chloride through a peripheral line is 10 mEq/hr.

Rates exceeding this limit significantly increase the risk of phlebitis, burning at the IV site, and systemic cardiac toxicity.

Evaluate the safety of the alternative actions provided.

Rule out the other options by recognizing that TPN requires a dedicated line and IV site assessment cannot be delegated to a UAP.

Maintaining fundamental safety principles for parenteral therapies ensures the correct action is solely focused on the safe infusion rate.

Key Concept

Safe administration of intravenous high-alert medications (Potassium Chloride)

Question 823Question →

A nurse is developing a feeding and basic care plan for a geriatric client who has right-sided hemiparesis and severe dysphagia following an ischemic stroke. Which specific intervention should the nurse include to promote safe swallowing and minimize the risk of aspiration?

Instruct the client to flex their chin slightly downward toward the chest when swallowing.

Maintain the client in a semi-Fowler's position at a 30-degree angle during meal consumption.

Delegate the continuous monitoring of the client's initial meal to the unlicensed assistive personnel (UAP).

Document the client's frequent coughing during oral intake as an expected, age-related decline in the gag reflex.

Show answer & explanation

Answer: Instruct the client to flex their chin slightly downward toward the chest when swallowing.

Answer

Instruct the client to flex their chin slightly downward toward the chest when swallowing.

The correct intervention utilizes the chin-tuck maneuver, a vital compensatory strategy for clients with dysphagia. Flexing the chin downward toward the chest physically narrows the opening to the airway (larynx) and widens the vallecular space. This structural shift helps prevent food or liquid from passively falling into the trachea and causing aspiration, ensuring basic safety and comfort during nutrition intake.

Step-by-Step Solution

Analyze the client's clinical presentation and risks.

The client has right-sided weakness and severe dysphagia post-stroke, placing them at an exceptionally high risk for airway compromise (aspiration) during meals.

Identifying specific neurological deficits allows the nurse to prioritize targeted, evidence-based feeding interventions over routine care.

Evaluate standard basic care interventions for dysphagia and aspiration prevention.

Safe feeding protocols require maximum upright positioning (90 degrees), placing food on the unaffected side of the mouth, avoiding thin liquids/straws, and using compensatory swallowing techniques.

Evidence-based practice guidelines dictate specific positional and mechanical strategies to actively protect the airway when physiological reflexes are impaired.

Select the option that correctly implements a protective swallowing strategy.

The chin-tuck maneuver is identified as the correct physiological intervention to prevent aspiration.

Tucking the chin downward physically narrows the airway entrance (larynx), directing the food bolus safely backward into the esophagus rather than down the trachea.

Key Concept

Aspiration Precautions and Dysphagia Management

Question 824Question →

A client who was admitted for diabetic ketoacidosis (DKA) now has a closed anion gap and a blood glucose of $180 \text{ mg/dL}$ ( $10.0 \text{ mmol/L}$ ). The healthcare provider prescribes transitioning the client from the continuous intravenous regular insulin infusion to a subcutaneous insulin regimen. To reduce the risk of physiological decompensation, in what order should the nurse perform the following actions? Arrange the actions from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Confirm the meal is at the bedside, administer the subcutaneous insulin, assist the client to eat, maintain the IV insulin for 1 to 2 hours, and finally discontinue the IV insulin.

When transitioning a client with resolved diabetic ketoacidosis (DKA) from intravenous (IV) to subcutaneous (SQ) insulin, the primary risk reduction goal is preventing a relapse of DKA while avoiding hypoglycemia. Because IV regular insulin has a half-life of only minutes, stopping it abruptly causes immediate insulin deficiency. The nurse must first ensure food is present, give the SQ insulin, have the client eat, and then crucially maintain the IV infusion for an overlap period of

1

2

hours. This allows the SQ insulin to reach a therapeutic level before the IV supply is removed.

Step-by-Step Solution

Assess the client's readiness to eat and ensure the meal is physically present at the bedside.

Hypoglycemia risk is mitigated before administering rapid-acting insulin.

Subcutaneous rapid-acting insulin has an onset of

10

15

minutes. Administering it without guaranteed immediate oral intake risks severe hypoglycemia.

Administer the prescribed subcutaneous dose of insulin.

The subcutaneous insulin depot is created.

This initiates the transition process, but the subcutaneous insulin will take time to absorb and reach therapeutic blood levels.

Instruct the client to consume the meal.

Carbohydrate absorption matches the onset of the rapid-acting insulin.

Provides glucose to prevent hypoglycemia as the insulin begins to peak.

Maintain the continuous intravenous regular insulin infusion for

1

2

hours.

Continuous insulin coverage is maintained during the subcutaneous absorption phase.

Intravenous regular insulin has a half-life of only minutes. An overlap period is required to prevent a critical gap in insulin coverage, which would cause rapid rebound hyperglycemia and potentially reopen the anion gap.

Discontinue the intravenous regular insulin infusion.

The transition to subcutaneous insulin is safely completed.

The subcutaneous insulin has now reached a therapeutic level, making the intravenous infusion unnecessary and preventing late hypoglycemia.

Key Concept

Diabetic Ketoacidosis (DKA) Intravenous to Subcutaneous Insulin Transition Protocol

Question 825Question →

A clinical nurse is guiding a client with generalized deconditioning on how to safely transfer from a seated position in a standard armchair to a standing position using a rolling walker. Place the following instructions and actions in the correct sequential order to prevent injury.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first apply the transfer belt, have the client scoot to the edge of the chair, place their hands on the chair's armrests, push up to a standing position, and finally grasp the walker handles once balanced.

Safe transferring with a walker requires strict adherence to biomechanics and device safety rules. The nurse must first apply a transfer belt to ensure client safety during the movement. Next, the client must scoot to the edge of the chair to bring their center of gravity forward. Crucially, the client must push up from the chair's armrests rather than pulling on the walker. Pulling on a wheeled walker can cause it to tip or roll, leading to a severe fall. Once the client has pushed up, is standing upright, and has established equilibrium, they can safely transfer their hands one at a time to the walker.

Step-by-Step Solution

Apply the transfer belt.

The nurse has a secure handhold on the client.

Applying the belt first ensures safety is established before initiating any movement.

Instruct the client to scoot to the edge of the chair.

The client's center of gravity is brought forward.

This reduces the distance the client must lift their body weight and prepares them for an efficient transfer.

Direct the client to place hands on the chair armrests.

The client's arms are positioned to provide upward thrust.

Using the stable chair for leverage prevents the dangerous mistake of pulling on the lightweight walker.

Have the client push up to stand.

The client transitions from sitting to full standing.

Combining the forward lean with arm and leg extension safely elevates the client against gravity.

Instruct the client to grasp the walker handles.

The client is fully stabilized with the assistive device.

Waiting until balance is achieved ensures the client does not rely on the walker while in a vulnerable, off-balance position.

Key Concept

Assistive Device Safety and Proper Transfer Biomechanics

Estimated Time:1m 0s

Question 826Question →

A nurse on a medical-surgical unit is reviewing the morning laboratory results for four assigned clients. To reduce the risk of a life-threatening complication, which client's result requires the most immediate intervention?

A client receiving a continuous intravenous heparin infusion who has a platelet count of

42,000/\text{mm}^3

(

42 \times 10^9/\text{L}

A client with severe chronic obstructive pulmonary disease (COPD) who has an arterial blood gas PaCO

_2

54 \text{ mm Hg}

A client who is two days postoperative following an open appendectomy with a white blood cell count of

12,000/\text{mm}^3

(

12.0 \times 10^9/\text{L}

A client prescribed daily oral furosemide for heart failure who has a serum potassium level of

4.2 \text{ mEq/L}

(

4.2 \text{ mmol/L}

Show answer & explanation

Answer: A client receiving a continuous intravenous heparin infusion who has a platelet count of $42,000/\text{mm}^3$ ( $42 \times 10^9/\text{L}$ ).

Answer

The client receiving intravenous heparin with a platelet count of

42,000/\text{mm}^3

A platelet count of

42,000/\text{mm}^3

(normal is

150,000

400,000/\text{mm}^3

) in a client receiving an intravenous anticoagulant is critically low. This places the client at imminent risk for spontaneous, severe hemorrhage or indicates the development of Heparin-Induced Thrombocytopenia (HIT). The nurse must immediately stop the infusion and notify the provider to reduce the risk of a fatal bleeding event.

Step-by-Step Solution

Analyze the normal reference ranges for the provided laboratory values.

Normal platelets:

150,000

400,000/\text{mm}^3

. Normal PaCO

_2

35

45 \text{ mm Hg}

. Normal WBC:

5,000

10,000/\text{mm}^3

. Normal Potassium:

3.5

5.0 \text{ mEq/L}

Establishing baseline normal values is required before identifying abnormalities.

Evaluate the clinical context for each abnormal finding.

The COPD client's elevated PaCO

_2

is an expected chronic condition. The postoperative client's slightly elevated WBC is expected inflammation. The client on heparin has critically low platelets.

Context determines whether an abnormal value is an expected chronic state, a normal physiological response, or an acute emergency.

Prioritize the finding that poses the most immediate, life-threatening risk to the client.

The severe thrombocytopenia (platelets

42,000/\text{mm}^3

) while on a high-alert anticoagulant poses a massive risk for internal bleeding.

Nurses must prioritize interventions that prevent imminent harm and rapidly mitigate severe risks.

Key Concept

Prioritization and Risk Reduction in Laboratory Interpretation

Question 827Question →

An adult client with a history of schizophrenia is brought to the emergency department from a residential care facility. The client exhibits "lead-pipe" muscle rigidity, a core body temperature of $104.2^\circ\text{F}$ ( $40.1^\circ\text{C}$ ), profuse diaphoresis, and a fluctuating level of consciousness. The client's daily medication regimen includes haloperidol and fluoxetine. Based on this clinical presentation, which of the following nursing actions should be prioritized? (Select all that apply.)

Select all that apply

Withhold all scheduled doses of haloperidol and notify the healthcare provider immediately.

Prepare to administer intravenous dantrolene sodium as prescribed.

Initiate active external cooling measures such as cooling blankets and ice packs.

Delegate the ongoing assessment of the client's vital signs and neurological status to the unlicensed assistive personnel (UAP).

Administer the scheduled dose of haloperidol to rapidly manage the client's altered mental status and severe agitation.

Administer prescribed intravenous emergency medications via secondary piggyback into the client's continuous total parenteral nutrition (TPN) line.

Show answer & explanation

Answer: Withhold all scheduled doses of haloperidol and notify the healthcare provider immediately.; Prepare to administer intravenous dantrolene sodium as prescribed.; Initiate active external cooling measures such as cooling blankets and ice packs.

Answer

The correct actions are to withhold all scheduled doses of haloperidol, prepare to administer intravenous dantrolene sodium, and initiate active external cooling measures.

Neuroleptic malignant syndrome (NMS) is a rare but life-threatening pharmacological emergency caused by antipsychotic medications (like haloperidol). It is characterized by severe autonomic instability, extreme hyperpyrexia, altered mental status, and 'lead-pipe' muscle rigidity. The immediate nursing and medical priorities are discontinuing the offending medication, administering specific antidotes such as dantrolene (a muscle relaxant) to halt the muscular hypermetabolism, and aggressively treating the hyperpyrexia with external cooling measures.

Step-by-Step Solution

Analyze the client's clinical presentation and medication history.

The combination of haloperidol use, lead-pipe rigidity, extreme hyperpyrexia, and autonomic instability identifies Neuroleptic Malignant Syndrome (NMS).

Recognizing the specific toxidrome is required to implement the correct pharmacological and physiological interventions.

Determine the immediate pharmacological priorities.

The offending drug (haloperidol) must be stopped immediately, and specific antidotes/relaxants (dantrolene) must be prepared.

Continuing the causative agent will worsen the life-threatening reaction, while dantrolene directly counteracts the extreme muscle contraction.

Identify physiological safety and supportive care needs.

External cooling is required for hyperpyrexia, the RN must maintain direct assessment of the unstable client, and safe IV administration rules (avoiding the TPN line) must be upheld.

Supportive care prevents mortality in NMS, and strict adherence to scope of practice and IV compatibility ensures patient safety during an emergency.

Key Concept

Pharmacological Management of Neuroleptic Malignant Syndrome (NMS) and Intravenous Safety

Estimated Time:1m 30s

Question 828Question →

A nurse is monitoring a client who is receiving an intravenous transfusion of packed red blood cells (PRBCs). Ten minutes into the transfusion, the client develops sudden, severe lower back pain, tachycardia, and hypotension. Place the following nursing actions in the correct priority order to manage this complication.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Stop the transfusion, disconnect the blood tubing, attach new saline tubing, assess the client, notify the healthcare provider and blood bank, and return the blood product to the blood bank.

In the event of a severe transfusion reaction, the priority is minimizing harm. The sequence follows the nursing process adapted for emergencies: intervene to stop harm (stop transfusion, disconnect tubing, maintain access with new saline), assess the impact (vital signs), communicate for further orders (notify HCP), and perform follow-up diagnostics (return product to blood bank).

Step-by-Step Solution

Stop the continuous flow of the packed red blood cells.

The client receives no further incompatible or contaminated blood.

Lower back pain, tachycardia, and hypotension are classic signs of a life-threatening acute hemolytic transfusion reaction. Immediate cessation is the most critical intervention.

Disconnect the existing blood administration set from the IV hub.

The source of the reaction is physically separated from the client's vascular access.

Leaving the tubing connected risks inadvertently pushing more of the reactant into the bloodstream during subsequent flushes.

Connect a new IV tubing setup primed with normal saline.

Intravenous access is maintained for emergency medications and volume expansion.

Normal saline must be infused through new tubing to prevent clotting of the IV site and to treat the resulting hypotension.

Perform a focused physiological assessment.

Baseline data during the reaction is obtained.

The nurse needs current vital signs, airway status, and hemodynamic parameters to accurately report the client's condition.

Communicate with the healthcare provider and blood bank.

Emergency medical orders are obtained and the facility's reaction protocol is activated.

Medical intervention (such as vasopressors, antihistamines, or diuretics) is required, and the blood bank must investigate the cause.

Package and send the blood bag, tubing, and required lab specimens.

Diagnostic testing can determine the exact cause of the reaction.

Analyzing the remaining product and the client's post-reaction blood and urine is necessary for root-cause analysis.

Key Concept

Management of Acute Hemolytic Transfusion Reactions

Question 829Question →

A hospitalized client is receiving a continuous infusion of a maintenance fluid through a single-lumen peripheral venous catheter. The healthcare provider has prescribed a scheduled intravenous (IV) bolus medication that is physically incompatible with the current infusion. Arrange the following actions in the correct chronological order to safely deliver the medication.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for administering an incompatible IV bolus medication through a continuous infusion line is to first stop the continuous infusion, flush the line with normal saline, administer the medication, flush the line again with normal saline at the same rate the medication was given, and finally restart the continuous infusion.

When administering an IV bolus medication that is incompatible with a continuous infusion through the same line, the nurse must prevent the two fluids from mixing. This is achieved using the SAS (Saline-Administer-Saline) method. The nurse stops the continuous infusion and flushes the line with a compatible solution (like 0.9% sodium chloride) to clear the tubing. After administering the medication over the prescribed time, the nurse flushes the line again to clear the medication before restarting the incompatible continuous infusion. This prevents precipitation in the line and ensures safe drug delivery.

Step-by-Step Solution

Stop the continuous intravenous infusion.

The flow of the incompatible maintenance fluid is halted.

Prevents the incompatible fluid from mixing with the medication in the intravenous line.

Flush the catheter with 10 mL of 0.9% sodium chloride.

The intravenous line is cleared of the incompatible maintenance fluid.

Creates a safe, neutral barrier in the tubing prior to medication administration.

Administer the prescribed intravenous bolus medication.

The medication is delivered to the client.

Provides the therapeutic intervention over the safe, recommended duration.

Flush the catheter again with 10 mL of 0.9% sodium chloride at the same administration rate.

The medication is completely cleared from the tubing.

Ensures the full dose is received and prevents rapid infusion of residual medication.

Restart the continuous maintenance fluid infusion.

The original fluid therapy is resumed.

Maintains the client's prescribed fluid requirements after the medication has been safely delivered.

Key Concept

Administration of an incompatible IV bolus medication via an existing continuous infusion line requires the Saline-Administer-Saline (SAS) technique to prevent drug precipitation and ensure patient safety.

Question 830Question →

Following a therapeutic right-sided thoracentesis to relieve a pleural effusion, a client on the medical-surgical unit suddenly exhibits acute agitation, tachypnea, and sharp right-sided chest pain. To mitigate the risk of severe physiological compromise, which actions must the nurse perform immediately? (Select all that apply.)

Select all that apply

Place the client in an upright, seated posture to optimize respiratory mechanics.

Transition the client into a flat, supine position to stabilize the thoracic cavity.

Alert the rapid response team and the primary healthcare provider.

Delay the administration of supplemental oxygen until an arterial blood gas sample is drawn.

Coordinate with the radiology department for a stat portable chest x-ray.

Administer the prescribed as-needed intravenous opioid analgesic before assessing oxygenation.

Show answer & explanation

Answer: Place the client in an upright, seated posture to optimize respiratory mechanics.; Alert the rapid response team and the primary healthcare provider.; Coordinate with the radiology department for a stat portable chest x-ray.

Answer

The correct actions are to place the client in an upright posture, alert the rapid response team, and coordinate a stat portable chest x-ray.

The client's presentation of acute agitation, tachypnea, and sharp chest pain following a thoracentesis is highly suspicious for a pneumothorax, a potentially life-threatening complication. Immediate risk reduction involves supporting the airway and breathing by placing the client in an upright position. Because this is a medical emergency, the nurse must activate the rapid response team to bring advanced critical care support to the bedside. Additionally, coordinating a stat portable chest x-ray is essential to confirm the diagnosis and guide definitive life-saving interventions, such as chest tube insertion.

Step-by-Step Solution

Analyze the clinical presentation.

The sudden onset of agitation, tachypnea, and sharp chest pain following a thoracentesis strongly suggests a pneumothorax.

Recognizing signs of life-threatening procedural complications is the first step in physiological risk reduction.

Prioritize interventions based on the ABCs (Airway, Breathing, Circulation).

Positioning the client upright maximizes lung expansion and immediately improves respiratory mechanics.

Airway and breathing are the highest priorities during an acute clinical deterioration.

Identify the need for collaborative care and rapid diagnostics.

The rapid response team is notified for advanced support, and a chest x-ray is requested to confirm the complication.

A pneumothorax requires definitive medical intervention, such as chest tube insertion, which must be guided by diagnostic imaging.

Key Concept

Post-thoracentesis complications and physiological risk reduction.

Question 831Question →

A nurse is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, pounding headache. The nurse notes profuse diaphoresis on the client's face and neck, and a blood pressure reading of 210/115 mm Hg. Arrange the following nursing actions in the correct priority order from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence of actions for managing autonomic dysreflexia is to first elevate the head of the bed, then check for bladder distention, followed by checking for bowel impaction, administering antihypertensive medication if unresolved, and finally documenting the event.

Autonomic dysreflexia is a medical emergency characterized by severe hypertension triggered by a noxious stimulus below the level of the spinal cord injury. The immediate priority is to lower the blood pressure mechanically by placing the client in a high-Fowler's position. Next, the nurse must locate and remove the triggering stimulus, starting with the most common cause (bladder distention) followed by the next most common (bowel impaction). If these non-pharmacological interventions fail, antihypertensive medications are administered. Documentation occurs last, after the client is stabilized.

Step-by-Step Solution

Elevate the head of the bed to a high-Fowler's position.

The client's upper body is raised to a 90-degree angle.

This immediately induces orthostatic pooling of blood in the lower extremities, helping to lower the dangerously high blood pressure.

Check the urinary catheter tubing for kinks or assess the bladder for distention.

The most common trigger for autonomic dysreflexia is evaluated.

Removing the noxious stimulus is the primary treatment; bladder issues are the most frequent cause.

Examine the client for signs of fecal impaction.

The second most common trigger is evaluated.

If the bladder is not the source, the bowel is the next logical system to assess for a noxious stimulus.

Administer the prescribed rapid-acting antihypertensive medication.

Medication is delivered to artificially lower the blood pressure.

This is necessary if the stimulus cannot be removed or if the blood pressure remains dangerously high despite removing the stimulus.

Document the event, the interventions provided, and the client's response.

The medical record is updated with accurate information.

Administrative and legal requirements are fulfilled after the client is safe and stable.

Key Concept

Management of Autonomic Dysreflexia

Question 832Question →

A nurse is changing the administration set for a client's central venous catheter. The client suddenly gasps, reports sharp chest pain, and becomes profoundly dyspneic and tachycardic. Suspecting a central line-associated air embolism, arrange the following nursing actions in the correct priority sequence to minimize physiological risk.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first clamp the catheter, then position the client in a left lateral Trendelenburg position, followed by administering high-flow oxygen, notifying the Rapid Response Team, and finally assessing continuous vital signs.

In the event of a suspected air embolism, the nurse must prioritize immediate actions that physically stop the embolism from worsening. Clamping the line prevents more air from entering. The left lateral Trendelenburg position traps the existing air in the right atrium/ventricle. Oxygen administration supports tissue perfusion and shrinks the nitrogen bubble. Only after these life-saving nursing interventions are applied should the nurse escalate the situation to the medical team and proceed with ongoing monitoring.

Step-by-Step Solution

Clamp the central venous catheter tubing immediately.

Further air entry into the central circulation is halted.

Source control is the most critical first step to prevent a fatal volume of air from entering the vascular system.

Place the client in a left lateral Trendelenburg position.

The air embolus is localized to the right side of the heart.

This positioning prevents the air from migrating into the pulmonary artery and causing right ventricular outflow tract obstruction.

Administer high-flow oxygen via a non-rebreather mask.

Systemic oxygenation is supported and nitrogen absorption is accelerated.

High-flow oxygen reduces hypoxia-induced tissue damage and decreases the size of the air embolus.

Notify the Rapid Response Team and the healthcare provider.

Emergency medical personnel are dispatched to the client's room.

Medical intervention, such as aspiration of the air from the right ventricle, may be required.

Assess continuous vital signs and prepare for potential cardiopulmonary resuscitation.

The client's hemodynamic status is closely monitored for deterioration.

An air embolism can rapidly lead to cardiovascular collapse, requiring immediate resuscitation efforts.

Key Concept

Management of a central venous catheter air embolism requires immediate source control and specific client positioning to prevent circulatory collapse.

Question 833Question →

A nurse is caring for a client who is receiving a continuous transfusion of packed red blood cells (PRBCs) through a primary peripheral intravenous (IV) catheter. The client's latest laboratory results reveal a critically low serum potassium level of 2.3 mEq/L, and the healthcare provider prescribes a dose of 40 mEq of IV potassium chloride. A second, saline-locked peripheral IV access is available on the client's other arm. Which of the following is the safest nursing action to implement?

Administer the potassium chloride as a slow, direct IV push into the saline-locked access over a minimum of 5 to 10 minutes.

Attach the potassium chloride as a secondary piggyback infusion to the IV line currently administering the packed red blood cells.

Connect a pre-mixed potassium chloride infusion to the saline-locked IV access and administer it via an electronic pump at a maximum rate of 10 mEq per hour.

Initiate the potassium infusion through the saline-locked access and instruct the unlicensed assistive personnel to assess the site hourly for phlebitis.

Show answer & explanation

Answer: Connect a pre-mixed potassium chloride infusion to the saline-locked IV access and administer it via an electronic pump at a maximum rate of 10 mEq per hour.

Answer

Connect a pre-mixed potassium chloride infusion to the saline-locked IV access and administer it via an electronic pump at a maximum rate of 10 mEq per hour.

The safest and standard practice for administering intravenous potassium chloride is to use a pre-mixed solution (to avoid mixing errors) and administer it via an electronic infusion pump. For a peripheral intravenous line, the maximum safe infusion rate is 10 mEq per hour to prevent burning at the site and to avoid life-threatening cardiac arrhythmias.

Step-by-Step Solution

Evaluate the prescribed medication and the client's current intravenous access.

The client requires a high-alert medication (40 mEq of IV potassium chloride). One IV line is infusing blood products, and a second line is saline-locked and available for use.

Identifying available access points is essential to prevent medication incompatibilities and ensure safe delivery.

Determine the safe administration rate and method for intravenous potassium chloride.

Potassium chloride must be properly diluted and administered via an infusion pump. The rate must not exceed 10 mEq per hour through a peripheral line.

Rapid infusion or direct IV push of potassium causes fatal cardiac arrhythmias.

Identify contraindications related to the current blood transfusion and delegation rules.

Potassium cannot be mixed with blood products, and the RN must personally assess the IV site for complications during the infusion.

Blood products are only compatible with 0.9% sodium chloride. Furthermore, assessing an IV site for vesicant extravasation requires nursing clinical judgment and cannot be delegated.

Key Concept

Intravenous potassium chloride administration safety, compatibility, and nursing delegation.

Question 834Question →

A client in the emergency department is experiencing a severe panic attack and is visibly hyperventilating. Which of the following assessment findings and laboratory values indicate the client is developing respiratory alkalosis? Select all that apply.

Select all that apply

Arterial blood pH of 7.52

Partial pressure of arterial carbon dioxide (PaCO2) of 28 mm Hg

Client reports tingling and numbness in the hands

Partial pressure of arterial carbon dioxide (PaCO2) of 48 mm Hg

Client exhibits a depressed respiratory rate of 10 breaths per minute

Show answer & explanation

Answer: Arterial blood pH of 7.52; Partial pressure of arterial carbon dioxide (PaCO2) of 28 mm Hg; Client reports tingling and numbness in the hands

Answer

The findings that indicate respiratory alkalosis are an arterial blood pH of 7.52, a PaCO2 of 28 mm Hg, and client reports of tingling and numbness in the hands.

Hyperventilation, common during severe panic attacks, leads to the excessive "blowing off" of carbon dioxide. Because carbon dioxide functions as an acid in the bloodstream, its rapid depletion causes the blood pH to rise above the normal upper limit of 7.45 (alkalosis) and the PaCO2 to fall below the normal lower limit of 35 mm Hg. Additionally, an alkalotic state increases the binding of circulating calcium to albumin, resulting in a functional hypocalcemia. This drop in ionized calcium triggers neuromuscular excitability, which frequently presents as tingling and numbness in the extremities.

Step-by-Step Solution

Identify the primary physiological impact of hyperventilation.

Hyperventilation causes the rapid elimination of carbon dioxide (CO2) from the lungs.

Carbon dioxide acts as an acid in the body; losing it shifts the blood pH toward alkalinity.

Determine the expected Arterial Blood Gas (ABG) values for this condition.

The ABG will show a decreased PaCO2 (below 35 mm Hg) and an elevated pH (above 7.45).

The decreased PaCO2 is the primary respiratory disturbance, which directly causes the systemic alkalosis (high pH).

Identify common clinical manifestations associated with systemic alkalosis.

Neuromuscular excitability, such as tingling, numbness, and tetany, are expected findings.

Alkalosis causes a temporary drop in ionized serum calcium, leading to the clinical signs of hypocalcemia.

Key Concept

Respiratory alkalosis occurs when hyperventilation causes excessive elimination of carbon dioxide, leading to a decreased PaCO2, an elevated pH, and secondary hypocalcemia causing neuromuscular symptoms.

Estimated Time:1m 0s

Question 835Question →

A nurse is caring for a client admitted with acute pancreatitis. Which of the following assessment findings should the nurse identify as indicators that the client is developing systemic inflammatory response syndrome (SIRS)? Select all that apply.

Select all that apply

Heart rate of 112 beats/min

Respiratory rate of 28 breaths/min

White blood cell count of 16,500/mm³

Core body temperature of 37.6°C (99.7°F)

Arterial PaCO2 of 42 mm Hg

Urine output of 45 mL/hr

Show answer & explanation

Answer: Heart rate of 112 beats/min; Respiratory rate of 28 breaths/min; White blood cell count of 16,500/mm³

Answer

The indicators of SIRS in this scenario include a heart rate of 112 beats/min, a respiratory rate of 28 breaths/min, and a white blood cell count of 16,500/mm³.

Systemic inflammatory response syndrome (SIRS) is a widespread inflammatory response to an insult, such as severe pancreatitis. It is defined by two or more of the following: temperature greater than 38.0°C or less than 36.0°C, heart rate greater than 90 beats/min, respiratory rate greater than 20 breaths/min (or PaCO2 < 32 mm Hg), and a white blood cell count greater than 12,000/mm³ or less than 4,000/mm³. The options presenting a heart rate of 112 beats/min, a respiratory rate of 28 breaths/min, and a WBC of 16,500/mm³ all exceed these thresholds and are clear indicators of SIRS.

Step-by-Step Solution

Recall the diagnostic criteria for systemic inflammatory response syndrome (SIRS).

SIRS is identified by the presence of two or more of the following: Temperature > 38.0°C or < 36.0°C, Heart rate > 90 beats/min, Respiratory rate > 20 breaths/min or PaCO2 < 32 mm Hg, and WBC > 12,000/mm³, < 4,000/mm³, or > 10% bands.

Accurate identification of SIRS is essential for recognizing early physiological decompensation.

Evaluate the client's vital signs and laboratory values against the SIRS criteria.

The heart rate of 112 beats/min, respiratory rate of 28 breaths/min, and WBC count of 16,500/mm³ all meet the criteria for SIRS.

Comparing client data to established clinical thresholds determines the presence of the syndrome.

Analyze the remaining options to confirm they do not meet SIRS criteria.

The temperature of 37.6°C is not > 38.0°C, the PaCO2 of 42 mm Hg is not < 32 mm Hg, and the urine output of 45 mL/hr is normal.

Eliminating distractors ensures that only true indicators of systemic inflammation are selected.

Key Concept

Systemic Inflammatory Response Syndrome (SIRS) Criteria

Question 836Question →

While caring for a client with a deep vein thrombosis, the registered nurse prepares to administer a scheduled dose of intravenous levofloxacin. The client has a single peripheral venous catheter currently infusing continuous intravenous heparin. What is the priority action the nurse must perform before proceeding?

Consult a medication reference resource to confirm that levofloxacin and heparin can be safely mixed in the same line.

Pause the continuous infusion, administer the antibiotic as a rapid bolus, and immediately resume the heparin.

Assign the unlicensed assistive personnel to monitor the insertion site for redness during the antibiotic administration.

Calculate the required drop factor to allow both fluids to infuse at the identical rate concurrently.

Show answer & explanation

Answer: Consult a medication reference resource to confirm that levofloxacin and heparin can be safely mixed in the same line.

Answer

Consult a medication reference resource to confirm that levofloxacin and heparin can be safely mixed in the same line.

Before administering multiple intravenous medications through a single access site, the nurse must verify that the drugs are physically and chemically compatible. Failure to do so can result in crystallization, precipitation, or inactivation of the drugs, which can cause severe harm to the client, such as an embolus or loss of venous access.

Step-by-Step Solution

Identify that two different medications are planned to infuse through a single venous access site.

Recognized a potential risk for drug-drug incompatibility in the intravenous tubing.

Different chemical compounds can form precipitates or inactivate each other when mixed together.

Determine the safest intervention prior to mixing the fluids.

Selected the action of checking a drug compatibility reference.

Verifying compatibility is a required safety standard before administering any secondary intravenous medication into an active line.

Key Concept

Intravenous Medication Compatibility

Question 837Question →

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

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct procedural sequence is to first position the client in the left lateral Sims position, then lubricate the enema tubing, carefully insert the tubing into the rectum, and finally raise the container to begin the infusion.

Administering a cleansing enema safely requires a logical, step-by-step approach. The nurse must first place the client in the left lateral Sims position to align with the anatomy of the lower GI tract. Next, the equipment is readied by lubricating the tubing tip. The tube is then carefully inserted. Only after the tube is securely in the rectum should the nurse raise the bag to allow the fluid to flow via gravity.

Step-by-Step Solution

Assist the client into the left lateral Sims position.

The client is in the safest and most effective anatomical position.

The left lateral Sims position utilizes gravity to help the fluid flow down into the sigmoid and descending colon.

Lubricate the tip of the enema tubing.

The tubing is prepared for safe insertion.

Lubrication minimizes tissue friction, preventing pain or damage to the sensitive rectal mucosa.

Insert the tubing 3 to 4 inches into the rectum.

The tube passes the internal sphincter and rests safely in the rectum.

Inserting the tube 3 to 4 inches in an adult, directed toward the umbilicus, ensures the fluid will be delivered appropriately without risking bowel wall perforation.

Raise the enema container and open the clamp.

Fluid begins to instill into the colon at a controlled rate.

The height of the bag controls the pressure and flow rate of the instillation. Raising it only after secure placement prevents spills and ensures a controlled, safe procedure.

Key Concept

Basic Care and Comfort: Enema Administration

Question 838Question →

A 68-year-old client is being monitored in the progressive care unit two hours after undergoing a bedside left-sided thoracentesis for a pleural effusion. The client suddenly becomes restless, diaphoretic, and has a respiratory rate of 34 breaths/min. The nurse observes diminished breath sounds on the left side and asymmetrical chest expansion. An arterial blood gas (ABG) reveals a pH of 7.49, PaCO2 of 29 mm Hg, PaO2 of 56 mm Hg, and HCO3 of 23 mEq/L. Which action should the nurse implement first to reduce the risk of severe physiological decompensation?

Apply high-flow supplemental oxygen and immediately notify the rapid response team for a suspected pneumothorax.

Coach the client to take slow, shallow breaths to reverse the acute respiratory alkalosis indicated by the blood gas results.

Assist the client into a flat, left lateral position to splint the puncture site and increase venous return to the heart.

Firmly palpate the upper left abdominal quadrant before auscultating bowel sounds to assess for an accidental splenic puncture.

Show answer & explanation

Answer: Apply high-flow supplemental oxygen and immediately notify the rapid response team for a suspected pneumothorax.

Answer

Apply high-flow supplemental oxygen and immediately notify the rapid response team for a suspected pneumothorax.

The client is exhibiting classic signs of an acute pneumothorax, a known high-risk complication of a thoracentesis. The asymmetrical chest expansion, diminished breath sounds, severe hypoxemia, and compensatory tachypnea require immediate escalation to a rapid response team and high-flow oxygen administration to prevent impending hemodynamic collapse.

Step-by-Step Solution

Analyze the client's clinical presentation and the diagnostic ABG data.

The client exhibits signs of a left-sided pneumothorax (diminished breath sounds, asymmetric chest expansion, restlessness). The ABG shows uncompensated respiratory alkalosis driven by critical hypoxemia (PaO2 56 mm Hg).

A thoracentesis carries a significant risk of puncturing the visceral pleura, leading to air entering the pleural space.

Determine the priority intervention using the ABC (Airway, Breathing, Circulation) framework.

The client has an acute, life-threatening breathing and oxygenation deficit that takes absolute precedence over other assessments.

Immediate oxygenation and advanced medical intervention are required to prevent the development of a tension pneumothorax and subsequent cardiopulmonary arrest.

Select the nursing action that directly mitigates the physiological threat.

Applying high-flow oxygen and activating the rapid response team is the safest and most urgent intervention.

This ensures immediate life-saving support and prepares the team for potential emergency chest tube insertion.

Key Concept

Post-procedure complication recognition and prioritization (Airway, Breathing, Circulation)

Question 839Question →

A client arrives at the medical-surgical unit after undergoing a flexible bronchoscopy with a transbronchial biopsy under conscious sedation. To reduce the risk of potential physiological complications, which actions should the nurse include in the client's immediate care plan? Select all that apply.

Select all that apply

Withhold all oral food and fluids until the return of the client's gag and swallow reflexes is clinically verified.

Delegate the initial post-procedure auscultation of lung sounds to the unlicensed assistive personnel to ensure frequent monitoring.

Monitor for sudden onset of pleuritic chest pain, asymmetrical chest wall expansion, and tracheal deviation.

Position the client completely flat in bed for the first 4 hours to minimize the risk of post-procedure hypotension.

Notify the rapid response team if a post-procedure arterial blood gas analysis demonstrates a PaCO2 of 42 mm Hg.

Assess for signs of laryngeal edema, such as inspiratory stridor or increasing hoarseness, which may threaten airway patency.

Show answer & explanation

Answer: Withhold all oral food and fluids until the return of the client's gag and swallow reflexes is clinically verified.; Monitor for sudden onset of pleuritic chest pain, asymmetrical chest wall expansion, and tracheal deviation.; Assess for signs of laryngeal edema, such as inspiratory stridor or increasing hoarseness, which may threaten airway patency.

Answer

The correct actions are to withhold oral intake until the gag reflex returns, monitor for signs of a pneumothorax (chest pain, asymmetrical expansion), and assess for laryngeal edema (stridor, hoarseness).

The correct interventions focus on protecting the airway and identifying life-threatening complications early. Verifying the gag reflex prevents aspiration, as topical anesthetics numb the throat. Monitoring for pleuritic chest pain and asymmetrical expansion detects a pneumothorax, a known severe complication of a transbronchial biopsy. Assessing for stridor and hoarseness ensures early recognition of laryngeal edema, which can rapidly compromise the airway.

Step-by-Step Solution

Identify the procedure and its associated physiological risks.

The client underwent a bronchoscopy with a transbronchial biopsy under conscious sedation. Primary risks include aspiration (due to topical anesthetics), pneumothorax (due to the biopsy puncturing the pleura), and airway edema (due to instrumentation trauma).

Understanding procedure-specific risks is essential for prioritizing focused post-operative assessments.

Evaluate the options related to airway protection.

Withholding oral intake until the gag reflex returns actively prevents aspiration. Assessing for stridor detects impending airway compromise. Positioning the client flat is contraindicated as it increases aspiration risk and limits diaphragmatic excursion.

Airway patency is always the highest clinical priority following procedures involving the respiratory tract.

Evaluate the options related to breathing and gas exchange.

Monitoring for asymmetrical chest expansion identifies a pneumothorax, a major complication of a transbronchial biopsy. Interpreting a PaCO2 of 42 mm Hg as an emergency is incorrect, as this is a normal physiological value.

Breathing complications must be quickly identified, but normal baseline findings must be recognized to prevent inappropriate interventions.

Evaluate the option related to delegation and care management.

Delegating initial post-procedure lung auscultation to a UAP is outside their scope of practice.

The Registered Nurse must perform initial assessments to establish a clinical baseline and exercise nursing judgment.

Key Concept

Post-Bronchoscopy Complication Prevention and Monitoring

Question 840Question →

An adult client is receiving scheduled enteral nutrition through a percutaneous endoscopic gastrostomy tube. Which intervention should the nurse implement to decrease the risk of aspiration?

Place the client in a strict flat, supine position while the formula is infusing.

Delegate the initial auscultation of lung sounds to an unlicensed assistive personnel.

Maintain the client's upper body in a semi-Fowler's position during the administration.

Perform deep abdominal palpation prior to auscultating bowel sounds to evaluate tolerance.

Show answer & explanation

Answer: Maintain the client's upper body in a semi-Fowler's position during the administration.

Answer

Maintain the client's upper body in a semi-Fowler's position during the administration.

Elevating the upper body into a semi-Fowler's position uses gravity to keep the administered formula inside the stomach, which directly decreases the likelihood of regurgitation and aspiration into the lungs.

Step-by-Step Solution

Identify the primary complication associated with enteral feedings.

The most significant severe risk is aspiration of stomach contents into the respiratory tract.

Formula introduced into the stomach can reflux into the esophagus if not properly managed.

Determine the physiological principle that prevents this complication.

Gravity assists in keeping gastric contents in the stomach and promotes downward emptying.

Elevating the upper body prevents fluid from traveling upward toward the airway.

Select the nursing action that applies this principle.

Positioning the client in a semi-Fowler's position elevates the upper body appropriately.

This specific position effectively reduces the risk of aspiration during and after the feeding.

Key Concept

Aspiration Precautions for Enteral Feedings

Estimated Time:45s

PreviousPage 42 / 98Next

Physiological Integrity

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept