Physiological Integrity

1960 soru

Tüm türler1,960 Çoktan seçmeli1,004 Çoklu seçim425 Sayısal102 Sıralama429

A nurse is caring for an adult client with end-stage cirrhosis who recently underwent an ultrasound-guided bedside paracentesis with the removal of $4.5 \text{ liters}$ of ascitic fluid. Prior to the procedure, the client's vital signs were blood pressure $126/82 \text{ mmHg}$ and heart rate $86 \text{ bpm}$ .

Thirty minutes post-procedure, the client reports feeling slightly dizzy. The current assessment reveals the following data:

Parameter	Current Value
Blood Pressure	$92/74 \text{ mmHg}$
Heart Rate	$118 \text{ bpm}$
Respiratory Rate	$20 \text{ breaths/min}$
$SpO_2$	$96\%$ on room air
Arterial $pH$	$7.32$
$PaCO_2$	$31 \text{ mmHg}$
$HCO_3^-$	$15 \text{ mEq/L}$

Which action should the nurse take next to reduce the risk of severe physiological compromise?

Continue routine monitoring, as the widened pulse pressure indicates an expected hemodynamic response to fluid removal.

Apply supplemental oxygen to treat the underlying respiratory acidosis shown on the morning laboratory results.

Initiate the prescribed intravenous infusion of 25% human albumin.

Elevate the head of the bed to a high Fowler's position to maximize diaphragmatic excursion.

Cevabı ve açıklamayı göster

Cevap: Initiate the prescribed intravenous infusion of 25% human albumin.

Cevap

The correct action is to initiate the prescribed intravenous infusion of 25% human albumin to prevent paracentesis-induced circulatory dysfunction.

The removal of a large volume of ascitic fluid rapidly decreases intra-abdominal pressure, leading to splanchnic vasodilation and a massive shift of intravascular fluid into the peritoneal space. This phenomenon, known as paracentesis-induced circulatory dysfunction (PICD), causes severe hypovolemia. The client's narrowing pulse pressure (

92 - 74 = 18 \text{ mmHg}

) and tachycardia (

118 \text{ bpm}

) are classic early compensatory signs of hypovolemic shock. Administering a hypertonic colloid, such as 25% human albumin, increases intravascular oncotic pressure, pulling fluid back into the vascular space and effectively mitigating the risk of cardiovascular collapse.

Adım Adım Çözüm

Analyze the vital sign changes from baseline.

The blood pressure has dropped significantly to

92/74 \text{ mmHg}

, the pulse pressure has narrowed to

18 \text{ mmHg}

(

92 - 74 = 18

), and the heart rate has increased to

118 \text{ bpm}

Recognizing early hemodynamic trends is essential for detecting the onset of compensatory hypovolemic shock.

Interpret the arterial blood gas (ABG) values.

The ABG indicates a metabolic acidosis (

pH

7.32

HCO_3^-

15

) with partial respiratory compensation (

PaCO_2

31

), not a respiratory acidosis.

Accurate ABG interpretation prevents implementing inappropriate interventions, such as attempting to correct a nonexistent respiratory problem.

Evaluate the physiological impact of large-volume fluid removal.

The rapid removal of

4.5 \text{ liters}

of fluid drastically decreases intra-abdominal pressure, causing splanchnic vasodilation and a massive intravascular fluid shift.

Understanding the fluid dynamics of a large-volume paracentesis highlights the immediate risk for profound hypovolemia.

Select the priority risk-reduction intervention.

Administering a hypertonic colloid, such as 25% human albumin, is selected to restore intravascular volume.

Albumin provides the necessary oncotic pressure to pull fluid back into the vascular space, stabilizing hemodynamics and preventing cardiovascular collapse.

Anahtar Kavram

Paracentesis-Induced Circulatory Dysfunction (PICD)

Soru 262Soru →

A nurse is preparing to initiate a continuous intravenous (IV) infusion of regular insulin for a client experiencing diabetic ketoacidosis (DKA). The pharmacy has provided a prepared bag containing 100 units of regular insulin mixed in 100 mL of 0.9% sodium chloride. Which of the following actions must the nurse take when setting up the primary IV tubing for this infusion?

Connect the insulin infusion as a secondary piggyback into the lowest Y-site of a rapidly infusing normal saline bolus.

Vigorously shake the IV bag for at least 30 seconds to ensure the regular insulin is thoroughly mixed with the diluent.

Prime the IV tubing with the insulin solution and discard approximately 50 mL of the fluid before connecting it to the client.

Attach a 1.2-micron in-line filter to the distal end of the IV tubing to prevent the administration of protein precipitates.

Cevabı ve açıklamayı göster

Cevap: Prime the IV tubing with the insulin solution and discard approximately 50 mL of the fluid before connecting it to the client.

Cevap

The nurse must prime the intravenous tubing with the insulin solution and discard approximately 50 mL of the fluid before connecting it to the client.

Insulin molecules readily adsorb (bind) to the inner plastic lining of standard polyvinyl chloride (PVC) intravenous tubing. If the tubing is not primed and saturated with the insulin solution prior to connection, the client will receive a significantly lower dose of insulin than prescribed during the crucial initial hours of therapy. Discarding approximately 20 to 50 mL of the primed fluid ensures the tubing's binding sites are completely saturated, allowing for immediate and accurate dose delivery to the client.

Adım Adım Çözüm

Identify the unique pharmacological properties of regular insulin when administered via a continuous intravenous infusion.

Regular insulin molecules naturally adsorb (bind) to the inner plastic lining of standard polyvinyl chloride (PVC) intravenous tubing.

Understanding this physical interaction is essential to prevent severe under-dosing during the critical initial hours of diabetic ketoacidosis treatment.

Determine the required nursing intervention to counteract insulin adsorption to the tubing.

The nurse must prime the tubing with the prepared insulin solution and allow 20 to 50 mL of the fluid to run through and be discarded.

This process fully saturates the binding sites on the PVC tubing, ensuring that the concentration of insulin reaching the client immediately matches the prescribed dose.

Evaluate the alternative interventions for safety and adherence to parenteral therapy protocols.

Avoid shaking the bag (which denatures proteins), do not use an unnecessary in-line filter, and never piggyback an insulin drip into a rapidly infusing fluid bolus.

Eliminating unsafe practices guarantees that the high-alert medication is administered correctly without risking cardiovascular collapse or hypoglycemia.

Anahtar Kavram

Intravenous Insulin Adsorption and Tubing Saturation

Soru 263Soru →

A $72$ -year-old client with advanced emphysema is admitted to the progressive care unit with acute respiratory failure. The client is receiving noninvasive positive pressure ventilation (NIPPV). During the reassessment, the nurse notes copious, thick pulmonary secretions, extreme agitation, and a respiratory rate of $32$ breaths/minute. The most recent arterial blood gas (ABG) analysis reveals a pH of $7.25$ , $\text{PaCO}_2$ of $74$ mmHg, $\text{HCO}_3^-$ of $32$ mEq/L, and $\text{PaO}_2$ of $54$ mmHg. To mitigate the risk of impending physiological collapse, which action should the nurse implement?

Discontinue the noninvasive positive pressure ventilation, initiate manual bag-valve-mask ventilation, and prepare for endotracheal intubation.

Administer a prescribed intravenous sodium bicarbonate bolus to rapidly correct the underlying metabolic acidosis.

Lower the head of the bed to a flat, supine position to facilitate effective postural drainage of the copious pulmonary secretions.

Apply bilateral soft wrist restraints to ensure the noninvasive ventilation mask remains securely in place against the client's face.

Cevabı ve açıklamayı göster

Cevap: Discontinue the noninvasive positive pressure ventilation, initiate manual bag-valve-mask ventilation, and prepare for endotracheal intubation.

Cevap

The nurse must discontinue the noninvasive positive pressure ventilation, begin manual bag-valve-mask ventilation, and prepare for immediate endotracheal intubation.

The correct action directly mitigates the highest risk to the client: imminent respiratory arrest. The combination of extreme agitation (a classic sign of severe hypoxia), copious secretions, and a drastically worsening ABG profile (pH

7.25

\text{PaCO}_2

74

mmHg) demonstrates that noninvasive positive pressure ventilation has failed. The client can no longer protect their airway, making immediate endotracheal intubation the only safe and effective intervention.

Adım Adım Çözüm

Analyze the arterial blood gas (ABG) results.

The ABG reveals uncompensated respiratory acidosis (pH

7.25

\text{PaCO}_2

74

mmHg) and severe hypoxemia (

\text{PaO}_2

54

mmHg).

Accurate ABG interpretation is essential to determine the adequacy of the client's current ventilation and oxygenation status.

Evaluate the clinical signs and symptoms in conjunction with the NIPPV therapy.

The presence of copious secretions and extreme agitation are identified as absolute contraindications for continuing NIPPV.

NIPPV masks block the expulsion of thick secretions, increasing aspiration risk, while agitation signals profound tissue hypoxia and air hunger.

Determine the priority risk-reduction intervention.

The decision is made to abandon the failing NIPPV strategy and secure a definitive airway.

When noninvasive measures fail to reverse life-threatening respiratory acidosis and airway protection is compromised, immediate endotracheal intubation is required to prevent respiratory arrest.

Anahtar Kavram

Recognizing the failure of noninvasive positive pressure ventilation (NIPPV) and identifying indications for immediate endotracheal intubation.

Soru 264Soru →

While providing care for an elderly client admitted with community-acquired pneumonia, the nurse notes a sudden shift in the client's baseline mental status, characterized by agitation and confusion. An immediate assessment yields the following data: blood pressure 86/52 mm Hg, heart rate 118 beats/min, respiratory rate 26 breaths/min, and an oral temperature of 96.8°F (36.0°C). Which intervention must the nurse execute first?

Notify the rapid response team and prepare to administer an isotonic fluid bolus.

Request a prescription for a mild sedative to manage the client's acute restlessness.

Document the new-onset confusion as an expected, age-related response to hospitalization.

Apply warmed blankets to correct the subnormal temperature before reassessing the blood pressure.

Cevabı ve açıklamayı göster

Cevap: Notify the rapid response team and prepare to administer an isotonic fluid bolus.

Cevap

The nurse must prioritize notifying the rapid response team and initiating an isotonic fluid bolus to treat impending septic shock.

The correct answer emphasizes immediate circulatory support. The client's clinical picture—hypotension, tachycardia, tachypnea, hypothermia, and a sudden change in mental status—indicates progression to septic shock. Because perfusion is severely compromised, the highest priority according to the ABC (Airway, Breathing, Circulation) framework is to notify the rapid response team and restore intravascular volume with isotonic crystalloid fluids.

Adım Adım Çözüm

Analyze the client's clinical presentation.

The client exhibits new-onset confusion, hypothermia (96.8°F / 36.0°C), tachycardia (118 beats/min), tachypnea (26 breaths/min), and severe hypotension (86/52 mm Hg).

Identifying abnormal assessment findings and recognizing acute deviations from the baseline is the foundational step in clinical reasoning.

Synthesize the findings to identify the underlying pathophysiological process.

The combination of these signs in an older adult with an existing infection strongly indicates systemic inflammatory response syndrome (SIRS) progressing to septic shock.

Older adults frequently present atypically with severe infections, often manifesting hypothermia and altered mental status rather than a traditional high fever.

Determine the priority nursing intervention based on the ABCs (Airway, Breathing, Circulation).

Circulatory collapse, evidenced by the severe hypotension and compensatory tachycardia, requires immediate life-saving intervention with fluid resuscitation.

Restoring intravascular volume is critical to reverse poor tissue perfusion and prevent irreversible multiorgan failure.

Anahtar Kavram

Early Recognition and Management of Septic Shock in Older Adults

Soru 265Soru →

A nurse is preparing to administer furosemide $80 \text{ mg}$ intravenous (IV) push to a client experiencing acute pulmonary edema. The medication is available in a vial labeled $10 \text{ mg/mL}$ . Which of the following is the most appropriate action for the nurse to take?

Administer

8 \text{ mL}

of the medication at a rate of

2 \text{ mL}

per minute.

Administer

8 \text{ mL}

of the medication at a calculated rate of

4 \text{ mL}

per minute.

Administer the medication through the nearest Y-site without pausing to verify compatibility with the continuous infusion.

Administer the dose rapidly over 30 to 60 seconds to prioritize the immediate resolution of respiratory distress.

Cevabı ve açıklamayı göster

Cevap: Administer $8 \text{ mL}$ of the medication at a rate of $2 \text{ mL}$ per minute.

Cevap

The nurse should administer

8 \text{ mL}

of the medication at a rate of

2 \text{ mL}

per minute.

The correct action involves accurately calculating both the volume to administer and the safe rate of administration. Furosemide is available at

10 \text{ mg/mL}

, so an

80 \text{ mg}

dose requires

8 \text{ mL}

. To prevent ototoxicity, IV furosemide should be administered no faster than

20 \text{ mg}

per minute. An

80 \text{ mg}

dose must be pushed over at least 4 minutes (

80 \div 20 = 4

). Administering

8 \text{ mL}

over 4 minutes equates to a safe and calculated rate of

2 \text{ mL}

per minute.

Adım Adım Çözüm

Calculate the required volume of the medication.

\frac{80 \text{ mg}}{10 \text{ mg/mL}} = 8 \text{ mL}

To ensure the correct dose is drawn from the vial.

Determine the minimum safe administration time.

\frac{80 \text{ mg}}{20 \text{ mg/min}} = 4 \text{ minutes}

High-dose IV furosemide must be administered no faster than

20 \text{ mg/min}

to prevent ototoxicity and hypotension.

Calculate the rate of administration in mL per minute.

\frac{8 \text{ mL}}{4 \text{ minutes}} = 2 \text{ mL/min}

To guide the nurse in pushing the medication safely over the required time frame.

Anahtar Kavram

Safe administration of high-alert intravenous medications requires precise calculation of both volume and administration rate to prevent iatrogenic harm, such as ototoxicity from rapid loop diuretic infusion.

Soru 266Soru →

A nurse is caring for a client who is immobilized in skeletal traction following a fractured right femur. The client reports sacral discomfort from prolonged bed rest. Which nursing intervention is most appropriate to promote comfort and maintain skin integrity?

Elevate the head of the bed to a high Fowler's position for extended periods to enhance comfort.

Direct the unlicensed assistive personnel to evaluate the skin integrity around the skeletal pin insertion sites.

Provide an overhead trapeze and instruct the client to use it to assist with lifting off the bed.

Temporarily lift the traction weights for several minutes each shift to relieve continuous tension on the leg.

Cevabı ve açıklamayı göster

Cevap: Provide an overhead trapeze and instruct the client to use it to assist with lifting off the bed.

Cevap

Provide an overhead trapeze and instruct the client to use it to assist with lifting off the bed.

Providing an overhead trapeze allows the client to safely assist with lifting their upper body off the mattress. This promotes client independence, prevents complications of immobility, and allows the nurse to provide back care and alleviate sacral pressure without disrupting the therapeutic alignment of the skeletal traction.

Adım Adım Çözüm

Analyze the client's current condition and therapeutic devices.

The client is experiencing sacral discomfort but is confined to bed with skeletal traction for a fractured femur.

Understanding the physical constraints of skeletal traction is necessary to determine which comfort measures are safe to implement.

Evaluate the proposed interventions against the principles of skeletal traction and safe nursing care.

Lifting weights and placing the client in high Fowler's position are contraindicated as they disrupt traction alignment and increase sacral shearing. Assessing pin sites cannot be delegated.

Therapeutic alignment and client safety must be maintained while attempting to address comfort.

Select the intervention that safely promotes comfort and skin integrity.

An overhead trapeze is identified as the safest and most effective intervention.

The trapeze offloads sacral pressure, promotes circulation, and assists with bed mobility while keeping the affected leg in continuous, correct alignment.

Anahtar Kavram

Basic Care and Comfort in Skeletal Traction

Soru 267Soru →

A nurse is preparing to administer a large-volume cleansing enema to an adult client who is experiencing severe constipation. In what order should the nurse perform the following actions? (Arrange the steps in the correct sequence from first to last.)

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is: assist the client into the left lateral Sims position, lubricate the tip of the rectal tube, instruct the client to take deep breaths, gently insert the tube into the rectum, and finally unclamp the tubing and elevate the bag.

Administering an enema requires a systematic approach to ensure safety, comfort, and efficacy. The procedure begins with proper anatomical positioning (left lateral Sims) to utilize gravity for fluid flow. Next, the equipment must be prepared by lubricating the tip of the tube. Immediately before insertion, the nurse instructs the client to take deep breaths to relax the external anal sphincter. Once relaxed, the tube is safely inserted to the correct anatomical depth of 3 to 4 inches. Finally, the solution is administered by unclamping the tubing and holding the bag at the correct height (12 to 18 inches) to ensure steady, safe hydrostatic pressure.

Adım Adım Çözüm

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

The client is anatomically positioned for the procedure.

This position facilitates the gravity-assisted flow of the enema solution directly into the sigmoid colon and descending colon.

Lubricate the tip of the rectal tube with a water-soluble lubricant.

The tube is prepared for atraumatic entry.

Lubrication decreases friction, preventing tissue injury and minimizing discomfort during insertion.

Instruct the client to take slow, deep breaths through the mouth.

The client begins deep breathing exercises.

Deep breathing naturally relaxes the external anal sphincter, which is necessary before attempting insertion.

Gently insert the rectal tube 3 to 4 inches (7.5 to 10 cm) into the rectum.

The tube safely passes the internal anal sphincter.

This specific depth ensures the fluid is delivered adequately into the lower bowel without causing deep tissue trauma.

Unclamp the tubing and hold the enema bag 12 to 18 inches (30 to 45 cm) above the rectum.

The solution begins to flow at a controlled rate.

Maintaining this exact height controls the pressure of the fluid instillation, preventing rapid bowel distention and severe cramping.

Anahtar Kavram

Enema Administration Protocol

Tahmini Süre:1m 0s

Soru 268Soru →

A nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation with a positive end-expiratory pressure (PEEP) of $15 \text{ cm H}_2\text{O}$ . Suddenly, the ventilator's high-pressure alarm activates. The nurse observes that the client's blood pressure has decreased from $122/76 \text{ mm Hg}$ to $82/48 \text{ mm Hg}$ , heart rate has increased from $94 \text{ /min}$ to $138 \text{ /min}$ , and oxygen saturation has dropped to $86\%$ . Which action is the nurse's priority?

Perform immediate in-line endotracheal suctioning to clear airway secretions.

Administer a rapid intravenous fluid bolus to address the severe hypotension.

Auscultate bilateral breath sounds and evaluate for tracheal deviation.

Place the client in a supine position with the lower extremities elevated.

Cevabı ve açıklamayı göster

Cevap: Auscultate bilateral breath sounds and evaluate for tracheal deviation.

Cevap

The correct action is to auscultate bilateral breath sounds and evaluate for tracheal deviation.

The client's presentation—a high-pressure ventilator alarm, sudden profound hypotension, tachycardia, and worsening hypoxemia—strongly suggests barotrauma resulting in a tension pneumothorax. High PEEP increases the risk of alveolar rupture. Leaked air becomes trapped in the pleural space, continuously increasing intrathoracic pressure. This pressure collapses the affected lung and compresses the vena cava, reducing venous return and causing obstructive shock. The nurse must prioritize immediate clinical assessment of breath sounds (which would be diminished or absent on the affected side) and tracheal alignment (deviated away from the affected side) to confirm the diagnosis and prepare for life-saving needle decompression.

Adım Adım Çözüm

Analyze the clinical presentation and ventilator alarms.

The combination of a high-pressure alarm, sudden hypotension, tachycardia, and hypoxemia in a client on high PEEP is identified.

High PEEP increases the risk of alveolar rupture (barotrauma), which can lead to air trapping in the pleural space.

Determine the underlying pathophysiological cause.

The acute hemodynamic deterioration indicates obstructive shock caused by a tension pneumothorax.

Trapped pleural air increases intrathoracic pressure, collapsing the lung and compressing the heart and major vessels, drastically reducing cardiac output.

Prioritize the immediate nursing intervention.

Physical assessment of breath sounds and tracheal alignment is selected as the priority.

Immediate clinical confirmation is required to initiate life-saving interventions such as needle thoracostomy.

Anahtar Kavram

Recognition and initial assessment of tension pneumothorax as a complication of positive pressure ventilation.

Soru 269Soru →

An intensive care nurse is configuring an infusion pump for a client requiring deep sedation. The new medication order specifies remifentanil to run at $0.05\text{ mcg/kg/min}$ . The client's admission weight is $230\text{ lb}$ . The available medication on the unit is a pre-mixed bag containing $2\text{ mg}$ of remifentanil dissolved in $250\text{ mL}$ of normal saline ( $0.9\%\text{ NaCl}$ ). Calculate the required pump setting in $\text{mL/hr}$ . (First, convert and round the client's weight to the nearest tenth of a kilogram. Then, perform your calculations and round the final answer to the nearest tenth.)

Cevabı ve açıklamayı göster

Cevap: 39.2

Cevap

The nurse should set the infusion pump to 39.2 mL/hr.

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

230\text{ lb} \div 2.2 = 104.5\text{ kg}

). The weight is then multiplied by the prescribed dose to find the per-minute requirement (

104.5\text{ kg} \times 0.05\text{ mcg/kg/min} = 5.225\text{ mcg/min}

). Because the pump runs in hours, this is multiplied by

60\text{ minutes}

(

313.5\text{ mcg/hr}

). Next, the concentration of the IV bag is determined by converting milligrams to micrograms (

2\text{ mg} = 2,000\text{ mcg}

) and dividing by the total volume (

2,000\text{ mcg} \div 250\text{ mL} = 8\text{ mcg/mL}

). Finally, the hourly dose is divided by the concentration (

313.5 \div 8 = 39.1875

) and rounded to the nearest tenth, resulting in

39.2\text{ mL/hr}

Adım Adım Çözüm

Convert the client's weight from pounds (lb) to kilograms (kg) and round to the nearest tenth.

230\text{ lb} \div 2.2\text{ lb/kg} = 104.545... \approx 104.5\text{ kg}

Critical care medication dosing is standardized using metric weights.

Calculate the total dose required per minute based on the client's weight.

104.5\text{ kg} \times 0.05\text{ mcg/kg/min} = 5.225\text{ mcg/min}

The prescription dictates how many micrograms the client needs for each kilogram of body weight every minute.

Convert the per-minute dose to an hourly dose.

5.225\text{ mcg/min} \times 60\text{ min/hr} = 313.5\text{ mcg/hr}

Intravenous infusion pumps are programmed in volume per hour (mL/hr), so the time unit must match.

Convert the total drug amount in the IV bag from milligrams (mg) to micrograms (mcg).

2\text{ mg} \times 1,000\text{ mcg/mg} = 2,000\text{ mcg}

The calculated dose is in micrograms, so the available medication supply must be converted to matching units.

Determine the concentration of the IV solution.

2,000\text{ mcg} \div 250\text{ mL} = 8\text{ mcg/mL}

Knowing how many micrograms are in a single milliliter allows you to calculate the total fluid volume needed to deliver the hourly dose.

Calculate the final infusion pump rate.

313.5\text{ mcg/hr} \div 8\text{ mcg/mL} = 39.1875\text{ mL/hr}

Dividing the total hourly medication requirement by the concentration yields the fluid rate in mL/hr.

Round the final rate to the nearest tenth.

39.1875\text{ mL/hr} \approx 39.2\text{ mL/hr}

The problem explicitly requires the final answer to be rounded to the nearest tenth.

Anahtar Kavram

Calculating complex weight-based continuous intravenous infusion rates requiring sequential conversions (lbs to kg, minutes to hours, and mg to mcg).

Soru 270Soru →

A nurse is caring for a client who underwent a percutaneous liver biopsy 4 hours ago. The client is currently positioned on their right side. The client's vital signs are heart rate 116 beats/minute, blood pressure 104/82 mm Hg, respiratory rate 24 breaths/minute, and temperature 98.8°F (37.1°C). The client reports a new onset of right shoulder pain and states, 'I must have slept on my arm wrong.' Which of the following is the most appropriate initial nursing action?

Assess the client's abdomen for rigidity and notify the healthcare provider.

Administer the prescribed as-needed analgesic for the client's shoulder pain.

Assist the client into a supine position to relieve pressure on the right shoulder.

Document the findings and continue to monitor the client's vital signs every hour.

Cevabı ve açıklamayı göster

Cevap: Assess the client's abdomen for rigidity and notify the healthcare provider.

Cevap

The most appropriate action is to assess the client's abdomen for rigidity and prepare to notify the healthcare provider, as the assessment findings strongly indicate early hemorrhagic shock.

The client is exhibiting early signs of hemorrhagic shock, indicated by tachycardia (116 beats/minute) and a narrowed pulse pressure (104 systolic minus 82 diastolic equals 22 mm Hg). Furthermore, the new onset of right shoulder pain is a classic presentation of Kehr's sign, which occurs when blood in the peritoneal cavity irritates the phrenic nerve. The nurse must prioritize assessing for further signs of internal bleeding, such as abdominal rigidity, and escalate the findings to the healthcare provider immediately for emergency interventions.

Adım Adım Çözüm

Analyze the vital signs for trends and abnormalities.

The heart rate is elevated (116 bpm) and the blood pressure reflects a narrow pulse pressure of 22 mm Hg (104 systolic minus 82 diastolic).

Tachycardia and a narrowing pulse pressure are classic, subtle early indicators of compensatory hemorrhagic shock.

Evaluate the client's new symptom in the context of the recent procedure.

The client developed new onset right shoulder pain following a percutaneous liver biopsy.

Referred right shoulder pain (Kehr's sign) occurs when blood accumulates in the peritoneal cavity and irritates the phrenic nerve, confirming the suspicion of internal hemorrhage.

Determine the highest priority nursing intervention.

The nurse must prioritize assessing for further signs of internal bleeding, such as a rigid or board-like abdomen, and immediately escalate to the healthcare provider.

Active internal hemorrhage is a life-threatening emergency that requires immediate medical intervention.

Anahtar Kavram

Identifying early hemodynamic changes of hemorrhagic shock and recognizing referred pain (Kehr's sign) as a critical indicator of internal bleeding post-procedure.

Soru 271Soru →

A nurse is evaluating a client admitted with a severe exacerbation of chronic obstructive pulmonary disease (COPD). The client's most recent arterial blood gas (ABG) analysis on room air reveals the following results: $pH$ of $7.25$ , $PaCO_2$ of $74$ mm Hg, $HCO_3^-$ of $32$ mEq/L, and $PaO_2$ of $52$ mm Hg. Based on these physiological values, which clinical manifestations should the nurse anticipate during the physical assessment? Select all that apply.

Geçerli olan tümünü seçin

Progressive somnolence and decreasing level of consciousness

Bounding peripheral pulses

Diaphoresis accompanied by tachycardia

Cool, pale, and clammy extremities

Deep, rapid, and unlabored respiratory pattern

Positive Chvostek's sign with carpopedal spasms

Cevabı ve açıklamayı göster

Cevap: Progressive somnolence and decreasing level of consciousness; Bounding peripheral pulses; Diaphoresis accompanied by tachycardia

Cevap

The nurse should anticipate progressive somnolence and decreasing level of consciousness, bounding peripheral pulses, and diaphoresis accompanied by tachycardia.

The correct answers identify the classic physiological manifestations of acute hypercapnic respiratory failure with hypoxemia. Severe hypercapnia (

PaCO_2

74

mm Hg) causes significant cerebral vasodilation, which increases intracranial pressure and depresses the central nervous system, leading to progressive somnolence. It also causes peripheral vasodilation, resulting in bounding peripheral pulses. Concurrently, the profound hypoxemia (

PaO_2

52

mm Hg) and acidemia trigger a compensatory sympathetic nervous system response, manifesting as tachycardia and diaphoresis.

Adım Adım Çözüm

Interpret the arterial blood gas (ABG) values to determine the primary physiological derangement.

The client has partially compensated acute-on-chronic respiratory acidosis with severe hypoxemia.

The acidemic

pH

(7.25) aligns with the elevated

PaCO_2

(74 mm Hg), indicating a respiratory primary cause. The elevated

HCO_3^-

(32 mEq/L) reflects chronic metabolic compensation that is insufficient for the acute exacerbation.

Determine the physiological adaptations directly caused by profound hypercapnia.

Severe hypercapnia acts as a potent vasodilator in both cerebral and peripheral vascular beds.

Cerebral vasodilation causes central nervous system depression (somnolence, lethargy, CO2 narcosis), while peripheral vasodilation produces bounding pulses and warm skin.

Determine the physiological adaptations triggered by acute hypoxemia and acidemia.

The body activates the sympathetic nervous system to increase oxygen delivery to vital organs.

Sympathetic stimulation manifests as tachycardia, increased cardiac output, and diaphoresis as the body attempts to compensate for tissue hypoxia.

Anahtar Kavram

In acute uncompensated respiratory acidosis, severe hypercapnia induces both cerebral and peripheral vasodilation (causing somnolence and bounding pulses), while concurrent hypoxemia triggers sympathetic nervous system activation (causing tachycardia and diaphoresis).

Soru 272Soru →

A client with suspected bacterial meningitis is admitted to the intensive care unit. The healthcare provider prescribes a stat dose of intravenous ceftriaxone and a continuous infusion of $0.9\% \text{ Sodium Chloride}$ at $100 \text{ mL/hr}$ . The client arrives from the emergency department with a single peripheral intravenous catheter currently infusing Lactated Ringer's solution at $100 \text{ mL/hr}$ . Based on these findings, which of the following is the priority action by the nurse?

Administer the ceftriaxone via the closest Y-site of the infusing Lactated Ringer's solution to ensure rapid antibiotic delivery.

Withhold the ceftriaxone and contact the healthcare provider to request an alternative antibiotic due to intravenous fluid incompatibility.

Stop the Lactated Ringer's solution, initiate the prescribed

0.9\% \text{ Sodium Chloride}

using new intravenous tubing, and administer the ceftriaxone.

Pause the Lactated Ringer's solution, flush the catheter with

10 \text{ mL}

of sterile water, administer the ceftriaxone, and flush again.

Cevabı ve açıklamayı göster

Cevap: Stop the Lactated Ringer's solution, initiate the prescribed $0.9\% \text{ Sodium Chloride}$ using new intravenous tubing, and administer the ceftriaxone.

Cevap

Stop the Lactated Ringer's solution, initiate the prescribed 0.9% Sodium Chloride using new intravenous tubing, and administer the ceftriaxone.

Ceftriaxone is contraindicated for administration with calcium-containing intravenous solutions, such as Lactated Ringer's, due to the high risk of forming lethal calcium-ceftriaxone precipitates in the client's bloodstream. To safely administer the stat antibiotic for a life-threatening infection (meningitis), the nurse must stop the incompatible fluid, change the intravenous tubing to prevent mixing with residual fluid, initiate the newly prescribed compatible fluid (

0.9\% \text{ Sodium Chloride}

), and administer the ceftriaxone immediately.

Adım Adım Çözüm

Identify the clinical priority based on the diagnosis.

Bacterial meningitis is a life-threatening neurological emergency requiring immediate (stat) antibiotic administration to prevent severe morbidity or mortality.

Delays in treatment directly correlate with poorer client outcomes in meningitis.

Assess for pharmacological incompatibilities.

Ceftriaxone is recognized as incompatible with any calcium-containing solution, such as Lactated Ringer's.

Ceftriaxone binds with calcium to form particulate precipitates that can cause fatal emboli in the lungs and kidneys.

Evaluate the current intravenous access and prescribed orders.

The client has a single IV line running the incompatible Lactated Ringer's, but the provider has already prescribed a continuous infusion of compatible 0.9% Sodium Chloride.

The nurse must transition the client to the newly prescribed, compatible fluid.

Determine the safest procedural intervention.

The nurse stops the Lactated Ringer's, removes the old tubing to ensure no residual calcium remains, connects the new 0.9% Sodium Chloride, and immediately administers the ceftriaxone.

This sequence rapidly and safely resolves the incompatibility while implementing all provider orders.

Anahtar Kavram

Ceftriaxone is strictly contraindicated for concurrent administration with calcium-containing intravenous solutions (like Lactated Ringer's) due to the risk of fatal crystal precipitation.

Tahmini Süre:1m 30s

Soru 273Soru →

A client is admitted to the emergency department with an active upper gastrointestinal bleed. The client's vital signs are blood pressure 84/52 mmHg, heart rate 126 beats per minute, and respiratory rate 22 breaths per minute. The client has a single 18-gauge peripheral intravenous catheter currently infusing 5% dextrose in water (D5W) at 100 mL/hr. The healthcare provider prescribes a stat transfusion of one unit of packed red blood cells (PRBCs) and intravenous pantoprazole. Which action should the nurse take first?

Discontinue the 5% dextrose in water infusion, flush the catheter with 0.9% sodium chloride, and begin the transfusion.

Connect the packed red blood cell administration set to the lowest Y-site port of the existing 5% dextrose in water infusion.

Delegate the continuous monitoring of the client's vital signs for the first 15 minutes of the transfusion to the unlicensed assistive personnel.

Administer the prescribed intravenous pantoprazole immediately to address the active source of the gastrointestinal bleeding.

Cevabı ve açıklamayı göster

Cevap: Discontinue the 5% dextrose in water infusion, flush the catheter with 0.9% sodium chloride, and begin the transfusion.

Cevap

The nurse should discontinue the 5% dextrose in water infusion, flush the intravenous catheter with 0.9% sodium chloride, and initiate the packed red blood cell transfusion.

The client is exhibiting signs of hypovolemic shock (hypotension, tachycardia) due to acute blood loss. The priority based on the ABC (Airway, Breathing, Circulation) framework is to restore intravascular volume and oxygen-carrying capacity. Because blood products are strictly incompatible with 5% dextrose in water (which causes hemolysis), the nurse must stop the incompatible infusion and flush the line with 0.9% sodium chloride before initiating the transfusion.

Adım Adım Çözüm

Assess the client's clinical presentation and vital signs.

The client exhibits profound hypotension (84/52 mmHg) and tachycardia (126 bpm), indicating hypovolemic shock resulting from the gastrointestinal bleed.

Identifying the client's physiological status is necessary to prioritize interventions according to the ABCs (Airway, Breathing, Circulation).

Prioritize the prescribed interventions.

Administering packed red blood cells is the immediate priority over administering the intravenous pantoprazole.

Restoring circulating volume and oxygen-carrying capacity directly addresses the life-threatening circulation deficit.

Evaluate the current intravenous access and infusing fluid for compatibility.

The client has a suitable 18-gauge catheter, but the infusing 5% dextrose in water is strictly incompatible with blood products.

Administering blood with dextrose causes hemolysis. 0.9% sodium chloride is the only intravenous fluid compatible with blood products.

Prepare the intravenous line for safe administration.

The incompatible infusion is stopped, and the line is thoroughly flushed with 0.9% sodium chloride before the blood administration set is attached.

Flushing clears the incompatible dextrose from the catheter, ensuring safe delivery of the blood product without causing cellular destruction.

Anahtar Kavram

Blood products must only be administered with 0.9% sodium chloride to prevent hemolysis. Furthermore, restoring circulating volume is the highest priority for a client in active hypovolemic shock.

Soru 274Soru →

A triage nurse in the emergency department is assessing a client who presents with an acute asthma exacerbation. Which of the following clinical findings indicate the client is experiencing impending respiratory failure and requires immediate life-saving intervention? Select all that apply.

Geçerli olan tümünü seçin

Arterial blood gas revealing a

pH

7.25

and a

PaCO_2

62

mm Hg

Sudden cessation of wheezing despite visible, labored respiratory efforts

Loud, continuous expiratory wheezing across all lung fields

Arterial blood gas revealing a

pH

7.48

and a

PaCO_2

30

mm Hg

New-onset profound lethargy and inability to maintain eye contact

Heart rate of

112

beats/min with a slightly narrowed pulse pressure

Cevabı ve açıklamayı göster

Cevap: Arterial blood gas revealing a $pH$ of $7.25$ and a $PaCO_2$ of $62$ mm Hg; Sudden cessation of wheezing despite visible, labored respiratory efforts; New-onset profound lethargy and inability to maintain eye contact

Cevap

The clinical findings that indicate impending respiratory failure are an arterial blood gas showing respiratory acidosis, the sudden cessation of wheezing, and new-onset profound lethargy.

Impending respiratory failure in an acute asthma exacerbation is characterized by severe air trapping, respiratory muscle fatigue, and poor gas exchange. An arterial blood gas showing respiratory acidosis indicates the client is exhausted and retaining carbon dioxide. A sudden cessation of wheezing (silent chest) is an ominous sign that airflow is too severely restricted to produce sound. Profound lethargy is a late, life-threatening sign of severe hypoxia and hypercapnia, meaning the client is losing the ability to protect their airway and requires immediate mechanical ventilation.

Adım Adım Çözüm

Analyze the pathophysiology of an acute asthma exacerbation.

Initial bronchospasm causes hyperventilation and respiratory alkalosis. As airway resistance increases over time, respiratory muscles fatigue.

Understanding the trajectory helps distinguish between expected early compensatory signs and ominous late signs of decompensation.

Evaluate the arterial blood gas (ABG) options.

A low pH and high carbon dioxide level represent respiratory acidosis, indicating the lungs can no longer expel adequate carbon dioxide.

Respiratory acidosis is a definitive sign of impending failure, whereas early respiratory alkalosis is a typical and expected compensatory mechanism.

Assess the physical examination findings.

A 'silent chest' and profound lethargy indicate critical airway closure and severe cerebral hypoxia, respectively, requiring immediate intubation.

While loud wheezing and mild tachycardia are concerning, they indicate the client is still actively moving air and neurologically compensating.

Anahtar Kavram

Identifying impending respiratory failure in status asthmaticus

Soru 275Soru →

A nurse is planning care for a client who has left lower extremity weakness and is learning to ambulate with a standard pick-up walker. Which of the following interventions should the nurse include in the plan of care?

Delegate the evaluation of the client's balance and gait during the initial ambulation to an unlicensed assistive personnel (UAP).

Adjust the height of the walker so that the client's elbows are fully extended when resting their hands on the grips.

Instruct the client to advance the walker forward first, step forward with the left leg, and then bring the right leg forward.

Teach the client to take an initial step with the strong right leg first while simultaneously advancing the walker.

Cevabı ve açıklamayı göster

Cevap: Instruct the client to advance the walker forward first, step forward with the left leg, and then bring the right leg forward.

Cevap

The correct intervention is to instruct the client to advance the walker forward first, step forward with the weak left leg, and then bring the right leg forward.

When ambulating with a standard walker, the client should first lift and advance the walker about 6 to 8 inches. Next, the client should step forward with the affected (weak) leg so that the upper body and the walker can safely support the body's weight. Finally, the client steps forward with the unaffected (strong) leg. This sequence ensures a wide base of support and maximum stability.

Adım Adım Çözüm

Identify the client's physical deficit and the assistive device being utilized.

The client has left lower extremity weakness and is using a standard pick-up walker.

Recognizing which leg is affected is critical for determining the safe and correct sequence of movement.

Determine the proper ambulatory sequence for using a standard walker.

The correct sequence is to move the walker forward, followed by the weak leg, and finally the strong leg.

Moving the weak leg while the upper body weight is supported by the arms on the walker provides maximum stability and safety.

Evaluate the distractors for safety, body mechanics, and procedural accuracy.

The distractors contain critical errors related to walker height adjustment, stepping sequence, and improper delegation.

Identifying incorrect practices ensures the selection of the safest, most appropriate evidence-based nursing intervention.

Anahtar Kavram

Assistive Devices and Mobility

Soru 276Soru →

A client with a history of chronic kidney disease is brought to the emergency department after missing three scheduled hemodialysis treatments. The client reports severe muscle weakness and abdominal cramping. Assessment reveals a heart rate of 54 bpm, respiratory rate of 22 breaths/min, and blood pressure of 92/58 mm Hg. The cardiac monitor displays a prolonged PR interval, wide QRS complexes, and tall, peaked T waves. Which of the following interventions should the nurse implement first?

Administer intravenous regular insulin and 50% dextrose

Administer a rapid intravenous fluid bolus of 0.9% sodium chloride

Administer intravenous calcium gluconate

Administer oral sodium polystyrene sulfonate

Cevabı ve açıklamayı göster

Cevap: Administer intravenous calcium gluconate

Cevap

Administer intravenous calcium gluconate.

The client is exhibiting signs of severe hyperkalemia, as evidenced by the missed hemodialysis sessions and classic ECG changes (bradycardia, prolonged PR interval, wide QRS complexes, and tall, peaked T waves). A widening QRS complex is a critical warning sign of impending ventricular fibrillation or asystole. Intravenous calcium gluconate is the absolute first priority because it rapidly antagonizes the cardiac toxicity of hyperkalemia. It stabilizes the myocardial cell membrane and raises the threshold potential, preventing lethal dysrhythmias. While calcium gluconate does not actually lower serum potassium levels, it provides immediate cardiac protection, buying time for other therapies to work.

Adım Adım Çözüm

Analyze the client's history and presenting clinical signs.

The client has missed dialysis (impaired excretion), muscle weakness, and specific ECG changes (bradycardia, prolonged PR, wide QRS, peaked T waves).

To identify the underlying physiological crisis, which is severe hyperkalemia.

Evaluate the immediate threats to the client's life.

The wide QRS complex indicates an impending lethal cardiac dysrhythmia (ventricular fibrillation or asystole).

Prioritization requires addressing the most acute, life-threatening condition first (ABC framework and critical ECG changes).

Determine the mechanism of action for each available intervention.

Calcium gluconate stabilizes the cardiac membrane. Insulin/dextrose temporarily shifts potassium into cells. Sodium polystyrene slowly excretes potassium.

To match the pharmacological intervention with the immediate physiological need.

Select the intervention that acts fastest to prevent cardiac arrest.

Intravenous calcium gluconate is selected.

Myocardial stabilization must occur before therapies that shift or remove potassium are initiated when critical ECG changes are present.

Anahtar Kavram

Emergency Management of Severe Hyperkalemia

Soru 277Soru →

The registered nurse is developing a comprehensive care profile for an 82-year-old client who exhibits profound immobility, frequent episodes of urinary incontinence, and an elevated risk for pressure injuries. Which of the following interventions should the nurse incorporate into the management plan? Select all that apply.

Geçerli olan tümünü seçin

Position the client using a 30-degree lateral tilt while side-lying

Utilize a friction-reducing device when moving the client upward in the bed

Maintain the head of the bed consistently at a 60-degree angle

Assign the initial Braden Scale skin assessment to the assistive personnel

Apply an evidence-based moisture barrier ointment to the perineum after cleansing

Document the recent onset of severe incontinence as an expected age-related change

Cevabı ve açıklamayı göster

Cevap: Position the client using a 30-degree lateral tilt while side-lying; Utilize a friction-reducing device when moving the client upward in the bed; Apply an evidence-based moisture barrier ointment to the perineum after cleansing

Cevap

The correct interventions are positioning the client in a 30-degree lateral tilt, utilizing a friction-reducing device for movement, and applying a moisture barrier ointment to the perineum.

Maintaining skin integrity in a highly vulnerable client requires a multi-faceted approach. Implementing a 30-degree lateral tilt effectively offloads weight from prominent bony structures without placing undue stress on the trochanter. Utilizing friction-reducing devices during repositioning prevents the mechanical shearing that tears epidermal layers. Finally, applying a moisture barrier shields the skin from the corrosive environment created by continuous urinary incontinence, preventing maceration.

Adım Adım Çözüm

Analyze the client's risk profile based on the clinical presentation.

The client has three major risk factors for skin breakdown: advanced age, profound immobility, and moisture from incontinence.

Identifying the specific etiologies of potential skin breakdown dictates which preventative nursing interventions are required.

Evaluate the proposed positioning and mobility interventions against evidence-based standards.

A 30-degree lateral tilt and the use of friction-reducing devices are proven methods to minimize direct pressure and shearing forces.

Standard clinical guidelines for pressure injury prevention mandate the reduction of both pressure magnitude and shear stress on vulnerable tissues.

Differentiate appropriate nursing responsibilities and pathological signs from normal aging.

Initial risk assessments must remain with the RN, and sudden severe incontinence requires medical investigation rather than acceptance as normal aging.

Patient safety relies on proper delegation scope and the accurate recognition of acute pathophysiological changes.

Anahtar Kavram

Pressure Injury Prevention and Skin Integrity Maintenance

Soru 278Soru →

A nurse is monitoring a client at $36$ weeks of gestation who is receiving a continuous intravenous (IV) infusion of magnesium sulfate for the management of severe preeclampsia. Which of the following assessment findings indicate potential magnesium toxicity or impaired clearance, requiring immediate intervention by the nurse? Select all that apply.

Geçerli olan tümünü seçin

Patellar deep tendon reflexes (DTRs) graded as

0

(absent)

Respiratory rate of

10

breaths per minute

Urinary output of

15 \text{ mL}

per hour over the last two hours

Client reports a generalized sensation of warmth and facial flushing

Fetal heart rate tracing demonstrating early decelerations with moderate variability

Serum magnesium level of

5.8 \text{ mEq/L}

Cevabı ve açıklamayı göster

Cevap: Patellar deep tendon reflexes (DTRs) graded as $0$ (absent); Respiratory rate of $10$ breaths per minute; Urinary output of $15 \text{ mL}$ per hour over the last two hours

Cevap

The findings requiring immediate intervention are absent patellar deep tendon reflexes, a respiratory rate of 10 breaths per minute, and a urinary output of 15 mL per hour.

The correct options identify the classic signs of magnesium toxicity and impaired clearance. Because magnesium sulfate is a central nervous system depressant, toxicity sequentially manifests as the loss of deep tendon reflexes (often the first sign), followed by respiratory depression (fewer than 12 breaths per minute), and eventually cardiac arrest. Furthermore, because magnesium is excreted exclusively by the kidneys, severe oliguria (urine output less than 30 mL/hr) causes rapid accumulation of the medication, requiring an immediate decrease or cessation of the infusion to prevent toxic serum levels.

Adım Adım Çözüm

Identify the purpose and mechanism of the medication.

Magnesium sulfate is a central nervous system depressant used to prevent seizures in severe preeclampsia.

Understanding the mechanism of action is essential to anticipate therapeutic effects and differentiate them from clinical toxicity.

Evaluate the assessment findings against known signs of toxicity and clearance failure.

Findings of absent DTRs (grade 0), respiratory rate < 12 breaths per minute, and severe oliguria (< 30 mL/hr) are critical indicators of toxicity or poor renal clearance.

Magnesium toxicity progresses predictably from loss of reflexes to respiratory depression and eventual cardiac arrest; renal impairment exacerbates this by preventing drug excretion.

Differentiate critical toxicity from expected side effects and therapeutic levels.

Flushing and warmth are expected vasodilatory side effects. A serum magnesium level of 5.8 mEq/L is within the therapeutic range (4.0 - 7.0 mEq/L). Early FHR decelerations are a normal labor finding.

Unnecessary intervention for expected or therapeutic findings can disrupt essential seizure prophylaxis and jeopardize maternal safety.

Anahtar Kavram

Recognition of magnesium sulfate toxicity and therapeutic monitoring in severe preeclampsia.

Soru 279Soru →

A nurse is caring for a $45$ -year-old client receiving total parenteral nutrition via a right subclavian central venous access device. While the nurse is changing the intravenous tubing, the catheter temporarily disconnects from the infusion line. The client immediately reports severe chest pain, shortness of breath, and a sense of impending doom. The client's heart rate is $128$ bpm, blood pressure is $86/52$ mmHg, and oxygen saturation is $82\%$ on room air. The nurse immediately clamps the catheter. Which of the following is the priority nursing action?

Place the client in a left lateral Trendelenburg position.

Elevate the head of the bed to a high-Fowler's position and administer high-flow oxygen.

Auscultate the client's lung fields to confirm absent breath sounds before initiating interventions.

Activate the rapid response team to obtain an immediate electrocardiogram and arterial blood gas.

Cevabı ve açıklamayı göster

Cevap: Place the client in a left lateral Trendelenburg position.

Cevap

Place the client in a left lateral Trendelenburg position.

The client's presentation (sudden dyspnea, hypotension, sense of doom) immediately following a central venous catheter disconnection is the classic presentation of an air embolism. After clamping the catheter to halt further air entry, placing the client in a left lateral Trendelenburg position (Durant's maneuver) is the most critical independent nursing action. This position utilizes gravity to trap the air bubble in the apex of the right ventricle, preventing it from migrating into the pulmonary artery and causing a right ventricular outflow obstruction.

Adım Adım Çözüm

Analyze the clinical presentation and mechanism of injury.

The acute onset of chest pain, dyspnea, doom, and shock-like vital signs immediately following a central line disconnection strongly indicates a venous air embolism.

Air entering the central venous system travels rapidly to the right side of the heart.

Determine the physiological goal of the intervention.

The immediate goal is to prevent the air from migrating into the pulmonary circulation (causing right ventricular outflow obstruction) or cerebral circulation.

Once the catheter is clamped to stop further air entry, positioning must be used to manipulate the movement of the trapped air.

Identify the correct therapeutic positioning.

The left lateral Trendelenburg position (Durant's maneuver) is selected.

This specific position keeps the air bubble in the apex of the right ventricle, allowing blood to flow past it while it slowly absorbs or until surgical/medical aspiration can occur.

Anahtar Kavram

Management of a Central Venous Air Embolism

Soru 280Soru →

A client in the intensive care unit with septic shock is receiving a continuous intravenous infusion of norepinephrine via the proximal lumen of a triple-lumen central venous catheter. The healthcare provider prescribes a stat dose of intravenous sodium bicarbonate to treat severe metabolic acidosis. Upon checking a drug reference guide, the nurse discovers that norepinephrine and sodium bicarbonate are chemically incompatible. Which action by the nurse is the most appropriate?

Administer the sodium bicarbonate dose through the medial or distal lumen of the existing central venous catheter.

Pause the norepinephrine infusion briefly, flush the proximal lumen with normal saline, administer the sodium bicarbonate, and flush again before resuming.

Establish a new peripheral intravenous access site specifically for the administration of the sodium bicarbonate.

Dilute the sodium bicarbonate in a bag of normal saline and piggyback it into the continuous norepinephrine infusion line.

Cevabı ve açıklamayı göster

Cevap: Administer the sodium bicarbonate dose through the medial or distal lumen of the existing central venous catheter.

Cevap

Administer the sodium bicarbonate dose through the medial or distal lumen of the existing central venous catheter.

The correct action is to use an alternative lumen on the existing multi-lumen central venous catheter. Multi-lumen catheters contain separate internal tubes that exit at different staggered points (proximal, medial, distal) along the catheter tip. Because these drugs do not mix within the catheter itself and are immediately dispersed by the high-volume blood flow of the superior vena cava upon exiting, it is entirely safe and standard practice to administer chemically incompatible medications through different lumens of the same central line.

Adım Adım Çözüm

Analyze the client's current condition and the prescribed therapies.

The client is hemodynamically unstable, requiring a continuous norepinephrine infusion (vasopressor) for septic shock, and has severe metabolic acidosis requiring a stat dose of sodium bicarbonate.

Understanding the critical nature of both infusions establishes the priority of care.

Evaluate the compatibility issue identified by the drug reference guide.

Norepinephrine and sodium bicarbonate are incompatible; mixing them in the same tubing will deactivate the norepinephrine.

Chemical incompatibility dictates that these drugs cannot share the same intravenous pathway.

Assess the capabilities of the existing intravenous access.

The client has a triple-lumen central venous catheter. Only the proximal lumen is currently being used for norepinephrine.

Multi-lumen central venous catheters are specifically designed to allow simultaneous administration of incompatible drugs.

Determine the safest and most efficient administration route for the new medication.

Using a separate, available lumen on the central venous catheter allows immediate administration of the stat medication without interrupting the critical vasopressor infusion or risking drug interaction.

Separate lumens keep the drugs completely isolated until they exit into the high-volume, rapid-flow environment of the superior vena cava.

Anahtar Kavram

Central Venous Catheter Multi-Lumen Management and IV Compatibility

ÖncekiSayfa 14 / 98Sonraki

Physiological Integrity

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram