Nursing Care and Interventions Flashcards

A practical nurse is caring for a client with chronic kidney disease who is receiving a continuous heparin infusion for a deep vein thrombosis. The client's aPTT result comes back at 180 seconds (therapeutic range: 60–100 seconds). The client is alert and oriented with no signs of active bleeding. What is the priority nursing action?

Answer: Hold the heparin infusion and notify the physician immediately

An aPTT of 180 seconds is nearly double the upper therapeutic limit, representing a critical supratherapeutic level that significantly increases hemorrhage risk. The priority action is to hold the infusion and notify the physician so the dose can be safely adjusted or protamine sulfate considered. Simply reducing the rate (option B) without physician direction is outside the PN scope for a critically abnormal value. Protamine sulfate (option C) is reserved for confirmed or life-threatening overdose with active bleeding, not a standing nursing decision. Continuing the infusion (option D) risks serious harm.

A practical nurse on a medical unit is preparing to administer an enteral feeding via nasogastric tube to a client who is semi-conscious following a stroke. Before initiating the feed, the nurse aspirates 280 mL of gastric residual volume (GRV). Current agency policy states: hold the feeding and reassess in 1 hour if GRV exceeds 250 mL. The client's last feeding was 4 hours ago. Which action is most appropriate?

Answer: Return the aspirate to the client, hold the feeding, and notify the physician

Current evidence and most agency policies recommend returning (re-instilling) gastric aspirate to preserve electrolytes and digestive enzymes — discarding it risks metabolic imbalance. The GRV exceeds the 250 mL policy threshold, requiring the feeding to be held. Because this is a stroke patient with altered consciousness (high aspiration risk) and a significantly elevated GRV, the physician must be notified rather than simply waiting and reassessing independently. Option A incorrectly discards the aspirate. Option C does not follow policy (the threshold was exceeded). Option D proceeds with feeding despite a contraindicated GRV.

A practical nurse is caring for a postoperative client 18 hours after an open appendectomy. The client reports sudden onset of severe chest pain radiating to the left shoulder, rated 9/10, with accompanying shortness of breath and diaphoresis. The client's blood pressure is 88/54 mmHg, heart rate 118 bpm, and SpO₂ 91% on room air. Which intervention takes highest priority?

Answer: Place the client in a high Fowler's position and call for the rapid response team

This presentation — severe chest pain, hypotension, tachycardia, diaphoresis, and oxygen desaturation — represents a hemodynamically unstable emergency requiring immediate activation of the rapid response team (RRT). High Fowler's position supports ventilation and reduces cardiac workload. Calling the RRT brings the highest level of rapid intervention. Obtaining an ECG (option A) is important but takes time and does not address the hemodynamic emergency first. Administering morphine (option C) to a hypotensive, desaturating patient is dangerous without immediate medical oversight. Fluid loading alone (option D) is insufficient and delays critical assessment of the likely cause (PE, MI, or internal hemorrhage).

A practical nurse is caring for a client with type 1 diabetes who is NPO after midnight for a scheduled colonoscopy at 08:00. At 06:30, the client's capillary blood glucose is 3.1 mmol/L and they report feeling shaky and sweaty. The client's morning insulin (10 units glargine) has not yet been given. What is the most appropriate immediate intervention?

Answer: Hold all insulin, notify the physician, and administer IV dextrose per hypoglycemia protocol

The client is NPO, symptomatic, and has a blood glucose of 3.1 mmol/L — confirmed hypoglycemia in a patient who cannot safely take anything by mouth due to NPO status and impending procedure. Oral carbohydrates (option A) are contraindicated in an NPO patient scheduled for a procedural sedation. The correct action is to hold insulin (giving glargine to a hypoglycemic NPO patient would worsen the situation), treat via IV dextrose per protocol, and notify the physician — who will also determine whether the procedure timing is affected. Options C and D both involve giving basal insulin to a currently hypoglycemic NPO patient, which is dangerous.

A practical nurse is performing a routine assessment on a client receiving a blood transfusion (packed red blood cells, unit 2 of 2). Twenty-five minutes into the transfusion the client develops low back pain, a temperature rise from 37.0°C to 38.4°C, chills, and flushed skin. Urine output over the last 30 minutes appears pink-tinged. What is the most critical immediate nursing action?

Answer: Stop the transfusion, keep the IV line open with normal saline, and notify the physician and blood bank

The constellation of low back pain, fever, chills, flushed skin, and hemoglobinuria (pink urine) is a hallmark presentation of an acute hemolytic transfusion reaction (AHTR) — the most life-threatening transfusion complication, caused by ABO incompatibility. The immediate priority is to STOP the transfusion and maintain IV access with a new normal saline line (NOT through the existing blood tubing). The physician and blood bank must be notified immediately for investigation. Option B is dangerous — continuing even at a slow rate delivers more incompatible blood. Option C is incorrect because the IV line should be maintained for emergency medications. Option D treats an allergic reaction, which does not fit the hemolytic presentation.

A practical nurse is caring for a client with end-stage COPD on long-term low-flow oxygen (2 L/min via nasal cannula). The client is acutely dyspneic with an SpO₂ of 84%, respiratory rate of 32 breaths/min, and appears cyanotic. A family member insists the nurse 'turn up the oxygen as high as it will go.' What is the most appropriate nursing response and action?

Answer: Titrate oxygen cautiously to achieve SpO₂ of 88–92%, notify the physician, and prepare for possible non-invasive ventilation

In chronic COPD, some patients (hypercapnic 'blue bloaters') rely on hypoxic drive; however, the target SpO₂ in acute COPD exacerbation per evidence-based guidelines (including Canadian respiratory guidelines) is 88–92% — not normoxia. Titrating oxygen to this range corrects life-threatening hypoxia without the risk of eliminating hypoxic drive and precipitating hypercapnic respiratory failure. Option A (high-flow O₂ to 10 L) risks suppressing ventilatory drive and worsening CO₂ retention. Option B is factually wrong — supplemental O₂ is appropriate and necessary. Option D with an SpO₂ of 84% is dangerous inaction.