Complex Care Flashcards

A practical nurse is caring for a client with chronic kidney disease (CKD) stage 4 who is admitted with heart failure exacerbation. The client's potassium is 5.8 mEq/L, BNP is 1,200 pg/mL, and they are oliguric. The physician orders furosemide 80 mg IV push. Which nursing action is MOST critical before administering this medication?

Answer: Ensure the IV rate does not exceed 4 mg/min to prevent ototoxicity

High-dose IV furosemide administered too rapidly causes sensorineural hearing loss. The maximum safe IV push rate is 4 mg/min; at 80 mg, administration should take at least 20 minutes. While allergy screening and hearing baseline assessment are relevant considerations, the immediate safety action before pushing the medication is ensuring the correct infusion rate. Hyperkalemia does not contraindicate furosemide — in fact, loop diuretics are often used to manage it.

A client on a medical-surgical unit has a tracheostomy and is receiving enteral nutrition via a PEG tube. During assessment, the PN notices the pilot balloon on the tracheostomy cuff feels flaccid. The client is alert and communicating by mouthing words. What is the PRIORITY nursing action?

Answer: Check cuff pressure with a manometer and inflate to maintain 20–30 cmH₂O

A flaccid pilot balloon indicates cuff deflation, which creates aspiration risk especially in a client receiving enteral feeds. The correct intervention is to use a manometer to measure and restore cuff pressure to the therapeutic range of 20–30 cmH₂O. Injecting air without measurement risks overcuffing, which causes tracheal necrosis. Halting feeds is appropriate but is not the priority action — restoring the cuff seal first prevents aspiration of any residual pharyngeal contents.

A PN is caring for a post-operative client who had a total laryngectomy 18 hours ago. The client is becoming increasingly restless, the stoma is producing pink-tinged secretions, and SpO₂ has dropped from 97% to 91% over the past 30 minutes. Which assessment finding would MOST change the PN's immediate course of action?

Answer: Bilateral breath sounds present but diminished at bases

The clinical picture — restlessness, pink-tinged secretions, and falling SpO₂ — is consistent with stoma obstruction from mucous plugging or bleeding. If breath sounds are present bilaterally (even if diminished), the airway is patent and the priority shifts to suctioning the stoma and notifying the physician about the SpO₂ trend. An absent gag reflex is expected post-laryngectomy and does not change the plan. Dressing saturation warrants monitoring but does not alter the immediate airway management. The BP rise is a compensatory response to hypoxia.

A client with type 1 diabetes mellitus is admitted in diabetic ketoacidosis (DKA). Orders include an insulin drip at 0.1 units/kg/hr and IV fluid resuscitation. Blood glucose is now 13.2 mmol/L (238 mg/dL), down from 28.8 mmol/L on admission. Serum potassium is 3.2 mEq/L. What is the MOST appropriate nursing action at this point?

Answer: Continue the current insulin drip and add dextrose to the IV fluid per protocol

In DKA management, when blood glucose reaches approximately 14 mmol/L (250 mg/dL), dextrose is added to IV fluids while the insulin drip continues — this prevents hypoglycemia while allowing insulin to continue clearing ketoacids. The drip is NOT discontinued at this glucose threshold; DKA resolution is defined by anion gap closure and bicarbonate normalization, not glucose alone. Holding insulin for a potassium of 3.2 mEq/L is indicated only if potassium falls below 3.3 mEq/L — at 3.2, repletion should begin but insulin protocols typically set the hold threshold at <3.3, making this a borderline case where continuing insulin with concurrent repletion is appropriate per most protocols.

A PN working in a complex continuing care facility is assigned a client with advanced ALS who uses non-invasive positive pressure ventilation (NIPPV) at night. At 0300, the ventilator alarm sounds and the client is visibly distressed. The mask is in place, but the client is paradoxically breathing — the chest sinks on inspiration. Which interpretation is MOST accurate?

Answer: The NIPPV interface has a significant leak, causing the machine to cycle out of synchrony with the client

Paradoxical chest movement (chest sinking during what should be an assisted inspiration) in a client on NIPPV most commonly indicates patient-ventilator asynchrony caused by a mask leak. When there is a significant air leak, the ventilator cannot generate adequate pressure, so the client's own inspiratory effort creates negative intrathoracic pressure while the machine fails to deliver flow — causing the chest to sink rather than rise. A tension pneumothorax would present with tracheal deviation, absent breath sounds, and hemodynamic instability. High-pressure alarms occur when resistance increases, not when there's a leak (which causes low-pressure alarms). Trigger sensitivity issues cause double-triggering or auto-cycling, not paradoxical breathing.

A practical nurse is caring for an older adult client with delirium superimposed on moderate dementia following hip arthroplasty. The client has been pulling at their urinary catheter and IV line throughout the night. At 0500, the client is calm and appears to be sleeping. The PN's colleague suggests applying wrist restraints 'just to be safe' before the morning rush. What is the MOST appropriate response by the PN?

Answer: Decline to apply restraints, reassess the client's current level of agitation, and explore non-restraint alternatives

Applying restraints to a currently calm patient based on anticipatory convenience — not an immediate safety threat — violates ethical and legal standards in Canadian nursing practice. Restraints require ongoing justification based on the client's current state, not predicted future behavior. The PN must first reassess whether the client currently poses a risk to themselves and must exhaust least-restrictive alternatives (e.g., removing the urinary catheter if appropriate, repositioning, engaging the client, bed alarms, 1:1 supervision). A physician's order is required in most jurisdictions for physical restraints, but obtaining an order doesn't justify applying them to a calm client. Applying a single restraint without an order is still a restraint and is not permissible.