Examkin

Physiological Integrity

1960 soru

Tüm türler1,960Çoktan seçmeli1,004Çoklu seçim425Sayısal102Sıralama429
Soru 941Soru →

A client is recovering on the surgical unit following a right total hip arthroplasty (posterior approach). The nurse is assisting the client with positioning in bed. Which intervention should the nurse implement to prevent dislocation of the new hip prosthesis?

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Cevap: Place an abductor pillow between the client's legs.

Cevap

Place an abductor pillow between the client's legs.
Maintaining the hip in a state of abduction prevents the head of the femur from dislocating out of the acetabulum following a posterior approach total hip arthroplasty. An abductor pillow keeps the legs spread apart, maintaining this safe, neutral alignment.

Adım Adım Çözüm

1
Analyze the surgical procedure and its inherent risks.
A posterior approach total hip arthroplasty carries a high risk of joint dislocation if specific movement precautions are not followed.
Understanding the surgical approach determines the necessary post-operative restrictions.
2
Identify the standard precautions for a posterior hip arthroplasty.
The primary restrictions are avoiding hip flexion greater than 90 degrees, avoiding hip adduction (crossing the midline), and avoiding internal rotation.
These specific movements place stress on the posterior capsule and can push the femoral head out of the acetabulum.
3
Evaluate the given options against these standard precautions.
Using an abductor pillow maintains safe alignment (abduction). The other choices describe actions that violate the restrictions (flexion > 90, adduction, internal rotation).
Selecting the intervention that actively prevents contraindicated movements ensures client safety.

Anahtar Kavram

Post-operative positioning and precautions for total hip arthroplasty
Soru 942Soru →

A client recovering from a right-hemisphere cerebrovascular accident has left-sided hemiplegia and requires assistance moving from the bed to a bedside wheelchair. The client is alert, able to follow commands, and can bear partial weight on their unaffected leg. Arrange the following procedural steps in the correct chronological order to ensure a safe transfer.

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Cevap

The correct sequence is to first position the wheelchair on the client's right (unaffected) side, assist the client to sit and dangle at the bedside, apply the transfer belt, block the client's left (weak) leg, and finally instruct the client to use their right hand to push up and pivot.
A safe transfer for a client with hemiplegia relies on biomechanics and compensating for the deficit. The environment is prepared first by placing the chair on the strong side. The client is then brought to a seated position to stabilize blood pressure. Safety equipment (transfer belt) is applied while seated. The nurse must then brace the weak extremity to prevent buckling before initiating the actual movement, which relies on the client's strong side pushing off.

Adım Adım Çözüm

1
Place wheelchair on the right side.
The chair is positioned on the client's strong side.
Transfers must always lead toward the unaffected side to maximize the client's stability and ability to assist.
2
Assist to a seated position on the bed edge.
The client is sitting up and assessed for orthostatic hypotension.
Dangling allows the cardiovascular system to adjust to gravity, preventing dizziness and falls.
3
Apply the transfer belt.
The belt is secured around the client's waist.
Provides a safe handhold for the nurse to control the client's center of gravity.
4
Brace the client's left knee and foot.
The hemiplegic leg is mechanically supported by the nurse.
Prevents the weak leg from buckling when the client attempts to bear weight during the pivot.
5
Execute the stand and pivot.
The client moves safely into the wheelchair.
Utilizing the strong right arm to push off and the strong right leg to bear weight ensures a controlled, safe transfer.

Anahtar Kavram

Safe client transfer techniques for hemiplegia require leading with the unaffected side and mechanically supporting the paralyzed extremity.
Tahmini Süre:1m 30s
Soru 943Soru →

A critically ill client with septic shock is being managed in the intensive care unit. The client has a double-lumen central venous catheter. The first lumen is dedicated to total parenteral nutrition (TPN). The second lumen is delivering a norepinephrine infusion to maintain the client's mean arterial pressure. Following a focal seizure, the healthcare provider prescribes an intravenous (IV) loading dose of phenytoin. Which of the following is the most appropriate nursing action?

Cevabı ve açıklamayı göster

Cevap: Establish a new peripheral intravenous access site and administer the phenytoin exclusively with 0.9% sodium chloride.

Cevap

The correct action is to establish a new peripheral intravenous access site and administer the phenytoin exclusively with 0.9% sodium chloride.
Phenytoin is highly incompatible with many solutions, especially dextrose (found in TPN), and can easily precipitate. It must be administered exclusively with 0.9% sodium chloride. Furthermore, TPN requires a dedicated line to prevent infection and incompatibilities. The norepinephrine infusion cannot be paused, even briefly, because of its short half-life and the client's dependence on it for hemodynamic stability in septic shock. Therefore, establishing a new IV site is the only safe option.

Adım Adım Çözüm

1
Evaluate the current use of the central venous catheter lumens.
The first lumen is dedicated to TPN. The second lumen is infusing a continuous, life-sustaining vasopressor (norepinephrine).
To determine if either existing line can safely accommodate a new intravenous medication.
2
Analyze the pharmacological properties and administration requirements for intravenous phenytoin.
Phenytoin is highly physically incompatible with most solutions and medications, especially dextrose (found in TPN), and must be administered with 0.9% sodium chloride.
To identify compatibility risks and prevent precipitation or crystallization in the IV line.
3
Determine the safest route of administration based on compatibility and patient hemodynamics.
Since the vasopressor cannot be paused without risking cardiovascular collapse, and TPN requires a dedicated line, a new peripheral IV is the only safe option.
To ensure the client safely receives the anticonvulsant without compromising life-sustaining therapies.

Anahtar Kavram

Safe administration of incompatible high-alert intravenous medications requires establishing separate vascular access when existing lines are dedicated to life-sustaining continuous infusions.

Alternatif Yöntem

If establishing a new peripheral IV is impossible due to severe edema or vascular collapse, an intraosseous (IO) line would be the next appropriate alternative for emergency access.
Tahmini Süre:1m 30s
Soru 944Soru →

A nurse is preparing to administer a scheduled dose of intravenous pantoprazole to a client. The client is currently receiving a continuous infusion of total parenteral nutrition (TPN) through a single-lumen peripherally inserted central catheter (PICC). Which of the following is the most appropriate action by the nurse?

Cevabı ve açıklamayı göster

Cevap: Establish a new peripheral intravenous catheter to administer the medication.

Cevap

Establish a new peripheral intravenous catheter to administer the medication.
Total Parenteral Nutrition (TPN) solutions have high glucose and amino acid concentrations, making them highly prone to bacterial growth and chemical incompatibilities. Evidence-based nursing practice dictates that TPN must be administered through a dedicated central line lumen. No other medications, intravenous fluids, or blood products should be administered through this specific lumen. Because the client currently has only a single-lumen PICC which is actively in use for the TPN, the nurse must establish a new peripheral intravenous site to administer the scheduled pantoprazole safely.

Adım Adım Çözüm

1
Identify the client's current intravenous access and ongoing infusions.
The client has a single-lumen PICC that is actively being used for a continuous TPN infusion.
Evaluating current vascular access is required before safely administering any new intravenous medication.
2
Recall the safety administration principles for Total Parenteral Nutrition.
TPN solutions require a dedicated central venous line or lumen; no other fluids or medications can share this access.
TPN has a high osmolarity, high glucose content, and specific pH that increases the risk of infection, chemical incompatibility, and precipitate formation when mixed with other drugs.
3
Determine the safest method to administer the prescribed pantoprazole.
Since the sole central line lumen is dedicated to TPN, a new peripheral IV catheter must be inserted.
Providing alternative venous access ensures the client receives the scheduled medication without compromising the safety of the TPN infusion.

Anahtar Kavram

Total Parenteral Nutrition (TPN) Dedicated Line Requirement
Tahmini Süre:1m 0s
Soru 945Soru →

A hospitalized client is receiving an ongoing continuous intravenous (IV) drip of 0.9% sodium chloride. The healthcare provider orders a single dose of an IV analgesic to manage the client's acute pain. What is the most critical action for the nurse to perform immediately before injecting the analgesic into the existing IV line?

Cevabı ve açıklamayı göster

Cevap: Check a reliable drug reference to ensure the analgesic and the sodium chloride solution can be safely mixed.

Cevap

Check a reliable drug reference to ensure the analgesic and the sodium chloride solution can be safely mixed.
Before administering any intravenous medication into an existing continuous infusion, the nurse must confirm that the two substances are physically and chemically compatible. This prevents the formation of precipitates, which can occlude the catheter or cause an embolism.

Adım Adım Çözüm

1
Identify the primary clinical task.
The nurse needs to administer an IV push medication into an active continuous IV line.
Understanding the exact route and current IV setup is the first step in ensuring patient safety.
2
Determine the highest priority safety requirement for IV push administration.
The nurse must verify that the two fluids will not cause an adverse chemical reaction or precipitate when mixed in the IV tubing.
Incompatible IV fluids can form solid particles that act as emboli, posing a life-threatening risk to the client.
3
Select the correct nursing intervention.
Consulting a compatibility chart or drug reference is required before injecting the medication.
This action directly prevents the administration of incompatible substances into the same line.

Anahtar Kavram

Intravenous Medication Compatibility
Soru 946Soru →

A nurse is preparing to draw a blood sample for laboratory testing from a client's central venous catheter (CVC). To reduce the risk of infection and ensure accurate laboratory results, arrange the following nursing actions in the correct chronological order.

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Cevabı ve açıklamayı göster

Cevap

The correct chronological sequence is: perform hand hygiene and don gloves, scrub the catheter hub, check patency by aspirating and flushing, discard the waste blood volume, and finally obtain the pure blood sample.
Following this exact procedural sequence prioritizes client safety by minimizing the risk of central line-associated bloodstream infections (CLABSI) and preventing the reporting of inaccurate laboratory values. Infection control (hand hygiene and scrubbing the hub) must always occur first. Next, verifying patency and flushing ensures the line is functional. Crucially, the nurse must then withdraw and discard the initial 'waste' blood to clear the line of any residual IV fluids or medications. Finally, a pristine, undiluted sample is drawn using a new syringe.

Adım Adım Çözüm

1
Initiate baseline infection control measures.
Hand hygiene is performed and clean gloves are donned.
To establish a clean environment and protect the client from exogenous pathogens.
2
Disinfect the access port.
The central line hub is scrubbed vigorously with an antimicrobial swab.
To mechanically remove and eliminate surface bacteria, minimizing the direct risk of introducing a central line-associated bloodstream infection (CLABSI).
3
Verify line patency and clear the line.
The nurse aspirates for a blood return and flushes the line with normal saline.
To confirm the central line is functioning properly and is free of occlusions or incompatible fluids before drawing blood.
4
Clear the catheter dead space.
A specific volume of blood is withdrawn and safely discarded.
To remove any residual medications or saline in the catheter that could dilute the blood sample, ensuring the laboratory results accurately reflect the client's systemic condition.
5
Collect the diagnostic specimen.
A new syringe is attached to draw the necessary volume for the prescribed laboratory tests.
To obtain an uncontaminated, undiluted blood sample for laboratory analysis.

Anahtar Kavram

Reduction of Risk Potential: Central Venous Catheter Blood Draw Sequence
Tahmini Süre:45s
Soru 947Soru →

A client is brought to the emergency department with a decreased level of consciousness, deep and rapid respirations, and a fruity breath odor. Laboratory results confirm a diagnosis of diabetic ketoacidosis (DKA) with a blood glucose level of 680 mg/dL. Arrange the following collaborative and nursing interventions in the chronological order they should be implemented.

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Cevabı ve açıklamayı göster

Cevap

The correct sequence is: 1) Establish intravenous access and infuse 0.9% sodium chloride, 2) Evaluate the client's initial serum potassium level, 3) Initiate a continuous intravenous infusion of regular insulin, and 4) Add 5% dextrose to the intravenous maintenance fluids.
The priority in DKA is restoring intravascular volume to ensure adequate organ perfusion. After initiating fluids, the potassium level must be checked because insulin therapy will lower serum potassium. Once potassium is confirmed safe, regular insulin is infused to reverse the ketoacidosis. Finally, when blood glucose drops to approximately 250 mg/dL, dextrose is added to prevent hypoglycemia while insulin continues to clear blood ketones.

Adım Adım Çözüm

1
Determine the most immediate life-threatening physiological need for a client with DKA.
Severe dehydration and intravascular volume depletion are identified as the primary threats.
Extreme hyperglycemia causes osmotic diuresis, leading to massive fluid loss that must be corrected immediately to prevent cardiovascular collapse.
2
Select the prerequisite assessment required before treating the hyperglycemia.
Evaluate the serum potassium level.
Insulin therapy drives both glucose and potassium into the intracellular space. If the client is already hypokalemic, giving insulin can precipitate life-threatening cardiac arrhythmias.
3
Identify the primary pharmacological intervention to reverse the ketoacidosis.
Initiate a continuous intravenous infusion of regular insulin.
With fluids running and potassium levels confirmed safe, intravenous regular insulin is administered to stop ketogenesis and safely lower the blood glucose level.
4
Anticipate necessary modifications to therapy as the client's condition improves.
Add 5% dextrose to the intravenous fluids when blood glucose reaches approximately 250 mg/dL.
This action prevents treatment-induced hypoglycemia and cerebral edema, allowing the insulin infusion to continue until the acidosis is fully resolved.

Anahtar Kavram

Diabetic Ketoacidosis (DKA) Management Sequence
Soru 948Soru →

A client with severe diabetic ketoacidosis (DKA) and hyperkalemia (serum potassium 7.2 mEq/L7.2\text{ mEq/L}) is receiving continuous intravenous (IV) infusions through a triple-lumen central venous catheter (CVC). The infusions are as follows:

- Proximal lumen: Regular insulin at 0.1 units/kg/hr0.1\text{ units/kg/hr} in 0.9% sodium chloride.
- Medial lumen: Isotonic 0.9% sodium chloride at 150 mL/hr150\text{ mL/hr}.
- Distal lumen: Sodium bicarbonate 150 mEq150\text{ mEq} in 1000 mL1000\text{ mL} of 5% dextrose in water (D5W) at 100 mL/hr100\text{ mL/hr}.

The client's cardiac monitor suddenly displays widening QRS complexes. The healthcare provider verbally prescribes an emergent IV bolus of 10%10\% calcium gluconate (1000 mg1000\text{ mg}) to stabilize the myocardium. The client currently has no peripheral IV access. Which of the following actions is the most appropriate for the nurse to take?

Cevabı ve açıklamayı göster

Cevap: Administer the calcium gluconate via the injection port of the medial lumen's IV tubing closest to the client, allowing the 0.9% sodium chloride to act as a carrier fluid.

Cevap

The most appropriate action is to administer the calcium gluconate via the medial lumen, utilizing the continuous 0.9% sodium chloride as a compatible carrier fluid.
The correct action is to administer the calcium gluconate via the medial lumen. The medial lumen contains 0.9% sodium chloride, which is fully compatible with calcium gluconate. Crucially, because the separate lumens of a CVC act as independent catheters with staggered exit ports in the superior vena cava, the calcium exiting the medial port will instantly dilute in the rapid central venous blood flow, preventing it from precipitating with the sodium bicarbonate exiting the distal port. Using this lumen ensures immediate, safe administration without interrupting necessary ongoing therapies or risking an accidental bolus of insulin.

Adım Adım Çözüm

1
Analyze the clinical emergency.
The client has hyperkalemia with widening QRS complexes, indicating impending ventricular fibrillation.
Immediate administration of calcium gluconate is required to stabilize the myocardial threshold. Delaying for peripheral IV access is contraindicated.
2
Evaluate the compatibility of the prescribed medication with the current infusions.
Calcium gluconate is highly incompatible with sodium bicarbonate (forms a chalky precipitate). It is compatible with 0.9% sodium chloride.
Identifying chemical incompatibilities prevents catastrophic line occlusion and embolization of precipitates.
3
Assess the multi-lumen CVC physiology and existing infusions.
The distal lumen has bicarbonate, the proximal has a high-alert insulin drip, and the medial has compatible normal saline. Separate CVC lumens act as completely independent IV lines.
Because CVC lumens exit at different points in the high-volume superior vena cava, incompatible drugs will instantly dilute in the blood without precipitating, eliminating the need for separate catheter insertion sites.
4
Select the safest lumen for IV push administration.
The medial lumen is selected.
It avoids mixing with bicarbonate (distal) and avoids flushing the dead space of the insulin line (proximal), which would cause a dangerous hypoglycemic bolus.

Anahtar Kavram

Multi-lumen central venous catheters (CVCs) function as completely independent intravenous lines, safely allowing the concurrent infusion of physically incompatible medications. Furthermore, medications should never be pushed through the tubing of a continuous high-alert medication due to the risk of delivering an unintended bolus from the tubing's dead space.
Soru 949Soru →

A nurse is caring for a critically ill client who has a multi-lumen central venous catheter (CVC) in place. The client is receiving a continuous intravenous (IV) vasopressor infusion. Which of the following actions by the nurse demonstrate safe parenteral therapy and catheter management? (Select all that apply)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Scrub the needleless connector hub with an appropriate antiseptic for at least 15 seconds before accessing.; Use a syringe with a barrel size of 10 mL or larger when flushing the catheter lumens.; Clamp any unused catheter lumens securely when they are not actively being used.

Cevap

The safe parenteral therapy practices are scrubbing the connector hub for at least 15 seconds, using a syringe with a 10 mL or larger barrel for flushing, and clamping unused lumens.
Safe central venous catheter management requires strict infection control (scrubbing the hub), preventing catheter damage (using at least a 10 mL syringe to avoid high pressure), and preventing air embolisms and blood reflux (clamping unused lumens).

Adım Adım Çözüm

1
Evaluate the risk of infection.
Scrubbing the hub for 15 seconds is required to prevent CLABSI.
Central lines provide direct access to the central circulation, making infection prevention paramount.
2
Evaluate the physical maintenance of the catheter.
A 10 mL or larger syringe must be used for flushing, and unused lumens must be clamped.
Smaller syringes create high pressure that can rupture the line, and unclamped lumens risk air embolism or blood reflux.
3
Evaluate medication administration and delegation practices.
Incompatible medications cannot share a lumen, vasopressors must not be paused, UAPs cannot perform sterile dressing changes, and air embolisms require the left lateral Trendelenburg position.
These actions prevent hemodynamic instability, precipitation of medications, scope of practice violations, and catastrophic circulatory compromise.

Anahtar Kavram

Central Venous Catheter (CVC) Safe Management and Complication Prevention
Soru 950Soru →

An adult client is being treated for a pulmonary embolism and is currently receiving a continuous intravenous heparin infusion at 15 units/kg/hr15 \text{ units/kg/hr}. The client weighs 198 lbs198 \text{ lbs}. The infusion bag supplied by the pharmacy contains 25,000 units25,000 \text{ units} of heparin in 500 mL500 \text{ mL} of 5%5\% Dextrose in Water (D5W). The client's most recent activated partial thromboplastin time (aPTT) result is 41 seconds41 \text{ seconds}.

The facility's heparin adjustment protocol states:

aPTT ResultRequired Action
<35 seconds< 35 \text{ seconds}Bolus 80 units/kg80 \text{ units/kg}, increase infusion by 4 units/kg/hr4 \text{ units/kg/hr}
36−44 seconds36 - 44 \text{ seconds}Bolus 40 units/kg40 \text{ units/kg}, increase infusion by 2 units/kg/hr2 \text{ units/kg/hr}
45−75 seconds45 - 75 \text{ seconds}No change to current infusion rate
76−90 seconds76 - 90 \text{ seconds}Decrease infusion by 2 units/kg/hr2 \text{ units/kg/hr}

Based on the protocol, at what rate in mL/hr\text{mL/hr} should the nurse set the infusion pump for the continuous maintenance drip? (Record your answer to the nearest tenth.)

Cevabı ve açıklamayı göster

Cevap: 30.6

Cevap

30.6
The correct pump rate is derived by first converting the client's weight to kilograms (198 lbs÷2.2=90 kg198 \text{ lbs} \div 2.2 = 90 \text{ kg}). Based on the aPTT result of 41 seconds41 \text{ seconds}, the protocol requires increasing the current infusion rate (15 units/kg/hr15 \text{ units/kg/hr}) by 2 units/kg/hr2 \text{ units/kg/hr}, making the new rate 17 units/kg/hr17 \text{ units/kg/hr}. Multiplying this by the client's weight yields a total hourly dose of 1530 units/hr1530 \text{ units/hr}. Dividing this hourly dose by the concentration of the IV solution (50 units/mL50 \text{ units/mL}) gives the required continuous pump rate of 30.6 mL/hr30.6 \text{ mL/hr}.

Adım Adım Çözüm

1
Convert the client's weight from pounds to kilograms.
198 lbs÷2.2 lbs/kg=90 kg198 \text{ lbs} \div 2.2 \text{ lbs/kg} = 90 \text{ kg}
Heparin dosing is weight-based in kilograms, so an accurate conversion is the foundational step for safe medication administration.
2
Determine the required protocol action based on the aPTT result.
The aPTT is 41 seconds41 \text{ seconds}, which falls into the 36−44 seconds36 - 44 \text{ seconds} range. The protocol requires an increase of the continuous infusion by 2 units/kg/hr2 \text{ units/kg/hr}.
Protocols standardize medication titration based on objective laboratory data to achieve a therapeutic window.
3
Calculate the new total hourly heparin dose.
Current rate (15 units/kg/hr15 \text{ units/kg/hr}) + Increase (2 units/kg/hr2 \text{ units/kg/hr}) = New rate (17 units/kg/hr17 \text{ units/kg/hr}). Total hourly dose = 17 units/kg/hr×90 kg=1530 units/hr17 \text{ units/kg/hr} \times 90 \text{ kg} = 1530 \text{ units/hr}.
The adjustment must be added to the baseline rate before calculating the total weight-based hourly dose.
4
Calculate the concentration of the available heparin bag.
25,000 units÷500 mL=50 units/mL25,000 \text{ units} \div 500 \text{ mL} = 50 \text{ units/mL}
Establishing the exact concentration is necessary to convert the ordered dose (units) into a fluid volume (mL).
5
Calculate the new infusion pump rate in mL/hr.
1530 units/hr÷50 units/mL=30.6 mL/hr1530 \text{ units/hr} \div 50 \text{ units/mL} = 30.6 \text{ mL/hr}. (Already at the nearest tenth).
Dividing the desired hourly dose by the concentration yields the exact programming parameter for the intravenous pump.

Anahtar Kavram

Weight-based intravenous medication calculations and protocol-driven heparin titration.
Soru 951Soru →

A client with symptomatic anemia is scheduled to receive a transfusion of packed red blood cells (PRBCs). The nurse is gathering supplies to prime the Y-type blood administration set. Which intravenous fluid must the nurse select to hang with the blood product?

Cevabı ve açıklamayı göster

Cevap: 0.9% sodium chloride

Cevap

The only safe and compatible fluid to use with a blood transfusion is 0.9% sodium chloride (normal saline).
Only 0.9% sodium chloride (normal saline) is isotonic and entirely compatible with blood products. It maintains the integrity of the red blood cells, preventing hemolysis (rupture) and ensuring no clots form within the administration set.

Adım Adım Çözüm

1
Identify the prescribed therapy and required equipment.
The client is receiving PRBCs, which require a Y-type administration set primed with a compatible fluid.
Safe administration of blood products requires specific protocols to prevent potentially fatal complications.
2
Evaluate the compatibility of standard intravenous fluids with blood products.
Fluids containing calcium cause clotting, while hypotonic or dextrose-containing fluids cause red blood cell hemolysis.
Mixing incompatible fluids with blood destroys the red blood cells before they enter the client's circulation.
3
Select the correct fluid.
0.9% sodium chloride is identified as the correct fluid.
It is isotonic and does not interact with the cellular components or preservatives in the blood product.

Anahtar Kavram

Blood Product Compatibility
Soru 952Soru →

The healthcare provider prescribes knee-length anti-embolic stockings for a newly admitted client who is on bed rest. To promote proper venous return and prevent tissue injury, in what order should the nurse perform the steps to apply the stockings? Arrange the actions in the correct chronological sequence.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence for applying anti-embolic stockings is to position the client supine, invert the stocking to the heel, slide it over the toes and heel, pull it up the calf, and finally smooth out any wrinkles.
Correct application of anti-embolic stockings requires preparation of both the client and the garment. The client must be supine to minimize edema. Preparing the stocking by inverting it to the heel pocket ensures a smooth application over the foot. Anchoring the foot first allows the nurse to pull the rest of the stocking up without twisting. Finally, ensuring the stocking is smooth prevents localized pressure points that could impede circulation.

Adım Adım Çözüm

1
Position the client supine in bed for 15 to 30 minutes.
Dependent fluid drains from the legs.
This prevents trapping venous blood and edema inside the stocking before compression is applied.
2
Invert the stocking by grasping the heel pocket.
The stocking is prepared for smooth application.
This technique allows the stocking to slide over the foot easily without bunching.
3
Slide the foot portion over the toes and heel.
The foot of the stocking is anchored correctly.
Proper alignment over the heel is crucial for the stocking's graduated compression design.
4
Pull the main body of the stocking over the calf.
The stocking covers the lower leg.
This provides the intended therapeutic compression to the superficial and deep veins.
5
Smooth out any wrinkles and check the top edge.
The stocking lies perfectly flat against the skin.
Wrinkles or rolled edges create areas of excessive pressure that can restrict blood flow like a tourniquet.

Anahtar Kavram

Immobility Interventions: Anti-Embolic Stocking Application
Soru 953Soru →

While conducting morning assessments, it is noted that a client's central venous catheter tubing has accidentally disconnected from the injection cap. The client abruptly gasps, exhibits severe dyspnea, and reports a sensation of impending doom. Suspecting an air embolism, arrange the following nursing interventions in the correct sequence to minimize physiological complications.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first clamp the catheter, then place the client in a left lateral Trendelenburg position, administer 100% oxygen, notify the rapid response team, and finally obtain a complete set of vital signs.
When an air embolism is suspected due to a disconnected central venous line, the absolute priority is to stop more air from entering by clamping the line. The next critical action is client positioning (left lateral Trendelenburg) to trap the air in the right ventricle, preventing it from reaching the lungs. Once the mechanical threat is stabilized, addressing hypoxia with 100% oxygen is necessary. Only after these immediate life-saving steps are taken should the nurse summon the rapid response team, followed by assessing vital signs to provide continuous data to the arriving team.

Adım Adım Çözüm

1
Clamp the open central venous catheter.
Halts the entry of ambient air into the bloodstream.
Source control is always the initial step in mitigating an active procedural complication to prevent worsening of the condition.
2
Turn the client onto their left side with the head lower than the feet (Trendelenburg).
Traps the air bubble in the right side of the heart.
This specific position prevents the embolus from migrating into the pulmonary circulation, where it would cause a massive and potentially fatal pulmonary embolism.
3
Apply high-flow oxygen.
Increases alveolar oxygen tension.
Addresses the severe hypoxia and promotes the diffusion and resorption of the nitrogen-rich air bubble.
4
Call the rapid response team.
Mobilizes advanced medical support to the bedside.
The client requires urgent medical evaluation and potential advanced interventions after initial physical safeguards are placed.
5
Measure vital signs.
Establishes a baseline post-event hemodynamic profile.
Provides critical assessment data to the response team immediately upon their arrival without delaying life-saving actions.

Anahtar Kavram

Management of a suspected air embolism from a central venous catheter
Soru 954Soru →

A nurse is caring for a client admitted with a severe acute asthma exacerbation. The client has been receiving continuous albuterol nebulization and intravenous corticosteroids. During reassessment, the nurse observes that the client is becoming increasingly lethargic and the respiratory rate has decreased from 34 to 12 breaths per minute. Auscultation reveals a 'silent chest' with no audible wheezing. The latest arterial blood gas (ABG) results on room air are: pH 7.28, PaCO2 62 mm Hg, PaO2 55 mm Hg, and HCO3 26 mEq/L. Which action is the priority for the nurse to reduce the risk of a fatal outcome?

Cevabı ve açıklamayı göster

Cevap: Activate the rapid response team and prepare the client for immediate endotracheal intubation.

Cevap

The priority action is to activate the rapid response team and prepare the client for immediate endotracheal intubation.
The correct answer addresses the immediate need for airway management. The client is exhibiting classic signs of impending respiratory failure: decreasing level of consciousness (lethargy), a paradoxical drop in respiratory rate due to muscle fatigue, and a 'silent chest'. A silent chest indicates severe airflow obstruction where there is not enough air movement to produce a wheeze. The ABG results confirm acute uncompensated respiratory acidosis with severe hypoxemia. The absolute priority is securing the airway and initiating mechanical ventilation to prevent cardiac and respiratory arrest.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client is lethargic, has a decreasing respiratory rate, and a 'silent chest'.
These are critical signs of muscle fatigue, impending respiratory arrest, and severe airflow obstruction, not signs of clinical improvement.
2
Interpret the arterial blood gas (ABG) results.
The ABG shows uncompensated respiratory acidosis (pH 7.28, PaCO2 62) and significant hypoxemia (PaO2 55).
This confirms acute respiratory failure and the client's inability to maintain adequate spontaneous ventilation.
3
Determine the highest priority intervention to reduce physiological risk.
The client requires immediate mechanical ventilatory support.
Airway and breathing are the immediate life-saving priorities according to the ABC (Airway, Breathing, Circulation) framework.

Anahtar Kavram

Recognizing impending respiratory failure in asthma and prioritizing airway management.
Soru 955Soru →

A nurse is developing a plan of care for a 76-year-old client admitted with a severe exacerbation of chronic obstructive pulmonary disease (COPD). The client has a newly placed percutaneous endoscopic gastrostomy (PEG) tube for continuous enteral nutrition, requires maximal assistance with mobility, and has been experiencing new-onset nocturnal confusion. Which of the following basic care and comfort interventions should the nurse include in the client's care plan? (Select all that apply.)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Maintain the head of the bed at an elevation of 30∘30^\circ to 45∘45^\circ continuously while the enteral nutrition is infusing.; Assist the client into an orthopneic position, sitting up and leaning forward over an overbed table, during episodes of severe dyspnea.

Cevap

The correct interventions are maintaining the head of the bed elevated between 30∘30^\circ and 45∘45^\circ during continuous enteral feedings, and assisting the client into an orthopneic position during acute dyspneic episodes.
Maintaining the head of the bed elevated between 30∘30^\circ and 45∘45^\circ uses gravity to prevent esophageal reflux and subsequent pulmonary aspiration of the continuous enteral feeding. Assisting the client into an orthopneic position (sitting up and leaning forward over an overbed table) optimizes diaphragmatic excursion, recruits accessory respiratory muscles, and significantly decreases the work of breathing during severe dyspneic episodes.

Adım Adım Çözüm

1
Analyze the client's primary diagnoses and compounding physiological risks.
The client presents with a severe COPD exacerbation (high risk for hypoxia and respiratory failure) and is receiving nutrition via a newly placed PEG tube (high risk for pulmonary aspiration).
Identifying overlapping physiological risks is essential for prioritizing safe and effective basic care interventions.
2
Evaluate the safety and therapeutic appropriateness of the proposed positioning interventions.
Elevating the head of the bed to 30∘30^\circ-45∘45^\circ safely mitigates aspiration risk. The orthopneic position safely maximizes lung expansion. A flat supine position is strictly contraindicated as it worsens both COPD respiratory distress and PEG aspiration risk.
Correct client positioning is a fundamental basic care intervention that directly impacts both respiratory efficiency and gastrointestinal safety.
3
Assess the administrative, delegation, and educational interventions for clinical and regulatory compliance.
Delegating initial PEG feedings and obtaining PRN restraint prescriptions are fundamentally unsafe and violate legal practice standards. Furthermore, dismissing acute sudden-onset confusion as normal aging ignores a critical warning sign of systemic hypoxia.
Safe nursing care plans must strictly adhere to legal delegation boundaries, rigorous restraint protocols, and accurate pathological assessment.

Anahtar Kavram

Basic Care and Comfort: Positioning and Safety Interventions for Complex Respiratory and Enteral Needs
Tahmini Süre:2m 0s
Soru 956Soru →

An 80-year-old client has just returned to the medical-surgical unit following a diagnostic lumbar puncture. The client is currently alert and oriented. Which of the following actions is the most appropriate for the nurse to implement in the client's immediate care plan?

Cevabı ve açıklamayı göster

Cevap: Maintain the client in a flat, supine position for the prescribed duration.

Cevap

Maintain the client in a flat, supine position for the prescribed duration.
Following a lumbar puncture, the client should remain in a flat, supine position for several hours as prescribed by the healthcare provider. This specific basic care intervention prevents cerebrospinal fluid from leaking out of the dural puncture site, which is the primary pathophysiological cause of a post-lumbar puncture headache.

Adım Adım Çözüm

1
Identify the procedure the client just underwent.
The client had a diagnostic lumbar puncture.
Different diagnostic procedures require specific post-operative care and positioning to ensure basic care and comfort.
2
Determine the standard of care for a post-lumbar puncture client.
The standard is to keep the client flat to prevent cerebrospinal fluid (CSF) leakage.
A decrease in CSF volume can cause a severe post-dural puncture headache, significantly impacting the client's comfort.
3
Evaluate the nursing actions against safe practice principles.
Keeping the client flat is safe and indicated. Elevating the head is contraindicated. Delegating an initial assessment is unsafe. Ignoring sudden confusion in older adults is unsafe.
Ensures evidence-based, safe, and effective nursing care.

Anahtar Kavram

Post-lumbar puncture care and positioning
Soru 957Soru →

During a shift in the cardiac intensive care unit, a nurse receives an order to titrate a continuous dobutamine infusion for a client in cardiogenic shock. The client's documented weight is 92 kg92\text{ kg}. The medication is infusing from a 250 mL250\text{ mL} bag of 5% dextrose in water (D5W) containing 500 mg500\text{ mg} of dobutamine. The current pump rate is displayed as 18 mL/hr18\text{ mL/hr}.

The prescribed titration parameter dictates: "Increase dobutamine dose by 2.5 mcg/kg/min2.5\text{ mcg/kg/min} every 15 minutes to maintain a mean arterial pressure (MAP) >65 mmHg> 65\text{ mmHg}."

The last titration was 20 minutes ago, and the client's current MAP is 58 mmHg58\text{ mmHg}. What new rate, in mL/hr\text{mL/hr}, must the nurse program into the infusion pump? Record your answer using one decimal place.

Cevabı ve açıklamayı göster

Cevap: 24.9

Cevap

24.9
To safely perform an upward titration of a continuous weight-based vasoactive infusion, the nurse must accurately calculate the incremental volume increase and add it to the current baseline rate. First, find the concentration: \(500\text{ mg} = 500,000\text{ mcg}\); \(500,000\text{ mcg} \div 250\text{ mL} = 2,000\text{ mcg/mL}\). Next, calculate the increase needed: \(2.5\text{ mcg/kg/min} \times 92\text{ kg} = 230\text{ mcg/min}\). Convert this to an hourly dose: \(230\text{ mcg/min} \times 60\text{ min/hr} = 13,800\text{ mcg/hr}\). Determine the pump volume for this increase: \(13,800\text{ mcg/hr} \div 2,000\text{ mcg/mL} = 6.9\text{ mL/hr}\). Finally, add this volume to the current rate: \(18\text{ mL/hr} + 6.9\text{ mL/hr} = 24.9\text{ mL/hr}\).

Adım Adım Çözüm

1
Calculate the concentration of the dobutamine infusion in mcg/mL.
\(2,000\text{ mcg/mL}\)
Converting to mcg/mL establishes the baseline concentration needed to calculate volume for the weight-based dose, since dobutamine is dosed in mcg/kg/min.
2
Determine the required dose increase per minute based on the client's weight.
\(230\text{ mcg/min}\)
The protocol requires an increase of 2.5 mcg/kg/min. Multiplying by the client's weight (92 kg) gives the total mcg per minute to add.
3
Convert the dose increase from a per-minute rate to a per-hour rate.
\(13,800\text{ mcg/hr}\)
IV pumps are programmed in mL/hr, so the medication dose must be converted to an hourly rate before calculating the corresponding fluid volume.
4
Calculate the additional volume rate (mL/hr) required to deliver the dose increase.
\(6.9\text{ mL/hr}\)
Dividing the hourly dose (13,800 mcg/hr) by the concentration (2,000 mcg/mL) determines how much additional fluid volume is needed per hour.
5
Add the calculated additional volume rate to the current infusion pump rate.
\(24.9\text{ mL/hr}\)
The question asks for the NEW rate on the IV pump, which is the sum of the current continuous rate (18 mL/hr) and the calculated titration increase (6.9 mL/hr).

Anahtar Kavram

Continuous IV Infusion Titration and Weight-Based Dosage Calculation
Soru 958Soru →

A nurse is providing care for several clients who require pharmacological and parenteral therapies. Which of the following nursing actions demonstrate the correct application of critical safety principles for intravenous (IV) administration? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Administering an intermittent IV infusion of vancomycin over 90 minutes to a client with a systemic infection.; Aspirating for a brisk blood return from an implanted central venous port prior to administering an intravenous vesicant medication.; Flushing a peripherally inserted central catheter (PICC) with a 10 mL syringe using a pulsatile (push-pause) technique after medication delivery.

Cevap

The correct safe actions are: administering vancomycin over 90 minutes, aspirating for blood return before giving vesicants, and flushing a central line with a push-pause technique using a 10 mL syringe.
The correct actions adhere to foundational safety standards for parenteral therapy. Vancomycin must be infused slowly to avoid histamine release. Vesicant administration demands verified catheter patency via brisk blood return to prevent tissue necrosis. Lastly, central lines must be flushed with large-barrel syringes (10 mL) to reduce pressure, utilizing a push-pause method to create turbulence that clears the lumen.

Adım Adım Çözüm

1
Evaluate each parenteral administration action for adherence to infection control, medication compatibility, and hemodynamic safety.
Identify actions that prevent complications like precipitation, extravasation, and speed shock.
Safe IV therapy requires verifying all physiological and pharmacological parameters before administration.
2
Identify the correct safety principles.
Vancomycin requires slow infusion, central lines require pulsatile flushing with a 10 mL syringe, and vesicants require confirmation of blood return.
These specific actions prevent red man syndrome, catheter occlusion or rupture, and tissue necrosis.
3
Identify the incorrect actions and their associated safety risks.
Recognize that phenytoin precipitates in D5W, pausing vasopressors causes hemodynamic shock, and estimating weight for heparin risks fatal hemorrhage.
These represent critical errors in IV compatibility, clinical prioritization, and medical math.

Anahtar Kavram

Safe administration of parenteral therapies requires strict adherence to medication-specific compatibility, infusion rate limits, accurate calculation parameters, and catheter patency verification to prevent life-threatening complications.
Soru 959Soru →

A nurse is caring for a client with enterococcal endocarditis who is receiving a continuous intravenous (IV) infusion of ampicillin. The healthcare provider prescribes a scheduled dose of IV gentamicin to be infused over 60 minutes. The client has a single-lumen peripherally inserted central catheter (PICC). Knowing that ampicillin and gentamicin are chemically incompatible, which action should the nurse take to safely administer the scheduled dose?

Cevabı ve açıklamayı göster

Cevap: Stop the ampicillin infusion, flush the PICC lumen with 10 mL of 0.9% sodium chloride, infuse the gentamicin, and flush the line again before restarting the ampicillin.

Cevap

The correct action is to stop the continuous ampicillin infusion, flush the line thoroughly with normal saline, administer the gentamicin over the prescribed 60 minutes, and flush the line again before restarting the ampicillin.
When administering an intermittent IV medication that is physically or chemically incompatible with a continuous infusion through a single-lumen catheter, the nurse must utilize sequential administration. This involves stopping the continuous infusion, flushing the line with a compatible fluid (such as 0.9% sodium chloride) to clear the catheter, administering the intermittent medication, and thoroughly flushing the line again before restarting the continuous infusion. This protocol ensures the two medications never physically interact.

Adım Adım Çözüm

1
Identify the chemical incompatibility between the continuous ampicillin (a penicillin) and the scheduled gentamicin (an aminoglycoside).
Recognition that these medications cannot be administered concurrently or allowed to mix in the same intravenous line.
Penicillins chemically inactivate aminoglycosides and can form precipitates if they come into contact.
2
Determine the safest administration method given the constraint of a single-lumen PICC line.
Selection of sequential administration utilizing a rigorous flushing protocol.
Flushing with a compatible fluid (0.9% sodium chloride) clears the catheter space of the first medication, allowing safe transit of the second medication without physical contact.

Anahtar Kavram

Safe sequential administration of incompatible intravenous medications requires thoroughly flushing the vascular access device with a compatible solution before and after the intermittent dose.
Tahmini Süre:1m 30s
Soru 960Soru →

A nurse is caring for an intubated client with acute respiratory distress syndrome (ARDS) who has just been placed in the prone position. The client is receiving continuous enteral nutrition via a nasogastric tube. Which basic care and comfort intervention is the priority for the nurse to implement?

Cevabı ve açıklamayı göster

Cevap: Adjust the entire bed frame into a reverse Trendelenburg tilt to maintain head elevation.

Cevap

Adjust the entire bed frame into a reverse Trendelenburg tilt to maintain head elevation.
When a client is positioned prone, standard elevation of the head of the bed is not physically possible without compromising spinal alignment and respiratory mechanics. Because the client is receiving continuous enteral nutrition, maintaining head elevation relative to the stomach is critical to utilize gravity, prevent gastric reflux, and eliminate the risk of pulmonary aspiration. The reverse Trendelenburg position tilts the entire bed frame, safely achieving this necessary elevation.

Adım Adım Çözüm

1
Identify the client's current clinical state and positioning constraints.
The client is intubated, receiving continuous enteral nutrition, and positioned prone (on their abdomen).
Establishing the specific physiological parameters is essential to identifying safety risks related to basic care.
2
Analyze the risks associated with the concurrent therapies.
Enteral feeding carries a high risk of aspiration if the head is not elevated, but the prone position prevents standard articulation of the head of the mattress.
Aspiration of gastric contents can be rapidly fatal, especially in a client already suffering from ARDS.
3
Determine the appropriate biomechanical intervention that satisfies all requirements.
Tilting the entire bed frame (reverse Trendelenburg) elevates the head and thorax relative to the stomach without bending the client's spine.
This utilizes gravity to promote gastric emptying and prevent reflux while allowing the life-saving prone therapy to continue.
4
Evaluate the remaining options for safety and scope of practice.
Stopping nutrition causes harm, assessing posterior pressure points is irrelevant for a prone client, and delegating airway management to a UAP is unsafe practice.
Ensuring all aspects of basic care adhere to safety standards and legal delegation rules.

Anahtar Kavram

Safe administration of enteral nutrition and physiological adaptation in the prone position
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Physiological Integrity Alıştırma Soruları — NCLEX-RN — Sayfa 48 | Examkin