Physiological Integrity

1960 questions

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A client with severe gastroenteritis is admitted with a serum potassium level of $2.7 \text{ mEq/L}$ ( $2.7 \text{ mmol/L}$ ). The healthcare provider prescribes an intravenous (IV) infusion of $40 \text{ mEq}$ ( $40 \text{ mmol}$ ) of potassium chloride (KCl) diluted in $250 \text{ mL}$ of $0.9\%$ sodium chloride to be administered via a peripheral intravenous catheter. Which of the following nursing actions are required for the safe administration of this medication? (Select all that apply.)

Select all that apply

Administer the infusion via a programmable electronic infusion pump.

Assess renal function by verifying a urine output of at least

30 \text{ mL/hr}

Ensure the infusion rate does not exceed

10 \text{ mEq}

per hour.

Administer the prescribed dose as a rapid intravenous (IV) push in the event of life-threatening arrhythmias.

Piggyback the potassium chloride solution into an IV line currently transfusing packed red blood cells.

Show answer & explanation

Answer: Administer the infusion via a programmable electronic infusion pump.; Assess renal function by verifying a urine output of at least $30 \text{ mL/hr}$ .; Ensure the infusion rate does not exceed $10 \text{ mEq}$ per hour.

Answer

The nurse must use a programmable electronic infusion pump, verify a minimum urine output of

30 \text{ mL/hr}

, and ensure the peripheral infusion rate does not exceed

10 \text{ mEq}

per hour.

The correct actions for safe intravenous potassium administration include using an electronic volumetric pump to ensure a precise delivery rate and prevent an accidental bolus. Verifying a urine output of at least

30 \text{ mL/hr}

is critical because potassium is primarily excreted by the kidneys; oliguria can quickly lead to fatal hyperkalemia. Furthermore, the standard safety guideline for infusing potassium through a peripheral line is to never exceed a rate of

10 \text{ mEq/hr}

to prevent cardiac toxicity and severe phlebitis.

Step-by-Step Solution

Identify the high-risk nature of the prescribed medication and the route of administration.

Recognize that intravenous potassium chloride is a high-alert medication that requires strict parenteral safety protocols to prevent cardiac toxicity.

Potassium dictates cardiac muscle action potentials; rapid shifts in serum levels can cause lethal dysrhythmias.

Evaluate the physiological assessment parameters required before initiating the infusion.

Determine that renal function must be adequate (indicated by a urine output of

>30 \text{ mL/hr}

) before giving potassium.

Because potassium is excreted by the kidneys, administering it to a client with acute kidney injury or oliguria quickly leads to hyperkalemia.

Determine the safe administration equipment and maximum rate limits for a peripheral IV line.

Select an electronic volumetric pump to prevent free-flow and confirm the rate is set to

\leq 10 \text{ mEq/hr}

Gravity drip tubing is unsafe for high-alert medications, and rates

>10 \text{ mEq/hr}

through a peripheral vein cause severe tissue irritation and cardiac risk.

Identify absolute contraindications for parenteral potassium administration to rule out unsafe actions.

Rule out direct IV push administration and incompatible concurrent infusions, such as blood products.

IV push potassium causes immediate cardiac arrest. Furthermore, blood products are incompatible with medication infusions.

Key Concept

Safe Parenteral Administration of High-Alert Electrolytes (Potassium Chloride)

Estimated Time:1m 30s

Question 1262Question →

A client is admitted to the intensive care unit with severe diabetic ketoacidosis (DKA). The client is lethargic, exhibiting Kussmaul respirations, and has a blood glucose level of 520 mg/dL (28.9 mmol/L). The healthcare provider has entered multiple initial prescriptions. In what order should the nurse perform the following actions? Arrange the interventions in the correct clinical sequence from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for managing severe DKA is: 1) Initiate 0.9% sodium chloride, 2) Evaluate serum potassium level, 3) Start a continuous IV regular insulin infusion, 4) Add 5% dextrose to IV fluids when glucose drops to 250 mg/dL, and 5) Administer the first subcutaneous insulin dose before stopping the IV insulin.

The management of Diabetic Ketoacidosis (DKA) follows a strict, evidence-based sequence designed to stabilize the client and prevent life-threatening complications. The absolute immediate priority is fluid resuscitation with isotonic saline (0.9% NaCl) to restore intravascular volume and tissue perfusion resulting from severe osmotic diuresis. Second, before administering any insulin, the serum potassium level must be evaluated. Insulin administration causes an intracellular shift of potassium, which can lead to profound hypokalemia and fatal cardiac arrhythmias. Third, once a safe potassium level is verified, a continuous IV infusion of regular insulin is initiated to steadily correct the hyperglycemia and resolve the metabolic acidosis. Fourth, as the blood glucose level decreases to approximately 250 mg/dL (13.9 mmol/L), 5% dextrose is added to the IV fluid regimen to prevent a rapid drop in glucose, which could precipitate hypoglycemia and cerebral edema. Finally, once the ketoacidosis has resolved (evidenced by a normalized anion gap), the client is transitioned to a subcutaneous insulin regimen. The first subcutaneous dose must be administered prior to discontinuing the IV insulin to provide overlapping coverage and prevent a rebound into ketoacidosis.

Step-by-Step Solution

Restore intravascular volume.

Initiate a rapid intravenous infusion of 0.9% sodium chloride.

Fluid resuscitation is the immediate first priority in DKA to reverse severe dehydration caused by osmotic diuresis and to improve tissue perfusion.

Assess electrolyte status.

Evaluate the client's initial serum potassium laboratory result.

It is critical to verify the potassium level before giving insulin, as insulin therapy causes an intracellular shift of potassium, potentially leading to severe hypokalemia.

Correct hyperglycemia and acidosis.

Start a continuous intravenous infusion of regular insulin.

After fluid resuscitation has begun and potassium is confirmed to be in a safe range, IV insulin is administered to lower glucose levels and stop ketone production.

Prevent hypoglycemia and cerebral edema.

Add 5% dextrose to the intravenous fluids when blood glucose decreases to 250 mg/dL (13.9 mmol/L).

As blood glucose drops closer to normal, adding dextrose prevents a rapid fluid shift into the brain cells (cerebral edema) and avoids inducing hypoglycemia.

Transition to maintenance therapy.

Administer the first dose of subcutaneous insulin before discontinuing the intravenous insulin infusion.

Providing a subcutaneous insulin dose while the IV insulin is still running ensures continuous insulin coverage, preventing a rebound into ketoacidosis.

Key Concept

Diabetic Ketoacidosis (DKA) Acute Management Sequence

Question 1263Question →

A nurse is preparing to administer an oral suspension of an antibiotic to a pediatric client who weighs $44 \text{ lb}$ . The prescription is for $10 \text{ mg/kg/day}$ to be given in two equally divided doses. The pharmacy dispenses an oral suspension with a concentration of $50 \text{ mg/mL}$ . How many milliliters should the nurse administer per dose?

2 \text{ mL}

4 \text{ mL}

4.4 \text{ mL}

8.8 \text{ mL}

Show answer & explanation

Answer: $2 \text{ mL}$

Answer

The nurse should administer

2 \text{ mL}

per dose.

To determine the correct dose, the nurse must first convert the client's weight from pounds to kilograms (

44 \text{ lb} \div 2.2 = 20 \text{ kg}

). Next, the total daily dose is calculated (

20 \text{ kg} \times 10 \text{ mg/kg} = 200 \text{ mg/day}

). Because the medication is given in two equally divided doses, the daily dose is divided by two (

200 \text{ mg} \div 2 = 100 \text{ mg/dose}

). Finally, the nurse calculates the required volume using the available concentration (

100 \text{ mg} \div 50 \text{ mg/mL} = 2 \text{ mL}

Step-by-Step Solution

Convert the client's weight from pounds to kilograms.

44 \text{ lb} \div 2.2 \text{ lb/kg} = 20 \text{ kg}

The medication dosage is prescribed based on kilograms of body weight.

Calculate the total daily dose in milligrams.

20 \text{ kg} \times 10 \text{ mg/kg} = 200 \text{ mg/day}

This determines the total amount of medication the client needs over a 24-hour period.

Calculate the individual divided dose.

200 \text{ mg/day} \div 2 \text{ doses} = 100 \text{ mg/dose}

The prescription specifies that the daily dose must be divided into two equal doses.

Calculate the volume to administer per dose using the available concentration.

100 \text{ mg} \div 50 \text{ mg/mL} = 2 \text{ mL}

This converts the required milligram dose into the physical milliliter volume to be drawn up in the syringe.

Key Concept

Weight-Based Dosage Calculation

Question 1264Question →

The healthcare provider prescribes a continuous intravenous (IV) infusion of sodium nitroprusside at $2 \text{ mcg/kg/min}$ for a client experiencing a hypertensive emergency. The client's documented weight is $78 \text{ kg}$ . The available medication is a $250 \text{ mL}$ bag of $5\% \text{ dextrose in water}$ containing $50 \text{ mg}$ of sodium nitroprusside. At what rate, in $\text{mL/hr}$ , should the nurse set the infusion pump? Record your answer rounded to the nearest whole number.

Show answer & explanation

Answer: 47

Answer

To find the correct pump rate, perform a sequential dimensional analysis. First, calculate the total required dose per minute based on weight:

2 \text{ mcg/kg/min} \times 78 \text{ kg} = 156 \text{ mcg/min}

. Next, convert this to an hourly dose:

156 \text{ mcg/min} \times 60 \text{ min/hr} = 9360 \text{ mcg/hr}

. Convert the dose to milligrams to match the supply:

9360 \text{ mcg/hr} / 1000 \text{ mcg/mg} = 9.36 \text{ mg/hr}

. The concentration of the supplied bag is

50 \text{ mg} / 250 \text{ mL} = 0.2 \text{ mg/mL}

. Finally, dividing the hourly dose by the concentration yields the rate:

9.36 \text{ mg/hr} / 0.2 \text{ mg/mL} = 46.8 \text{ mL/hr}

. Rounding

46.8

to the nearest whole number gives

47

Step-by-Step Solution

Calculate the required dose in

\text{mcg/min}

156 \text{ mcg/min}

Multiply the prescribed dose (

2 \text{ mcg/kg/min}

) by the client's weight (

78 \text{ kg}

) to determine the total amount of medication needed per minute.

Convert the minute dose to an hourly dose.

9360 \text{ mcg/hr}

Multiply

156 \text{ mcg/min}

60 \text{ minutes/hour}

because infusion pumps are programmed in

\text{mL/hr}

Convert the dose from micrograms (

\text{mcg}

) to milligrams (

\text{mg}

9.36 \text{ mg/hr}

Divide

9360 \text{ mcg/hr}

1000 \text{ mcg/mg}

to match the unit of the supplied medication.

Determine the concentration of the medication in the IV bag.

0.2 \text{ mg/mL}

Divide the total milligrams (

50 \text{ mg}

) by the total volume (

250 \text{ mL}

) to establish how much medication is in each milliliter of fluid.

Calculate the final volume rate in

\text{mL/hr}

46.8 \text{ mL/hr}

Divide the required hourly dose (

9.36 \text{ mg/hr}

) by the concentration (

0.2 \text{ mg/mL}

) to determine the volume of fluid needed to deliver the correct dose.

Round the final answer.

47

The question explicitly asks for the answer to be rounded to the nearest whole number.

Key Concept

Weight-based continuous intravenous medication dose calculation and pump rate programming.

Question 1265Question →

An 82-year-old client with a history of vascular dementia is receiving continuous enteral nutrition through a nasoenteric tube. The client becomes acutely restless, repeatedly attempts to swing their legs over the edge of the bed, and pulls at the nasal tubing. Which action should the registered nurse take first?

Assess the client for a full bladder and provide a folded washcloth for the client to manipulate.

Reposition the bed into a flat, horizontal alignment to make it more difficult for the client to exit the bed.

Delegate to the assistive personnel the task of evaluating the client's sudden change in orientation.

Obtain a prescription to apply bilateral limb holders to prevent the immediate dislodgement of the feeding tube.

Show answer & explanation

Answer: Assess the client for a full bladder and provide a folded washcloth for the client to manipulate.

Answer

The correct action is to assess the client for a full bladder and provide a folded washcloth for the client to manipulate.

When a client with dementia exhibits acute restlessness, the nurse should first use the nursing process to assess for underlying physiological triggers, such as urinary retention or pain. Providing a folded washcloth is a therapeutic, least-restrictive intervention that safely redirects the client's manual focus away from the medical tubing while the nurse addresses their basic care needs.

Step-by-Step Solution

Identify the client's immediate risks based on the clinical presentation.

The client is at high risk for self-extubation of the feeding tube and falls due to acute restlessness.

Establishing the primary safety threats directs the prioritization of care.

Recognize the standard nursing principles for managing sudden agitation in clients with dementia.

Acute agitation often indicates an unmet physiological need, such as a full bladder, constipation, pain, or hypoxia.

Identifying the root cause using the nursing process (assessment) is required before implementing symptom-masking interventions.

Evaluate the safety and appropriateness of the proposed alternative interventions.

Laying the client flat introduces a critical aspiration risk. Delegating the assessment violates scope of practice. Applying restraints skips mandatory less-restrictive protocols.

Each distractor represents a severe safety violation or breach of nursing standards.

Select the intervention that addresses the underlying cause and provides a safe, least-restrictive alternative.

Assessing elimination needs and offering a tactile distraction is prioritized.

This action aligns with standard basic care and comfort guidelines for protecting medical devices without resorting to chemical or physical restraints.

Key Concept

Management of Acute Agitation and Enteral Feeding Safety

Estimated Time:1m 30s

Question 1266Question →

A 68-year-old client with a history of chronic obstructive pulmonary disease (COPD) is admitted to the cardiac intensive care unit following a percutaneous coronary intervention (PCI) with stent placement via the right femoral artery. The client is receiving a continuous intravenous heparin infusion and a glycoprotein IIb/IIIa inhibitor. To reduce the risk of severe, life-threatening complications, which of the following assessment findings would require the nurse to intervene immediately? (Select all that apply.)

Select all that apply

The client reports a sudden onset of severe, unrelenting lower back and flank pain.

The client's right pedal pulse is currently detectable only via Doppler ultrasound, whereas it was manually palpable on admission.

The client's blood pressure changes from 138/82 mm Hg to 108/90 mm Hg, accompanied by a heart rate increase from 78 to 118 beats/minute.

The client's continuous telemetry monitor displays occasional, isolated unifocal premature ventricular contractions (PVCs) at a rate of 2 per minute.

The client is observed resting in a supine position with the head of the bed elevated to 15 degrees and the right leg kept straight.

An arterial blood gas (ABG) analysis on room air reveals a pH of 7.36, PaCO2 of 49 mm Hg, and HCO3- of 28 mEq/L.

Show answer & explanation

Answer: The client reports a sudden onset of severe, unrelenting lower back and flank pain.; The client's right pedal pulse is currently detectable only via Doppler ultrasound, whereas it was manually palpable on admission.; The client's blood pressure changes from 138/82 mm Hg to 108/90 mm Hg, accompanied by a heart rate increase from 78 to 118 beats/minute.

Answer

The findings that require immediate intervention are the sudden onset of severe lower back and flank pain, the diminished right pedal pulse (now only Doppler-detectable), and the vital signs demonstrating a narrowing pulse pressure with tachycardia.

The correct findings indicate acute, life-threatening complications of a percutaneous coronary intervention via a femoral approach. Sudden, unrelenting lower back and flank pain is a hallmark sign of a retroperitoneal hemorrhage, a critical bleeding complication. A pulse that was manually palpable and is now only detectable by Doppler indicates significantly decreased perfusion, suggesting an arterial occlusion or a rapidly expanding hematoma compromising blood flow. A narrowing pulse pressure (e.g., from 56 mm Hg to 18 mm Hg) coupled with tachycardia is an early, compensatory physiological response to hypovolemic shock, likely due to internal bleeding. All three findings require immediate nursing intervention and physician notification to prevent irreversible ischemic or hemorrhagic damage.

Step-by-Step Solution

Analyze the clinical scenario and the client's risk profile.

The client is post-PCI via the femoral artery and is heavily anticoagulated (heparin and a glycoprotein IIb/IIIa inhibitor), placing them at extreme risk for bleeding (hematoma, retroperitoneal hemorrhage) and arterial occlusion.

Identifying the highest-risk complications directs the assessment priorities.

Evaluate the presenting symptoms and physical assessment findings for acute decompensation.

Sudden flank pain indicates retroperitoneal bleeding. A diminished pedal pulse indicates acute arterial compromise. Both are medical emergencies.

Early recognition of tissue ischemia and internal bleeding is critical for limb and life preservation.

Interpret the vital sign trends for early indicators of shock.

The change in blood pressure from 138/82 to 108/90 reveals a significantly narrowed pulse pressure (from 56 mm Hg to 18 mm Hg). Combined with a heart rate jumping from 78 to 118, this demonstrates early compensatory hypovolemic shock.

Compensatory mechanisms can mask a falling systolic blood pressure; narrowing pulse pressure and tachycardia are earlier, more subtle signs of severe blood loss.

Differentiate expected or stable findings from acute emergencies.

Occasional PVCs are expected reperfusion rhythms. The 15-degree supine position is correct for femoral access site care, despite the COPD history. The ABG shows a compensated baseline for COPD, not an acute failure.

Intervening on expected baseline findings wastes critical time and can cause harm (e.g., elevating the head of the bed to treat the COPD could cause the femoral artery to bleed).

Key Concept

Prioritization of early hemorrhagic and ischemic complications following endovascular procedures

Question 1267Question →

The nursing team is developing a care plan for an older adult resident in an extended care facility who reports frequent nighttime awakenings and daytime fatigue. Which nursing intervention is most appropriate to promote healthy sleep patterns for this resident?

Encourage participation in light daytime physical activities and restrict afternoon napping.

Reassure the resident that frequent nighttime awakenings are a normal, expected part of the aging process.

Assign the unlicensed assistive personnel to perform a comprehensive assessment of the resident's sleep patterns.

Obtain a prescription for a nightly sedative to manage the awakenings before attempting behavioral interventions.

Show answer & explanation

Answer: Encourage participation in light daytime physical activities and restrict afternoon napping.

Answer

The most appropriate action is to encourage daytime physical activity and limit afternoon naps to naturally promote a regular sleep-wake cycle.

Encouraging physical activity during the day and restricting late naps are core non-pharmacological comfort measures. These actions help regulate the body's natural circadian rhythm, increasing the physiological drive for sleep at night without introducing the risks associated with medications.

Step-by-Step Solution

Review the principles of basic care and comfort related to sleep hygiene in older adult populations.

Non-pharmacological interventions that support natural circadian rhythms should always be prioritized as first-line treatments.

Promoting natural sleep patterns reduces the risk of adverse medication side effects and falls.

Evaluate the distractors against fundamental nursing guidelines for safety and delegation.

Aging does not inherently cause severe insomnia, UAPs cannot perform assessments, and chemical restraints are a last resort.

Maintaining client safety, adhering to proper delegation scope, and applying accurate physiological knowledge are mandatory in basic care.

Key Concept

Non-pharmacological sleep promotion and comfort measures

Question 1268Question →

A nurse is caring for a $58$ -year-old client who is $12$ hours post-operative following a partial gastrectomy and Billroth II anastomosis. The client has a nasogastric (NG) tube set to low continuous wall suction and is receiving continuous total parenteral nutrition (TPN) via a central venous catheter. Which of the following assessment findings or planned nursing actions indicate an increased risk for complications and require immediate intervention? Select all that apply.

Select all that apply

An arterial blood gas (ABG) analysis revealing a pH of

7.49

, a

\text{PaCO}_2

45\text{ mm Hg}

, and an

\text{HCO}_3^-

32\text{ mEq/L}

The nurse plans to administer a prescribed dose of intravenous (IV) phenytoin through the Y-site port of the TPN infusion line.

The client's pulse pressure has narrowed from

45\text{ mm Hg}

20\text{ mm Hg}

over the past hour, accompanied by a heart rate increase from

88

112\text{ bpm}

The nurse elevates the head of the client's bed to a

45

-degree semi-Fowler's position to support ventilation and prevent aspiration.

The nurse completes the abdominal assessment by auscultating all four quadrants for bowel sounds before proceeding to gentle palpation.

The drainage in the NG tube collection canister has transitioned from bright red to a dark brownish-red color, with

50\text{ mL}

collected over the last

4

hours.

Show answer & explanation

Answer: An arterial blood gas (ABG) analysis revealing a pH of $7.49$ , a $\text{PaCO}_2$ of $45\text{ mm Hg}$ , and an $\text{HCO}_3^-$ of $32\text{ mEq/L}$ .; The nurse plans to administer a prescribed dose of intravenous (IV) phenytoin through the Y-site port of the TPN infusion line.; The client's pulse pressure has narrowed from $45\text{ mm Hg}$ to $20\text{ mm Hg}$ over the past hour, accompanied by a heart rate increase from $88$ to $112\text{ bpm}$ .

Answer

The findings and actions requiring immediate intervention are the ABG indicating metabolic alkalosis, the planned administration of IV phenytoin through a TPN line, and the narrowing pulse pressure accompanied by tachycardia.

The correct answers identify critical physiological derangements or dangerous nursing missteps that increase the client's risk for severe complications. An ABG with a high pH (

7.49

) and high

\text{HCO}_3^-

(

32\text{ mEq/L}

) indicates metabolic alkalosis, a dangerous complication of prolonged gastric acid loss from NG suctioning that requires fluid and electrolyte correction. Administering IV phenytoin through a TPN line is contraindicated; TPN requires a dedicated line, and phenytoin is highly incompatible with most fluids, risking severe precipitation and embolism. A narrowing pulse pressure combined with tachycardia is a subtle but critical early indicator of hypovolemic or hemorrhagic shock, necessitating immediate fluid resuscitation before overt hypotension occurs.

Step-by-Step Solution

Analyze the ABG values and NG tube context.

The client has uncompensated metabolic alkalosis (pH

7.49

\text{HCO}_3^-

32\text{ mEq/L}

Prolonged NG suction removes stomach acid, causing a dangerous systemic alkalotic state that requires immediate correction, thus warranting intervention.

Evaluate the IV medication administration plan.

IV phenytoin is highly incompatible with TPN.

Administering phenytoin via the TPN line risks severe precipitation and central line occlusion or embolism, necessitating a dedicated line and immediate intervention to stop the planned action.

Assess the hemodynamic trends.

The pulse pressure has significantly narrowed (from

45

20\text{ mm Hg}

) with accompanying tachycardia.

A narrowing pulse pressure is a classic early, subtle indicator of impending shock (hypovolemic or hemorrhagic), requiring immediate intervention before frank hypotension develops.

Evaluate the post-operative positioning, assessment sequence, and NG drainage.

Semi-Fowler's positioning, auscultating before palpating, and dark brownish-red drainage at

12

hours post-op are all expected, appropriate findings.

Recognizing expected clinical progression prevents inappropriate interventions and allows focus on true physiological deterioration.

Key Concept

Reduction of Risk Potential: Recognizing Subtle Decompensation and Preventing Iatrogenic Complications

Estimated Time:2m 0s

Question 1269Question →

A 72-year-old client is admitted to the intensive care unit following an endovascular aneurysm repair (EVAR) for an abdominal aortic aneurysm. The procedure was performed via bilateral femoral artery access. The nurse is performing a continuous post-procedure assessment. Which of the following clinical findings indicate a potential complication that requires IMMEDIATE intervention? (Select all that apply.)

Select all that apply

Urine output totaling 25 mL over the past two consecutive hours

Core body temperature of 37.7°C (99.9°F) four hours post-procedure

Sudden, severe lower back pain that radiates to the client's groin

Absence of a previously palpable +2 left pedal pulse, confirmed by Doppler

Capillary refill time of 2 seconds in the bilateral lower extremities

A 1-cm, non-expanding hematoma at the right femoral catheter insertion site

Show answer & explanation

Answer: Urine output totaling 25 mL over the past two consecutive hours; Sudden, severe lower back pain that radiates to the client's groin; Absence of a previously palpable +2 left pedal pulse, confirmed by Doppler

Answer

The findings requiring immediate intervention are the oliguria (25 mL over two hours), the sudden severe lower back pain radiating to the groin, and the absent left pedal pulse.

The correct findings represent critical, life-threatening complications following an EVAR procedure. A urine output of 25 mL over two hours (12.5 mL/hr) falls significantly below the minimum expected 30 mL/hr, indicating potential renal artery occlusion (due to stent graft migration) or hypovolemia from internal hemorrhage. Sudden, severe lower back pain radiating to the groin is a classic manifestation of a retroperitoneal hemorrhage or an endoleak (graft failure or rupture). The absence of a previously palpable pedal pulse is a hallmark sign of acute limb ischemia, likely caused by graft thrombosis or distal arterial embolization, requiring immediate emergency evaluation.

Step-by-Step Solution

Analyze the surgical procedure and its associated physiological risks.

EVAR carries specific risks including retroperitoneal hemorrhage, endoleak (graft failure), renal artery occlusion, and distal arterial embolization.

Understanding specific procedure-related risks is essential to guide targeted assessment and recognize early signs of decompensation.

Evaluate each assessment finding to distinguish between expected post-operative conditions and life-threatening complications.

Mild fever, small stable hematomas, and normal capillary refill are expected or non-urgent findings. Conversely, oliguria, severe back pain, and loss of peripheral pulses are highly abnormal.

Safe nursing practice requires the ability to prioritize and identify subtle cues of physiological failure.

Select the findings that represent an immediate threat to life, limb, or organ viability.

The findings indicating renal ischemia, retroperitoneal hemorrhage, and acute limb ischemia are selected.

These complications require emergency physiological or surgical intervention to prevent irreversible damage.

Key Concept

Post-operative monitoring and complication identification following Endovascular Aneurysm Repair (EVAR).

Question 1270Question →

A nurse finds a conscious client who has diabetes mellitus profusely sweating and reporting tremors and palpitations. Arrange the following nursing actions in the priority order they should be performed.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

First, check the blood glucose level. Second, administer 15 grams of a fast-acting carbohydrate. Third, wait 15 minutes. Fourth, recheck the blood glucose level. Finally, provide a snack containing protein and a complex carbohydrate.

The sequence follows the standard '15-15 rule' for hypoglycemia management. The nursing process dictates assessment first (checking the blood glucose) to confirm the condition. Once confirmed, immediate treatment with a fast-acting carbohydrate is provided. The nurse must wait 15 minutes for absorption before rechecking the glucose level. Finally, a complex carbohydrate and protein snack is given to maintain blood glucose stability and prevent a secondary drop.

Step-by-Step Solution

Assess the client's current glycemic status.

The capillary blood glucose level is checked.

Symptoms of hypoglycemia can mimic other acute conditions. Assessment must precede intervention to confirm the diagnosis.

Administer immediate treatment for hypoglycemia.

15 grams of a fast-acting carbohydrate is given.

A simple carbohydrate rapidly absorbs into the bloodstream to quickly elevate the blood glucose level.

Allow time for the intervention to work.

The nurse waits 15 minutes.

It takes approximately 15 minutes for the simple carbohydrate to take effect and accurately reflect in the blood.

Evaluate the effectiveness of the intervention.

The capillary blood glucose level is rechecked.

The nurse must verify that the blood glucose has risen above 70 mg/dL (3.9 mmol/L). If it has not, the previous treatment steps are repeated.

Prevent recurrence of hypoglycemia.

A snack with protein and a complex carbohydrate is provided.

Simple carbohydrates have a short duration of action. Protein and complex carbohydrates provide sustained glucose release to prevent a subsequent drop.

Key Concept

Management of acute hypoglycemia using the 15-15 rule

Question 1271Question →

A pediatric client with neuroblastoma is scheduled to receive a cyclophosphamide infusion. The client's height is $144 \text{ cm}$ and weight is $36 \text{ kg}$ . The provider prescribes cyclophosphamide $825 \text{ mg/m}^2$ IV to infuse continuously over $4 \text{ hours}$ . The Mosteller formula for calculating Body Surface Area (BSA) is provided: $\text{BSA (m}^2) = \sqrt{\frac{\text{Height (cm)} \times \text{Weight (kg)}}{3600}}$ . The pharmacy dispenses reconstituted cyclophosphamide with a concentration of $20 \text{ mg/mL}$ . The nurse must draw up the prescribed dose and inject it into a $150 \text{ mL}$ bag of $0.9\%$ sodium chloride for administration.

What should the nurse set the intravenous infusion pump rate to in mL/hr? (Round the final answer to the nearest tenth.)

Show answer & explanation

Answer: 49.9

Answer

49.9

The correct infusion rate is determined by accurately calculating the body surface area (1.2 m^2), using it to find the total medication dose (990 mg), determining the medication volume based on concentration (49.5 mL), adding this medication volume to the base IV fluid volume to find the total volume (199.5 mL), and dividing by the total infusion time (4 hours). Finally, the unrounded rate of 49.875 mL/hr must be correctly rounded to the nearest tenth (49.9 mL/hr).

Step-by-Step Solution

Calculate the Body Surface Area (BSA) using the Mosteller formula.

BSA = 1.2 m^2

The prescribed dose is based on body surface area, which must be accurately determined first using the client's height and weight.

Calculate the required total dose in milligrams.

990 mg

Multiplying the prescribed dose (825 mg/m^2) by the client's BSA (1.2 m^2) determines the absolute amount of medication needed.

Calculate the volume of medication to draw from the vial.

49.5 mL

Dividing the required dose (990 mg) by the vial concentration (20 mg/mL) yields the volume of reconstituted medication to administer.

Calculate the total volume of the infusion.

199.5 mL

The IV pump will infuse the entire contents of the bag, so the total volume must account for both the base IV fluid (150 mL) and the added medication (49.5 mL).

Calculate the final IV pump infusion rate and round to the nearest tenth.

49.9 mL/hr

Dividing the total infusion volume (199.5 mL) by the infusion time (4 hours) gives 49.875 mL/hr, which rounds to 49.9 mL/hr.

Key Concept

Safe parenteral therapy administration requires accurate multi-step calculation of Body Surface Area (BSA), appropriate conversion of dose to volume, and inclusion of the medication volume into the total diluent volume when programming continuous infusion pump rates.

Question 1272Question →

An emergency department nurse is evaluating a client who presented 45 minutes ago with a severe asthma exacerbation. Initially, the client exhibited profound expiratory wheezing, use of accessory muscles, and a respiratory rate of 34 breaths per minute. Currently, the nurse notes that the client is becoming increasingly lethargic, the respiratory rate has decreased to 14 breaths per minute, and breath sounds are notably diminished bilaterally. An arterial blood gas (ABG) analysis reveals a pH of 7.29, PaCO2 of 54 mm Hg, HCO3 of 24 mEq/L, and PaO2 of 62 mm Hg. Which of the following is the most appropriate interpretation and corresponding priority action?

Uncompensated respiratory acidosis indicating impending respiratory failure; prepare for immediate advanced airway management.

Uncompensated metabolic acidosis resulting from lactic acid buildup; prepare to administer an intravenous sodium bicarbonate infusion.

Clinical improvement evidenced by decreased wheezing and respiratory rate; maintain current continuous bronchodilator therapy.

Uncompensated respiratory alkalosis due to initial tachypnea; administer a prescribed intravenous anxiolytic medication.

Show answer & explanation

Answer: Uncompensated respiratory acidosis indicating impending respiratory failure; prepare for immediate advanced airway management.

Answer

The clinical findings and ABG indicate uncompensated respiratory acidosis and impending respiratory failure, requiring preparation for immediate advanced airway management.

The client is exhibiting signs of a 'silent chest,' a critical and life-threatening complication of severe asthma. As respiratory muscles fatigue, the respiratory rate drops, and airflow becomes so restricted that wheezing is no longer audible. This clinical picture, accompanied by lethargy, indicates severe carbon dioxide retention and impending respiratory arrest. The ABG confirms uncompensated respiratory acidosis (pH < 7.35, PaCO2 > 45 mm Hg, normal HCO3). The highest priority action is to prepare for immediate advanced airway management (endotracheal intubation and mechanical ventilation) to prevent cardiopulmonary arrest.

Step-by-Step Solution

Analyze the clinical presentation trend.

The client transitioned from tachypnea and profound wheezing to lethargy, a decreased respiratory rate, and diminished breath sounds.

Identifying changes in clinical status is crucial for detecting a 'silent chest,' which indicates severe airflow obstruction and respiratory muscle fatigue.

Interpret the arterial blood gas (ABG) values.

pH is 7.29 (acidosis), PaCO2 is 54 mm Hg (respiratory origin), and HCO3 is 24 mEq/L (normal, uncompensated).

ABG analysis confirms the physiological state of uncompensated respiratory acidosis due to profound carbon dioxide retention.

Determine the priority nursing intervention based on the synthesis of data.

Prepare for immediate advanced airway management, such as endotracheal intubation.

The combination of uncompensated respiratory acidosis and clinical signs of respiratory muscle fatigue requires immediate mechanical ventilation to sustain life and reverse the hypoxemia and hypercapnia.

Key Concept

Recognition and management of impending respiratory failure ('silent chest') in severe asthma exacerbations.

Question 1273Question →

A nurse is teaching a client who has a non-weight-bearing cast on the right lower extremity how to ascend stairs using crutches. Arrange the following actions in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

To ascend stairs with crutches while non-weight-bearing, the client places weight on the crutches, steps up with the unaffected leg, shifts weight to the unaffected leg, and finally brings the crutches and affected leg up to the stair tread.

When ascending stairs using a three-point gait with crutches (non-weight-bearing), the standard safe practice follows the phrase 'up with the good.' The client must start from a stable tripod position, bear weight on the crutches, and step up with the unaffected (strong) leg first. Once the unaffected leg is planted on the stair tread, the client shifts their weight onto that leg. This securely allows the client to lift the crutches and the affected leg simultaneously to the same step, maintaining a non-weight-bearing status on the injured extremity.

Step-by-Step Solution

Place weight on crutches.

The unaffected leg is freed to move.

Establishing a solid base of support is required before initiating upward movement.

Advance the unaffected leg to the stair tread.

The strong leg is now positioned on the higher level.

The unaffected leg must lead when going up stairs ('up with the good') to lift the body's weight safely.

Shift body weight to the unaffected leg.

The crutches and the affected leg are no longer bearing weight.

Weight must be transferred to the elevated strong leg so the crutches can be lifted.

Bring the crutches and affected leg up to the step.

The client is fully positioned on the new stair tread.

This completes the movement sequence safely without placing any weight on the injured leg.

Key Concept

Mobility and Assistive Devices: Ascending Stairs with Crutches

Question 1274Question →

A client is admitted to the medical-surgical unit and is receiving a continuous intravenous (IV) infusion of $5\%$ dextrose in water (D5W) at $75 \text{ mL/hr}$ . To manage newly developed focal seizure activity, the healthcare provider prescribes a stat dose of phenytoin $100 \text{ mg}$ IV push. Which action by the nurse is the most appropriate?

Administer the medication rapidly over

30 \text{ seconds}

into the Y-port closest to the client to immediately achieve therapeutic levels.

Dilute the phenytoin in a

50 \text{ mL}

bag of

5\%

dextrose in water and infuse it as a secondary piggyback over

30 \text{ minutes}

Stop the IV infusion, flush the line with

0.9\%

sodium chloride, administer the phenytoin over

2 \text{ minutes}

, and flush again with

0.9\%

sodium chloride.

Pause the continuous D5W infusion, inject the phenytoin directly into the lowest IV port, and immediately resume the D5W infusion.

Show answer & explanation

Answer: Stop the IV infusion, flush the line with $0.9\%$ sodium chloride, administer the phenytoin over $2 \text{ minutes}$ , and flush again with $0.9\%$ sodium chloride.

Answer

Stop the IV infusion, flush the line with

0.9\%

sodium chloride, administer the phenytoin over

2 \text{ minutes}

, and flush again with

0.9\%

sodium chloride.

Phenytoin is highly incompatible with dextrose-containing solutions and will rapidly precipitate if mixed. Therefore, the primary D5W infusion must be stopped, and the line must be thoroughly flushed with

0.9\%

sodium chloride (normal saline) before and after administration. Additionally, phenytoin must be administered slowly (not exceeding

50 \text{ mg/min}

) to prevent severe hypotension and cardiac arrhythmias; therefore, pushing a

100 \text{ mg}

dose evenly over

2 \text{ minutes}

is the correct and safe rate.

Step-by-Step Solution

Assess the compatibility of the prescribed medication (phenytoin) with the currently infusing primary IV fluid (D5W).

Phenytoin is determined to be highly incompatible with dextrose.

Mixing phenytoin with any dextrose-containing solution causes immediate crystallization and precipitation, which can obstruct the IV line and harm the client.

Determine the appropriate administration technique to prevent drug-drug interaction in the IV tubing.

The IV line must be thoroughly flushed with a compatible solution (

0.9\%

sodium chloride) both before and after the phenytoin is given.

Flushing clears the residual dextrose from the tubing, creating a safe environment for the phenytoin to pass through without precipitating.

Calculate the safe rate of administration for the prescribed dose of

100 \text{ mg}

The medication must be administered slowly over a minimum of

2 \text{ minutes}

The maximum safe IV push rate for phenytoin is

50 \text{ mg/min}

. Rapid administration can induce severe cardiovascular toxicity, including hypotension and arrhythmias.

Key Concept

Phenytoin IV administration safety and compatibility

Question 1275Question →

A nurse is evaluating a client who was recently admitted with a diagnosis of diabetic ketoacidosis (DKA). The nurse draws an arterial blood gas (ABG) sample to assess the client's acid-base balance. Which of the following ABG findings are consistent with the primary acid-base disturbance and the expected physiological compensation for this condition? Select all that apply.

Select all that apply

Arterial pH of

7.28

Bicarbonate (

HCO_3^-

) level of

14

mEq/L

Partial pressure of carbon dioxide (

PaCO_2

) of

28

mm Hg

Arterial pH of

7.46

Partial pressure of carbon dioxide (

PaCO_2

) of

48

mm Hg

Show answer & explanation

Answer: Arterial pH of $7.28$ ; Bicarbonate ( $HCO_3^-$ ) level of $14$ mEq/L; Partial pressure of carbon dioxide ( $PaCO_2$ ) of $28$ mm Hg

Answer

The expected findings include an arterial pH of 7.28, a bicarbonate level of 14 mEq/L, and a PaCO2 of 28 mm Hg.

The correct findings represent a state of partially compensated metabolic acidosis, which is expected in diabetic ketoacidosis. The accumulation of ketoacids decreases the arterial pH (acidemia) and consumes bicarbonate, resulting in a low bicarbonate level. The body adapts to this metabolic acidosis via respiratory compensation. The lungs attempt to blow off excess acid in the form of carbon dioxide through deep, rapid breathing (Kussmaul respirations). This compensatory hyperventilation lowers the partial pressure of carbon dioxide below the normal range of 35-45 mm Hg.

Step-by-Step Solution

Identify the primary acid-base disturbance caused by diabetic ketoacidosis.

The primary disturbance is metabolic acidosis.

The accumulation of ketones (acids) in the bloodstream lowers the blood pH and depletes bicarbonate buffers.

Determine the expected ABG values for metabolic acidosis.

An arterial pH less than 7.35 and a bicarbonate level less than 22 mEq/L.

Normal arterial pH ranges from 7.35 to 7.45, and normal bicarbonate ranges from 22 to 26 mEq/L. Both values are decreased in metabolic acidosis.

Identify the body's compensatory mechanism for metabolic acidosis.

The respiratory system compensates by increasing the rate and depth of breathing (Kussmaul respirations).

Hyperventilation helps blow off excess acid in the form of carbon dioxide.

Determine the expected ABG value resulting from the compensatory mechanism.

A partial pressure of carbon dioxide (PaCO2) less than 35 mm Hg.

Normal PaCO2 is 35 to 45 mm Hg. Hyperventilation effectively lowers this value to reduce the overall acidic load in the blood.

Key Concept

Diabetic ketoacidosis leads to metabolic acidosis with compensatory respiratory alkalosis.

Estimated Time:1m 30s

Question 1276Question →

A nurse is caring for a client who was admitted with a massive pulmonary embolism and is receiving a continuous intravenous heparin infusion. The client is now difficult to arouse. Current assessment findings include: blood pressure 82/48 mm Hg, heart rate 134 beats/minute and thready, and respiratory rate 28/minute. The client's skin is cold and diaphoretic. The central venous pressure (CVP) reading is 15 mm Hg (normal: 2 to 8 mm Hg), and urine output was 10 mL over the last hour. Which of the following prescribed interventions should the nurse prioritize?

Administering a rapid 500 mL intravenous bolus of 0.9% sodium chloride

Administering intravenous protamine sulfate to reverse the anticoagulation

Initiating a continuous intravenous infusion of norepinephrine

Placing the client in the modified Trendelenburg position to increase venous return

Show answer & explanation

Answer: Initiating a continuous intravenous infusion of norepinephrine

Answer

Initiating a continuous intravenous infusion of norepinephrine is the priority intervention to support systemic blood pressure in this client experiencing obstructive shock.

This client is demonstrating definitive signs of obstructive shock due to a massive pulmonary embolism, which causes acute right ventricular failure. The significantly elevated CVP (15 mm Hg) indicates that the right ventricle is already overloaded and failing to pump blood forward through the pulmonary circulation. In this critical situation, administering a vasopressor like norepinephrine is the priority to increase systemic vascular resistance. This intervention maintains the systemic blood pressure necessary to perfuse the right ventricular myocardium and prevent total cardiovascular collapse until definitive therapies (like embolectomy or thrombolytics) can be administered.

Step-by-Step Solution

Analyze the client's vital signs and physical assessment findings.

The client exhibits profound hypotension, severe tachycardia, altered mental status, oliguria, and cold, diaphoretic skin.

These findings indicate a critical state of shock with severe systemic tissue hypoperfusion.

Interpret the central venous pressure (CVP) reading in the context of the client's massive pulmonary embolism diagnosis.

The CVP is significantly elevated at 15 mm Hg (normal is 2 to 8 mm Hg).

An elevated CVP combined with systemic hypotension in a client with a pulmonary embolism indicates acute right ventricular failure and obstructive shock, rather than hypovolemic shock.

Determine the priority hemodynamic intervention based on the specific type of shock identified.

Select an intervention that supports systemic blood pressure without causing further right ventricular fluid overload, such as a vasopressor like norepinephrine.

Vasopressors increase systemic vascular resistance, thereby maintaining the necessary blood pressure to perfuse the right ventricular myocardium and prevent cardiovascular collapse without the detrimental effects of fluid volume loading on a failing right heart.

Key Concept

Management of obstructive shock and right ventricular failure secondary to a massive pulmonary embolism requires vasopressor support rather than fluid resuscitation.

Question 1277Question →

A nurse is caring for a client who has been receiving continuous nasogastric (NG) tube suctioning for the past 48 hours. The nurse reviews the client's most recent arterial blood gas (ABG) results:

Parameter	Result
pH	7.54
PaCO2	40 mm Hg
HCO3-	30 mEq/L

Based on these results, which acid-base imbalance is the client experiencing?

Uncompensated metabolic alkalosis

Uncompensated respiratory alkalosis

Uncompensated metabolic acidosis

Uncompensated respiratory acidosis

Show answer & explanation

Answer: Uncompensated metabolic alkalosis

Answer

Uncompensated metabolic alkalosis

The client is experiencing uncompensated metabolic alkalosis. The pH is elevated (greater than 7.45), indicating alkalosis. The bicarbonate (HCO3-) is also elevated (greater than 26 mEq/L), which matches the alkalotic pH and confirms a metabolic origin. The PaCO2 is within the normal range (35-45 mm Hg), meaning the respiratory system has not yet begun to compensate by retaining carbon dioxide. Furthermore, continuous nasogastric suctioning depletes gastric acid (hydrochloric acid), a common clinical cause of metabolic alkalosis.

Step-by-Step Solution

Analyze the pH to determine if acidosis or alkalosis is present.

The pH is 7.54, which is greater than the normal range of 7.35 to 7.45. This indicates alkalosis.

Establishing the overall acid-base status is the first step in ABG interpretation.

Evaluate the PaCO2 and HCO3- to determine the primary cause of the alkalosis.

The HCO3- is 30 mEq/L (elevated above normal 22-26 mEq/L), which aligns with the alkalotic pH. The PaCO2 is 40 mm Hg, which is within the normal range (35-45 mm Hg).

Matching the abnormal value to the pH determines whether the imbalance is respiratory or metabolic in origin.

Determine the level of compensation.

Because the PaCO2 is normal, the respiratory system has not yet initiated a compensatory response to retain CO2.

A normal opposing value in the presence of an abnormal primary value indicates an uncompensated state.

Key Concept

Arterial Blood Gas (ABG) Interpretation

Question 1278Question →

A nurse is planning basic care for an older adult client who has limited mobility and is experiencing new-onset urinary incontinence. Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.

Select all that apply

Apply a moisture barrier cream to the perineal area after each incontinence episode.

Delegate the initial evaluation of the client's skin integrity to the Unlicensed Assistive Personnel (UAP).

Reassure the client that sudden urinary incontinence is a normal, expected change of aging.

Keep the head of the bed completely flat during meals to reduce shear on the sacrum.

Establish an individualized, scheduled toileting routine every 2 to 3 hours during waking hours.

Show answer & explanation

Answer: Apply a moisture barrier cream to the perineal area after each incontinence episode.; Establish an individualized, scheduled toileting routine every 2 to 3 hours during waking hours.

Answer

The correct interventions are applying a moisture barrier cream to the perineal area and establishing a scheduled toileting routine.

Applying moisture barrier creams and implementing scheduled toileting are foundational nursing interventions that promote comfort, protect skin integrity from urine exposure, and actively manage elimination needs in clients with limited mobility.

Step-by-Step Solution

Identify the primary basic care needs presented in the scenario.

The client has limited mobility and new-onset urinary incontinence, placing them at high risk for skin breakdown and loss of dignity.

Understanding the core deficits allows the nurse to prioritize appropriate hygiene and comfort measures.

Evaluate the independent nursing interventions that directly promote skin integrity and continence.

Using barrier creams and implementing a scheduled toileting routine are recognized best practices for basic care.

These actions proactively manage moisture and encourage normal elimination patterns.

Identify and eliminate contraindicated or unsafe actions in the remaining choices.

Delegating initial assessments, assuming new symptoms are normal aging, and laying flat during meals are eliminated.

These actions violate the nursing scope of practice, misinterpret pathological signs, and compromise airway safety.

Key Concept

Basic care measures for urinary incontinence and mobility deficits.

Question 1279Question →

A nurse is preparing to administer several intravenous (IV) medications to a client who has a continuous primary IV infusion. Which of the following actions demonstrate safe principles of parenteral medication administration? (Select all that apply.)

Select all that apply

Checking a pharmacological reference to confirm Y-site compatibility before attaching a secondary infusion.

Flushing the IV line with normal saline before and after administering an incompatible IV push medication.

Scrubbing the needleless access port with an appropriate antiseptic swab before attaching a syringe.

Assuming all standard electrolyte replacement infusions are universally compatible with broad-spectrum antibiotics.

Estimating the administration time for an IV push medication instead of using a watch to time the exact rate.

Show answer & explanation

Answer: Checking a pharmacological reference to confirm Y-site compatibility before attaching a secondary infusion.; Flushing the IV line with normal saline before and after administering an incompatible IV push medication.; Scrubbing the needleless access port with an appropriate antiseptic swab before attaching a syringe.

Answer

The correct actions are checking a reference for Y-site compatibility, flushing the line with normal saline before and after an incompatible medication, and scrubbing the access port prior to use.

Safe parenteral therapy requires strict adherence to infection control protocols (scrubbing the hub), prevention of adverse drug reactions (verifying Y-site compatibility), and proper line maintenance (flushing to clear incompatible medications).

Step-by-Step Solution

Evaluate the need for compatibility verification.

Checking Y-site compatibility is required to prevent physical or chemical incompatibilities.

Precipitation in an IV line can cause emboli or inactivate the medications.

Determine the proper procedure for administering a medication incompatible with the primary fluid.

The nurse must pause the infusion and flush the line with a compatible solution (like normal saline) before and after the IV push.

This creates a fluid barrier that prevents the two incompatible medications from mixing.

Assess infection control and administration rate standards.

The hub must always be scrubbed, and the push rate must be timed precisely.

Scrubbing prevents the introduction of pathogens. Accurate timing prevents toxic peak levels and speed shock.

Key Concept

Safe Parenteral Medication Administration

Question 1280Question →

A client in the intensive care unit is receiving a continuous intravenous (IV) infusion of norepinephrine at $12 \text{ mcg/min}$ via a single-lumen peripherally inserted central catheter (PICC) for septic shock. The client's current mean arterial pressure (MAP) is $64 \text{ mmHg}$ . The healthcare provider prescribes a stat dose of IV push hydrocortisone. Which action by the nurse is the most appropriate?

Pause the norepinephrine infusion, flush the PICC with

10 \text{ mL}

0.9\%

sodium chloride, administer the hydrocortisone, and flush again.

Dilute the hydrocortisone in

50 \text{ mL}

0.9\%

sodium chloride and infuse it as a secondary piggyback into the PICC line.

Establish a separate peripheral intravenous catheter to administer the hydrocortisone.

Administer the hydrocortisone over

2 \text{ minutes}

through the Y-site closest to the client while the norepinephrine continues to infuse.

Show answer & explanation

Answer: Establish a separate peripheral intravenous catheter to administer the hydrocortisone.

Answer

The most appropriate action is to establish a separate peripheral intravenous catheter to administer the hydrocortisone.

Vasoactive medications like norepinephrine have a very short half-life and potent hemodynamic effects. They require a dedicated intravenous line to maintain a steady, precisely titrated state. Flushing the line or pushing medications through the same lumen displaces the highly concentrated vasopressor residing in the catheter's dead space, delivering a rapid, potentially lethal bolus to the client. Additionally, pausing the infusion causes immediate hypotension. Therefore, the safest action is to establish a new peripheral intravenous catheter for any additional medications.

Step-by-Step Solution

Analyze the client's current physiological status and intravenous access.

The client is in septic shock with a borderline MAP (

64 \text{ mmHg}

), entirely dependent on a continuous norepinephrine infusion running through a single-lumen central line.

Understanding the client's hemodynamic fragility is necessary to evaluate the safety of altering the vasoactive infusion.

Evaluate the fluid dynamics of administering an IV push medication into a continuous vasopressor line.

Pushing a medication or flushing the line will rapidly force the concentrated norepinephrine residing in the catheter lumen into the client's systemic circulation.

This unintended bolus can cause life-threatening hypertension and arrhythmias, while pausing the infusion removes life-sustaining vascular support.

Determine the safest route for administering the stat medication.

The nurse must leave the single-lumen PICC undisturbed to maintain continuous hemodynamic stability and start a new peripheral IV catheter for the hydrocortisone.

Vasoactive continuous infusions must have a dedicated line to ensure safe, uninterrupted delivery without bolus effects.

Key Concept

Safe administration of parenteral therapies requires a dedicated intravenous line for continuous vasoactive medications (like norepinephrine) to prevent unintended boluses and sudden hemodynamic collapse.

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