Physiological Integrity

1960 questions

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During mealtime on a medical-surgical unit, an elderly client with a known history of dysphagia requires assistance. What is the most appropriate action by the registered nurse to ensure safe ingestion and comfort?

Maintain the client in a high-Fowler's position for the duration of the meal and for at least 30 minutes afterward.

Assist the client into a flat, supine position immediately after eating to promote energy conservation and rest.

Assign the unlicensed assistive personnel (UAP) to evaluate the intactness of the client's gag reflex before offering solid foods.

Document the client's sudden episodes of coughing during fluid intake as a normal physiological consequence of advanced age.

Show answer & explanation

Answer: Maintain the client in a high-Fowler's position for the duration of the meal and for at least 30 minutes afterward.

Answer

The nurse must ensure the client remains in an upright, high-Fowler's position during the meal and for at least 30 minutes after eating to prevent aspiration.

For a client with dysphagia, sitting fully upright in a high-Fowler's position uses gravity to direct food and fluids safely into the stomach rather than the airway. Maintaining this elevated position for at least 30 minutes after the meal prevents the regurgitation of gastric contents, serving as a fundamental and highly effective aspiration precaution.

Step-by-Step Solution

Identify the client's primary risk factor during basic care.

The client has a history of dysphagia, which places them at a high risk for aspirating food or fluids into the lungs.

Recognizing specific physical vulnerabilities determines which safety precautions must be implemented during routine tasks like feeding.

Determine the optimal physical position for oral intake.

The client should be positioned in a high-Fowler's position (sitting up at 90 degrees).

An upright position enlists gravity to help guide the bolus of food down the esophagus and away from the trachea.

Establish the necessary post-meal positioning timeline.

The upright position must be maintained for 30 to 45 minutes after the meal has concluded.

Maintaining the position after eating allows time for gastric emptying and prevents the reflux of stomach contents back into the upper airway.

Key Concept

Aspiration Precautions and Safe Client Positioning

Question 1162Question →

A nurse is instructing a client who has a cast on the right lower extremity and is prescribed non-weight-bearing status. The client is learning to ascend stairs using axillary crutches. Arrange the following actions in the correct sequence from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for ascending stairs with crutches is: 1. Assume the tripod stance at the base of the stairs, 2. Place body weight entirely onto the crutches, 3. Advance the unaffected leg onto the step above, 4. Shift body weight from the crutches to the unaffected leg, 5. Bring the affected leg and both crutches up to the step.

Safe stair navigation with crutches relies on the principle that the unaffected ('good') leg must power the upward movement. The client must first establish stability (tripod stance) and shift weight to the crutches to free the strong leg. The unaffected leg is placed on the higher step, followed by a weight shift onto that leg, which then lifts the rest of the body, the affected leg, and the crutches up to the same step.

Step-by-Step Solution

Establish a stable base of support.

The client assumes the tripod stance at the base of the stairs.

Safety and balance must be ensured before initiating any upward movement.

Unweight the unaffected leg.

The client places their body weight entirely onto the crutches.

This allows the strong leg to move freely without bearing weight during the transition.

Lead with the strong extremity.

The client advances the unaffected leg onto the step above.

When ascending stairs, the unaffected leg ('good' leg) should always go up first to lift the body's weight.

Transfer weight to the newly positioned leg.

The client shifts body weight from the crutches to the unaffected leg on the step.

The strong leg is now in position to stabilize and pull the rest of the body upward.

Complete the upward sequence.

The client brings the affected leg and both crutches up to the step.

The crutches and the non-weight-bearing affected leg follow the strong leg up to the new step, completing the maneuver.

Key Concept

Crutch walking on stairs (Three-point gait)

Estimated Time:1m 30s

Question 1163Question →

A nurse is preparing to administer an initial loading dose of $1000$ mg of intravenous phenytoin to an adult client experiencing continuous seizure activity. The client has a single peripheral intravenous catheter currently infusing 5% dextrose in water (D5W) at $100$ mL/hr. Which sequence of actions is the most appropriate for safe parenteral administration of this medication?

Connect the medication syringe to the lowest Y-site of the primary tubing and administer the medication concurrently with the infusing dextrose solution over

20

minutes.

Dilute the

1000

mg of phenytoin into a

250

mL bag of 5% dextrose in water and administer it as a secondary intermittent infusion.

Pause the primary dextrose infusion, flush the line with 0.9% sodium chloride, administer the phenytoin rapidly over

5

minutes to quickly halt the seizure, and flush again.

Pause the primary dextrose infusion, flush the line with 0.9% sodium chloride, administer the phenytoin over at least

20

minutes, and flush again with 0.9% sodium chloride.

Show answer & explanation

Answer: Pause the primary dextrose infusion, flush the line with 0.9% sodium chloride, administer the phenytoin over at least $20$ minutes, and flush again with 0.9% sodium chloride.

Answer

The most appropriate action is to pause the primary dextrose infusion, flush the line with 0.9% sodium chloride, administer the phenytoin over at least

20

minutes, and flush again with 0.9% sodium chloride.

The correct approach comprehensively addresses both the chemical incompatibility of the medication and its strict administration rate limit. Phenytoin rapidly precipitates in dextrose solutions, meaning the existing D5W infusion must be paused and the line thoroughly flushed with 0.9% sodium chloride both before and after the dose. Furthermore, intravenous phenytoin must not be administered faster than

50

mg/minute in adults. For a

1000

mg loading dose, the absolute minimum administration time is

20

minutes (

1000

mg /

50

mg/minute) to minimize the risk of cardiovascular collapse and severe hypotension.

Step-by-Step Solution

Identify the primary medication incompatibility.

Phenytoin physically precipitates when mixed with 5% dextrose in water (D5W).

Recognizing drug-solution incompatibility is crucial to prevent line occlusion and the infusion of solid crystalline emboli.

Determine the necessary intravenous line management strategy.

The primary D5W infusion must be paused and the line completely flushed with 0.9% sodium chloride before and after the medication is given.

0.9% sodium chloride is physically compatible with phenytoin and clears the line of any residual dextrose.

Calculate the safe maximum administration rate.

Dividing the

1000

mg dose by the maximum safe rate of

50

mg/minute yields a minimum required infusion time of

20

minutes.

Rapid intravenous administration of phenytoin can cause severe hypotension, severe bradycardia, and fatal cardiovascular collapse.

Key Concept

Intravenous Phenytoin Administration, Fluid Compatibility, and Rate Calculation

Alternative Method

Nurses may utilize an intravenous pump to deliver the medication over

20

30

minutes rather than a manual IV push, provided the primary line is flushed and verified to contain only 0.9% sodium chloride.

Estimated Time:2m 0s

Question 1164Question →

A nurse is providing morning hygiene and nutritional support for an older adult client who underwent a right total hip arthroplasty via a posterior approach on the previous day. Which of the following actions should the nurse take?

Place an abduction pillow between the client's legs prior to turning them onto their unaffected side for a linen change.

Elevate the head of the bed to a 90-degree angle to ensure the client is comfortable while eating breakfast.

Assign an unlicensed assistive personnel (UAP) to evaluate the client's skin integrity over the sacrum during the bed bath.

Attribute the client's sudden onset of confusion and restlessness to normal, age-related cognitive decline and proceed with care.

Show answer & explanation

Answer: Place an abduction pillow between the client's legs prior to turning them onto their unaffected side for a linen change.

Answer

The nurse should maintain hip precautions by using an abduction pillow between the legs when turning the client.

Maintaining hip precautions is essential to prevent dislocation of the new prosthesis. For a posterior approach, the hip must not be flexed beyond 90 degrees, and adduction or internal rotation must be avoided. Using an abduction pillow between the legs while turning the client prevents the hip from adducting across the midline during basic care activities such as linen changes.

Step-by-Step Solution

Identify the client's surgical procedure and post-operative risks.

The client had a right total hip arthroplasty (posterior approach).

Understanding the specific procedure determines which movements are safe and which are contraindicated.

Determine the necessary positioning precautions for a posterior approach.

The hip must not be flexed beyond 90 degrees, and adduction or internal rotation must be strictly avoided.

These movements can cause the head of the femur to pop out of the acetabular cup, leading to posterior dislocation.

Evaluate each nursing action against basic care principles and safety precautions.

Using an abduction pillow during turning safely prevents adduction, whereas elevating the bed to 90 degrees causes excessive flexion.

Basic care and comfort measures must be adapted to integrate safe post-procedure positioning.

Key Concept

Postoperative positioning and safety in basic care

Question 1165Question →

A nurse is assessing a client who experienced an acute anterior myocardial infarction $24$ hours ago. Which of the following clinical findings indicate that the client is developing cardiogenic shock? Select all that apply.

Select all that apply

Urine output of

15

mL over the past hour

Sudden onset of restlessness and agitation

Warm, flushed skin in the distal extremities

Arterial blood gas showing a pH of

7.50

\text{PaCO}_2

40

mm Hg, and

\text{HCO}_3^-

32

mEq/L

Show answer & explanation

Answer: Urine output of $15$ mL over the past hour; Sudden onset of restlessness and agitation

Answer

The clinical findings that indicate developing cardiogenic shock are a urine output of 15 mL over the past hour and a sudden onset of restlessness and agitation.

Cardiogenic shock occurs when severe myocardial damage reduces cardiac output, compromising systemic perfusion. A urine output of

15

mL over the past hour indicates inadequate renal blood flow, prompting the kidneys to retain fluid. A sudden onset of restlessness and agitation is a sensitive, early indicator of decreased cerebral perfusion and hypoxia. Both findings signal failing compensatory mechanisms and worsening shock.

Step-by-Step Solution

Identify the primary physiological risk for the client.

The client is at high risk for cardiogenic shock due to compromised left ventricular function following a large anterior myocardial infarction.

Myocardial damage impairs the heart's pumping ability, which can severely reduce cardiac output and systemic perfusion.

Analyze each assessment finding to determine if it reflects decreased cardiac output.

Oliguria (

15

mL/hr) reflects poor renal blood flow, and new-onset agitation reflects early cerebral hypoxia. Both are direct consequences of falling cardiac output.

During early shock, blood is shunted away from the kidneys (lowering urine output), and the brain is highly sensitive to even mild decreases in oxygen delivery.

Evaluate the remaining options to rule out distractors.

The skin temperature finding and the ABG values do not align with the hemodynamics of cardiogenic shock.

Cardiogenic shock triggers compensatory vasoconstriction (causing cool, clammy skin) and anaerobic metabolism (causing metabolic acidosis, not alkalosis).

Key Concept

Early Assessment of Cardiogenic Shock

Question 1166Question →

A registered nurse is assigned to care for a client who is receiving a continuous intravenous infusion of $0.45\%$ sodium chloride. The healthcare provider prescribes a new intravenous (IV) push medication for the client. Which action represents the most critical safety check before injecting the medication into the existing IV line?

Confirm the compatibility of the new medication with the infusing

0.45\%

sodium chloride solution.

Assign an unlicensed assistive personnel (UAP) to monitor the insertion site for redness or swelling.

Stop the continuous fluid for

30\text{ minutes}

prior to the injection to clear the IV tubing.

Calculate the IV tubing drop factor to determine the precise injection speed for the medication.

Show answer & explanation

Answer: Confirm the compatibility of the new medication with the infusing $0.45\%$ sodium chloride solution.

Answer

The nurse must confirm the compatibility of the new medication with the infusing

0.45\%

sodium chloride solution.

When administering an IV push medication into an existing continuous IV line, the nurse must first verify that the new medication is compatible with the infusing fluid. Mixing incompatible medications or fluids in the IV tubing can result in crystallization or precipitation, which can cause a severe adverse event such as an embolism. Ensuring compatibility is a fundamental standard of medication safety.

Step-by-Step Solution

Analyze the clinical scenario.

The nurse is preparing to administer an IV push medication through a line that already contains an infusing continuous fluid.

Understanding the route and current state of the IV line is essential for safe medication administration.

Identify potential patient safety risks.

Mixing two different intravenous substances carries a high risk of incompatibility, which can lead to precipitation in the IV tubing.

Patient safety relies on preventing adverse drug interactions before they reach the bloodstream.

Determine the priority nursing action.

The nurse must consult a drug reference guide or pharmacist to verify that the IV push medication and the continuous IV fluid are safe to mix.

Verifying compatibility is the mandatory first step before administering concurrent IV therapies in the same line.

Key Concept

Intravenous Medication Compatibility

Estimated Time:1m 0s

Question 1167Question →

A nurse is evaluating the arterial blood gas (ABG) results of an adult client admitted with an acute asthma exacerbation. Which of the following laboratory values indicate that the client is experiencing uncompensated respiratory acidosis? Select all that apply.

Select all that apply

pH of 7.28

PaCO2 of 56 mm Hg

HCO3- of 24 mEq/L

pH of 7.46

PaCO2 of 32 mm Hg

Show answer & explanation

Answer: pH of 7.28; PaCO2 of 56 mm Hg; HCO3- of 24 mEq/L

Answer

The laboratory values that confirm uncompensated respiratory acidosis are a pH of 7.28, a PaCO2 of 56 mm Hg, and an HCO3- of 24 mEq/L.

Uncompensated respiratory acidosis is characterized by three fundamental criteria: a low pH (below 7.35) confirming acidemia, an elevated PaCO2 (above 45 mm Hg) demonstrating respiratory dysfunction due to carbon dioxide retention, and a normal bicarbonate level (22-26 mEq/L) indicating that the renal system has not yet initiated a compensatory metabolic response.

Step-by-Step Solution

Analyze the pH to determine if the primary disturbance is acidosis or alkalosis.

The correct finding must be a pH less than 7.35.

The normal pH range is 7.35 to 7.45. Any value below 7.35 definitively establishes an acidotic state in the blood.

Examine the PaCO2 level to identify if the acidosis has a respiratory origin.

The correct finding must be a PaCO2 greater than 45 mm Hg.

Because carbon dioxide acts as an acid in the body, alveolar hypoventilation leads to CO2 retention. This establishes the respiratory component of the disorder.

Evaluate the HCO3- level to determine the presence or absence of metabolic compensation.

The correct finding must be an HCO3- within the normal range of 22 to 26 mEq/L.

An uncompensated state means the kidneys have not yet started to retain excess bicarbonate to offset the high acid levels in the blood.

Key Concept

Interpretation of uncompensated respiratory acidosis requires identifying a low pH (acidemia), an elevated PaCO2 (respiratory origin), and a normal HCO3- (lack of renal compensation).

Estimated Time:1m 0s

Question 1168Question →

A nurse is preparing to feed a client who has dysphagia and left-sided facial weakness following the surgical resection of a brain tumor. Arrange the following nursing actions in the correct chronological sequence to prevent aspiration and promote safe swallowing. All options must be used.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The sequence must prioritize immediate airway protection through initial positioning, utilize the client's intact neurological function for feeding, apply a protective swallowing maneuver, verify complete swallowing, and finally maintain post-meal aspiration precautions.

Feeding a client with dysphagia and unilateral weakness requires a strict, chronological approach centered entirely on airway protection. The nurse must first establish safe positioning (high-Fowler's). Next, food is placed specifically on the unaffected side to maximize mechanical control of the bolus. The client then utilizes a compensatory swallowing technique (chin-tuck) to anatomically protect the airway. Immediate post-swallow assessment is critical to check for pocketing on the weak side. Finally, upright post-meal positioning is maintained for an extended period to prevent reflux and delayed aspiration.

Step-by-Step Solution

Elevate the head of the bed to 90 degrees.

The client is positioned optimally upright before the meal begins.

Prevents reflux and establishes baseline airway protection before introducing any food.

Place a small amount of food on the right side of the oral cavity.

The bolus is placed on the unaffected, stronger side of the mouth.

Allows the client to sense and control the food using intact facial muscles, as the left side is weak.

Instruct the client to flex the neck and tuck the chin against the chest.

The airway opening is anatomically protected at the exact moment of the swallow.

Narrows the laryngeal inlet to prevent the bolus from entering the trachea during the swallowing reflex.

Inspect the left buccal cavity for pocketed food.

The affected side of the mouth is cleared of hidden residual food.

Prevents delayed silent aspiration caused by leftover food falling into the airway post-swallow.

Maintain the upright seated position for at least 30 minutes.

The client remains safe during initial digestion.

Prevents gastroesophageal reflux which could lead to delayed aspiration of stomach contents.

Key Concept

Aspiration prevention and safe feeding techniques for clients with dysphagia and unilateral neurological weakness.

Question 1169Question →

A nurse is caring for a client with a central venous access device (CVAD) that is completely occluded. The healthcare provider has prescribed alteplase to declot the line. Arrange the following steps for administering this thrombolytic agent in the correct chronological sequence. All steps must be used.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first assess for mechanical obstruction, then instill the alteplase using negative pressure, allow it to dwell for 30 to 120 minutes, aspirate the drug and clot, and finally flush the restored line with normal saline.

Safe administration of a thrombolytic for CVAD clearance requires a specific sequence to protect the patient from emboli and systemic bleeding. The nurse must first confirm the occlusion, use negative pressure to safely draw the drug into the lumen, allow sufficient dwell time for fibrinolysis, aspirate the dissolved clot and medication to prevent systemic administration, and finally flush with saline to clear the line.

Step-by-Step Solution

Assess the catheter for mechanical obstruction by attempting to aspirate blood and flush with 0.9% sodium chloride.

The nurse confirms the occlusion is thrombotic and rules out simple mechanical issues.

Pharmacological declotting should only be attempted after confirming a true intraluminal occlusion.

Instill the prescribed dose of alteplase into the occluded lumen using a negative-pressure technique.

The alteplase enters the catheter lumen without causing catheter rupture.

Applying positive pressure to an occluded line can rupture the catheter or dislodge a clot systemically. Negative pressure safely draws the medication in.

Allow the thrombolytic solution to dwell inside the catheter lumen for 30 to 120 minutes.

The alteplase converts plasminogen to plasmin, breaking down the fibrin matrix of the clot.

Thrombolytics require time to enzymatically dissolve the thrombosis.

Aspirate the medication and dissolved clot remnants until 4 to 5 mL of blood is returned.

The drug and clot fragments are safely removed from the catheter.

Flushing the medication into the systemic circulation poses a severe bleeding risk and could release emboli into the bloodstream.

Vigorously flush the cleared catheter lumen with 10 to 20 mL of sterile 0.9% sodium chloride.

The catheter is cleared of residual blood and patency is verified.

A final flush ensures the line is fully restored and safe for subsequent infusions.

Key Concept

Management of Central Venous Access Device (CVAD) Occlusion

Question 1170Question →

A client weighing $198\text{ lb}$ is receiving a continuous intravenous (IV) heparin infusion for the treatment of a deep vein thrombosis. The client's morning activated partial thromboplastin time (aPTT) is reported as $42\text{ seconds}$ . According to the facility's weight-based heparin protocol, for this aPTT result, the nurse must administer an IV push bolus of $40\text{ units/kg}$ and increase the continuous infusion rate by $2\text{ units/kg/hr}$ . The continuous IV infusion is currently running at $14\text{ units/kg/hr}$ . The pharmacy provides a premixed heparin bag containing $25,000\text{ units}$ in $250\text{ mL}$ of $0.9\%$ sodium chloride, and a separate heparin vial containing $1,000\text{ units/mL}$ for the bolus dose.

After administering the required bolus, at what rate in $\text{mL/hr}$ should the nurse set the IV pump for the new continuous infusion? (Record your answer to the nearest tenth.)

Show answer & explanation

Answer: 14.4

Answer

14.4

To find the correct continuous infusion rate, the nurse must first convert the client's weight to kilograms (

198 \div 2.2 = 90\text{ kg}

). Next, determine the new infusion rate by adding the

2\text{ units/kg/hr}

protocol increase to the current

14\text{ units/kg/hr}

rate, resulting in

16\text{ units/kg/hr}

. Multiply this rate by the client's weight to find the total hourly dose (

16 \times 90 = 1440\text{ units/hr}

). Finally, calculate the required volume from the continuous infusion bag (which has a concentration of

100\text{ units/mL}

) by dividing the hourly dose by the concentration (

1440 \div 100 = 14.4\text{ mL/hr}

Step-by-Step Solution

Convert the client's weight from pounds to kilograms.

90\text{ kg}

Medication dosing in the protocol is weight-based in kg (

198 \div 2.2 = 90

Determine the new prescribed continuous infusion rate.

16\text{ units/kg/hr}

The protocol requires adding

2\text{ units/kg/hr}

to the current rate of

14\text{ units/kg/hr}

Calculate the total units per hour required.

1440\text{ units/hr}

Multiply the new rate (

16\text{ units/kg/hr}

) by the client's weight (

90\text{ kg}

Determine the concentration of the continuous heparin bag.

100\text{ units/mL}

Divide the total units in the bag (

25,000\text{ units}

) by the total volume (

250\text{ mL}

Calculate the new IV pump rate in mL/hr.

14.4\text{ mL/hr}

Divide the hourly unit requirement (

1440\text{ units/hr}

) by the bag concentration (

100\text{ units/mL}

Key Concept

Weight-Based Intravenous Medication Titration

Question 1171Question →

A nurse is preparing to administer a large-volume cleansing enema to an adult client who is experiencing severe constipation. Arrange the following steps of the procedure in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first position the client, then prepare for insertion by donning gloves and lubricating the tip. Next, the nurse inserts the tip while the client exhales, elevates the bag to the correct height to begin infusion, and finally manages any potential cramping by clamping the tubing.

This sequence ensures patient safety, anatomical alignment, and procedure effectiveness. Positioning the client first ensures the descending colon is optimally oriented. Donning gloves and lubricating immediately prior to insertion prevents contamination. Exhaling during insertion relaxes the sphincter, and properly elevating the bag controls the fluid pressure. Finally, anticipating and reacting to cramping by clamping the tube represents safe intra-procedure monitoring.

Step-by-Step Solution

Assist the client into the left lateral Sims position with the right knee flexed.

The client's gastrointestinal tract is anatomically aligned for the procedure.

This position allows gravity to help the enema solution flow smoothly into the sigmoid and descending colon.

Don clean gloves and apply a water-soluble lubricant to the tip of the enema tubing.

The equipment is prepared for safe insertion while maintaining infection control.

Lubrication reduces friction, preventing trauma to the rectal mucosa. Doing this after positioning prevents accidental contamination of the tip.

Instruct the client to breathe out slowly while inserting the tip 3 to 4 inches into the rectum.

The tip is safely advanced into the adult rectum without excessive resistance.

Exhaling relaxes the external anal sphincter, reducing discomfort and minimizing the risk of tissue injury during insertion.

Elevate the enema container 12 to 18 inches above the level of the anus and unclamp the tubing.

The solution begins to flow into the colon at a safe, controlled rate.

This specific height limits the hydrostatic pressure. Holding the bag too high forces fluid in too rapidly, causing severe distention and pain.

Clamp the tubing temporarily if the client reports fullness or abdominal cramping.

The instillation is safely paused, relieving the client's discomfort.

Cramping is a sign of rapid bowel distention. Stopping the flow allows the intestinal muscles to relax, preventing premature expulsion of the fluid.

Key Concept

Safe administration of a large-volume cleansing enema

Estimated Time:1m 30s

Question 1172Question →

A nurse is preparing to assess an adult client for orthostatic hypotension to determine their risk for falls. In what order should the nurse perform the following actions to ensure accurate results?

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first have the client rest supine for 5 to 10 minutes, then measure baseline vital signs, assist the client to a standing position, and finally wait 1 to 3 minutes before reassessing vital signs.

The correct sequence ensures that an accurate physiological baseline is established at rest, followed by a controlled postural change. Providing a 1 to 3 minute delay before the final measurement is critical to allow the body's compensatory mechanisms time to act, ensuring an accurate diagnosis of orthostatic hypotension.

Step-by-Step Solution

Instruct the client to lie flat in a supine position for 5 to 10 minutes.

The cardiovascular system stabilizes at a resting baseline.

Recent movement or position changes can falsely elevate vital signs, which would skew the baseline comparison.

Measure the client's blood pressure and heart rate while supine.

Baseline control metrics are obtained.

These initial measurements are required to calculate any pathological drop in blood pressure or spike in heart rate upon standing.

Assist the client safely to a standing position.

A sudden gravitational shift of blood to the lower extremities occurs.

This physical maneuver tests the autonomic nervous system's ability to maintain adequate cardiac output and vascular tone.

Wait 1 to 3 minutes, then take a second blood pressure and heart rate measurement.

The final diagnostic values are recorded.

Measuring immediately upon standing may yield false-negative results; waiting allows time to observe if compensatory mechanisms fail.

Key Concept

Orthostatic Blood Pressure Measurement Sequence

Question 1173Question →

A 68-year-old client with severe osteoarthritis arrives on the orthopedic unit after undergoing a right total hip arthroplasty using a posterior surgical approach. The client is drowsy but responsive, with stable vital signs. Which action must the nurse prioritize to prevent dislocation of the new joint prosthesis?

Place an abductor wedge pillow between the client's legs while the client is supine.

Elevate the head of the bed to a 90-degree angle during meal times.

Turn the client onto the unaffected left side with both legs resting together.

Delegate the client's initial out-of-bed transfer to the unlicensed assistive personnel.

Show answer & explanation

Answer: Place an abductor wedge pillow between the client's legs while the client is supine.

Answer

The nurse must prioritize placing an abductor wedge pillow between the client's legs while the client is supine.

Placing an abductor wedge pillow between the legs is essential because it actively prevents adduction of the operative hip across the body's midline. Following a posterior approach total hip arthroplasty, avoiding adduction, internal rotation, and extreme flexion (greater than 90 degrees) is critical to reduce the risk of the prosthesis dislocating from the newly formed acetabulum.

Step-by-Step Solution

Identify the surgical procedure and its specific postoperative risks.

The client had a total hip arthroplasty via a posterior approach, which carries a high risk of joint dislocation if proper alignment is not maintained.

Understanding the surgical approach determines which specific movements are contraindicated in the postoperative period.

Recall the standard posterior hip precautions used to reduce the risk of dislocation.

The client must avoid hip flexion greater than 90 degrees, adduction of the leg across the body's midline, and internal rotation of the hip.

These specific movements place excessive mechanical stress on the posterior capsule, potentially forcing the femoral head out of the acetabulum.

Evaluate the given interventions against these strict precautions.

Placing an abductor wedge actively prevents adduction. The other options violate positional precautions or represent an unsafe delegation of initial mobility.

Selecting the intervention that directly aligns with established hip precautions actively reduces the physiological risk of joint dislocation.

Key Concept

Reduction of Risk Potential: Posterior Hip Precautions

Question 1174Question →

A nurse is evaluating a newly hired colleague who is preparing to administer an intravenous (IV) push medication into a client's existing primary IV line. Which actions by the newly hired colleague demonstrate safe parenteral medication administration? (Select all that apply.)

Select all that apply

Consulting a drug reference guide to confirm the medication can safely mix with the primary IV fluid

Flushing the injection port with a compatible solution immediately before and after the medication is given

Using a timepiece to carefully monitor the rate of administration according to manufacturer guidelines

Assuming the medication and primary fluid are compatible as long as no visible crystals form in the tubing

Administering the medication as quickly as possible to minimize the client's discomfort during the procedure

Show answer & explanation

Answer: Consulting a drug reference guide to confirm the medication can safely mix with the primary IV fluid; Flushing the injection port with a compatible solution immediately before and after the medication is given; Using a timepiece to carefully monitor the rate of administration according to manufacturer guidelines

Answer

The correct actions include consulting a drug reference guide to confirm compatibility, flushing the injection port with a compatible solution before and after administration, and using a timepiece to monitor the rate of administration.

Safe administration of intravenous push medications requires verifying chemical compatibility with a reliable reference, flushing the line to ensure the medication clears the tubing and does not mix with incompatible fluids, and timing the injection accurately to prevent systemic adverse reactions.

Step-by-Step Solution

Identify the core requirements for safe intravenous push (IVP) medication administration.

Safe IVP requires compatibility verification, appropriate line flushing, and precise rate control.

Direct injection delivers medication immediately into the bloodstream, requiring strict adherence to safety protocols to prevent adverse reactions.

Evaluate each proposed action against evidence-based parenteral therapy standards.

Using a drug reference, flushing the line, and timing the push are correct safe practices. Relying on visual checks for compatibility and pushing the medication quickly are unsafe practices.

Visible clarity does not rule out chemical incompatibility, and rapid administration can cause speed shock.

Key Concept

Safe administration of intravenous push medications

Question 1175Question →

A nurse is caring for a client who is receiving intravenous fluid therapy via a subclavian central venous catheter. The nurse enters the room and observes that the intravenous tubing has disconnected from the catheter hub. The client is suddenly grasping their chest, gasping for air, and appears cyanotic. Arrange the following nursing interventions in the priority sequence they should be performed, from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first clamp the catheter, then place the client in a left lateral Trendelenburg position, administer high-flow oxygen, activate the rapid response team, and finally assess vital signs and heart sounds.

The correct priority sequence adheres to the principles of basic life support and emergency source control. When an air embolism occurs, the immediate priority is to stop further air from entering by clamping the line. The second immediate priority is positional (Durant's maneuver) to prevent the air already in the system from blocking pulmonary circulation. Once the immediate mechanical threats are mitigated, the nurse supports oxygenation, calls for advanced help, and then performs a comprehensive assessment.

Step-by-Step Solution

Clamp the central venous catheter immediately.

Stops further atmospheric air from entering the circulatory system.

Source control is the absolute highest priority in an emergency to prevent the condition from rapidly worsening. Even a few seconds of delay can allow a fatal amount of air to enter.

Place the client in a left lateral Trendelenburg position.

Traps the air bubble in the apex of the right ventricle.

This specific anatomical position (Durant's maneuver) prevents the air from migrating into the pulmonary artery, avoiding a deadly right ventricular outflow tract obstruction.

Administer 100% supplemental oxygen via a nonrebreather mask.

Increases blood oxygenation and helps shrink the air embolus.

High-flow oxygen treats the resulting hypoxemia and creates a nitrogen concentration gradient that promotes the rapid resorption of the air bubble into the blood.

Activate the rapid response team and notify the healthcare provider.

Summons advanced medical support and resources.

Once immediate independent stabilizing interventions have been performed, the nurse must obtain help for further medical management, such as potential aspiration of the air from the central line.

Obtain a complete set of vital signs and auscultate heart sounds.

Establishes a post-intervention hemodynamic baseline and identifies clinical signs.

After securing the airway, breathing, circulation, and calling for help, the nurse assesses the client's current status, listening for a classic 'mill wheel' murmur that confirms air in the heart.

Key Concept

Prioritization of care during a suspected central line air embolism.

Question 1176Question →

A client receiving continuous enteral nutrition via a nasogastric (NG) tube has just returned to the medical-surgical unit following a diagnostic lumbar puncture. The healthcare provider has prescribed strict flat bed rest for 6 hours to minimize the risk of a post-dural puncture headache. Which nursing action safely integrates the client's continuous nutritional requirements with the prescribed post-procedure positioning?

Adjust the entire bed frame into a reverse Trendelenburg position while continuing the feeding.

Elevate the head of the bed to 30 degrees using the upper mattress articulation controls.

Maintain the bed completely horizontal and continue the enteral infusion at a 50% reduced rate.

Delegate continuous monitoring of the client's respiratory status during horizontal feeding to an unlicensed assistive personnel.

Show answer & explanation

Answer: Adjust the entire bed frame into a reverse Trendelenburg position while continuing the feeding.

Answer

Adjust the entire bed frame into a reverse Trendelenburg position while continuing the feeding.

The client has competing physiologic needs: maintaining a flat spinal alignment to prevent cerebrospinal fluid leakage post-lumbar puncture, while simultaneously requiring head elevation to prevent pulmonary aspiration of continuous enteral feedings. The reverse Trendelenburg position tilts the entire bed frame so the head is elevated relative to the feet without bending the spinal column. This brilliantly satisfies the requirement for a flat anatomical alignment while safely utilizing gravity to prevent reflux and aspiration.

Step-by-Step Solution

Identify the competing physiological safety requirements for the client.

The client requires a flat spinal alignment to prevent cerebrospinal fluid leakage (lumbar puncture protocol) and concurrent head elevation to prevent aspiration (continuous NG feeding protocol).

Recognizing contradictory standard protocols is essential before implementing basic care interventions.

Evaluate standard positioning interventions against both clinical constraints.

Articulating the head of the bed bends the spine, violating the post-lumbar puncture protocol. Lying completely horizontal causes a severe reflux risk, violating the enteral feeding protocol.

Standard single-condition interventions become unsafe when multiple complex physiologic constraints overlap.

Select the specialized positioning intervention that simultaneously satisfies all safety constraints.

The reverse Trendelenburg position is implemented, which tilts the entire bed plane.

This elevates the head relative to the stomach to utilize gravity against reflux, while keeping the entire spinal column in a straight, non-articulated alignment.

Key Concept

Safe positioning integration for continuous enteral nutrition and strict spinal precautions.

Question 1177Question →

A client on a medical-surgical unit has a hemoglobin level of 6.8 g/dL (68 g/L) and is prescribed a transfusion of packed red blood cells (PRBCs). The client has a single 20-gauge peripheral intravenous (IV) catheter, which is currently infusing a continuous maintenance fluid of 5% dextrose in water (D5W) at 75 mL/hr. What is the most appropriate action by the nurse?

Stop the continuous D5W infusion, flush the IV catheter with 0.9% sodium chloride, and initiate the blood transfusion.

Attach the blood administration set to the lowest Y-site of the active D5W infusion.

Start the blood transfusion immediately and take the first set of vital signs 15 minutes after initiation.

Request a prescription for a central venous access device, as a 20-gauge catheter is too small for PRBCs.

Show answer & explanation

Answer: Stop the continuous D5W infusion, flush the IV catheter with 0.9% sodium chloride, and initiate the blood transfusion.

Answer

The nurse must stop the D5W infusion, flush the line with 0.9% sodium chloride, and then administer the PRBCs.

Blood products can only be safely infused with 0.9% sodium chloride (normal saline). Solutions containing dextrose (like D5W) or lactated Ringer's will cause red blood cells to hemolyze or clot. When a client only has one adequate IV site (a 20-gauge is appropriate for blood), the nurse must stop the incompatible continuous fluid, clear the catheter completely with a normal saline flush, and then initiate the transfusion.

Step-by-Step Solution

Identify the compatibility of the prescribed blood product with the current continuous IV fluid.

Packed red blood cells (PRBCs) are incompatible with 5% dextrose in water (D5W).

Dextrose solutions cause red blood cell hemolysis and clumping.

Determine the adequacy of the current IV access for the prescribed therapy.

A 20-gauge peripheral IV catheter is adequate for PRBC administration in an adult.

18- to 20-gauge catheters provide sufficient lumen size to prevent mechanical damage to the red blood cells during infusion.

Formulate a safe administration plan utilizing the single IV access.

The nurse will stop the D5W, flush the line with 0.9% sodium chloride (normal saline) to clear the dextrose, and then connect the blood administration set.

Normal saline is the only IV fluid compatible with blood products. Flushing the line ensures no incompatible fluid comes into contact with the PRBCs.

Key Concept

Blood products must only be administered with 0.9% sodium chloride to prevent hemolysis, and a 20-gauge IV is sufficient for administration.

Question 1178Question →

A nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation. The ventilator settings include a positive end-expiratory pressure (PEEP) of 15 cm $H_2O$ . The most recent arterial blood gas (ABG) analysis indicates a pH of $7.29$ , $PaCO_2$ of $54$ mm Hg, $HCO_3^-$ of $25$ mEq/L, and $PaO_2$ of $62$ mm Hg. Over the last $10$ minutes, the client's blood pressure drops rapidly from $115/72$ mm Hg to $82/48$ mm Hg, and the heart rate increases from $95$ to $132$ bpm. Which action should the nurse implement first to reduce the client's risk of imminent physiological collapse?

Place the client in a Trendelenburg position to rapidly increase venous return and systemic blood pressure.

Auscultate bilateral lung sounds and evaluate chest excursion to assess for a suspected tension pneumothorax.

Administer an intravenous bolus of sodium bicarbonate to correct the uncompensated metabolic acidosis.

Perform immediate endotracheal suctioning to clear airway resistance that is causing the acute hypercapnia.

Show answer & explanation

Answer: Auscultate bilateral lung sounds and evaluate chest excursion to assess for a suspected tension pneumothorax.

Answer

The nurse must first auscultate bilateral lung sounds and evaluate chest excursion to determine if the client has developed a tension pneumothorax.

The correct action prioritizes focused physical assessment to identify a life-threatening complication of high PEEP. Clients with ARDS requiring high levels of PEEP are at extreme risk for barotrauma, such as a tension pneumothorax. The sudden onset of profound hypotension and tachycardia strongly suggests this complication, as the trapped air increases intrathoracic pressure and severely impairs venous return to the heart. Auscultating for absent or diminished breath sounds is the critical first step to confirm this diagnosis before preparing for emergency needle decompression.

Step-by-Step Solution

Analyze the arterial blood gas (ABG) values.

The low pH (

7.29

) combined with an elevated

PaCO_2

(

54

mm Hg) and a normal

HCO_3^-

(

25

mEq/L) indicates uncompensated respiratory acidosis.

Establishing the baseline acid-base status prevents inappropriate treatments for metabolic imbalances.

Evaluate the sudden change in the client's hemodynamic status.

The client has developed acute hypotension (

82/48

mm Hg) and significant tachycardia (

132

bpm).

Sudden hemodynamic instability in an intubated client signals severely decreased cardiac output, requiring immediate investigation of the root cause.

Correlate the mechanical ventilation settings with the new assessment findings.

The use of high PEEP (15 cm

H_2O

) places the client at an extreme risk for barotrauma, specifically alveolar rupture leading to a tension pneumothorax.

A tension pneumothorax traps air in the pleural space, severely increasing intrathoracic pressure, which compresses the vena cava, restricts venous return, and causes rapid circulatory collapse.

Determine the safest priority nursing intervention.

Physical assessment of the lungs (auscultation and observation of chest excursion) is selected as the immediate first step.

Confirming the presence of absent or diminished breath sounds on one side is clinically required before preparing the client for an emergency needle decompression or chest tube insertion.

Key Concept

Complications of Mechanical Ventilation: Barotrauma and Hemodynamic Compromise

Question 1179Question →

A client admitted with severe sepsis is receiving a continuous intravenous (IV) infusion of piperacillin/tazobactam through a peripheral IV catheter. The healthcare provider prescribes a scheduled dose of IV vancomycin $1,500\text{ mg}$ . The pharmacy dispenses the vancomycin in a $300\text{ mL}$ bag of $0.9\%$ sodium chloride. Institutional protocol requires vancomycin doses greater than $1,000\text{ mg}$ to be infused over a minimum of $90\text{ minutes}$ to prevent adverse infusion reactions. The client has only one patent peripheral IV line. Which of the following is the most appropriate nursing action?

Pause the piperacillin/tazobactam infusion, flush the IV line thoroughly with

0.9\%

sodium chloride, and infuse the vancomycin using a pump set at

200\text{ mL/hr}

Connect the vancomycin tubing as a secondary piggyback to the most proximal Y-site on the piperacillin/tazobactam line and infuse at

200\text{ mL/hr}

Pause the piperacillin/tazobactam infusion, flush the line with

0.9\%

sodium chloride, and set the vancomycin infusion pump to

300\text{ mL/hr}

Withhold the vancomycin dose and notify the provider to request a prescription for oral vancomycin to avoid interrupting the continuous antibiotic infusion.

Show answer & explanation

Answer: Pause the piperacillin/tazobactam infusion, flush the IV line thoroughly with $0.9\%$ sodium chloride, and infuse the vancomycin using a pump set at $200\text{ mL/hr}$ .

Answer

The correct action is to pause the primary continuous infusion of piperacillin/tazobactam, thoroughly flush the line with normal saline, infuse the vancomycin at the correctly calculated rate of

200\text{ mL/hr}

, and then flush again before restarting the primary infusion.

Piperacillin/tazobactam and vancomycin are physically incompatible and will form a precipitate if mixed in the same IV tubing. Because the client only has one peripheral access site, the nurse must use the stop-flush-administer-flush-restart method to ensure the medications never come into contact. Additionally, the nurse must correctly calculate the infusion rate to meet the 90-minute protocol. To administer a

300\text{ mL}

volume over

90\text{ minutes}

(

1.5\text{ hours}

), the pump must be set to

200\text{ mL/hr}

(

300 \div 1.5 = 200

). This ensures the vancomycin is given safely and prevents vancomycin flushing syndrome (previously known as Red Man syndrome).

Step-by-Step Solution

Evaluate the compatibility of the prescribed intravenous medications.

Vancomycin and piperacillin/tazobactam are physically incompatible at the Y-site.

When mixed, these two medications form a visible precipitate that can occlude the catheter or cause a fatal embolus, meaning they cannot run concurrently.

Determine the proper administration technique for a single IV line.

The nurse must use the stop-flush-administer-flush-restart sequence.

Flushing the line with a neutral compatible fluid (like

0.9\%

sodium chloride) before and after the secondary medication prevents the incompatible drugs from ever coming into contact.

Calculate the correct infusion pump rate in mL/hr.

The pump should be set to

200\text{ mL/hr}

The formula is

\frac{\text{Total Volume}}{\text{Time in hours}}

. Converting

90\text{ minutes}

1.5\text{ hours}

\frac{300\text{ mL}}{1.5\text{ hours}} = 200\text{ mL/hr}

Key Concept

IV Medication Incompatibility Management and Infusion Rate Calculation

Estimated Time:1m 30s

Question 1180Question →

During the management of a critically ill adult in the intensive care unit, a triple-lumen central venous catheter (CVC) is utilized for multiple continuous infusions. The client's distal lumen is infusing epinephrine to maintain hemodynamic stability, the medial lumen is reserved for continuous total parenteral nutrition (TPN), and the proximal lumen is delivering a standard heparin protocol. Suddenly, the cardiac monitor displays symptomatic supraventricular tachycardia (SVT), and the healthcare provider prescribes an immediate dose of adenosine via rapid intravenous push. Which parenteral administration technique represents the safest clinical judgment?

Pause the heparin infusion, aspirate blood from the proximal lumen to clear residual medication, flush with 0.9% sodium chloride, rapidly administer the adenosine followed by a 20 mL flush, and restart the heparin.

Pause the epinephrine infusion, administer the adenosine rapidly through the distal lumen's most proximal injection port, follow immediately with a 20 mL flush, and restart the epinephrine.

Administer the adenosine rapidly through the Y-site of the medial lumen without pausing the TPN, utilizing the continuous flow to assist in pushing the medication centrally.

Withhold the adenosine until another clinician can establish a large-bore peripheral intravenous catheter in the antecubital fossa to prevent disrupting the critical central infusions.

Show answer & explanation

Answer: Pause the heparin infusion, aspirate blood from the proximal lumen to clear residual medication, flush with 0.9% sodium chloride, rapidly administer the adenosine followed by a 20 mL flush, and restart the heparin.

Answer

The safest method is to pause the heparin infusion, aspirate the residual drug from the proximal lumen, flush with saline, administer the adenosine, flush again, and restart the heparin.

The option describing pausing the heparin, aspirating the line, and flushing before and after administration is correct because it identifies the only safe lumen to use. Aspiration is critical; it removes the residual heparin in the catheter's dead space, preventing an accidental bolus. A brief pause in heparin therapy will not harm the client, and this route provides the necessary central access for a drug with an ultra-short half-life like adenosine.

Step-by-Step Solution

Analyze the pharmacological properties of the prescribed emergency medication.

Adenosine has an ultra-short half-life (under 10 seconds) and requires rapid IV push followed immediately by a rapid flush. Central venous access is highly advantageous for delivery directly to the heart.

Understanding the pharmacokinetic requirements dictates the need for the fastest and most direct intravenous route available.

Evaluate the safety of utilizing the distal lumen infusing epinephrine.

The catheter tubing (dead space) is filled with concentrated epinephrine. Flushing this line to push adenosine would simultaneously deliver a massive bolus of epinephrine into the central circulation.

Administering a bolus of a potent chronotropic/vasopressor agent to a client in symptomatic SVT could trigger a lethal hypertensive crisis or myocardial infarction. This lumen is contraindicated for flushing.

Evaluate the safety of utilizing the medial lumen infusing TPN.

Standard parenteral therapy protocols strictly prohibit administering IV push medications through a TPN line due to extreme incompatibility risks, lipid emulsion destabilization, and high infection rates.

Maintaining the integrity of a dedicated TPN line is a core patient safety standard.

Determine the optimal management of the proximal lumen infusing heparin.

Heparin has a comparatively longer half-life and does not cause immediate hemodynamic collapse if paused for one minute. By pausing the infusion and aspirating the blood/drug from the dead space, the nurse safely clears the lumen.

Aspiration prevents an unintended heparin bolus. This provides a safe, clear central pathway for the emergency administration of adenosine without delaying care to start a peripheral line.

Key Concept

Central Venous Catheter Dead Space and High-Alert Medication Compatibility

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