Exam 4 Evolve questions (partial)

Remove the transparent dressing or tape and gauze in the direction of catheter insertion

How can the nurse minimize the risk of dislodging the catheter when removing a dressing? A. Lower the patient's head during the dressing change. B. Remove the transparent dressing or tape and gauze in the direction of catheter insertion. C. Apply skin protectant while the stabilization device is off. D. Cleanse the insertion site quickly and gently in concentric circles

Check the gastric residual volume

How could the nurse assess the patency of a nasogastric (NG) tube being used for enteral nutrition? A. Elevate the head of the patient's bed to at least 30 degrees. B. Use an intravenous fluid infusion set. C. Check the gastric residual volume. D. Monitor the amount of intake the patient tolerates in an 8-hour period.

Disinfecting the IV needleless connector and the end of the IV tubing

After drawing blood from a peripherally inserted central catheter (PICC), which action would minimize the patient's risk for infection when reconnecting prescribed intravenous fluids? A. Wearing clean gloves B. Changing the IV tubing C. Disinfecting the IV needleless connector and the end of the IV tubing D. Aspirating for blood return before flushing the catheter

Obtain a product designed to unclog NG tubes

After unsuccessfully attempting to flush a nasogastric (NG) tube with water, what is the most appropriate action for the nurse to take? A. Flush the tube with ginger ale. B. Use apple juice to flush the tube. C. Obtain a product designed to unclog NG tubes. D. Force-flush the system with sterile normal saline.

Flush the catheter with preservative-free 0.9% sodium chloride, per agency policy.

After drawing blood from a patient's peripherally inserted central catheter (PICC), what would the nurse do to ensure that the device resumes proper functioning? A. Discard the initial 6 mL of aspirated blood. B. Apply an antiseptic to the injection cap. C. Wear clean treatment gloves during the procedure. D. Flush the catheter with preservative-free 0.9% sodium chloride, per agency policy.

Central parenteral nutrition

A nurse is teaching a new nurse about midline catheters. The new nurse is asked about which intravenous infusions can be administrated through a midline catheter. Which of the following responses would indicate the new nurse needs more teaching? A. Long-term antibiotic therapy B. Red blood cells C. Central parenteral nutrition D. Fresh frozen plasma

Do not disrupt the dressing on the midline catheter

A nurse is educating a patient with a new midline catheter. Which of the following teaching points should the nurse emphasize? A. Close the clamp on the catheter when getting out of bed B. Keep the affected arm straight at all times C. Expect pain at the catheter exit site D. Do not disrupt the dressing on the midline catheter

After removing the syringe (When using a neutral displacement valve, the catheter can be clamped either before or after removing the syringe as the sequence does not matter. A catheter should never be left unclamped when not in use.)

A nurse is flushing and locking a midline catheter through a positive displacement valve needleless access device. When should the nurse clamp the catheter? A. Before removing the syringe B. After removing the syringe C. Before or after removing the syringe D. Never, because the catheter does not need to be clamped

A gauze dressing placed over catheter exit site (A transparent dressing may not properly adhere to the skin and is not indicated for this patient. Antibacterial ointment is no longer routinely used for intravenous dressing changes because it has been found to be of no benefit to the patient.)

A nurse is preparing for a midline dressing change with a patient who is extremely diaphoretic. Which of the following dressings is most appropriate for this patient? A. A gauze dressing placed over catheter exit site B. A transparent dressing applied over catheter exit site C. A transparent dressing placed over the gauze dressing at the catheter exit site D. Antibacterial ointment applied at the exit site and covered with a gauze dressing

Check the catheter for pinholes and tears.

How would the nurse assess a patient's central venous access device (CVAD) for damage or breakage? A. Assess the patient's neck veins for distention. B. Palpate the patient's arm. C. Check the catheter for pinholes and tears. D. Palpate the area around the insertion site.

Palpate the skin for coiling (Blood return is checked to assess for an occlusion. Gurgling sounds could indicate catheter migration or pinch-off syndrome. Catheter dislodgement is not associated with pain at the insertion site)

The nurse is concerned that a patient's central venous access device (CVAD) may have become dislodged. How might the nurse assess for this complication? A. Check for blood return. B. Palpate the skin for coiling. C. Listen for gurgling sounds. D. Assess for pain at the site.

Review the medications the patient is currently taking

What is the initial step in preparing to perform a gastric occult blood test for a patient with recurrent vomiting? A. Determine the patient's ability to help obtain the specimen. B. Gather a Gastroccult slide and developing solution. C. Review the medications the patient is currently taking. D. Perform hand hygiene, and apply treatment gloves.

Change the dressing every 48 hours (It is not necessary to wear sterile gloves to remove the soiled dressing)

What is the most important way in which the nurse can reduce the risk for infection in a patient with a CVAD that has a gauze dressing? A. Change the dressing every 48 hours. B. Apply sterile gloves to remove the original dressing. C. Cleanse the catheter and insertion site with sterile saline. D. Label the dressing with the date and time of application and the nurse's initials.

Plan to check the feeding for completion within the next 3 hours. (Recalculating the present drip factor for accuracy does not address the issue of time needed to infuse the feeding)

What is the proper response to the nurse's observation that the patient's closed-system enteral feeding has 150 mL of formula remaining and that the infusion order rate is for 50 mL/hr? A. Recalculate the present drip factor for accuracy. B. Terminate the fluid, and prepare to hang a new bag of formula. C. Plan to check the feeding for completion within the next 3 hours. D. Check with the pharmacy to see if the formula has been hanging too long.

Examine each naris for patency and skin breakdown

What might the nurse do to reduce the patient's discomfort before inserting a nasogastric tube? A. Examine each naris for patency and skin breakdown. B. Place the patient in the high-Fowler's position. C. Anesthetize the throat. D. Have the patient take a few sips of water.

Remove the catheter stabilization device, if present (the site is only cleaned after the stabilization device is removed)

What will the nurse do after removing the soiled dressing from a patient's CVAD device? A. Cleanse the site with soap and water. B. Use 2% chlorhexidine swabs to cleanse the site. C. Apply a skin protectant. D. Remove the catheter stabilization device, if present.

Check NG tube placement

What would the nurse do before providing the patient with a scheduled intermittent feeding through a nasogastric (NG) tube? A. Listen to bowel sounds. B. Listen to lung sounds. C. Check NG tube placement. D. Turn the patient onto his or her left side.

Withdraw the tube to the nasopharynx. (If the patient starts to cough, experiences a drop in oxygen saturation, or shows other signs of respiratory distress, withdraw the tube into the posterior nasopharynx until normal breathing resumes.)

What would the nurse do if he or she encountered resistance when inserting a nasogastric tube? A. Ask the patient to cough. B. Withdraw the tube to the nasopharynx. C. Encourage the patient to swallow. D. Instruct the patient to hyperextend the neck.

Notify the physician that the attempts were unsuccessful.

What would the nurse do if he or she were not able to insert a nasogastric tube in either of a patient's nares? A. Ask another nurse to attempt the insertion. B. Document the attempts in the patient's medical record. C. Notify the physician that the attempts were unsuccessful. D. Allow the patient to rest for 30 minutes before resuming the process.

Notify the health care provider (this indicates bleeding)

What would the nurse do if material aspirated from a patient's nasogastric tube resembled coffee grounds in color and texture? A. Check the tube placement. B. Assess the pH of the contents. C. Notify the health care provider. D. Irrigate the tube with water.

Purified water

What would the nurse use to irrigate a patient's nasogastric tube after providing medications? A. Coffee B. Purified water C. Tea D. Apple juice

Patient's oral temperature gradually increases

When caring for a patient who has a CVAD, which sign may indicate infection at the insertion site? A. Occlusion alarm sounds on infusion pump B. Patient's oral temperature gradually increases C. Patient's neck veins become distended D. The nurse cannot achieve blood return

Notify the practitioner (these are signs of infection)

When changing a midline dressing, the nurse notices redness, swelling, and drainage at the catheter exit site. Which of the following actions should the nurse take next? A. Notify the practitioner B. Discontinue the catheter and start a peripheral IV line C. Flush each catheter lumen with 10 ml of normal saline followed by an antibiotic flush solution D. Swab the site with antiseptic solution, apply povidone-iodine ointment, and apply a gauze dressing

Anticipate a chest x-ray

When checking gastric aspirate from an NG tube, the nurse assesses a pH of 7. What would the nurse do next? A. Nothing, since this is an expected pH value B. Advance the tube C. Anticipate a chest x-ray D. Pull back on the tube

Use a 10-mL syringe for the flush.

When drawing blood from a patient's peripherally inserted central catheter (PICC), what can the nurse do to minimize pressure on the device during flushing? A. Clamp the device. B. Use a 3-mL syringe for the flush. C. Use a 10-mL syringe for the flush. D. Cleanse the catheter hub with an alcohol swab.

The longest

When drawing blood from a peripherally inserted central catheter (PICC) in which all ports are patent, it is recommended that the nurse select which lumen? A. The shortest B. The longest C. The proximal port D. The largest

Discard the first 6 to 9 mL of blood drawn (Discarding the first sample reduces the risk of drug concentrations or a diluted specimen.Flushing the catheter after aspirating for blood return would have no effect on the quality of the sample)

Which action can the nurse take to ensure a quality blood sample when drawing blood from a patient's peripherally inserted central catheter (PICC) site? A. Allow fluid infusions to continue to flow right up to the time of the sample. B. Flush the catheter after aspirating for blood return. C. Ensure that the patient has been resting quietly for at least 15 minutes before taking the sample. D. Discard the first 6 to 9 mL of blood drawn.

Use sterile technique throughout the process.

Which action would the nurse take to minimize the patient's risk for infection when changing the dressing on a CVAD? A. Use sterile technique throughout the process. B. Apply a stabilization device if the initial sutures are no longer intact. C. Apply a mask to the patient during the procedure. D. Change the transparent dressing every 48 hours.

"Let me know immediately if the patient's dressing becomes damp."

Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a CVAD? A. "Assess the site frequently for signs of inflammation." B. "Be sure to change the transparent dressing on the site once every 7 days." C. "Let me know immediately if the patient's dressing becomes damp." D. "Make sure the patient knows to notify me if the site is painful or swollen."

"Tell me if you see any vomit in the patient's mouth during oral care."

Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a nasogastric (NG) tube? A. "Remember to aspirate 5 mL to 10 mL of stomach contents before flushing the tube." B. "Let me know if the patient complains of anything related to the NG tube's placement." C. "Tell me if you see any vomit in the patient's mouth during oral care." D. "Please see if the NG tubing has advanced at all."

Positioning the patient in a high-Fowler's position

Which intervention might the nurse delegate to nursing assistive personnel (NAP) when inserting a nasogastric tube? A. Positioning the patient in a high-Fowler's position B. Assessing the patient's abdomen for bowel sounds C. Determining any history of unexplained nosebleeds D. Educating the patient about the need for the intervention

Ensuring appropriate hand hygiene before and after testing

Which nursing action addresses the risk for infection related to gastric occult blood testing? A. Maintaining aseptic technique while handling the Gastroccult slide B. Performing the test in the patient's bathroom C. Assessing the patient's history of previous gastrointestinal (GI) bleeding D. Ensuring appropriate hand hygiene before and after testing

Return it to the stomach via the feeding tube (If the volume of the residual stomach contents is less than 250 mL, it can be returned to the stomach via the feeding tube.)

Which nursing action is appropriate when feeding gastric residual is 50 mL? A. Return it to the stomach via the feeding tube. B. Dispose of the residual contents down the commode. C. Discard the stomach contents as a liquid biohazard. D. Return half of the volume to the stomach, and discard the rest.

A 28-year-old patient who fractured a femur after heavy drinking

Which patient does not have a medical condition that contraindicates placement of a nasogastric tube? A. A 28-year-old patient who fractured a femur after heavy drinking. B. A 73-year-old patient who is on anticoagulation therapy. C. A 54-year-old patient who broke a cheekbone in a fall. D. A 67-year-old patient with a history of unexplained nosebleeds.

"If the test sample turns blue, it is positive for blood." (Noting the sample turned green after about 60 seconds indicates correct interpretation of a negative result, not a positive result)

Which statement best illustrates correct interpretation of a positive gastric occult blood test? A. "We don't need to retest the patient right now, because the sample turned green after about 60 seconds." B. "If the test sample turns blue, it is positive for blood." C. "The monitor area needs to turn blue within 30 seconds." D. "Because it was positive, I notified the patient's physician."

"The next time the patient vomits, please test it for occult blood."

Which statement best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) in carrying out a gastric occult blood test for a patient with a low hemoglobin and hematocrit? A. "Have you used the new Gastroccult testing system?" B. "The next time the patient vomits, please test it for occult blood." C. "Is the patient capable of assisting with the specimen collection?" D. "Remember to tell me the results of the test immediately."

"Let me know immediately if the patient's dressing becomes damp."

Which statement might the nurse make to nursing assistive personnel (NAP) when caring for a patient with a dressed central venous access device (CVAD) site? A. "Assess the site frequently for signs of inflammation." B. "Be sure to change the transparent dressing on the site once every 7 days." C. "Let me know immediately if the patient's dressing becomes damp." D. "Make sure the patient knows to notify me if the site becomes painful or swollen."

Subcutaneous emphysema (this is a manifestation of pneumothorax, hemothorax, air embolism, or hydrothorax. A crackling or popping sound does not indicate catheter occlusion and is not associated with infection or with skin erosion)

While palpating the skin around a patient's CVAD insertion site, the nurse elicits a crackling sound. What might this finding indicate? A. Catheter occlusion B. Infection C. Skin erosion D. Subcutaneous emphysema

Elevating the head of the bed reduces the risk for aspiration

Why does the nurse elevate the head of the bed to 30 degrees for a patient receiving an intermittent tube feeding? A. Elevating the head of the bed reduces the risk for aspiration. B. Proper elevation of the head of the bed promotes the patient's digestion. C. Acid reflux is reduced when the head of the bed is elevated at least 30 degrees. D. Nutrients are absorbed more efficiently when the head of the bed is elevated.

This skill may be delegated if performed on vomited stomach contents

Why might the nurse delegate to nursing assistive personnel (NAP) the skill of performing a gastric occult blood test for a patient who has vomited? A. The task is easy to demonstrate to NAP. B. The likelihood of a positive result is minimal. C. This skill may be delegated if performed on vomited stomach contents. D. The agency trains NAP to perform only NG tube testing.