Advanced Fundamentals Exam 1

IM site: dorsalgluteal

-patient in prone position -select buttox and divide into fourths -select the upper out quadrant (away from sciatic nerve)

SubQ volume

0.5 - 1 mL

Medium IV length

1 1/4 inch

Small IV length

1 inch

IM deltoid volume

1 mL max

IM length

1-2 inches

Calculate the IV infusion rate using the following provider's order: 1000mL of NS over 8 Hours. Infusion set has a drop rate of 10 drops/mL. 1. 10 drops/minute 2. 41 drops/minute 3. 21 drops/minute 4. 30 drops/minute

21 drops/minute (1000ml/480minutes) x 10 drops/mL

SubQ angle

45 or 90 degrees

Intradermal angle

5-15 degrees

IM deltoid Length

5/8 - 1 inch

IM angle

90 degrees

IM deltoid angle

90 degrees

A patient is concerned about a medication the nurse is administering. The patient states that the medication is not normally something that is administered. What is the best response by the nurse? 1. I will hold the medication and find out for you 2. it is probably a generic medication for something you normally get 3. the provider has ordered it for you 4. we should probably update your medication reconciliation forms

I will hold the medication and find out for you

Mona's laboratory work indicates an elevated white blood cell count with a left shift in the differential. The nurse interprets this to mean which of the following? 1. a left shift in the differential means that there is no infection present 2. there is a high number of white blood cells, but not immature white blood cells, present in the circulation 3. there is a high number of white blood cells to fight the infection, and the red blood cells are compensating 4. there is a high number of white blood cells and immature white blood cells present to fight the infection

There is a high number of white blood cells and immature white blood cells present to fight the infection

A nurse rounding on a patient with pneumonia notices the patient is more confused than at the beginning of the shift. What is the best response by the nurse? 1. check oxygen saturation level 2. document findings in the medical record 3. notify the provider 4. ensure a sitter is available to watch the patient

check oxygen saturation level

The nurse is caring for an adolescent patient who appears withdrawn and isolated. What strategy should the nurse use to work with this patient? 1. Develop a therapeutic, trusting relationship with the patient. 2. talk to the patient's parents about what is going on with the patient 3. tell the patient what the patient needs to do in order to get better 4. leave the patient alone as much as possible

develop a therapeutic, trusting relationship with the patient

Considering Mr. Ahmed's diagnosis of dehydration and the possibility of neurological impairment, which nursing intervention is directed towards minimizing his risk for possible injury? 1. educating the patient on the use of a calibrated urinal 2. implementing fall precautions 3. administering ondansetron with a full glass of water 4. assessing for orthostatic hypertension daily

implementing fall precautions

A patient demonstrates correct use of the incentive spirometer when the patient places the mouthpiece in the mouth and does which of the following? 1. inhales quickly and forcefully 2. inhales slowly and deeply 3. exhales slowly and deeply 4. exhales quickly and forcefully

inhales slowly and deeply (Place mouthpiece into mouth and inhale slowly and deeply. Then hold the breath for 5 sec before exhaling)

Orange cap syringe for...

insulin, ALWAYS SQ

Mona asks the nurse why it is necessary to use the incentive spirometer when she is already having difficulty breathing. What is the best response by the nurse? 1. it is ordered by your provider 2. it increases the oxygen taken in by the lungs when you inhale 3. it helps prevent atelectasis or collapsing of the alveoli in the the lungs 4. it decreases cardiac workload during inspiration

it helps prevent atelectasis or collapsing of the alveoli in the lungs

During her hospitalization for pneumonia, the provider orders arterial blood gases for Mona. What is the best explanation for why this is ordered? 1. patient has shallow, ineffective breathing 2. patient has a history of smoking ½ pack of cigarettes per day 3. patient has fever and malaise 4. patient has a productive cough with rust colored sputum

patient has shallow, ineffective breathing

6 rights of medication

patient, dose, drug, route, time, and documentation

A nurse is caring for an 18-yr old patient who has recently started living on his own and has experienced a greater than 5% weight loss over two weeks. He has a low body mass index and complains of feeling fatigue. According to Maslow's hierarchy of needs, the nurse identifies which of the following as the patient's priority need at this time? 1. safety and security 2. physiologic 3. love and belonging 4. self-esteem

physiologic

Hypokalemia is confirmed by what serum blood result? 1. potassium 3.0 2. potassium 5.5 3. sodium 133 4. sodium 146

potassium 3.0

In preparation for calculating the infusion rate for a newly ordered intravenous (IV) solution, the nurse must first secure what information? 1. the infusion set's drop factor 2. patient's history of allergies 3. the status of the patient's IV site 4. when the IV is to be started

the infusion set's drop factor

The higher the gauge number....

the smaller the diameter of the needle

Reduced skin turgor is characteristically altered among which population 1. smokers 2. infants 3. older adults 4. premenstrual females

older adults

SQ sites: abdomen

-avoid 2 inch radius around umbilicus, 2 inches below ribs, and 2 inches above iliac crest

IM deltoid gauge

23-25

SQ sites: subscapular

below scapula

A nurse is preparing to admit a patient with cystic fibrosis and altered nutrition status. The nurse plans to implement with precautions to be used in the patient's care? 1. droplet 2. contact 3. standard 4. airborne

standard

Mixing Insulins

-45 or 90 degree angle injection -DON'T aspirate -inject slowly -cloudy last -if refrigerated, let it warm to room temp -determine compatibility of the meds -do not contaminate one med with another -ensure the final dose is accurate -maintain aseptic technique

IV Insertion technique

-Apply disposable gloves search for possible vein -place tourniquet 10-15 cm above insertion site -choose vein -clean insertion site using -proper technique and allow to dry completely -re-apply the tourniquet -stabilize the skin below or beside vein -insert the catheter with bevel up at 20-30 degree angle -observe for blood return through cannula. When seen, lower angle of cannula until almost flush with the skin -Advance cannula and stylet only ¼ inch. Then loosen stylet -advance catheter over stylet into vein until hub rests at puncture site. -stabilize catheter by holding hub -release the tourniquet -remove the stylet

SQ sites: posterior arm

-Find acromion process and olecranon -divide the length between processes into 3 equal lengths. -Find the middle ⅓ and slide hand to the posterior portion of the arm

IM site: deltoid

-Find acromion process, place 2-3 fingers below it -move other hand up from the olecranon processs until you feel resistance, where the deltoid attached to the humerus. -Find the middle of the triangle you made with your 2 hands

SQ sites: anterior thigh

-Find greater trochanter and patella. -Divide the length of space between trochanter and patella in 3 equal lengths. -Find the middle ⅓ and find the middle of that area.

What two insulin's CANNOT be mixed with others?

-Lantus (long acting insulin) -NPH

Review Heparin Administration

-WATCH THE DOSE -Use the higher dose because it's a smaller amount and will not intimidate patient as much -pick correct syringe size

Hypertonic Solution

-a solution of higher osmotic pressure- pulls fluid from cells causing them to shrink -EX: 3% NACL

Identify the following potential problems or actual problems that the nurse should include when planning care for the patient diagnosed with pneumonia? (select all that apply) 1. acute pain 2. not able to tolerate activity 3. metabolic acidosis 4. difficulty breathing 5. ineffective respiratory gas exchange

-acute pain -not able to tolerate activity -difficulty breathing -ineffective respiratory gas exchange

What information should be included when documenting a change in the infusion rate of an IV solution? (select all that apply) 1. change made to flow rate 2. date and time change was made 3. patient's response to IV therapy 4. nurse's initials 5. original flow rate

-change made to flow rate -date and time change was made -patient's response to IV therapy -nurse's intials

Proper Technique for SQ and IM injections

-choose carefully the right vial when given a choice -choose carefully the right syringe -choose carefully the right needle -6 rights of medication -Minimize discomfort -Use proper technique -Position client comfortably -Select proper site -Divert client's attention -Insert the needle quickly and smoothly -Hold the syringe steady -Inject the medication slowly and steadily -Do NOT hold your finger or thumb over plunger while inserting

A patient with a low body mass index is found to have low albumin and prealbumin levels. Which of the following nursing actions should be considered? (select all that apply) 1. encourage oral intake of foods and fluids as ordered 2. monitor input and output for the patient 3. request nutrition consult 4. assess for signs and symptoms of infection 5. assess gastrointestinal function

-encourage oral intakes of foods and fluids as ordered -monitor input and output for the patient -request nutrition consult -assess gastrointestinal funciton

IM site: rectus femoris

-find greater trochanter and patella -divide the length of space between trochanter and patella in 3 equal lengths -find the middle 1/3 and find the middle of that area

A nurse is creating a care plan for a young adult patient with a chronic illness. Which of the following nursing diagnoses might be included in the care plan? (select all that apply) 1. ineffective health maintenance 2. activity intolerance 3. Risk-prone health behavior 4. caregiver role strain 5. social isolation

-ineffective health maintenance -activity intolerance -social isolation -Risk-prone health behavior

IM site: vastus lateralis

-patient side lying -find greater trochanter and patella -dive the length of space between trochanter and patella in 3 equal lengths -find the middle 1/3 and the middle of that area

IM site: ventrogluteal

-patient side lying -place palm on greater trochanter with thumb pointing toward groin -index finger should brush the anterior superior iliac spine and the other 3 fingers follow the curve of the posterior superior iliac spine

The nurse titrates the patient's oxygen to 3L per nasal cannula in order to maintain an oxygen saturation of at least 94%, per provider's orders. What is the rationale for this order? (select all that applies) 1. promotes a decrease in respiratory effort 2. allows the body to meet metabolic demands 3. prevents atelectasis in a patient with pneumonia 4. promotes a decrease in myocardial workload 5. Allows the patient to receive 100% oxygen

-promotes a decrease in respiratory effort -allows the body to meet metabolic demands -promotes a decrease in myocardial workload

Mona's blood gas results indicate respiratory acidosis. Her oxygen saturation is 95% per the pulse oximeter. Which intervention should the nurse provide? (select all that apply) 1. provide supplemental oxygen as ordered 2. ensure the patient is well hydrated 3. none; the patient has 95% oxygenation 4. promote voluntary coughing activities to clear secretions 5. assist the patient with adequate ventilation

-provide supplemental oxygen as ordered -ensure the patient is well hydrated -promote voluntary coughing activities to clear secretions -assist the patient with adequate ventilation

Isotonic solution

-same osmolarity as blood plasma expands body and fluid without causing a fluid shift from one compartment to another -EX: 0.9 NS

Preventing needle sticks

-sharps disposal -one handed recapping technique (when preparing medication ONLY) -NEVER EVER recap a needle that you have just used to give your patient an injeciton

Intradermal injections

-skin testing -great for TB testing -formation of a small bleb

SQ sites: Flanks (love handles)

-stand behind patient and place hands on hips -flip hands so the four fingers point towards buttocks.

Expected assessment findings of a patient with pneumonia may include which of the following (select all that apply) 1. tachypnea 2. use of accessory muscles 3. enuresis 4. malaise 5. fever

-tachypnea -use of accessory muscles -malaise -fever

The nurse is preparing to discharge Mona from the hospital. Which of the following instructions should the nurse include in the discharge education? (select all that apply) 1. use the incentive spirometer every one to two hours to move secretions out of your lungs 2. stop taking your antibiotics once you are feeling better 3. continue to focus on ambulating several times per day 4. quitting smoking will improve your recovery 5. take your antibiotics as directed, even if you are feeling better

-use the incentive spirometer every one to two hours to move secretions out of your lungs -continue to focus on ambulating several times per day -quitting smoking will improve your recovery -take your antibiotics as directed, even if you are feeling better

Intradermal gauge

26-28

SubQ guage

26-30

IM volume

3 mL max

What pathology is responsible for metabolic acidosis 1. an increase of CO2 2. an excess of HCO3 and/or a decrease in H ions 3. a decrease of carbonic acid 4. a decrease in bicarbonate or an increase in hydrogen icons

a decrease in bicarbonate or an increase in hydrogen ions

What is the initial step in assessing a patient for orthostatic hypotension 1. encourage the patient to drink eight ounces of fluid, then take and record blood pressure and pulse 2. assist patient into a standing position lasting two to three minutes, then take and record blood pressure and pulse 3. after having the patient sit upright with legs dangling for one to three minutes, take and record blood pressure 4. after having the patient lie in supine position for three to 10 minutes, take and record blood pressure and pulse

after having the patient lie in supine position for three to 10 minutes, take and record blood pressure and pulse

Which diagnostic test serves as the basis for determining acid-base imbalances 1. serum potassium 2. blood urea nitrogen 3. arterial blood gas 4. specific gravity of urine

arterial blood gas

Upon entering the room, the nurse observes Mona slumped over in a semi-Fowler's position, struggling to catch her breath. What is the priority nursing action at this time? 1. obtain an oxygen saturation level 2. assist the patient into a high Fowler's position 3. Titrate her oxygen so that her oxygen is greater than or equal to 95% 4. Obtain vital signs

assist the patient into a high Fowler's position

A nurse is planning on administering a tube feeding to a patient with a nasogastric tube. The patient appears asleep flat in bed. What should the nurse do first? 1. administer the feeding quietly without waking the patient 2. carefully connect the nasogastric tube to the tube feeding 3. flush the nasogastric tube with 30-60 ml of water 4. assist the patient to a semi-Fowler's position or higher.

assist the patient to a semi-Fowler's position or higher

A nurse has just finished placing a nasogastric tube into a patient for the purpose of administering feedings. What should the nurse do first? 1. irrigate the nasogastric tube with 30-60 mL of water 2. administer the tube feeding as ordered 3. assess how much of the tube was inserted into the ient to verify placement 4. confirm the placement of the nasogastric tube per facility policy

confirm the placement of the NG tube per facility policy

A nurse is assessing a patient with cystic fibrosis. Based on a diagnosis of cystic fibrosis, the nurse expect to find which of the following common physical systems upon assessment 1. shortness of breath, headache, and vision changes 2. nausea, vomiting and hyperreflexia 3. cyanosis or pallor, dyspnea and arrhythmias 4. increased activity, diaphoresis and tachycardia

cyanosis or pallor, dyspnea and arrhythmias

A provider orders a high-fat, high-protein, high-carb diet for a patient with cystic fibrosis. What is the best rationale for this diet order? 1. Cystic fibrosis interferes with the digestion of food and absorption of nutrients 2. thickened mucus secretions predispose the patient to anemia 3. the diet was ordered according to the patient's preferred food intake 4. cystic fibrosis is a chronic disease characterized by altered electrolytes

cystic fibrosis interferes with the digestion of food and absorption of nutrients

A patient complains of nausea after a tube feeding. What is the priority action of the nurse at this time? 1. Position the patient on left side 2. ensure the head of the bed remains elevated 3. aspirate the tube feeding contents from the patient's stomach 4. flush the tube with 30 to 60 mL water

ensure the head of the bed remains elevated

Mona complains of shortness of breath with activity and does not want to exacerbate her condition by moving to the chair or ambulating three times a day as ordered. How should the nurse respond? 1. even short activities such as moving to the chair will help you cough mucus out of your lungs 2. you should wait until your breathing improves to try to get out of bed again, because it makes you short of breath 3. You really need to walk as much as possible in order to prevent your pneumonia from getting worse 4. pneumonia causes thick secretions in your lungs, making it difficult to breath

even short activities such as moving to the chair will help you cough mucus out of your lungs

A nurse is planning patient education about a prescribed medication for a patient. What should the nurse do first? 1. educate the patient about potential allergic reactions to the med 2. review the signs and symptoms of drug toxicity with the patient 3. find out what the patient already knows about the med 4. educate the patient about potential drug interactions

find out what the patient already knows about the med

A patient with newly diagnosed pneumonia has an oxygen saturation of 94% on room air, an increased respiratory rate, and an increased pulse. The patient is pale and anxious. The nurse questions the oxygen saturation results and looks up which of the following test results? 1. white blood cell count 2. chest x-ray 3. hemoglobin 4. gram stain

hemoglobin (a pulse oximeter measures the oxygen saturation of hemoglobin. A pts hemoglobin may be adequately saturated with oxygen, but if they have low hemoglobin, they might not have enough oxygen to meet demands).

A patient which cystic fibrosis has five capsules of pancrelipase (amylase, lipase and protease) ordered to be administered now with his breakfast. The patient is currently experiencing nausea and intermittent vomiting. What should the nurse do with the medication 1. crush the medication to administer to patient 2. administer the medication as ordered 3. hold the medication until the patient is able to eat again 4. call the provider immediately

hold the medication until the patient is able to eat again

Which statement by Mr. Ahmed best reflects his ability to assume some responsibility in tracking his urinary output? 1. i will always use the calibrated urinal to measure my urine 2. i listened as you discussed the instructions about the calibrated urinal 3. i will notify staff when I need to use the calibrated urinal 4. i understand that it's important to measure my urine with the calibrated urinal

i will always use the calibrated urinal to measure my urine

What information will the nurse provide to a patient to best assure minimizing the risk of side effects associated with sulfamethoxazole-trimethoprim therapy? 1. arrange for a yearly flu vaccination 2. increase dietary consumption of dairy products 3. notify health care provider immediately if experiencing palpitations 4. increase fluid intake in order to remain well hydrated.

increase fluid intake in order to remain well hydrated

Gray cap syringe for....

intradermal or small SQ injections

A nurse is teaching a patient with cystic fibrosis about nutrition in the high-fat, high-protein, high-carbohydrate diet that has been recommended. Which of the following should be included in this education? 1. it is not necessary to monitor dietary intake 2. it is important to focus on eating calorie-dense foods 3. it is important to select a variety of nutrient-dense foods 4. it is important to only eat high-fat, high-protein, high-carb foods

it is important to select a variety of nutrient-dense foods

While completing discharge instructions with a patient, the nurse notices the patient is short of breath. What is the priority nursing action at this time? 1. determine if the patient has any questions 2. reassure the patient 3. listen to the patient's lungs 4. ask if the patient has support at home

listen to the patient's lung

Christopher has a low body mass index and has lost 12 pounds over the past two weeks. Which method could the nurse use to assess his overall dietary intake in order to provide nutrition education? 1. ask the patient if he has a healthy diet 2. track the percentage of food eaten at each meal while in the hospital 3. ask the patient to keep a food diary log 4. obtain a food frequency assessment

obtain a food frequency assessment

Which physical finding poses the greatest safety risk for a patient diagnosed with hyponatremia? 1. dry mucous membranes 2. anxiety 3. cold, clammy skin 4. orthostatic hypotension

orthostatic hypotension

A patient in semi-Flower's position is having difficulty breathing. What is the priority action of the nurse? 1. auscultate the lungs 2. conduct a pain assessment 3. raise the head of the bed 4. call respiratory therapy

raise the head of the bed

In addition to regular monitoring of serum potassium level, which intervention will the nurse implement to address the safety needs of a patient prescribed intravenous potassium chloride 1. deliver the medication by slow IV push 2. shading windows to minimize sun exposure 3. screening electrocardiograms (ECG) regularly 4. monitor for hyperactivity

screening ECG regurlary

The nurse must take into consideration of _____ of _____ when choosing the needle for IM injections

size, patient

Hyponatremia is associated with a decrease of which electrolyte: 1. chloride 2. phosphorus 3. potassium 4. sodium

sodium

Which of Mr. Ahmed's lab results best supports his diagnosis of dehydration 1. sodium 130 2. creatinine 1.1 3. hemoglobin 16.7 4. white blood cells 21x109

sodium 130

Which statement concerning fluid balance demonstrates a need for additional instruction concerning fluid intake and output? 1. a desirable amount of fluid intake and output in adults ranges from 1500 to 3500 mL daily 2. the balance between fluid intake and output must be achieved each day to maintain homeostasis 3. fluid output is comprised of feces, sweat and exhaled air 4. it is recommended that a healthy adult consume 1.5 quarts of water daily

the balance between fluid intake and output must be achieved each day to maintain homeostasis (the balance between fluid intake and output may not occur daily but should occur every two to three days)

A patient states he does not want to use the incentive spirometer because it makes the patient cough up too much sputum, and it is difficult to breathe. What is the correct information to teach the patient about the incentive spirometer? 1. the incentive spirometer helps you to maximize lung function and minimize the risk of atelectasis 2. You have to use your incentive spirometer because your provider has ordered it for you. 3. The incentive spirometer will cause you to cough less because you are moving more air through your lungs 4. You should wait to use your incentive spirometer until you are not coughing up so much sputum

the incentive spirometer helps you to maximize lung function and minimize the risk of atelectasis (partial or complete collapsed lung) Patient should use incentive spirometer regularly to maximize lung function through alveolar inflation, preventing complications of atelectasis. The the spirometer will likely cause patient to cough up sputum because patient is breathing deeply, but it will not decrease the amount of sputum.

What determines the acidity of a substance like body fluids? 1. the number of existing H ions 2. the fluid's pH measurement 3. the amount of available HCO3 4. the body's ability to trigger chemical reactions

the number of existing H ions

The nurse plans on assessing the patient's gastrointestinal system. Which statement below reflects the best prioritization of this assessment 1. the nurse should palpate and then auscultate the abdomen 2. the nurse should percuss and then auscultate the abdomen 3. the nurse should percuss and then inspect the abdomen 4. the nurse should auscultate and then palpate the abdomen

the nurse should auscultate and then palpate the abdomen

Which statement by the nurse indicates a need for further education on the role of water as a body fluid? 1. tissue lubrication is facilitated by water 2. water is transported to cells when it is attached to electrolytes 3. waste products are removed from the cell by water 4. water helps maintain normal body temperature

water is transported to cells when it is attached to electrolytes

A nurse is assessing an adolescent patient. Which of the following questions best represents therapeutic communication techniques? 1. what do you hope happens here today 2. you don't smoke, do you 3. do you know what to do to stay healthy 4. are you feeling well

what do you hope happens here today

Which statement concerning the measure of intake and output is true? 1. liquid medications are not considered when calculating intake 2. health care agencies have adopted standard volumes fro common beverage containers 3. when possible, intake and output should be measured rather than estimated 4. only foods that are consumed as liquid are included in the intake calculations

when possible, intake and output should be measured rather than estimated

As the nurse administer Mona's prescribed medication, guaifenesin, the patient states: "I don't like this medication. It makes me cough too much." How should the nurse respond? 1. I will let your provider know you have questions about your medications 2. This medication is given to you because of your pneumonia 3. When you cough out secretions, oxygenation is more effective 4. This medication will help make your breathing easier

when you cough out secretions, oxygenation is more effective

A patient has just completed a tube feeding that has run throughout the night. What is the best education the nurse can provide to the patient at this time? 1. It is important that you ambulate three times a day 2. you should remain upright for the next hour 3. you should lie down to get some sleep 4. you should wear your pneumatic compression device when you are in bed

you should remain upright for the next hour

Z-Track technique

-Form of IM injection -Displace the SubQ tissue -pull all the skin off to the side -GREAT for iron

Large IV lenth

1.88 inch

SubQ Length

1/2 - 5/8 inch

Intradermal length

1/2 inch

Large IV gauge

14

Medium IV gauge

20

IM gauge

21-23

Small IV gauge

22