Examkin

Physiological Integrity

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Question 961Question →

A nurse is preparing to administer a prescribed intravenous (IV) push medication through an established peripheral IV saline lock. Arrange the following steps in the correct order of performance from first to last.

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Answer

The correct sequence is to first cleanse the port, aspirate and flush with normal saline, administer the medication, flush with normal saline again at the medication's administration rate, and finally clamp the tubing.
The standard evidence-based sequence for administering an IV push medication through a saline lock is the SAS method: Saline, Administer, Saline. First, infection control requires cleansing the port. Second, patency is verified by aspirating for blood and flushing with normal saline to prevent extravasation. Third, the medication is administered at the correct rate. Fourth, a second saline flush clears the line, which must be pushed at the same slow rate to avoid pushing residual medication too quickly. Finally, the line is clamped using positive pressure to prevent blood reflux and subsequent occlusion.

Step-by-Step Solution

1
Cleanse the IV injection port with an antimicrobial swab and allow it to dry completely.
The port is effectively disinfected.
Prevents the introduction of pathogens into the client's bloodstream.
2
Attach a normal saline syringe, aspirate for a blood return, and flush the catheter.
IV patency is confirmed.
Ensures the catheter is correctly placed in the vein and the line is clear, preventing extravasation.
3
Attach the medication syringe and administer the drug over the recommended time.
Medication is delivered safely and therapeutically.
Prevents speed shock and cardiovascular collapse by adhering to the recommended administration rate.
4
Attach a second normal saline syringe and flush the catheter at the same rate the medication was given.
Residual medication is completely cleared from the tubing.
Ensures the complete dose reaches the patient without inadvertently delivering the remaining drug in the tubing too rapidly.
5
Clamp the extension tubing while maintaining positive pressure on the syringe plunger.
The IV line is securely closed off.
Maintains positive pressure inside the catheter, preventing blood reflux and potential clotting.

Key Concept

Safe administration of IV push medications requires the SAS (Saline-Administer-Saline) method to ensure line patency, deliver the drug safely, and maintain the integrity of the IV access.
Estimated Time:1m 30s
Question 962Question →

A nurse is monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs). Fifteen minutes into the infusion, the client reports sudden, severe lower back pain, chills, and shortness of breath. Arrange the following nursing actions in the correct sequential order of priority to minimize the risk of further physiological deterioration.

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Answer

The correct sequence of actions is to first stop the transfusion, then replace the tubing and infuse normal saline, followed by assessing the client, notifying the healthcare provider and blood bank, and finally returning the blood bag and tubing to the blood bank.
In any suspected transfusion reaction, the primary goal is to minimize physiological risk. The first and most critical action is to stop the transfusion to prevent further exposure to the offending antigen. The next priority is to maintain a patent IV line with normal saline using new tubing to allow for emergency medication administration while preventing residual blood from entering the client. Once the immediate source of harm is mitigated and access is secured, the nurse must assess the client's current status to gather clinical data. This assessment data is then communicated to the healthcare provider and the blood bank. Finally, sending the blood bag and tubing to the blood bank is done after all immediate client safety and communication needs are met.

Step-by-Step Solution

1
Stop the blood transfusion immediately.
The infusion of incompatible blood is halted.
This is the most critical first step to limit the amount of incompatible blood entering the systemic circulation, thereby reducing the severity of the acute hemolytic reaction.
2
Replace the blood tubing with a new administration set and initiate an infusion of normal saline.
Intravenous access is maintained without administering residual blood.
Intravenous access is necessary for emergency resuscitation. New tubing must be used because flushing the existing tubing would push the remaining incompatible blood into the client.
3
Assess the client's vital signs and cardiopulmonary status.
Objective clinical data regarding the client's physiological state is obtained.
The nurse needs current baseline data (blood pressure, heart rate, oxygen saturation, and respiratory effort) to determine the severity of shock and to report to the healthcare provider.
4
Notify the prescribing healthcare provider and the blood bank about the suspected reaction.
The medical team and laboratory are alerted to the emergency.
The provider will need to prescribe emergency interventions (e.g., vasopressors, diuretics). The blood bank must be alerted to halt any other potential incompatible transfusions and begin an investigation.
5
Return the discontinued blood bag and attached tubing to the blood bank.
Physical evidence is provided for laboratory analysis.
The blood bank will type and crossmatch the remaining blood in the bag and tubing to identify the exact cause of the hemolytic reaction and prevent future occurrences.

Key Concept

Prioritization of interventions during an acute hemolytic transfusion reaction to reduce risk of systemic compromise.
Estimated Time:1m 30s
Question 963Question →

A client recovering from abdominal surgery has a continuous peripheral intravenous (IV) infusion of 0.45% sodium chloride. The nurse brings a syringe containing a scheduled dose of IV ondansetron to the bedside. Which of the following actions is the most critical for the nurse to perform before administering this medication through the Y-site port?

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Answer: Confirm that the IV ondansetron is chemically compatible with the 0.45% sodium chloride solution.

Answer

The nurse must verify that the IV ondansetron is chemically compatible with the infusing 0.45% sodium chloride solution.
Verifying compatibility between an infusing IV fluid and an IV bolus medication is a fundamental safety step. If incompatible substances mix, they can form precipitates that may occlude the IV catheter or cause a life-threatening embolus.

Step-by-Step Solution

1
Identify the planned clinical task.
The nurse needs to administer an IV push medication into an actively infusing primary IV line.
Understanding the medication route and current line setup dictates the necessary safety precautions.
2
Recognize the risk of intravenous drug-fluid interactions.
Mixing incompatible medications and fluids can cause crystallization or precipitation in the tubing.
Precipitates can occlude the IV catheter or enter the client's bloodstream as a dangerous embolus.
3
Determine the priority safety action prior to administration.
The nurse must consult a standard drug compatibility resource to check the medication against the primary fluid.
This is a fundamental safety step to ensure the ondansetron will not adversely react with the 0.45% sodium chloride.

Key Concept

Intravenous Medication Compatibility
Question 964Question →

An older adult client is recovering on a telemetry unit two hours after undergoing a left femoral cardiac catheterization. The client expresses mild back pain from prolonged bed rest and demonstrates new-onset confusion. Which of the following actions should the nurse include in the immediate care plan? Select all that apply.

Select all that apply

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Answer: Offer the client a bedpan for elimination to avoid bending the affected left leg.; Guide the client through deep breathing and relaxation exercises to help manage back discomfort.

Answer

The correct actions are to offer the client a bedpan for elimination and to guide them through deep breathing and relaxation exercises.
Offering a bedpan allows the client to eliminate without getting out of bed or bending the affected leg, which perfectly aligns with the strict positioning requirements following a femoral procedure. Additionally, guiding the client through deep breathing exercises provides a safe, effective, non-pharmacological comfort measure to manage back pain when turning is strictly contraindicated.

Step-by-Step Solution

1
Identify the client's strict post-procedure positioning requirements.
Following a left femoral cardiac catheterization, the client must remain supine with the left leg completely straight to prevent severe bleeding at the arterial puncture site.
Maintaining vascular integrity is the highest priority.
2
Address the client's report of back pain.
Because the client cannot be rolled or repositioned to relieve pressure, alternative non-pharmacological comfort measures like deep breathing and relaxation must be utilized.
Basic comfort must be maintained without compromising the required therapeutic positioning.
3
Evaluate the new-onset confusion.
Sudden confusion is an acute clinical change requiring direct RN assessment. It cannot be dismissed as normal aging, cannot be managed immediately by applying restraints, and its assessment cannot be delegated.
Confusion in an older adult often points to hypoxia, stroke, or infection, necessitating a higher level of clinical judgment.

Key Concept

Basic care and comfort post-femoral catheterization requires maintaining a straight extremity to prevent bleeding. Comfort and elimination must be managed without altering this position. Furthermore, new-onset confusion in older adults requires acute nursing assessment and is never a normal age-related change.
Question 965Question →

A nurse is caring for a client who is recovering from a right total hip arthroplasty using a posterior approach. Which of the following nursing actions should the nurse implement to reduce the client's risk for hip dislocation? Select all that apply.

Select all that apply

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Answer: Place an abduction pillow between the client's legs while resting in bed.; Ensure the client's operative leg remains in a neutral position to prevent internal rotation.; Instruct the client to use an elevated toilet seat when using the restroom.

Answer

The correct actions are placing an abduction pillow between the legs, ensuring the operative leg remains in a neutral position, and instructing the client to use an elevated toilet seat.
Following a posterior approach total hip arthroplasty, the client is at high risk for joint dislocation if the hip is flexed past 90 degrees, adducted across the body's midline, or internally rotated. Using an abduction pillow effectively prevents adduction. Maintaining a neutral leg position prevents internal rotation. Instructing the client to use an elevated toilet seat prevents the hips from flexing more than 90 degrees when sitting down. Implementing all three of these actions directly reduces the risk of the surgical joint dislocating.

Step-by-Step Solution

1
Analyze the surgical procedure and the specific risk involved.
The client had a posterior approach total hip arthroplasty, which carries a high risk for posterior hip dislocation if specific movement precautions are not followed.
Understanding the mechanism of injury allows for the identification of safe versus unsafe positioning.
2
Identify the specific movements that cause posterior hip dislocation.
The movements to strictly avoid are hip flexion greater than 90 degrees, adduction (crossing the midline), and internal rotation.
These positions place excessive stress on the posterior surgical joint capsule, potentially popping the prosthesis out of place.
3
Evaluate each nursing action against the identified movement precautions.
Using an abduction pillow prevents adduction, a neutral leg position prevents internal rotation, and an elevated toilet seat prevents excessive flexion. Low chairs and crossing legs violate these rules.
Selecting only the interventions that avoid flexion >90 degrees, adduction, and internal rotation ensures the risk for dislocation is effectively minimized.

Key Concept

Postoperative hip precautions for posterior arthroplasty to prevent dislocation
Question 966Question →

A nurse is monitoring a postoperative client for signs of hemorrhage. Which of the following assessment findings is the earliest physiological indicator that the client is developing hypovolemic shock?

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Answer: Mild tachycardia and restlessness

Answer

Mild tachycardia and restlessness are the earliest indicators of hypovolemic shock.
In the early, compensatory stage of hypovolemic shock, the sympathetic nervous system is stimulated in response to decreased blood volume. This results in an increased heart rate (mild tachycardia) to maintain cardiac output, and decreased oxygen delivery to the cerebral cortex often manifests early as restlessness, mild anxiety, or confusion. Blood pressure typically remains normal during this initial phase.

Step-by-Step Solution

1
Identify the primary condition being assessed
The nurse is looking for early signs of hypovolemic shock due to potential postoperative hemorrhage.
Understanding the timeline of shock (early vs. late) is crucial for accurate assessment.
2
Evaluate physiological compensatory mechanisms
In early shock, the sympathetic nervous system activates, causing an increased heart rate to maintain cardiac output, and slight hypoxia to the brain causes altered mental status like restlessness.
The body compensates before blood pressure drops.
3
Differentiate early from late signs
Hypotension, lethargy, and cyanosis only occur after compensatory mechanisms fail.
Waiting for a drop in blood pressure delays critical life-saving interventions.

Key Concept

Early indicators of hypovolemic shock include subtle vital sign changes (mild tachycardia) and altered mental status (restlessness) prior to a drop in blood pressure.
Estimated Time:45s
Question 967Question →

A nurse is evaluating a 64-year-old client who is 3 hours post-cardiac catheterization via the right femoral artery. The client reports new-onset, severe lower back pain and requests to have the head of the bed raised to eat a snack. The client's current vital signs are: blood pressure 98/60 mm Hg (baseline 135/82 mm Hg), heart rate 114/min, and respiratory rate 20/min. Which of the following actions should the nurse take first?

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Answer: Maintain the client in a flat, supine position with the right leg straight and inspect the right flank and groin.

Answer

The nurse must maintain the client in a flat, supine position with the right leg straight and immediately inspect the flank and groin for signs of bleeding.
The client's presentation of new-onset severe back pain, hypotension, and tachycardia shortly after a femoral artery procedure is highly suspicious for a retroperitoneal hemorrhage, where blood leaks backward into the retroperitoneal space. Maintaining the client in a flat, supine position with the affected leg completely straight is essential to prevent dislodging the clot at the femoral puncture site. The nurse must immediately assess the groin and flank for swelling, firmness, or ecchymosis (Grey Turner's sign) to confirm the bleeding and intervene effectively.

Step-by-Step Solution

1
Analyze the client's clinical presentation and vital sign trends.
The client is experiencing severe back pain, a significant drop in blood pressure, and new-onset tachycardia 3 hours after a femoral artery procedure.
Recognizing the combination of these specific symptoms differentiates an expected minor discomfort from a critical, life-threatening complication (retroperitoneal hemorrhage).
2
Determine the priority nursing intervention based on risk reduction principles.
The nurse must prevent further arterial bleeding and assess the extent of the complication before leaving the client or calling the provider.
Keeping the affected leg completely straight and the bed flat prevents mechanical disruption of the femoral clot, which is the immediate priority to reduce the risk of exsanguination.

Key Concept

Reduction of Risk Potential: Recognizing and preventing retroperitoneal hemorrhage post-cardiac catheterization
Question 968Question →

A 70-year-old client is recovering in the telemetry unit 3 hours after a percutaneous transluminal coronary angioplasty (PTCA) utilizing the right femoral artery approach. The client suddenly reports severe lower back pain and generalized weakness. The nurse observes that the client's blood pressure is 84/50 mm Hg and heart rate is 118 beats per minute. A stat arterial blood gas (ABG) reveals a pH of 7.30, PaCO2 of 36 mm Hg, and HCO3 of 16 mEq/L. Which action must the nurse take immediately to mitigate the risk of further physiological decompensation?

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Answer: Notify the healthcare provider immediately and prepare to administer rapid intravenous fluid resuscitation.

Answer

Notify the healthcare provider immediately and prepare to administer rapid intravenous fluid resuscitation.
The client's presentation of sudden lower back pain, hypotension, and tachycardia shortly after a femoral artery procedure is a classic clinical picture of a retroperitoneal hemorrhage. The accompanying arterial blood gas results demonstrate metabolic acidosis, which occurs secondary to poor tissue perfusion and lactic acid buildup during hypovolemic shock. Immediate provider notification and rapid fluid volume replacement are essential to stabilize the client and prevent life-threatening cardiovascular collapse.

Step-by-Step Solution

1
Analyze the client's presenting symptoms and vital signs.
The client exhibits severe lower back pain, hypotension (84/50 mm Hg), and tachycardia (118 beats per minute).
These are hallmark indicators of retroperitoneal bleeding, a severe complication of femoral artery access that quickly leads to hypovolemic shock.
2
Interpret the arterial blood gas (ABG) values.
The ABG demonstrates a pH of 7.30 (acidemia), PaCO2 of 36 mm Hg (normal), and HCO3 of 16 mEq/L (low).
These values confirm uncompensated metabolic acidosis, which occurs when poor tissue perfusion from shock causes lactic acid accumulation in the bloodstream.
3
Determine the priority risk reduction intervention.
The nurse must immediately notify the healthcare provider and prepare for rapid intravenous fluid administration.
Restoring intravascular volume is the critical first step to stabilize the client's hemodynamic status and prevent cardiovascular collapse.

Key Concept

Identifying and managing retroperitoneal hemorrhage and hypovolemic shock following femoral artery catheterization.
Question 969Question →

A nurse is caring for a client who is receiving a packed red blood cell (PRBC) transfusion. The client suddenly develops severe chills, lower back pain, and dyspnea. Arrange the following nursing actions in the correct order of priority from first to perform to last.

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Answer

The correct sequence is: first, stop the blood transfusion immediately; second, maintain the IV line with new tubing and 0.9% sodium chloride; third, assess the client's vital signs; and fourth, notify the healthcare provider and blood bank.
In any acute allergic or hemolytic reaction to an intravenous therapy, the absolute priority is to stop the offending agent immediately. Following this, the nurse must maintain IV access with normal saline using new tubing so that emergency medications can be administered safely. Only after securing the line and halting the harm should the nurse perform a full assessment to gather data, which is then relayed to the healthcare provider to obtain further medical orders.

Step-by-Step Solution

1
Identify the primary threat and stop the offending agent.
The blood transfusion is stopped immediately.
Chills, lower back pain, and dyspnea are classic signs of an acute hemolytic transfusion reaction. Stopping the blood prevents further physiological harm.
2
Secure intravenous access for emergency interventions.
A normal saline infusion is started using completely new IV tubing.
The client may require emergency medications or fluid resuscitation to maintain blood pressure and urine output. New tubing ensures no residual blood is flushed into the client.
3
Gather clinical data regarding the client's status.
Vital signs and respiratory status are assessed.
The severity of the reaction must be evaluated to provide the healthcare provider with an accurate clinical picture.
4
Escalate the situation to the appropriate interdisciplinary team members.
The healthcare provider and blood bank are notified.
The provider needs to prescribe emergency medical interventions, and the blood bank must initiate a transfusion reaction investigation.

Key Concept

Prioritization of Interventions in Acute Transfusion Reactions
Question 970Question →

A nurse is caring for a client who exhibits sudden carpopedal spasms, facial twitching, and a prolonged QT interval on the electrocardiogram. The client's serum calcium level is 6.4 mg/dL6.4\text{ mg/dL} (1.6 mmol/L1.6\text{ mmol/L}). The healthcare provider urgently prescribes '1 gram1\text{ gram} Calcium Chloride IV piggyback over 10 minutes10\text{ minutes}'. The client's only vascular access is a 22-gauge22\text{-gauge} peripheral intravenous (PIV) catheter located in the dorsum of the right hand. Which of the following is the PRIORITY action by the nurse?

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Answer: Contact the healthcare provider to request changing the prescription to intravenous calcium gluconate

Answer

The nurse should contact the healthcare provider to request changing the prescription to intravenous calcium gluconate, which is safe for peripheral administration.
The correct answer recommends requesting a prescription change to calcium gluconate. Calcium chloride is highly hyperosmolar and a severe vesicant. If extravasation occurs, especially from a small fragile vein like a 22-gauge22\text{-gauge} in the hand, it causes catastrophic tissue necrosis and sloughing. Therefore, calcium chloride is generally restricted to central venous administration. Calcium gluconate provides the same therapeutic cation but is significantly less irritating, making it the preferred and safe choice for urgent peripheral intravenous administration.

Step-by-Step Solution

1
Analyze the client's clinical presentation and laboratory data.
The client has severe, symptomatic hypocalcemia (6.4 mg/dL6.4\text{ mg/dL}) with cardiac involvement (prolonged QT interval), requiring urgent intravenous calcium replacement.
Identifying the severity of the condition establishes the urgency of the intervention; delays can lead to life-threatening arrhythmias.
2
Evaluate the prescribed medication and route against safety parameters.
The provider prescribed calcium chloride to be given via a 22-gauge22\text{-gauge} peripheral IV line in the hand.
Nurses must verify the pharmacological safety of the route for the specific medication ordered.
3
Synthesize pharmacological knowledge regarding calcium chloride administration.
Calcium chloride is a severe vesicant and hyperosmolar solution that poses a massive risk of tissue necrosis if extravasated. It is strongly recommended for central line administration only.
Administering a severe vesicant through a small peripheral vein in the hand is clinically unsafe.
4
Determine the safest immediate intervention.
The nurse must contact the provider to request calcium gluconate, which provides the necessary electrolyte but is significantly less irritating to tissues.
This action safely addresses both the immediate physiological threat and the pharmacological safety hazard without delaying care.

Key Concept

Safe parenteral administration of calcium salts and prevention of vesicant extravasation
Estimated Time:2m 0s
Question 971Question →

A client arrives at the medical unit after undergoing a diagnostic lumbar puncture. To decrease the risk of a post-dural puncture headache, which action is most important for the nurse to implement?

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Answer: Ensure the client remains in a flat, supine position for several hours.

Answer

Ensure the client remains in a flat, supine position for several hours.
Following a lumbar puncture, keeping the client flat and supine for several hours is a standard intervention. This position minimizes the pressure on the dural puncture site, significantly reducing the risk of cerebrospinal fluid (CSF) leakage and the development of a painful post-dural puncture headache.

Step-by-Step Solution

1
Identify the procedure performed and its common complications.
The client had a lumbar puncture, which carries a high risk for a post-dural puncture headache due to cerebrospinal fluid (CSF) leakage.
Recognizing procedure-specific risks is essential for determining appropriate post-procedure care.
2
Determine the appropriate nursing intervention to prevent the complication.
Maintaining a flat, supine position is required to equalize pressure and minimize CSF leakage from the puncture site.
Gravity increases the pressure on the dural puncture site when the client is upright, leading to fluid loss and subsequent headaches.

Key Concept

Post-lumbar puncture positioning to prevent complications
Question 972Question →

A nurse is preparing to reposition a bedridden client who is receiving continuous enteral tube feedings. Which of the following actions is most appropriate for the nurse to take?

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Answer: Pause the enteral feeding pump before lowering the head of the bed to turn the client.

Answer

Pause the enteral feeding pump before lowering the head of the bed to turn the client.
The correct action is to pause the enteral feeding pump before lowering the head of the bed. Clients receiving continuous enteral tube feedings are at a high risk for aspiration. Standard practice dictates that the head of the bed should be elevated to at least 30 to 45 degrees while the feeding is infusing. When repositioning or providing care requires the bed to be lowered, the nurse must first pause the feeding to prevent regurgitation and aspiration of the stomach contents into the lungs.

Step-by-Step Solution

1
Identify the primary risk associated with continuous enteral tube feedings.
The most significant risk is regurgitation of stomach contents and subsequent aspiration into the lungs.
Enteral feedings bypass the upper digestive safety mechanisms, requiring gravity to help keep food in the stomach.
2
Recall the standard positioning required during continuous enteral feedings.
The head of the bed must be elevated to at least 30 to 45 degrees.
Elevation uses gravity to prevent reflux and aspiration.
3
Determine the necessary safety steps if the client must be laid flat for repositioning.
The nurse must pause the continuous feeding before lowering the head of the bed.
This temporarily stops the introduction of new formula while the protective effect of gravity is removed, keeping the airway safe.

Key Concept

Aspiration Prevention and Client Positioning During Enteral Feedings
Question 973Question →

A 24-year-old client is preparing for the removal of a thoracostomy (chest) tube, which was placed three days ago for a primary spontaneous pneumothorax. Current clinical assessments indicate symmetrical chest excursion and full lung re-expansion on the morning radiograph. To safely reduce the risk of procedural complications and prevent atmospheric air entry into the pleural space, arrange the following nursing actions in the correct chronological sequence.

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Answer

The correct sequence begins with prophylactic analgesia, followed by procedural preparation, instructing the Valsalva maneuver, applying the occlusive dressing simultaneously with tube removal, and finally obtaining a post-procedure chest radiograph.
This sequence strictly prioritizes risk reduction by ensuring client comfort first, establishing the sterile field to prevent procedural delays, utilizing the Valsalva maneuver to artificially create positive intrathoracic pressure precisely when the tube is pulled, instantly sealing the anatomical tract, and ultimately verifying patient safety with radiographic imaging.

Step-by-Step Solution

1
Administer the prescribed prophylactic intravenous analgesic to the client.
The client achieves adequate systemic pain control.
Chest tube removal is highly painful; pre-medicating ensures the client can endure the procedure without reflexively flinching or hyperventilating.
2
Position the client in a semi-Fowler's position and prepare a sterile field with petroleum-impregnated gauze.
The client and physical environment are ready for the sterile procedure.
Proper positioning provides optimal provider access, and having the occlusive dressing immediately accessible is critical before the tube is dislodged.
3
Coach the client to perform the Valsalva maneuver by inhaling deeply, exhaling completely, and bearing down.
The client generates sustained positive intrathoracic pressure.
Positive pressure gradients prevent atmospheric air from being drawn into the negative-pressure pleural space during the extraction of the tube.
4
Apply the airtight petroleum gauze dressing immediately as the provider extracts the tube.
The chest wall defect is instantly and hermetically sealed.
An immediate airtight seal prevents air entry through the exposed insertion tract, mitigating the risk of iatrogenic lung collapse.
5
Facilitate a STAT post-procedure portable chest radiograph to evaluate for potential lung collapse.
Lung expansion status is objectively confirmed via diagnostic imaging.
Radiographic verification is the definitive standard of care to ensure no occult pneumothorax occurred during the removal process.

Key Concept

The precise chronological coordination of the Valsalva maneuver and the immediate application of an occlusive dressing are critical risk reduction protocols to prevent an iatrogenic pneumothorax during chest tube removal.
Question 974Question →

The nurse receives the shift report for four clients on a medical-surgical unit. Which client should the nurse assess first?

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Answer: A client with a pelvic fracture whose blood pressure changed from 128/74 mm Hg to 118/84 mm Hg and resting heart rate increased from 84 to 108 bpm.

Answer

The client with a pelvic fracture, narrowing pulse pressure, and tachycardia.
The correct answer identifies the client exhibiting early signs of shock. Pelvic fractures carry a high risk of massive internal hemorrhage. The client's vital signs show a narrowing pulse pressure (systolic blood pressure decreasing while diastolic increases) and tachycardia, indicating compensatory mechanisms are attempting to maintain cardiac output in the face of fluid volume loss. This client is the most unstable and requires immediate intervention to prevent progression to decompensated shock.

Step-by-Step Solution

1
Identify the clinical status and potential risks for each client based on the provided data.
Three clients have expected or stable chronic findings, while one client has acute vital sign changes.
Systematic evaluation ensures the most unstable client is identified.
2
Analyze the arterial blood gas values for the client with COPD.
The values (pH 7.33, PaCO2 52, HCO3 26) indicate compensated respiratory acidosis, typical for chronic COPD.
Understanding baseline versus acute changes prevents unnecessary prioritization of stable chronic conditions.
3
Analyze the vital sign changes in the client with a pelvic fracture.
The pulse pressure narrowed from 54 mm Hg to 34 mm Hg, accompanied by tachycardia.
These are classic early compensatory signs of hypovolemic shock, a major risk with pelvic fractures.
4
Apply the ABCs (Airway, Breathing, Circulation) prioritization framework.
The client in early shock has a critical Circulation impairment, taking precedence over pain management or chronic edema.
Life-threatening acute changes must be addressed before expected post-operative findings or chronic disease management.

Key Concept

Prioritization of care and recognition of early hypovolemic shock
Question 975Question →

The healthcare provider prescribes 40 mEq40\text{ mEq} of intravenous (IV) potassium chloride for a client whose morning laboratory results reveal a serum potassium level of 2.5 mEq/L2.5\text{ mEq/L}. The client currently has a continuous transfusion of packed red blood cells (PRBCs) running through a single-lumen peripheral IV catheter. Which of the following actions should the nurse take to safely administer the medication?

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Answer: Establish a new peripheral IV site and administer the potassium chloride via an infusion pump at a maximum rate of 10 mEq/hr10\text{ mEq/hr}.

Answer

The correct action is to establish a new peripheral IV site and administer the potassium chloride via an infusion pump at a maximum rate of 10 mEq/hr10\text{ mEq/hr}.
Potassium chloride must be administered via an electronic infusion pump at a strictly controlled rate (maximum 10 mEq/hr10\text{ mEq/hr} for a peripheral line) to prevent cardiac toxicity and venous irritation. Furthermore, because the client's only IV access is actively being used for a PRBC transfusion—which is incompatible with all medications except normal saline—a dedicated secondary IV site must be established.

Step-by-Step Solution

1
Evaluate the current IV access and fluid compatibility.
The client has a single-lumen IV currently infusing PRBCs.
Blood products are only compatible with 0.9%0.9\% sodium chloride; mixing them with potassium or any other medication causes hemolysis and clot formation, requiring a new IV access.
2
Determine the correct administration method for IV potassium chloride.
IV potassium must be diluted and given via an electronic infusion pump.
Potassium is a high-alert medication. Rapid infusion or an IV push causes immediate, fatal cardiac arrhythmias.
3
Determine the safe maximum infusion rate.
The maximum safe rate for peripheral administration is 10 mEq/hr10\text{ mEq/hr}.
Rates exceeding this limit increase the risk of cardiac toxicity and severe venous irritation (phlebitis).
4
Identify prerequisite nursing safety assessments.
The nurse must verify adequate renal function (urine output ≥30 mL/hr\geq 30\text{ mL/hr}) prior to administration.
Because potassium is primarily excreted by the kidneys, administering it to an oliguric client can quickly result in life-threatening hyperkalemia.

Key Concept

Safe administration of intravenous potassium chloride requires an infusion pump, strict rate control (maximum 10 mEq/hr10\text{ mEq/hr} peripherally), verification of renal function, and ensuring line compatibility.
Question 976Question →

A nurse is preparing to ambulate a client who has multiple sclerosis and resulting right leg weakness using a standard (non-rolling) pickup walker. Arrange the nurse's actions and instructions in the correct chronological sequence.

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Answer

The correct sequence prioritizes safety and proper body mechanics: apply the transfer belt, verify the walker's fit, advance the walker, step with the weaker leg, and finally step with the stronger leg.
The correct chronological sequence integrates essential fall prevention (transfer belt), ergonomic assessment (wrist crease alignment), and the evidence-based gait pattern for a standard walker (Device -> Weak Leg -> Strong Leg). This order ensures maximum support is available when the weakest extremity is in motion.

Step-by-Step Solution

1
Apply a transfer belt securely around the client's waist before assisting them to a standing position.
The client is safely prepared to transition from sitting to standing.
Fall prevention is the highest priority. A transfer belt provides a secure hold for the nurse to assist the client against gravity.
2
Verify that the walker's handgrips align with the client's wrist creases while their arms hang naturally.
The walker is confirmed to be at the correct height.
Proper walker height cannot be accurately assessed until the client is standing. Aligning the grips with the wrist creases ensures proper elbow flexion (15-30 degrees) for optimal upper body strength utilization.
3
Instruct the client to lift and advance the entire walker forward by approximately 6 inches.
The walker provides a new base of support ahead of the client.
The assistive device must move first to create a stable boundary into which the client can safely step.
4
Direct the client to step forward into the walker with the right (weaker) leg while bearing weight on the handgrips.
The affected leg is safely advanced while the body's weight is supported.
The weaker leg must move while the strong arms and walker provide maximum stability. Moving the weak leg first prevents it from having to support the body's entire weight alone.
5
Tell the client to step forward with the left (stronger) leg to align evenly with the right leg.
The step is completed, and the client is balanced within the walker.
The strong leg can safely support the client's weight as it pushes off the ground to advance and join the weaker leg.

Key Concept

Safe Ambulation and Assistive Device Sequencing
Question 977Question →

A nurse is evaluating a client who has experienced severe, persistent vomiting for the past three days. Which of the following acid-base imbalances should the nurse anticipate as a direct physiological consequence of this condition?

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Answer: Metabolic alkalosis

Answer

Metabolic alkalosis
The correct answer identifies that gastric fluids are highly acidic. When a client experiences prolonged vomiting, they lose large amounts of hydrogen ions (hydrochloric acid). The depletion of this acid leads to a proportional increase in bicarbonate in the extracellular fluid, resulting in a state of metabolic alkalosis.

Step-by-Step Solution

1
Analyze the client's primary symptom.
The client has been experiencing severe, persistent vomiting.
Identifying the method of fluid loss determines which electrolytes or acids/bases are being depleted.
2
Determine the physiological composition of the lost fluid.
Gastric secretions contain high concentrations of hydrochloric acid (HCl).
Understanding what is lost helps predict the resulting systemic imbalance.
3
Correlate the fluid loss with the corresponding acid-base imbalance.
The loss of significant amounts of acid leaves the body with a relative excess of bicarbonate, causing an elevated pH.
Losing acid from the gastrointestinal tract directly leads to a metabolic acid-base shift, specifically metabolic alkalosis.

Key Concept

Acid-Base Imbalances from Gastrointestinal Losses
Question 978Question →

A nurse is caring for a client who is recovering from open abdominal surgery. The client coughs forcefully, reports a "popping" sensation, and the nurse observes a wound evisceration. 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

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Answer

The correct sequence of actions is: 1. Stay with the client and call for assistance, 2. Place the client in a low Fowler's position with the knees flexed, 3. Cover the protruding organs with sterile, saline-moistened dressings, 4. Obtain the client's vital signs, 5. Prepare the client for emergency surgery.
Wound evisceration is a medical emergency requiring rapid, prioritized interventions. First, the nurse must ensure the client's immediate safety by staying with them and calling for help. Second, positioning the client in a low Fowler's position with knees flexed minimizes abdominal tension. Third, protecting the exposed organs with sterile, moist dressings prevents tissue necrosis and infection. Fourth, obtaining vital signs helps monitor for shock. Finally, preparing the client for surgery addresses the definitive treatment.

Step-by-Step Solution

1
Ensure immediate safety and get help.
The nurse stays with the client and calls for assistance.
The nurse must remain with the client to monitor their status during this surgical emergency while getting a colleague to notify the surgeon.
2
Position the client appropriately.
The client is placed in a low Fowler's position with flexed knees.
This position immediately reduces tension on the abdominal wall, preventing further evisceration.
3
Protect the exposed organs.
Sterile, saline-moistened dressings are applied over the wound.
The bowel or other organs must be protected from drying out and from infection using sterile technique.
4
Assess for hemodynamic stability.
Vital signs are obtained.
Monitoring for physiological decompensation (like shock) is crucial after the physical threat of further evisceration is mitigated.
5
Prepare for definitive treatment.
The client is prepared for emergency surgery.
The ultimate treatment for an evisceration is surgical repair, requiring NPO status and IV access preparation.

Key Concept

Management of Abdominal Evisceration
Question 979Question →

A client admitted with a pulmonary embolism has a new prescription for a continuous intravenous heparin infusion at 18 units/kg/hr18\text{ units/kg/hr}. The client weighs 187 lbs187\text{ lbs}. The pharmacy dispenses a premixed bag containing 25,000 units25,000\text{ units} of heparin in 500 mL500\text{ mL} of 0.9%0.9\% sodium chloride. At what rate in mL/hr\text{mL/hr} should the nurse program the infusion pump? (Round the final answer to the nearest whole number.)

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Answer: 31

Answer

31
To find the correct infusion rate, first convert the weight to kilograms (187÷2.2=85 kg187 \div 2.2 = 85\text{ kg}). Next, multiply the weight by the prescribed dose to find the hourly requirement (85 kg×18 units/kg/hr=1530 units/hr85\text{ kg} \times 18\text{ units/kg/hr} = 1530\text{ units/hr}). Then, divide the total units in the bag by the total volume to find the concentration (25,000 units÷500 mL=50 units/mL25,000\text{ units} \div 500\text{ mL} = 50\text{ units/mL}). Finally, divide the hourly requirement by the concentration to find the rate in mL/hr (1530÷50=30.6 mL/hr1530 \div 50 = 30.6\text{ mL/hr}) and round to the nearest whole number (31 mL/hr31\text{ mL/hr}).

Step-by-Step Solution

1
Convert the client's weight from pounds to kilograms.
187 lbs÷2.2=85 kg187\text{ lbs} \div 2.2 = 85\text{ kg}
The prescription is weight-based using the metric system.
2
Calculate the target hourly dose.
85 kg×18 units/kg/hr=1530 units/hr85\text{ kg} \times 18\text{ units/kg/hr} = 1530\text{ units/hr}
To determine how much medication the client needs per hour based on their body weight.
3
Determine the concentration of the IV solution.
25,000 units÷500 mL=50 units/mL25,000\text{ units} \div 500\text{ mL} = 50\text{ units/mL}
To find out how many units are contained in a single milliliter of the provided IV fluid.
4
Calculate the required volume to be infused per hour.
1530 units/hr÷50 units/mL=30.6 mL/hr1530\text{ units/hr} \div 50\text{ units/mL} = 30.6\text{ mL/hr}
To determine the exact rate for the infusion pump before rounding.
5
Round the result to the nearest whole number.
31 mL/hr31\text{ mL/hr}
The prompt specifies to round the final answer to the nearest whole number, as is standard for most adult IV infusion pumps.

Key Concept

Weight-Based Intravenous Medication Dosage Calculation
Question 980Question →

A nurse is preparing to administer a prescribed intravenous (IV) piggyback medication to a client who is currently receiving a continuous IV infusion of 0.9% sodium chloride. What is the priority nursing action before attaching the secondary IV tubing to the primary line?

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Answer: Verify the compatibility of the piggyback medication with the continuous IV fluid.

Answer

The correct action is to verify the compatibility of the piggyback medication with the primary IV fluid.
Before administering any secondary intravenous medication (piggyback) into an existing continuous IV line, it is a critical safety standard to verify that the two fluids are compatible. Administering incompatible fluids together can cause chemical reactions, rendering the medication ineffective, or creating solid precipitates that can cause fatal embolisms.

Step-by-Step Solution

1
Identify the clinical scenario
The nurse is preparing to administer an IV piggyback medication into an existing, running continuous IV line.
Understanding the context is required to determine the necessary safety steps before administration.
2
Recall the principles of safe parenteral medication administration
Medications administered via the same IV line must be physically and chemically compatible to prevent adverse reactions like precipitation.
Mixing incompatible medications can cause crystal formation, which can lead to catheter occlusion or dangerous emboli in the client.
3
Evaluate the provided options against priority safety actions
Checking IV compatibility is the essential priority safety action. Delegating to UAP is out of scope, combining rates is mathematically incorrect, and assuming compatibility based on missing warning labels is dangerous.
Ensuring medication compatibility directly addresses the highest physiological risk to the client in this specific scenario.

Key Concept

Safe Intravenous (IV) Medication Administration and Compatibility
Estimated Time:1m 0s
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