Set B rationales, items 6–10

Item 6 — Answer: 3, 5, 4, 1, 2

Why sitting the client upright is first: it treats nothing and it buys everything. Upright positioning uses orthostatic pooling to drop a blood pressure of 188/104 within a minute, and the immediate threat in autonomic dysreflexia is the pressure itself, which causes stroke, seizure, and retinal hemorrhage. It is the only action on the list that works before you know the cause. Why loosening constrictive clothing is second: a tight waistband, an abdominal binder, or a compression stocking is both a possible trigger and a fast one to remove. Two seconds of effort, no equipment. Why bladder assessment is third: a distended bladder or a kinked catheter is the cause in the large majority of episodes, so this is the highest-yield place to look once the pressure is falling. Why checking for impaction is fourth: it is the second most common trigger, and it goes after the bladder because rectal stimulation can itself worsen dysreflexia, which is why an anesthetic lubricant is used. Why notifying the provider is last: the nurse has an established protocol for the first four actions, and the call is made with information rather than instead of action. Antihypertensive treatment follows if the pressure does not fall. Why the order 4, 3, 5, 1, 2 fails: it hunts for the cause before lowering the pressure. Finding the kinked catheter two minutes later does not undo two minutes of a systolic of 188. Why the order 2, 3, 5, 4, 1 fails: it calls the provider first. The provider will tell you to sit the client up.

The rule: remove the stimulus, but raise the head first.

Item 7 — Answer: 1, 2, 3, 4

Why 1 is right: tachycardia is the first compensation. The stroke volume has fallen, so the rate rises to hold cardiac output. Why 2 is right: a narrowing pulse pressure is often the earliest blood pressure change, because vasoconstriction raises the diastolic while the systolic is already falling. It appears before the systolic drops. Why 3 is right: cool, pale skin with delayed refill is peripheral vasoconstriction shunting blood to the core. It is compensation made visible. Why 4 is right: restlessness and anxiety are the brain reporting reduced perfusion, and they arrive well before confusion does. Why 5 is wrong: a heart rate of 52 is the opposite of compensation. In the compensated phase the rate rises. A falling rate in a bleeding client is a late and ominous change, not an early one. Why 6 is wrong: 70 mL per hour is a healthy output. In hypovolemia the kidneys conserve, and output falls before the blood pressure does.

The rule: compensation is loud before it is quiet.

Item 8 — Answers: [1] an air leak in the system, [2] assess the system from the client's dressing along the tubing to the drainage unit

Why an air leak is right: bubbling in the water seal chamber that is continuous, vigorous, and unrelated to the respiratory cycle means air is entering the system from somewhere. Air that varies with breathing is tidaling; air that does not vary is a leak. Why expected tidaling is wrong: tidaling is a gentle rise and fall of the water level with respiration, not vigorous continuous bubbling. Why normal suction control function is wrong: gentle continuous bubbling belongs in the suction control chamber of a wet system, not in the water seal chamber. Why complete lung re-expansion is wrong: a re-expanded lung produces no bubbling and no tidaling at all. Why assessing the system from the dressing outward is right: the leak is located by working from the client toward the unit, checking the insertion site dressing, then each connection, then the tubing, then the unit. Locating it determines whether the problem is a loose connection you can fix or air coming from the client, which you cannot. Why clamping the chest tube for 30 minutes is wrong: prolonged clamping of a chest tube in a client with an air leak can convert a leak into a tension pneumothorax. Clamping is momentary and only for specific purposes. Why increasing the wall suction is wrong: suction level is prescribed, more suction does not seal a leak, and it can worsen the air entrainment. Why milking and stripping the tubing is wrong: it generates high negative pressure in the pleural space and damages tissue, and it is not a leak assessment.

The rule: expected sounds have a rhythm, and leaks do not.

Item 9 — Answer: 2

Why 2 is right: glucagon 1 mg intramuscularly is the treatment for severe hypoglycemia when the client cannot swallow safely and there is no intravenous access. It works within minutes, requires no vein, and can be given by a single responder. The client is turned to the side afterward, because glucagon commonly causes vomiting. Why 1 is wrong: nothing goes in the mouth of an unresponsive client. Glucose gel is correct for a client with hypoglycemia who is awake and able to swallow, and it is wrong for this one. Correct for a different client is the most persuasive kind of wrong answer. Why 3 is wrong: the stem states there is no intravenous access, and 5% dextrose in water is a maintenance fluid rather than a rescue dose. It answers a question that was not asked using a route that is not available. Why 4 is wrong: waiting is not an intervention. A glucose of 32 mg/dL causes neuronal injury, and a treatment exists that requires nothing this nurse does not have.

The rule: no airway, no oral route.

Item 10 — Answer: 15 mL per hour

Why 15 is right: 176 lb divided by 2.2 is 80 kg. At 5 micrograms per kilogram per minute, the client needs 400 micrograms per minute, which is 24,000 micrograms or 24 mg per hour. The bag holds 400 mg in 250 mL, a concentration of 1.6 mg per mL. 24 divided by 1.6 is 15 mL per hour. Why 33 is wrong: this uses 176 as the weight in kilograms, skipping the conversion entirely. Born at CONVERT. Why 73 is wrong: this multiplies 176 by 2.2 instead of dividing, producing a 387 kg client. Pounds are heavier in number and lighter in mass, so the conversion always makes the number smaller. Born at CONVERT, and it is the error that most often survives a self-check because the arithmetic afterward is flawless. Why 0.25 is wrong: this stops at micrograms per minute converted to milliliters per minute and never multiplies by 60. Born at SOLVE.

The rule: weigh in the unit the prescription is written in.

Set B close. Compare your set A percentage with your set B percentage on page 76 before you draw any conclusion from either. One number alone means nothing. The gap between them is the finding.

Margin note: "raise the head, then hunt the cause."

> Watch out on item 9: an unresponsive client has no protected airway, and that fact outranks every drug preference. > ☐ I can recite the dysreflexia order. > → BOOK 10 · P5 and → BOOK 06 · P7

Takeaway. In an emergency sequence, the action that buys time comes before the action that fixes the cause.