NCLEX- RN Practice Exam 17

EXPLANATION

✔Correct answer:

Lactated Ringer's Solution. In cases of trauma with significant hypotension and suspected hypovolemia due to blood loss, the most appropriate initial intravenous fluid for resuscitation is Lactated Ringer's (LR) solution. LR is an isotonic crystalloid solution that closely resembles the body's extracellular fluid. It provides fluid volume to restore intravascular space, helps maintain adequate tissue perfusion and oxygenation, and contains electrolytes such as sodium, potassium, calcium, and lactate, which can help buffer acidosis—a common complication in trauma patients with hypovolemia.

Trauma, especially with fractures of the pelvis or lower extremities, can result in significant hemorrhage. The resulting hypovolemia leads to decreased cardiac output, tissue hypoperfusion, and oxygen deprivation, progressing to hypovolemic shock if untreated. Administering an isotonic fluid like LR helps rapidly restore circulating blood volume and improves hemodynamic stability. Lactate in LR is metabolized in the liver to bicarbonate, helping to correct metabolic acidosis commonly seen in shock.

Think of your blood vessels as pipes carrying water to a garden. After a break in the pipe (trauma and blood loss), the garden (your organs) doesn't get enough water. Using LR solution is like quickly refilling the pipes with water that mimics what's naturally there, helping the garden recover efficiently.

Early and aggressive fluid resuscitation is crucial for stabilizing trauma patients. After initial resuscitation with fluids like LR, other treatments such as blood transfusion and definitive surgical intervention to stop bleeding should follow.

• Monitor the patient’s vital signs (e.g., blood pressure, heart rate) and urine output to assess the effectiveness of fluid resuscitation.
• Prepare for the potential administration of blood products (e.g., packed red blood cells) if hemorrhage continues or hemoglobin levels drop.
• Monitor for signs of fluid overload (e.g., pulmonary edema), especially in patients with coexisting cardiac or renal dysfunction.
• Document the amount and type of fluid administered and assess for changes in the patient’s mental status and hemodynamic stability.
• Collaborate with the healthcare team to initiate damage control surgery if necessary to manage ongoing hemorrhage.

✘Incorrect answer options:

5% Dextrose in Water (D5W). D5W is a hypotonic solution once dextrose is metabolized, and it is not appropriate for trauma resuscitation. It does not provide adequate intravascular volume expansion, and its use could worsen intracellular swelling, leading to complications such as cerebral edema.

0.45% Sodium Chloride (Half-Normal Saline). Half-normal saline is also a hypotonic solution and is not suitable for initial resuscitation in trauma or hypovolemic shock. It does not adequately expand the intravascular volume and may exacerbate electrolyte imbalances.

3% Sodium Chloride. Hypertonic saline (e.g., 3% sodium chloride) is generally used in specific situations like managing severe hyponatremia or intracranial hypertension but is not appropriate for routine fluid resuscitation in trauma. Its administration can cause a rapid shift of fluid from intracellular to extracellular compartments, which can lead to complications like hypernatremia or osmotic demyelination.

EXPLANATION

✔Correct answer:

An increase in insulin dosage. During times of infection, clients with Type 1 diabetes mellitus should anticipate a possible increase in their insulin dosage. Infections, fevers, and illnesses are forms of physiological stress that trigger the release of counterregulatory hormones such as cortisol, epinephrine, and glucagon. These hormones increase blood glucose levels by stimulating gluconeogenesis (the production of glucose in the liver) and decreasing the effectiveness of insulin (insulin resistance). As a result, blood glucose levels can rise significantly during infections, requiring more insulin to maintain glycemic control.

It is important to educate clients with Type 1 diabetes about the need to monitor their blood glucose levels more frequently during illness and to adjust their insulin doses accordingly, as directed by their healthcare provider. Failing to manage hyperglycemia during illness can lead to serious complications, such as diabetic ketoacidosis (DKA), which is life-threatening.

Type 1 diabetes mellitus is characterized by an absolute insulin deficiency due to autoimmune destruction of pancreatic beta cells. The lack of endogenous insulin means that clients must rely entirely on exogenous insulin to regulate their blood glucose levels. During illness, when blood glucose levels rise due to stress hormones, insulin needs increase to counteract this hyperglycemic response.

Think of blood glucose as the fuel in a car’s engine. During infection, the body’s "engine" works harder (due to stress hormones), which increases the amount of fuel (blood glucose) needed. The insulin acts like a regulator to balance this fuel, so more insulin is required to keep the system running smoothly during illness.

Educating clients about sick-day management is critical to help them maintain glycemic control during periods of illness.

• Instruct the client to monitor blood glucose levels every 4 hours or more frequently during illness.
• Advise the client to never stop taking insulin, even if they are unable to eat normally. Basal insulin is especially important to prevent DKA.
• Encourage adequate hydration to prevent dehydration, which is common during infections and can worsen hyperglycemia.
• Teach the client to test for urine ketones if blood glucose levels are consistently elevated (e.g., >240 mg/dL) or if symptoms of DKA (e.g., nausea, vomiting, abdominal pain) occur.
• Reinforce the importance of seeking medical attention if they experience persistent hyperglycemia, moderate to large ketones, or symptoms of DKA.

✘Incorrect answer options:

No changes to their routine. This is incorrect because infection typically raises blood glucose levels, requiring adjustments to the insulin regimen. Sticking to the usual insulin dosage without accounting for increased glucose levels may result in hyperglycemia or DKA.

A reduction in insulin dosage. Reducing insulin during an infection would worsen hyperglycemia, as blood glucose levels are more likely to rise due to stress hormones. Clients may need additional insulin rather than less during illness.

A switch to oral diabetic medications. Oral antidiabetic medications are not used in the management of Type 1 diabetes mellitus, as this condition involves an absolute insulin deficiency. Insulin therapy is the cornerstone of treatment for Type 1 diabetes, regardless of whether the client is ill.

EXPLANATION

✔Correct answer:

Diluting the medication in normal saline solution only. Phenytoin (Dilantin) is an anticonvulsant used to manage and prevent seizures. When administering phenytoin intravenously (IV), it must be diluted in normal saline (0.9% sodium chloride) only. This is because phenytoin is incompatible with dextrose-containing solutions, which can cause the drug to precipitate, leading to complications such as catheter occlusion or embolism. Additionally, phenytoin is highly sensitive to pH changes, and diluting it in solutions other than normal saline can lead to instability of the medication.

Proper IV administration of phenytoin also requires close monitoring due to the risk of complications, such as hypotension, bradycardia, and local tissue damage (extravasation).

Phenytoin has a low water solubility and is formulated in a solution containing propylene glycol and ethanol to enhance its solubility. These additives make phenytoin highly pH-sensitive and prone to precipitation when mixed with incompatible solutions, such as dextrose. Using normal saline ensures the medication remains stable for administration.

Think of phenytoin like a sugar cube that dissolves only in hot water (normal saline) but forms clumps in cold water (dextrose solution). To avoid clogging or "clumping" in the veins, it must be mixed with the correct solution.

When administering IV phenytoin, adherence to specific safety guidelines is critical to avoid complications and ensure patient safety.

• Administer IV phenytoin slowly, at a rate not exceeding 50 mg/min in adults, to minimize the risk of cardiovascular side effects such as bradycardia and hypotension.
• Use a dedicated IV line for phenytoin infusion, as it is incompatible with many other medications and solutions.
• Flush the IV catheter with normal saline before and after administration to prevent precipitation and ensure the line is clear.
• Monitor the patient’s vital signs closely during administration, particularly heart rate and blood pressure.
• Watch for signs of extravasation (e.g., redness, swelling, pain at the IV site), as phenytoin is highly irritating to tissues.

✘Incorrect answer options:

Use of an in-line filter during infusion. While an in-line filter may sometimes be used with medications prone to particulate formation, it is not a specific requirement for IV phenytoin administration. The more critical guideline is ensuring dilution in normal saline and proper flushing of the IV line.

Temporarily discontinuing other prescribed anticonvulsant medications. Discontinuing other anticonvulsant medications is not appropriate and may put the patient at risk of seizures. Phenytoin can be administered alongside other anticonvulsants, provided proper timing and compatibility precautions are taken.

Flushing the intravenous catheter with dextrose solution before and after administration. Flushing the catheter with dextrose solution is contraindicated because phenytoin is incompatible with dextrose. Doing so increases the risk of precipitation of the drug within the IV line, which can lead to complications such as occlusion or embolism.

EXPLANATION

✔Correct answer:

“Use a pillow to splint your chest when you cough.” The most beneficial instruction for a patient with a persistent, painful cough due to pneumonia is to use a pillow to splint their chest while coughing. Splinting involves holding a pillow firmly against the chest wall to provide support and reduce pain during coughing. This technique helps the patient perform effective coughing without excessive discomfort. Effective coughing is essential for clearing mucus and secretions from the lungs, which is a key part of pneumonia management.

Pain associated with coughing can discourage the patient from coughing effectively, leading to retained secretions, increased risk of infection progression, and impaired gas exchange. By reducing pain through splinting, the patient is more likely to cough productively, which aids in clearing the airways and promoting recovery.

Imagine trying to clean a clogged drain but hesitating because your tools hurt your hand when you press down. By using a glove for protection (like splinting the chest), you can apply the pressure needed without pain, effectively clearing the drain (removing mucus).

Nurses should focus on patient comfort and education to encourage effective airway clearance while minimizing pain.

• Teach the patient to use a pillow or blanket to splint the chest during coughing episodes.
• Encourage the patient to stay hydrated to thin secretions, making them easier to expectorate.
• Administer prescribed analgesics or antitussives to help manage pain and discomfort as needed.
• Encourage the use of incentive spirometry to maintain lung expansion and prevent atelectasis.
• Advise the patient to rest as needed but perform deep breathing and coughing exercises regularly to promote lung function and prevent complications.

✘Incorrect answer options:

“Try to suppress your cough as much as possible.” Suppressing the cough is counterproductive in pneumonia management. Coughing is a natural mechanism to expel mucus and secretions from the lungs. Encouraging the patient to suppress their cough could lead to retained secretions, worsening the infection, and potentially causing complications like atelectasis or respiratory distress.

“Keep your bed flat to facilitate effective coughing.” Keeping the bed flat is not beneficial for coughing or respiratory function. Raising the head of the bed to a semi-Fowler’s or Fowler’s position helps improve lung expansion and facilitates effective coughing by enhancing diaphragmatic movement.

“Limit your fluid intake to reduce sputum production.” Reducing fluid intake is inappropriate and can worsen the patient’s condition. Adequate hydration helps thin mucus, making it easier to cough up. Dehydration can cause secretions to become thick and sticky, leading to increased difficulty in clearing the airways.

EXPLANATION

✔Correct answer:

Lactated Ringer’s solution. During the initial (emergent) phase of burn management, Lactated Ringer’s solution is the fluid of choice for resuscitation. This isotonic crystalloid solution is used to replace the massive fluid losses that occur in burn patients due to increased capillary permeability, which leads to fluid shifts from the intravascular space to the interstitial space (third-spacing). Lactated Ringer's solution contains electrolytes (sodium, potassium, calcium, and lactate) that closely mimic the body’s extracellular fluid, making it ideal for restoring fluid balance and preventing hypovolemia and shock.

The goal of fluid resuscitation in the first 24-48 hours after a burn injury is to restore circulating volume, maintain organ perfusion, and prevent complications such as burn shock. The Parkland formula is commonly used to calculate the total amount of fluid needed during the first 24 hours, with half of the volume given in the first 8 hours after the burn.

In the emergent phase of burns, increased capillary permeability leads to massive fluid shifts, protein loss, and the development of hypovolemia. If not treated promptly with fluid resuscitation, this can result in inadequate tissue perfusion, multi-organ failure, and death. Lactated Ringer’s solution provides essential electrolytes and lactate, which acts as a buffer to correct metabolic acidosis often seen in burn patients.

Think of the blood vessels after a burn injury as leaky pipes, losing water (fluid) into the surrounding area. Lactated Ringer’s solution acts like a replacement supply, helping refill the pipes (blood vessels) and keeping the system functioning properly.

Effective fluid resuscitation is critical during the emergent phase of burn care. Nurse Alex should ensure that fluids are administered according to the patient’s calculated needs and that the response to therapy is closely monitored.

• Calculate fluid requirements using the Parkland formula:
  4 mL × body weight in kg × % total body surface area (TBSA) burned = total fluid in mL over 24 hours.

  Administer half of this volume in the first 8 hours post-burn and the remaining half over the next 16 hours.

• Monitor urine output as the most reliable indicator of adequate fluid resuscitation. Target urine output is 0.5-1 mL/kg/hr in adults.
• Assess vital signs, including heart rate and blood pressure, to detect signs of hypovolemia or over-resuscitation.
• Monitor for signs of fluid overload, such as crackles in the lungs, dyspnea, or edema, especially in patients with comorbidities like cardiac dysfunction.
• Evaluate serum electrolytes, as burn injuries can cause shifts in sodium and potassium levels.

✘Incorrect answer options:

Albumin. Albumin, a colloid solution, may be used later in burn care (typically after the first 24 hours) to help pull fluid back into the intravascular space. However, it is not appropriate during the initial phase because capillary permeability remains increased, and albumin would leak into the interstitial space, exacerbating edema.

D5W. D5W (5% dextrose in water) is a hypotonic solution that is not suitable for initial burn resuscitation because it does not adequately replace lost electrolytes or restore circulating volume. It can worsen electrolyte imbalances and contribute to water intoxication.

0.9% sodium chloride solution with 2 mEq of potassium per 100 ml. While 0.9% sodium chloride (normal saline) is isotonic and may be used in some resuscitation protocols, it lacks the lactate found in Lactated Ringer’s, which helps buffer acidosis. Adding potassium to fluids is not appropriate during the initial phase of burn care, as potassium levels may already be elevated due to cellular damage and release of intracellular potassium into the bloodstream.

EXPLANATION

✔Correct answer:

Roll a sterile swab gently from the center of the wound outward to collect drainage. To obtain an accurate wound culture specimen, the proper technique involves gently rolling a sterile swab from the center of the wound outward. This ensures the collection of organisms that are actively growing in the wound bed, which are the most relevant to the infection. Collecting from the wound bed minimizes contamination from surrounding skin or debris that may not accurately represent the causative pathogen.

This technique avoids sampling superficial contaminants or materials from dressings, which could lead to inaccurate culture results and inappropriate treatment. Rolling the swab ensures contact with a sufficient area of the wound bed to capture representative microorganisms for laboratory analysis.

Wound infections occur when microorganisms invade the wound bed and cause an inflammatory response. Proper wound culture collection is critical for identifying the causative organisms and guiding appropriate antibiotic therapy. Sampling from the wound bed ensures that pathogens present in the infected tissue are accurately identified.

Imagine testing water in a swimming pool for contamination. You wouldn’t sample from the surface or the pool walls, but from the water itself to get an accurate representation of what’s causing the problem. Similarly, collecting a wound specimen directly from the wound bed gives the most accurate results.

Nurse Mia should use sterile technique and follow facility policies to minimize the risk of contamination when obtaining a wound culture.

• Irrigate the wound with sterile normal saline before collecting the sample to remove surface contaminants, dried exudate, and non-viable tissue.
• Use a sterile swab or culture device, and avoid touching surrounding skin, edges, or dressings.
• Collect the sample from the wound bed by rolling the swab over an area with visible drainage or tissue.
• Label the specimen container accurately with the patient’s information, wound site, and date/time of collection.
• Deliver the specimen promptly to the laboratory to ensure accurate analysis and prevent degradation of the sample.

✘Incorrect answer options:

Irrigate the wound thoroughly before obtaining the specimen. While irrigation with sterile normal saline is an important step before collecting the sample, irrigating thoroughly immediately before collecting the specimen may wash away organisms from the wound bed. Use gentle irrigation to remove surface debris, but avoid excessive rinsing that might eliminate the pathogens you need to culture.

Use a sterile swab to wipe the crusty area around the wound's edges. Sampling from the crusty edges of the wound does not provide an accurate representation of the organisms causing the infection. The edges often contain contaminants or dead tissue, which do not reflect the pathogens in the wound bed.

Use a sterile swab to collect drainage directly from the dressing. Collecting drainage from the dressing will likely lead to contamination, as dressings may contain bacteria from the skin or environment rather than the wound itself. This technique would not yield an accurate culture result.

EXPLANATION

✔Correct answer:

Performing passive range of motion (ROM) exercises regularly. Passive range of motion (ROM) exercises are the most effective intervention for preventing foot drop and contractures in a patient recovering from a subdural hematoma, especially if they are immobile or have motor deficits. Foot drop occurs due to weakness or paralysis of the dorsiflexor muscles (e.g., tibialis anterior), often as a result of prolonged immobility or nerve damage. Contractures develop when the soft tissues around a joint become stiff due to immobility, leading to permanent shortening and deformity.

Regularly performing passive ROM exercises maintains joint flexibility, prevents muscle atrophy, and minimizes the risk of contractures. ROM exercises also improve circulation and reduce stiffness in the muscles and tendons, allowing for better long-term recovery of function.

Immobility or neurological impairments following a subdural hematoma can lead to disuse atrophy, joint stiffness, and the formation of contractures. Without regular movement, the affected muscles, ligaments, and tendons can lose their elasticity and flexibility. Passive ROM involves a caregiver or nurse moving the patient's joints through their normal range of motion, which prevents these complications in patients who cannot move independently.

Imagine a door hinge that isn’t used for a long time. Without movement, the hinge becomes stiff and may eventually rust, making it hard to move. Performing ROM exercises is like oiling and moving the hinge regularly to keep it functional.

In addition to passive ROM exercises, other measures can be taken to prevent complications of immobility, such as foot drop and contractures.

• Position the patient’s feet in a neutral position using foot splints or braces to prevent plantar flexion deformity.
• Encourage active ROM exercises when the patient regains mobility to strengthen muscles and improve independence.
• Reposition the patient every 2 hours to prevent pressure injuries and improve circulation.
• Provide education to caregivers or family members about performing passive ROM exercises at home if needed.
• Monitor the patient for signs of joint stiffness, pain, or swelling, and report any concerns to the healthcare provider.

✘Incorrect answer options:

Applying compression stockings to both legs. Compression stockings are used to prevent venous thromboembolism (VTE) and improve circulation, but they do not prevent foot drop or contractures. They do not maintain muscle or joint mobility, which is necessary to avoid these complications.

Placing a soft pillow under the knees for support. Placing a pillow under the knees can lead to knee flexion contractures and increased pressure on the lower back. It does not address the issue of foot drop or promote joint movement, making it an ineffective intervention.

Encouraging the patient to stay in a semi-Fowler's position at all times. While the semi-Fowler's position may aid breathing and comfort, prolonged positioning can contribute to immobility-related complications, including foot drop and contractures. It is important to reposition the patient regularly and promote movement.

EXPLANATION

✔Correct answer:

Lumbar discomfort. The most indicative sign of rapid expansion or imminent rupture of an abdominal aortic aneurysm (AAA) is lumbar (lower back) discomfort or pain. This occurs because an expanding or leaking AAA can irritate nearby structures, such as the lumbar nerves, or due to retroperitoneal pressure from the enlarging aneurysm. If rupture occurs, the retroperitoneal space or abdominal cavity may fill with blood, causing sudden, severe pain that may radiate to the back or flank. This is a critical emergency and requires immediate intervention to prevent fatal hemorrhage.

An AAA is a localized dilation of the abdominal aorta, often caused by weakening of the arterial wall due to factors such as atherosclerosis, hypertension, or genetic predisposition. As the aneurysm enlarges, the wall tension increases, making it prone to rupture. Pain in the lumbar region signals irritation of the surrounding tissues or structures and is a red flag for impending rupture.

Imagine an overfilled balloon that is starting to stretch thinly at one point. As the tension increases, that spot becomes painful and more likely to burst. In the case of an aneurysm, the "pain" is the lumbar discomfort, signaling that the aorta is nearing rupture.

Nurses should be vigilant in assessing for signs of AAA rupture and be prepared to act quickly if such symptoms arise.

• Monitor for sudden, severe, and persistent back or abdominal pain that may radiate to the flank or groin.
• Assess for signs of hypovolemic shock, such as hypotension, tachycardia, pallor, and diaphoresis, which indicate rupture.
• Ensure rapid access to emergency services, as a ruptured AAA requires immediate surgical intervention.
• Notify the healthcare provider immediately if lumbar discomfort is reported or observed.
• Provide emotional support to the patient and family while explaining the urgency of the situation.

✘Incorrect answer options:

Abdominal discomfort. While abdominal discomfort can occur with an AAA, it is a nonspecific symptom and does not necessarily indicate rapid expansion or imminent rupture. Lumbar pain is more indicative of critical changes in the aneurysm.

Non-palpable pedal pulses. Non-palpable pedal pulses suggest impaired distal perfusion, possibly due to arterial embolism or severe aortic occlusion, but this is not a hallmark sign of an expanding or rupturing AAA. Pedal pulses are usually preserved unless distal ischemia occurs.

Chest discomfort. Chest discomfort is not a typical sign of an abdominal aortic aneurysm. It is more commonly associated with thoracic aortic aneurysms, myocardial ischemia, or other thoracic conditions. Lumbar discomfort is more relevant in the context of an AAA.

EXPLANATION

✔Correct answer:

Maintaining NPO (nothing by mouth) status and providing IV hydration. The priority in the nursing management of a patient with acute pancreatitis is to maintain NPO (nothing by mouth) status and ensure adequate IV hydration. Keeping the patient NPO helps to rest the pancreas by reducing stimulation of pancreatic enzyme secretion, which exacerbates inflammation and pain. Pancreatitis involves the activation of pancreatic enzymes within the pancreas, leading to auto-digestion and tissue damage. Avoiding oral intake allows the pancreas to "rest" and reduces further injury.

Intravenous (IV) hydration is essential to address fluid losses due to vomiting, third-spacing of fluids, and systemic inflammation. Adequate hydration improves organ perfusion and prevents complications such as hypovolemia, hypotension, and acute kidney injury, which are common in severe pancreatitis.

Acute pancreatitis is characterized by inflammation of the pancreas, often triggered by gallstones, alcohol use, or other factors. The pancreas releases digestive enzymes prematurely, which attack the pancreatic tissue, causing inflammation, swelling, and pain. Resting the pancreas by keeping the patient NPO is a cornerstone of treatment.

Imagine the pancreas as a factory that’s overheating from overwork. Stopping food intake (NPO) is like turning off the factory to allow it to cool down and repair itself, while IV hydration provides the essential "fuel" (fluids) the body needs to keep running during the shutdown.

Nurses should focus on reducing pancreatic stimulation, preventing complications, and managing symptoms like pain.

• Maintain NPO status until the healthcare provider determines that oral intake is safe to resume.
• Administer IV fluids, such as lactated Ringer's solution or normal saline, as prescribed to restore hydration and electrolyte balance.
• Monitor for signs of dehydration, such as hypotension, decreased urine output, and dry mucous membranes.
• Assess for complications of pancreatitis, including respiratory distress, hypovolemic shock, and infection.
• Administer prescribed analgesics (e.g., opioids) to manage severe pain, and position the patient for comfort (e.g., sitting up or leaning forward).

✘Incorrect answer options:

Encouraging a high-protein diet to promote healing. A high-protein diet is inappropriate during the acute phase of pancreatitis when the pancreas must be rested. Oral nutrition is typically resumed only after inflammation subsides and bowel function normalizes, starting with a low-fat, easily digestible diet.

Administering pancreatic enzyme supplements with meals. Pancreatic enzyme supplements (e.g., pancrelipase) are used in chronic pancreatitis to aid digestion but are not indicated for acute pancreatitis. During the acute phase, the goal is to reduce pancreatic enzyme activity by keeping the patient NPO.

Performing abdominal massage to relieve pain. Abdominal massage is contraindicated in pancreatitis as it may increase discomfort and exacerbate inflammation by applying pressure to the inflamed pancreas. Pain management in acute pancreatitis focuses on medications and positioning, not physical manipulation.

EXPLANATION

✔Correct answer:

Instructing the patient to sit or rest. The immediate priority intervention for a patient experiencing chest pain while ambulating is to instruct them to sit or rest. This action helps decrease myocardial oxygen demand by reducing physical exertion and lowering the workload on the heart. Resting is essential because continued activity can exacerbate ischemia, leading to more severe symptoms or complications such as myocardial infarction.

Chest pain during activity often indicates insufficient oxygen delivery to the myocardium (angina). Sitting down or resting helps to improve oxygen supply relative to demand, providing initial relief and allowing time to further assess the situation and implement other interventions.

Angina occurs when there is an imbalance between myocardial oxygen supply and demand. Physical exertion increases the heart's oxygen requirements, and if coronary blood flow is insufficient (due to conditions like atherosclerosis), chest pain results. Resting reduces oxygen demand, stabilizing the patient while additional interventions are initiated.

Imagine you’re driving a car up a steep hill, and the engine begins to overheat. The best initial action is to pull over and let the engine cool down (rest). Similarly, when the heart is under strain, stopping activity gives it a chance to recover.

Once the patient is sitting or resting, other interventions can be prioritized to manage the chest pain and investigate its cause.

• Assess the patient’s vital signs, including heart rate, blood pressure, respiratory rate, and oxygen saturation.
• Perform a quick pain assessment (location, intensity, duration, and associated symptoms).
• Prepare to administer sublingual nitroglycerin if prescribed, but ensure the patient is sitting or lying down to prevent hypotension and dizziness.
• Obtain an ECG as soon as possible to evaluate for ischemic changes or arrhythmias.
• Communicate with the healthcare provider for further orders and potential escalation of care if symptoms persist or worsen.

✘Incorrect answer options:

Assisting the patient back to bed. While assisting the patient back to bed may seem reasonable, the immediate priority is to stop the activity by having the patient sit or rest wherever they are. Moving the patient back to bed may unnecessarily increase their exertion and worsen the chest pain.

Obtaining an electrocardiogram (ECG). An ECG is essential to evaluate the cause of chest pain, particularly to identify ischemic changes or arrhythmias. However, it is not the first step. Ensuring the patient stops exerting themselves is more critical initially to prevent further cardiac strain.

Administering sublingual nitroglycerin. Nitroglycerin is an effective treatment for relieving angina by dilating coronary arteries and improving blood flow to the myocardium. However, it is not the first step. The patient should rest or sit before nitroglycerin is administered to avoid exacerbating symptoms such as dizziness or hypotension due to vasodilation.

EXPLANATION

✔Correct answer:

Hypertrophic cardiomyopathy. In hypertrophic cardiomyopathy (HCM), cardiac output often remains within normal limits during rest because the systolic function of the heart (the ability to pump blood) is typically preserved. HCM is characterized by abnormal thickening (hypertrophy) of the myocardium, especially the left ventricle. While the thickened walls can cause diastolic dysfunction (reduced filling of the heart due to decreased ventricular compliance), resting cardiac output is generally not severely impaired because the heart can still pump blood effectively during systole.

However, during exertion, cardiac output may become insufficient due to the decreased filling time and/or obstruction of blood flow in the left ventricular outflow tract, which is a hallmark feature in some cases of HCM.

The hypertrophied myocardium in HCM results in a smaller ventricular chamber and reduced compliance, leading to impaired diastolic filling. This diastolic dysfunction can limit the heart's ability to increase cardiac output under stress. Additionally, the thickened ventricular septum can obstruct blood flow out of the heart, further reducing output during exertion.

Imagine trying to fill a water bottle with a narrow neck very quickly. At rest, the bottle fills adequately over time, but under stress (such as when you pour too fast), the narrow neck limits the amount of water (blood) that can flow in or out efficiently. Similarly, in HCM, the heart manages to maintain normal output at rest but struggles under stress due to limited filling and possible outflow obstruction.

Nurses caring for patients with HCM should focus on recognizing symptoms, preventing complications, and providing appropriate patient education.

• Monitor for signs of exertional dyspnea, syncope, or chest pain, which may indicate outflow obstruction or reduced cardiac output.
• Advise the patient to avoid strenuous physical activity or competitive sports, which can exacerbate symptoms or trigger sudden cardiac arrest in HCM.
• Administer beta-blockers or calcium channel blockers as prescribed to reduce heart rate and improve diastolic filling.
• Educate the patient about the importance of follow-up care, including echocardiography to monitor the progression of hypertrophy.
• Discuss genetic counseling, as HCM is often inherited in an autosomal dominant pattern.

✘Incorrect answer options:

Dilated cardiomyopathy. In dilated cardiomyopathy (DCM), cardiac output is often reduced, even at rest, due to systolic dysfunction. The heart's ventricles are enlarged and weakened, impairing the heart's ability to pump blood effectively.

Obliterative cardiomyopathy. Obliterative cardiomyopathy is not a standard classification of cardiomyopathy. This term may be used in specific contexts (e.g., referring to conditions like endomyocardial fibrosis), but it does not accurately apply to the classifications commonly studied in nursing practice.

Restrictive cardiomyopathy. In restrictive cardiomyopathy, diastolic dysfunction due to stiff ventricles leads to impaired ventricular filling. While cardiac output may initially be normal at rest, it typically becomes progressively reduced as the disease advances, even during rest.

EXPLANATION

✔Correct answer:

Acute respiratory distress syndrome (ARDS). The firefighter’s clinical presentation of severe hypoxia 48 hours after smoke inhalation is most consistent with acute respiratory distress syndrome (ARDS). ARDS is a severe inflammatory condition of the lungs characterized by diffuse alveolar damage, increased capillary permeability, and the development of non-cardiogenic pulmonary edema. This condition is often triggered by direct lung injury (e.g., smoke inhalation, burns, aspiration) or systemic inflammatory responses (e.g., sepsis, trauma).

In ARDS, the inflammatory process damages the alveolar-capillary membrane, leading to fluid leakage into the alveoli. This disrupts gas exchange and results in refractory hypoxemia (low oxygen levels that do not improve with supplemental oxygen alone). The firefighter’s need for intubation and mechanical ventilation indicates a progression of ARDS, which is commonly seen within 24-48 hours of the initial injury.

The hallmark of ARDS is the development of acute hypoxemic respiratory failure due to fluid-filled alveoli, decreased lung compliance, and impaired oxygenation. In smoke inhalation, chemical irritants and toxins damage the alveolar epithelium and trigger an inflammatory cascade, which contributes to the development of ARDS. The condition can rapidly progress to respiratory failure if not treated promptly.

Imagine the alveoli (air sacs in the lungs) are sponges that allow air to pass through freely. With ARDS, these sponges become soaked with fluid and inflamed, making it almost impossible for air to move through and for oxygen to reach the bloodstream.

ARDS is a medical emergency that requires comprehensive and multidisciplinary care. Nurse Smith should focus on interventions to optimize oxygenation, monitor for complications, and support the patient during mechanical ventilation.

• Monitor the patient’s oxygen saturation, arterial blood gases (ABGs), and respiratory effort frequently.
• Collaborate with the healthcare team to optimize mechanical ventilation settings, including low tidal volume ventilation and positive end-expiratory pressure (PEEP), to improve oxygenation and prevent further lung injury.
• Monitor for complications of ARDS and mechanical ventilation, such as barotrauma, volutrauma, and ventilator-associated pneumonia (VAP).
• Administer prescribed medications, such as sedatives, paralytics, or vasopressors, as indicated to support oxygenation and hemodynamic stability.
• Provide emotional support to the patient and family and explain the severity of the condition and treatment plan.

✘Incorrect answer options:

Atelectasis. Atelectasis refers to the collapse of alveoli, which can cause mild to moderate hypoxemia. While it can occur after smoke inhalation, it does not typically lead to the severe, refractory hypoxia seen in ARDS. Additionally, atelectasis would not usually require mechanical ventilation unless severe.

Bronchitis. Bronchitis involves inflammation of the bronchi and is often associated with cough, mucus production, and mild hypoxia. It is unlikely to cause severe hypoxia requiring intubation and is not consistent with the timeline of ARDS development 48 hours post-incident.

Pneumonia. Pneumonia is an infection of the lung tissue, which can cause hypoxia due to inflammation and consolidation of alveoli. While pneumonia is a differential diagnosis, the firefighter’s clinical scenario, including the rapid progression of hypoxia after smoke inhalation, is more characteristic of ARDS. Pneumonia typically develops over days to weeks and is often accompanied by fever, chills, and purulent sputum.

EXPLANATION

✔Correct answer:

Right side-lying, with the bed completely flat. After a liver biopsy, the patient should be positioned in the right side-lying position with the bed completely flat. This position helps to apply direct pressure to the biopsy site, which is located in the right upper quadrant of the abdomen. By compressing the liver, this positioning minimizes the risk of bleeding, which is a primary complication of the procedure.

The liver is a highly vascular organ, and bleeding is a significant concern following a biopsy due to the risk of injury to blood vessels during the procedure. Maintaining pressure on the biopsy site for 2-4 hours by having the patient lie on their right side can prevent hemorrhage and promote clot formation at the puncture site.

The liver receives blood supply from both the hepatic artery and the portal vein, making it prone to bleeding after invasive procedures such as a biopsy. By positioning the patient on their right side, gravity and the patient’s body weight provide consistent pressure to seal the puncture site and reduce the chance of post-procedural hemorrhage.

Imagine a sponge filled with water (the liver). If you poke a hole in it, water will leak out (bleeding). To stop the leak, you press down on the sponge where the hole is. Similarly, lying on the right side applies pressure to the liver and helps stop bleeding.

After positioning the patient, Nurse Jenna should monitor for signs of complications and provide patient education about post-procedure care.

• Keep the patient in the right side-lying position for at least 2-4 hours to prevent bleeding.
• Monitor vital signs, including blood pressure and heart rate, for indications of hemorrhage (e.g., hypotension, tachycardia).
• Assess the biopsy site for any visible signs of bleeding or swelling.
• Instruct the patient to avoid heavy lifting, coughing, or straining for at least 24-48 hours to reduce the risk of increased intra-abdominal pressure and bleeding.
• Observe for symptoms of complications such as severe abdominal pain, signs of shock, or referred shoulder pain (indicating potential bleeding or bile leakage).

✘Incorrect answer options:

Left side-lying, with the bed completely flat. The left side-lying position does not apply pressure to the biopsy site in the right upper quadrant and does not help prevent bleeding. It is an inappropriate position after a liver biopsy.

Left side-lying, with the bed in a semi-Fowler’s position. Although a semi-Fowler’s position may promote comfort and respiratory function in some scenarios, positioning on the left side is not suitable after a liver biopsy because it does not apply pressure to the biopsy site.

Right side-lying, with the bed in a semi-Fowler’s position. While lying on the right side is correct for applying pressure to the biopsy site, the bed should be kept completely flat to maximize pressure and minimize the risk of bleeding. A semi-Fowler’s position reduces the effectiveness of this pressure.

EXPLANATION

✔Correct answer:

Interference with the viral replication process. Zidovudine (AZT) is an antiretroviral medication classified as a nucleoside reverse transcriptase inhibitor (NRTI). Its primary mechanism of action is to interfere with the replication process of the human immunodeficiency virus (HIV). Zidovudine works by targeting the enzyme reverse transcriptase, which HIV uses to convert its RNA into DNA (a critical step in the viral replication process). Zidovudine mimics natural nucleosides and becomes incorporated into the growing viral DNA chain. However, because it lacks the necessary components to continue chain elongation, it causes premature termination of the viral DNA synthesis, effectively stopping the replication of HIV.

HIV is a retrovirus that uses reverse transcriptase to replicate inside host cells, primarily CD4+ T lymphocytes. By inhibiting this enzyme, zidovudine reduces viral replication, decreasing the viral load and slowing disease progression. It does not directly destroy the virus but prevents its multiplication, allowing the immune system to function more effectively.

Imagine a copy machine (HIV) that uses a specific type of paper (RNA) to produce duplicates (viral DNA). Zidovudine acts like a defective piece of paper fed into the copy machine. Once it's used, the machine jams and can’t produce more copies, effectively stopping the process.

Patients on zidovudine therapy require regular monitoring and education to ensure the medication is effective and to minimize adverse effects.

• Monitor the patient’s viral load and CD4+ count to assess treatment efficacy.
• Assess for side effects, particularly bone marrow suppression, which can lead to anemia or neutropenia, and report significant findings to the healthcare provider.
• Educate the patient about the importance of adherence to the prescribed regimen to prevent drug resistance.
• Instruct the patient to report symptoms of severe fatigue, pallor, or recurrent infections, which may indicate anemia or neutropenia.
• Reinforce the importance of safe practices to prevent the transmission of HIV to others.

✘Incorrect answer options:

Direct destruction of the viral envelope, leading to viral death. Zidovudine does not directly attack or destroy the virus. Medications that target the viral envelope, such as fusion inhibitors (e.g., enfuvirtide), work by preventing the virus from entering host cells, but this is not the mechanism of zidovudine.

Stimulation of the host’s immune system. While antiretroviral therapy (ART) reduces viral load and helps restore immune function over time, zidovudine does not directly stimulate the immune system. Immunomodulators, such as interleukins, are used to boost immune function but are not part of zidovudine’s therapeutic action.

Enhancement of viral antibody elimination. Zidovudine does not enhance antibody production or elimination of the virus. Its effect is through inhibition of viral replication rather than direct enhancement of the immune system’s antibody-mediated response.

EXPLANATION

✔Correct answer:

Angina or cardiac arrhythmia. A patient undergoing therapy for hypothyroidism, especially with levothyroxine, is at risk for developing angina or cardiac arrhythmias as a serious complication. This occurs because thyroid hormone replacement therapy increases the metabolic rate and oxygen demand of body tissues, including the heart. If the patient has pre-existing cardiovascular disease (e.g., coronary artery disease), the increased workload on the heart can lead to myocardial ischemia (manifesting as angina) or disturbances in cardiac conduction (arrhythmias).

Thyroid hormones also increase heart rate and contractility, which can exacerbate underlying cardiac conditions. For this reason, levothyroxine therapy is typically initiated at a low dose and titrated upward cautiously in patients, especially those with cardiac risk factors, to prevent cardiac complications.

Hypothyroidism slows down the metabolism and reduces oxygen demand, which may "protect" a patient with subclinical or undiagnosed coronary artery disease. When thyroid hormone replacement is introduced, the sudden increase in metabolic activity and oxygen consumption may unmask or worsen pre-existing cardiac issues, leading to angina or arrhythmias.

Imagine a car that has been sitting idle for a long time (hypothyroidism). Suddenly revving the engine at full speed (starting levothyroxine therapy without caution) can strain the car’s worn-out components (the heart), potentially causing it to malfunction.

When monitoring a patient undergoing therapy for hypothyroidism, particularly with levothyroxine, the nurse should focus on assessing for cardiovascular complications and ensuring gradual adjustment to therapy.

• Monitor for signs of angina, such as chest pain, pressure, or discomfort, especially during physical activity.
• Assess the patient’s heart rate and rhythm for arrhythmias, such as atrial fibrillation or tachycardia.
• Monitor blood pressure, as levothyroxine therapy can lead to hypertension in some patients.
• In patients with cardiac risk factors, administer thyroid hormone replacement therapy cautiously, starting at low doses and gradually increasing as prescribed.
• Educate the patient about reporting symptoms such as chest pain, palpitations, or shortness of breath immediately.

✘Incorrect answer options:

Acute hemolytic reaction. An acute hemolytic reaction occurs in conditions such as mismatched blood transfusion or autoimmune hemolytic anemia, not in hypothyroidism or its treatment. It is unrelated to levothyroxine therapy.

Retinopathy. Retinopathy is a complication commonly associated with chronic conditions like diabetes or hypertension, not hypothyroidism or its treatment. Thyroid hormone therapy does not directly affect the retina.

Thrombocytopenia. Thrombocytopenia refers to a low platelet count, which can occur with certain autoimmune disorders or medications that suppress bone marrow function. It is not a typical complication of hypothyroidism treatment.

EXPLANATION

✔Correct answer:

Development of a hematoma. A decreased hematocrit level following a vaginal hysterectomy raises concern for the possible development of a hematoma, which is an accumulation of blood in the tissues near the surgical site. A hematoma can result from bleeding that occurs during or after surgery and may not be immediately evident. Over time, significant blood loss into the tissues can lower hematocrit and hemoglobin levels, indicating anemia.

In the context of a vaginal hysterectomy, hematomas are a known potential complication due to the vascular nature of the pelvic region and the risk of surgical disruption to blood vessels. If a hematoma is large enough, it can lead to symptoms such as pelvic pain, pressure, swelling, and even hemodynamic instability in severe cases.

A hematoma forms when blood collects in the tissues due to the rupture of blood vessels, which may occur as a result of surgical trauma, inadequate hemostasis, or excessive strain during recovery. As blood accumulates in the hematoma, the total circulating blood volume decreases, which may be reflected as a drop in hematocrit on lab results.

Imagine a sponge soaking up water (blood) from a leaky faucet (bleeding vessel). The sponge hides the leak, but over time, you notice there’s less water in the faucet’s supply (lower hematocrit) as it’s being absorbed into the sponge (hematoma).

When a hematoma is suspected, prompt assessment and intervention are required to prevent further complications such as infection or significant blood loss.

• Monitor the patient for clinical signs of a hematoma, such as pelvic pain, swelling, bruising, or a feeling of pressure in the vaginal area.
• Assess vital signs regularly, particularly for signs of hemodynamic instability (e.g., tachycardia, hypotension) that could indicate significant blood loss.
• Notify the healthcare provider about the decreased hematocrit and any accompanying symptoms to facilitate further evaluation (e.g., pelvic examination, imaging studies).
• Educate the patient about signs to watch for at home, including worsening pain, vaginal bleeding, or a sensation of fullness in the pelvic area, and to seek immediate medical attention if these occur.
• Provide supportive care, including pain management and monitoring for secondary complications such as infection.

✘Incorrect answer options:

Hypovolemia. Hypovolemia refers to a significant loss of circulating blood volume, which could lead to a drop in hematocrit. However, in the case of a vaginal hysterectomy, hematomas are a more likely explanation for decreased hematocrit unless there are overt signs of systemic blood loss (e.g., persistent vaginal bleeding or signs of hypovolemic shock).

Presence of an infection. An infection does not typically result in decreased hematocrit. Instead, infection is associated with elevated white blood cell counts, fever, and localized signs of inflammation (e.g., redness, warmth, or purulent discharge).

Pulmonary embolism (PE). A pulmonary embolism would present with respiratory symptoms such as sudden-onset shortness of breath, chest pain, or hypoxemia. While a PE can result from postoperative immobility or a hypercoagulable state, it is not directly related to decreased hematocrit.

EXPLANATION

✔Correct answer:

Restlessness and confusion. The earliest indicator of increasing intracranial pressure (ICP) is often a change in the patient's level of consciousness, which manifests as restlessness, confusion, or irritability. These subtle changes are caused by cerebral hypoxia and impaired brain function as pressure increases within the rigid cranial vault. As the brain becomes compressed and blood flow decreases, it affects higher cortical functions first, leading to altered behavior and mental status.

Early recognition of these symptoms is critical because they often precede more severe manifestations of rising ICP, such as bradycardia, widened pulse pressure, or abnormal posturing, which occur later in the progression of ICP elevation.

Increased ICP can result from trauma, bleeding, swelling, or space-occupying lesions. As pressure rises, it compresses cerebral blood vessels, leading to reduced perfusion and oxygen delivery to brain tissue. Since the brain is enclosed within the rigid skull, even small increases in pressure can disrupt neuronal function, with mental status changes being the earliest sign.

Imagine a balloon slowly filling with air (the brain within the skull). At first, it presses gently against the sides (causing subtle symptoms like restlessness), but as more air is added, the pressure builds up, causing more dramatic effects like bradycardia or a widened pulse pressure.

Recognizing early changes in mental status is critical for prompt intervention. Nurses should closely monitor patients at risk for increased ICP and take appropriate steps to prevent further complications.

• Perform frequent neurological assessments, including Glasgow Coma Scale (GCS) scoring, to detect changes in consciousness or mental status.
• Monitor vital signs, including blood pressure, heart rate, and respiratory rate, to identify late signs of increased ICP (e.g., Cushing's triad).
• Maintain the head of the bed elevated at 30-45 degrees to promote venous drainage and reduce ICP.
• Ensure proper oxygenation and ventilation to prevent hypoxia and hypercapnia, which can exacerbate ICP.
• Report any changes in neurological status immediately to the healthcare provider to facilitate prompt intervention.

✘Incorrect answer options:

Bradycardia. Bradycardia is a late sign of increasing ICP and is part of Cushing's triad (bradycardia, hypertension with widened pulse pressure, and irregular respirations). It occurs due to brainstem compression and the activation of reflexes to maintain perfusion pressure. Restlessness and confusion typically appear earlier.

Polyuria (large amounts of dilute urine). Polyuria is not a common sign of increased ICP. It may indicate other conditions, such as diabetes insipidus, which can occur with pituitary or hypothalamic dysfunction after a head injury but is not an early indicator of rising ICP.

Widened pulse pressure. A widened pulse pressure (the difference between systolic and diastolic blood pressure) is a late sign of increased ICP and occurs as part of Cushing's triad due to brainstem dysfunction and the body’s attempt to maintain cerebral perfusion pressure. It develops after earlier signs such as changes in mental status.

EXPLANATION

✔Correct answer:

Diabetes insipidus. Fluid replacement and vasopressin therapy are critical components of managing diabetes insipidus (DI), a condition characterized by insufficient production or response to antidiuretic hormone (ADH), also known as vasopressin. In DI, the kidneys are unable to concentrate urine, leading to excessive water loss (polyuria) and severe dehydration if untreated.

Vasopressin therapy (e.g., desmopressin, a synthetic form of ADH) is used to replace or mimic the action of ADH, which helps the kidneys reabsorb water and reduce urine output. Fluid replacement is also essential to prevent dehydration and maintain hemodynamic stability in patients with DI.

DI occurs due to a deficiency of ADH (central DI) or the kidneys' resistance to ADH (nephrogenic DI). ADH normally acts on the renal collecting ducts to promote water reabsorption. In the absence of ADH or its effect, large amounts of dilute urine are excreted, resulting in dehydration, hypernatremia, and an increased serum osmolality.

Imagine a faucet that won’t turn off (DI). Water (urine) keeps pouring out, leaving the reservoir (the body) dry. Vasopressin therapy acts like fixing the faucet so that water stays in the reservoir, and fluid replacement is like refilling the reservoir to prevent it from drying up completely.

Effective management of DI requires close monitoring of fluid balance, electrolyte levels, and the response to vasopressin therapy.

• Administer prescribed vasopressin (desmopressin) and monitor its effectiveness by tracking urine output and specific gravity.
• Provide fluid replacement (e.g., oral fluids or IV fluids such as hypotonic saline) to correct dehydration and maintain hydration status.
• Monitor serum sodium levels and osmolality, as DI often causes hypernatremia due to water loss.
• Measure and document intake and output closely to detect changes in urine volume and fluid balance.
• Educate the patient and family about recognizing signs of dehydration (e.g., thirst, dry mucous membranes, dizziness) and the importance of adherence to treatment.

✘Incorrect answer options:

Diabetes mellitus. Diabetes mellitus is characterized by hyperglycemia due to insulin deficiency or resistance. While fluid replacement may be necessary in cases of dehydration (e.g., in diabetic ketoacidosis), vasopressin therapy is not part of the treatment for diabetes mellitus.

Diabetic ketoacidosis (DKA). DKA involves severe hyperglycemia, ketosis, and metabolic acidosis due to insulin deficiency in diabetes mellitus. Management includes fluid replacement, insulin therapy, and electrolyte correction, but vasopressin therapy is not used.

Syndrome of inappropriate antidiuretic hormone secretion (SIADH). SIADH involves excessive release of ADH, leading to water retention, hyponatremia, and diluted plasma osmolality. Treatment typically includes fluid restriction and, in some cases, medications like vasopressin receptor antagonists, but vasopressin therapy would worsen SIADH by promoting further water retention.

EXPLANATION

✔Correct answer:

Administering supplemental oxygen. When a patient presents with acute chest pain and a pulse oximetry reading (SpO2) of 89%, the primary focus should be on correcting the hypoxia. Supplemental oxygen is administered to improve oxygen saturation and ensure adequate oxygen delivery to tissues, which is especially critical in cases of suspected myocardial ischemia or infarction. Hypoxia can worsen cardiac stress and tissue damage, making oxygenation a top priority.

A pulse oximetry reading of 89% indicates hypoxemia (low blood oxygen levels). The myocardium relies on adequate oxygen delivery to function properly, and a lack of oxygen can exacerbate ischemia, leading to further chest pain, potential arrhythmias, and myocardial damage. Oxygen therapy helps stabilize the patient by increasing the arterial oxygen concentration and improving tissue oxygenation.

Think of the heart as an engine that needs fuel (oxygen) to run smoothly. If the oxygen level (fuel supply) drops too low, the engine starts to sputter, and damage can occur. Administering supplemental oxygen is like refueling the engine to help it function properly.

In the context of acute chest pain and low oxygen saturation, nurses must prioritize stabilizing the patient and addressing hypoxia promptly while preparing for further diagnostic and therapeutic interventions.

• Administer oxygen therapy as prescribed (e.g., via nasal cannula or mask) to achieve a target SpO2 of 94–98% (or as per institutional protocols).
• Monitor the patient’s vital signs, including oxygen saturation, to assess the effectiveness of oxygen therapy.
• Prepare for further diagnostic tests, such as a 12-lead ECG, to evaluate the cause of chest pain (e.g., myocardial infarction).
• Communicate with the healthcare team about the patient’s status and any changes in condition.
• Educate the patient about the importance of oxygen therapy and its role in symptom relief and stabilization.

✘Incorrect answer options:

Administering morphine sulfate. Morphine is used for pain relief and anxiety reduction in cases of acute myocardial infarction (AMI); however, it is not the first intervention. Addressing hypoxia with supplemental oxygen takes precedence, as it directly impacts myocardial oxygenation.

Administering sublingual nitroglycerin. Nitroglycerin is effective for relieving chest pain caused by myocardial ischemia by dilating coronary arteries and reducing myocardial oxygen demand. However, if oxygen saturation is critically low (below 90%), supplemental oxygen must be prioritized first to correct hypoxia before administering nitroglycerin.

Obtaining a 12-lead electrocardiogram (ECG). While an ECG is a critical diagnostic tool for identifying ischemic changes or myocardial infarction, it is not the initial intervention in the presence of hypoxia. Stabilizing the patient’s oxygenation status is necessary before proceeding with diagnostic tests.

EXPLANATION

✔Correct answer:

Administer a bronchodilator via nebulizer. In an acute asthma exacerbation, the primary issue is bronchoconstriction leading to airflow obstruction, which results in respiratory distress, hypoxia, and increased respiratory rate (tachypnea). Administering a bronchodilator, such as albuterol, via nebulizer is the first priority to rapidly relieve bronchospasm, improve airway patency, and reduce the patient’s work of breathing.

Beta-agonist bronchodilators, like albuterol, stimulate beta-2 receptors in the smooth muscle of the airways, causing relaxation and dilation of the bronchial passages. This intervention is life-saving as it directly addresses the underlying cause of respiratory distress in an asthma attack. Delaying bronchodilator administration can lead to further deterioration, including hypoxemia, exhaustion, or respiratory failure.

During an asthma exacerbation, airway inflammation, bronchial hyperresponsiveness, and excessive mucus production cause airway narrowing and obstruction. These changes make it difficult for the patient to move air in and out of their lungs, resulting in respiratory distress. Rapid bronchodilation improves oxygenation and helps prevent progression to life-threatening conditions such as status asthmaticus.

Imagine trying to blow air through a straw that’s squeezed shut. The harder you try to breathe, the more tired you become. A bronchodilator is like someone unclamping the straw, allowing air to flow freely again.

After administering the bronchodilator, other supportive measures and assessments should follow to monitor and optimize the patient’s condition.

• Assess the patient’s respiratory status (e.g., respiratory rate, effort, lung sounds, oxygen saturation) after the bronchodilator is administered.
• Administer supplemental oxygen if the patient’s oxygen saturation is below 90% to ensure adequate oxygenation.
• Prepare to administer additional medications, such as corticosteroids, to address airway inflammation and prevent recurrence.
• Monitor for potential side effects of bronchodilators, such as tachycardia, tremors, or nervousness.
• Provide reassurance and education after stabilization to reduce anxiety, which can exacerbate symptoms.

✘Incorrect answer options:

Obtain a comprehensive medical history. While obtaining a medical history is important for understanding the patient’s asthma triggers, medication regimen, and previous exacerbations, it is not the first priority during acute respiratory distress. Stabilizing the patient by relieving bronchoconstriction is critical before gathering detailed history.

Apply cardiac monitoring. Cardiac monitoring may be useful in patients receiving bronchodilators, as medications like albuterol can cause tachycardia or arrhythmias. However, it is not the immediate priority. Addressing the respiratory emergency takes precedence over monitoring, which can follow stabilization.

Provide emotional reassurance and support. Emotional reassurance is important because anxiety can worsen respiratory distress. However, it is not the first intervention in a life-threatening asthma exacerbation. Bronchodilation must be achieved urgently to relieve the physiological cause of the distress.

EXPLANATION

✔Correct answer:

Absence of fluctuation (tidaling) in the water-seal chamber when suction is discontinued. The absence of fluctuation (tidaling) in the water-seal chamber when suction is discontinued is the most reliable indicator that the chest tube can be safely removed. Tidaling refers to the rise and fall of water in the water-seal chamber with the patient's inspiration and expiration, which reflects changes in intrapleural pressure. When tidaling stops after suction is discontinued, it suggests that the lung has fully re-expanded, and there is no ongoing air leak or abnormal communication between the pleural space and the atmosphere.

Chest radiographs and clinical assessments are often used in conjunction with this finding to confirm that the lung has re-expanded and the pneumothorax has resolved. Once these indicators are met, the chest tube can be safely removed.

A pneumothorax occurs when air enters the pleural space, causing lung collapse. Chest tubes are inserted to evacuate air or fluid from the pleural space, allowing the lung to re-expand. When the lung has fully re-expanded and there is no more air or fluid entering the pleural space, the chest tube is no longer needed.

Think of a balloon (the lung) that had a leak and needed to be patched. Once the leak is sealed and the balloon is fully inflated, there’s no more air escaping, and no further need for a pump (chest tube).

Before removing a chest tube, thorough assessment and preparation are essential to prevent complications and ensure patient safety.

• Assess for the cessation of tidaling in the water-seal chamber after discontinuing suction, indicating the resolution of the pneumothorax.
• Verify findings with a chest radiograph to confirm lung re-expansion.
• Monitor the patient for signs of respiratory distress or recurrence of pneumothorax, such as sudden shortness of breath or decreased oxygen saturation.
• Educate the patient about deep breathing exercises and ensure close monitoring after chest tube removal to detect potential complications.
• Document the removal procedure, patient response, and post-removal assessments.

✘Incorrect answer options:

Copious drainage is observed from the chest tube. Copious drainage is not a sign that the chest tube can be removed; in fact, it may indicate a complication, such as ongoing bleeding or fluid accumulation in the pleural space. Drainage volume and type should be monitored, but they are not the most reliable indicators for removal.

Arterial blood gas (ABG) values are within normal limits. While normal ABG values suggest adequate gas exchange, they do not directly confirm lung re-expansion or resolution of the pneumothorax. ABGs alone are insufficient to determine whether the chest tube can be removed.

A chest radiograph reveals persistent lung collapse of 35%. Persistent lung collapse of 35% indicates that the pneumothorax has not fully resolved and that the lung has not fully re-expanded. A chest tube should remain in place until the lung has re-expanded completely or as directed by the healthcare provider.

EXPLANATION

✔Correct answer:

The body's immune response. Corticosteroids primarily suppress the body’s immune response by reducing inflammation and inhibiting various immune system processes. These medications mimic the effects of cortisol, a hormone naturally produced by the adrenal glands, which regulates inflammation and the immune system. Corticosteroids work by reducing the production of pro-inflammatory substances such as cytokines, prostaglandins, and leukotrienes. They also decrease the activity and proliferation of immune cells, such as T-cells and macrophages. This immunosuppressive effect is why corticosteroids are widely used in conditions involving excessive immune activation, such as autoimmune disorders (e.g., rheumatoid arthritis, lupus) and to prevent rejection in organ transplantation.

Inflammation is a natural immune response to injury or infection, marked by swelling, redness, heat, and pain. While inflammation is essential for healing, excessive or chronic inflammation can damage tissues and organs. Corticosteroids interfere with the inflammatory cascade, inhibiting processes such as vasodilation, capillary permeability, and white blood cell migration, thereby reducing inflammation and immune activity.

Imagine the immune system as a firefighter responding to a fire (inflammation). If the fire becomes too big, the firefighter (immune system) might unintentionally damage nearby structures. Corticosteroids act like a water valve, turning down the pressure to prevent excessive damage caused by the immune response.

Nurses should educate patients about the potential side effects of corticosteroids and monitor for complications associated with long-term use.

• Monitor for signs of infection, as corticosteroids suppress the immune response and increase the risk of infections.
• Educate the patient about potential side effects, such as hyperglycemia, osteoporosis, weight gain, and fluid retention.
• Advise the patient not to stop corticosteroids abruptly, as this can cause adrenal insufficiency; they must be tapered under medical supervision.
• Encourage patients to take their medication with food to reduce gastrointestinal side effects.
• Monitor blood glucose levels in diabetic patients, as corticosteroids can increase blood sugar levels.

✘Incorrect answer options:

Adrenal hyperfunction (Cushing's syndrome). Cushing's syndrome is a potential side effect of long-term corticosteroid use but is not the physiological process suppressed by these medications. Instead, corticosteroids mimic or enhance cortisol activity and can induce symptoms resembling Cushing's syndrome.

Nociceptor activity (pain perception). While corticosteroids can indirectly reduce pain by decreasing inflammation (a major cause of pain), they do not directly suppress nociceptor activity. Nociceptors are sensory neurons that respond to pain stimuli and are influenced more directly by analgesics such as NSAIDs or opioids.

Nerve impulse conduction. Corticosteroids do not affect the conduction of nerve impulses. Medications like local anesthetics (e.g., lidocaine) or anticonvulsants (e.g., gabapentin) directly influence nerve conduction, not corticosteroids.

EXPLANATION

✔Correct answer:

Abduction. Following surgical repair of a hip fracture or total hip replacement, maintaining the hip in an abducted position is most crucial to prevent dislocation of the hip prosthesis. Abduction refers to positioning the legs away from the midline of the body, which keeps the femoral head properly seated in the acetabulum or prosthetic socket. This position minimizes stress on the surgical repair and prevents the hip from slipping out of alignment, particularly during movements like sitting or turning in bed.

Adduction (bringing the legs toward the midline) increases the risk of dislocating the hip prosthesis by forcing the femoral head out of the socket. Nurses play a key role in educating the patient about safe positioning techniques and using equipment, such as abduction pillows, to maintain proper alignment.

Hip dislocation after surgery occurs when the femoral head is displaced from the acetabulum or prosthetic socket, often due to improper positioning or excessive stress on the joint. The posterior approach to hip surgery, which is commonly used, has a higher risk of dislocation because the posterior capsule is weakened during the procedure. Abduction keeps the hip in a neutral and stable position, reducing strain on the joint and preventing dislocation.

Imagine the hip joint is like a ball in a cup. If you keep the ball centered by slightly pushing it outward (abduction), it stays in the cup. But if you bring the ball inward too far (adduction), it can pop out of the cup, just like a hip dislocation.

Nurses should implement positioning strategies and educate patients to prevent complications such as dislocation and pain after hip surgery.

• Use an abduction pillow or wedge between the patient’s legs, especially when turning or positioning in bed.
• Advise the patient to avoid crossing their legs or bending the hip more than 90 degrees, as these movements increase the risk of dislocation.
• Position the patient with the head of the bed elevated no more than 30-45 degrees to prevent excessive hip flexion.
• Educate the patient about using assistive devices, such as a raised toilet seat or long-handled grabbers, to avoid positions that stress the hip joint.
• Monitor for signs of hip dislocation, such as sudden severe pain, shortening of the affected leg, or external rotation of the leg, and report these findings immediately.

✘Incorrect answer options:

Adduction. Adduction, or bringing the legs toward the midline, is contraindicated after hip surgery because it increases the risk of dislocating the hip prosthesis. Patients should be instructed to avoid crossing their legs or allowing the knees to touch.

Prone. Prone positioning (lying on the stomach) is not recommended for patients after hip surgery, as it can place undue strain on the hip joint and surgical repair. While prone positioning is sometimes used for other conditions (e.g., to improve oxygenation in respiratory failure), it is not appropriate in this context.

Subluxation. Subluxation refers to a partial dislocation of the joint and is not a patient position. It is a condition that may occur if proper precautions are not taken to maintain hip alignment postoperatively.

EXPLANATION

✔Correct answer:

Disseminated intravascular coagulation (DIC). Abruptio placentae, the premature separation of the placenta from the uterine wall, places the patient at significant risk for developing disseminated intravascular coagulation (DIC). This condition is a severe, life-threatening complication characterized by widespread activation of the clotting cascade, resulting in microvascular thrombosis and secondary consumption of clotting factors and platelets, which leads to uncontrollable bleeding (coagulopathy).

In abruptio placentae, the release of thromboplastin from the damaged placental tissue into maternal circulation can trigger the DIC process. This creates a cycle of excessive clotting and subsequent depletion of clotting components, leading to bleeding complications in the patient.

DIC occurs due to an imbalance in the coagulation and fibrinolysis systems. In abruptio placentae, tissue injury and placental separation lead to the release of procoagulant substances, which cause systemic activation of clotting factors. The depletion of platelets and clotting factors results in hemorrhage. In severe cases, this can lead to multi-organ failure due to microvascular ischemia and hypoperfusion caused by the formation of fibrin clots.

Imagine a dam (the placenta) breaking and flooding a valley (maternal circulation). The sudden release of water (procoagulants) overwhelms the system, causing uncontrolled flooding (clotting and bleeding). This imbalance leads to widespread damage, just as DIC disrupts normal coagulation in the body.

Prompt recognition and intervention are critical in managing DIC in a patient with abruptio placentae.

• Monitor for signs of bleeding (e.g., petechiae, ecchymosis, oozing from IV sites, hematuria) and signs of hypovolemic shock (e.g., hypotension, tachycardia, pallor).
• Assess laboratory values, including platelet count, fibrinogen levels, prothrombin time (PT), activated partial thromboplastin time (aPTT), and D-dimer levels, to evaluate for DIC.
• Administer blood products (e.g., platelets, fresh frozen plasma, cryoprecipitate) as ordered to replace depleted clotting factors and restore hemostasis.
• Ensure large-bore IV access for rapid fluid or blood product administration.
• Collaborate with the healthcare team to stabilize the patient and prepare for potential emergent delivery if indicated to address the underlying cause.

✘Incorrect answer options:

Thrombocytopenia. While thrombocytopenia (low platelet count) may occur as part of DIC, it is not an isolated hematological complication in abruptio placentae. The systemic nature of DIC includes thrombocytopenia along with consumption of clotting factors, making DIC the more appropriate answer.

Idiopathic thrombocytopenic purpura (ITP). ITP is an autoimmune disorder in which the body produces antibodies that destroy platelets. It is not directly related to abruptio placentae or its complications. ITP is a separate condition with distinct pathophysiology.

Heparin-induced thrombocytopenia (HIT). HIT is a condition that occurs in response to heparin therapy, involving an immune-mediated reduction in platelets and increased risk of thrombosis. Since abruptio placentae is not associated with heparin therapy, this option is incorrect.

EXPLANATION

✔Correct answer:

High Fowler's position. In acute pulmonary edema, the most beneficial position for the patient is the High Fowler's position, which involves sitting the patient upright at a 60-90 degree angle. This position helps promote improved respiratory function by reducing venous return to the heart (preload), which decreases pulmonary congestion. It also enhances lung expansion, allowing for better ventilation and oxygen exchange.

Pulmonary edema occurs when fluid accumulates in the alveoli and lung interstitium, impairing gas exchange and causing respiratory distress. The High Fowler's position decreases pressure on the diaphragm and improves the mechanics of breathing. Additionally, by reducing preload, this position alleviates the burden on the left ventricle, which is often overloaded in conditions such as heart failure.

Imagine trying to breathe with someone pressing on your chest while lying flat—that’s similar to what happens when fluid builds up in the lungs. Sitting upright (High Fowler's position) is like standing up to relieve that pressure, allowing you to breathe more easily.

Proper positioning is a critical nursing intervention in managing acute pulmonary edema, but additional actions are needed to stabilize the patient.

• Administer supplemental oxygen as prescribed to improve oxygenation.
• Monitor oxygen saturation levels and vital signs frequently to assess the patient’s respiratory and cardiovascular status.
• Prepare for the administration of diuretics (e.g., furosemide) to reduce fluid overload and preload.
• Ensure the patient remains calm and provide reassurance to reduce anxiety, which can exacerbate respiratory distress.
• Collaborate with the healthcare provider for further management, including consideration of vasodilators or non-invasive positive pressure ventilation (e.g., CPAP or BiPAP) if needed.

✘Incorrect answer options:

Supine position. The supine position (lying flat on the back) is inappropriate for patients with acute pulmonary edema as it increases venous return to the heart and exacerbates pulmonary congestion. It also limits lung expansion, worsening respiratory distress.

Left lateral decubitus position. While the left lateral decubitus position may reduce pressure on the lungs in certain scenarios, it does not provide the same benefits as the High Fowler's position in terms of reducing venous return and promoting lung expansion.

Semi-Fowler's position. Although the Semi-Fowler's position (elevating the head of the bed to 30–45 degrees) can provide some relief, it is less effective than the High Fowler's position in reducing preload and facilitating optimal lung expansion. For severe cases like acute pulmonary edema, the upright position is the preferred choice.