MCAII TTLs

When looking for a well-dilated vein in which to insert an IV catheter, the nurse keeps the extremity in a dependent position and applies heat. What is another technique that the nurse might use? A. Stroke the extremity from distal to proximal below the proposed venipuncture site. B. Stroke the extremity from proximal to distal below the proposed venipuncture site. C. Elevate the arm on pillows for several minutes before attempting insertion. D. Apply a second tourniquet below the anticipated site to isolate the targeted vein.

A. Stroke the extremity from distal to proximal below the proposed venipuncture site. Stroking the extremity from distal to proximal below the proposed venipuncture site promotes venous filling. Stroking the extremity from proximal to distal, elevating the arm, and applying a second tourniquet all have the reverse effect.

After placing an IV catheter in a patient's forearm, the nurse should take which action to secure it in place? A. Tape all edges of a 2 × 2-inch sterile gauze pad. B. Place a piece of tape securely over the insertion site. C. Wrap gauze over the insertion site and around the entire arm. D. Place a piece of tape across the transparent dressing to keep it in place.

A. Tape all edges of a 2 × 2-inch sterile gauze pad. If using a gauze dressing, the nurse should tape all edges to minimize IV site contamination. Tape should never be placed on the insertion site because it may introduce contaminants and prevents easy observation of the site. Wrapping gauze around the arm may prevent observation of the insertion site and cause constriction. Tape on top of a transparent dressing prevents moisture from being carried away from the skin.

The nurse is preparing to connect an administration set to the needleless connector of an existing extension set on a peripheral catheter. Before connecting or reconnecting any device or infusion, what action should the nurse take? A. Trace the tubing or catheter from the patient to the point of origin. B. Set the flow rate for the solution as prescribed. C. Check vital signs immediately per the organization's practice. D. Unclamp the catheter lumen.

A. Trace the tubing or catheter from the patient to the point of origin. Rationale: To avoid the chance of a misconnection, the nurse should first trace the tubing or catheter from the patient to the point of origin. After tracing the tubing or catheter, the nurse should set the flow rate for the solution on the pump as prescribed and unclamp the catheter lumen. Vital signs should be checked before administration of certain solutions, particularly blood products.

A patient is receiving a propofol infusion for sedation. How often should the nurse change the IV tubing? A. Every 4 to 8 hours B. Every 6 to 12 hours C. Every 12 to 24 hours D. Every 48 to 96 hours

B. Every 6 to 12 hours Rationale: Propofol infusions should be changed every 6 to 12 hours. Lipid infusions should be changed every 12 hours as they can promote bacterial growth. Blood tubing should be changed every 4 hours. Intermittent infusion tubing should be changed every 24 hours, while continuous infusion tubing only needs to be changed every 96 hours.

A preceptor is teaching an orientee about NPPV and its potential complications. Which condition is a complication of NPPV? A. Nasal trauma B. Excessive secretions C. Abdominal distention D. Impaired swallow reflex

C. Abdominal distention Rationale: Abdominal distention secondary to gastric insufflation is a complication of NPPV that can result in aspiration. Nasal trauma is not a complication of NPPV; however, pressure injury to the nose can occur. Excessive secretions and an impaired swallow reflex are contraindications to NPPV, not complications of NPPV.

The nurse is preparing to use a secondary administration set that was hung 12 hours earlier and notices the tubing does not have a cap on the end of it. Which action should the nurse take next? A. Continue with the preparation of the IV administration set. B. Put a sterile cap on the end of the tubing. C. Discard the IV tubing and prepare another set. D. Clean off the end of the IV tubing with alcohol to continue using it.

C. Discard the IV tubing and prepare another set. If the end of the secondary administration set does not have a cap on the end of it, it is considered contaminated and a new IV tubing set is required to prevent infection. Putting a sterile cap on the end or continuing with the same IV set may lead to infection and sepsis. Time is not a major factor in contamination. Cleaning off the end of the administration set with alcohol would not be sufficient to destroy potential pathogens on the end of the tubing.

A nurse is about to obtain blood from a patient. How should the nurse insert the needle to prevent possible damage to the vein? A. Insert the needle at a 10-degree angle with the bevel facing up. B. Grasp the needle loosely and insert it quickly into the vein. C. Insert the needle at a 30-degree angle with the bevel facing up. D. Insert the needle at a 30-degree angle with the bevel facing down.

C. Insert the needle at a 30-degree angle with the bevel facing up. Rationale: To prevent damage to the vein, the needle should be inserted slowly into the vein at a 30-degree angle with the bevel facing up. If the needle was inserted with the bevel facing down, it is more likely that blood return would be impaired and the needle would be inserted through the vein. If the needle was inserted at 10 degrees, the needle would probably miss the vein because the needle is too shallow. The needle should be grasped firmly and inserted slowly into the vein.

During rapid resuscitation of a trauma patient, the blood filter has become clogged. What is the most appropriate intervention? A. Squeeze the filter. B. Use a rapid infuser. C. Flush the IV line with normal saline. D. Change the entire tubing.

D. Change the entire tubing. Rationale: A clogged filter must be changed to facilitate effective blood transfusion. Squeezing the filter and flushing the IV line do not help unclog the filter. A rapid infuser may be used to transfuse blood but does not help when a filter is clogged.

The patient has a history of heparin-induced thrombocytopenia (HIT). Which is the preferred solution to lock the PICC after blood sampling? A. 5% dextrose in water (D5W) B. Heparin locking solution C. Bacteriostatic saline D. Normal saline

D. Normal saline Rationale: If heparin-induced thrombocytopenia is suspected, do not use heparin. Normal saline is the preferred locking solution. Use 5% dextrose in water (D5W) as a flush solution if a medication that is incompatible with normal saline has been infusing in the port. Bacteriostatic saline (0.9% sodium chloride with benzyl alcohol) may be used as a flush solution, however, do not administer more than 30 ml of bacteriostatic saline to adults within a 24-hour period because of the alcohol content.

A patient is being started on NPPV therapy. Which outcome would indicate the patient is tolerating the therapy? A. Hypercarbia B. Claustrophobia C. Patient-ventilator asynchrony D. Reduced work of breathing

D. Reduced work of breathing Rationale: If the patient is tolerating the procedure, the patient should exhibit a reduction in the work of breathing. The presence of hypercarbia, claustrophobia, and patient-ventilator asynchrony would indicate that the patient is having some difficulty tolerating the NPPV therapy.

2. A patient who is comatose but not intubated, requires frequent oral suctioning. After suctioning, in which position should the patient be placed? A. Fowler position B. Prone position C. Semi-Fowler position D. Sims position

D. Sims position Rationale: The Sims position encourages drainage and should be used after suctioning if the patient has a decreased level of consciousness. The prone position places pressure on the patient's thorax, thereby restricting his or her ability to breathe effectively. The semi-Fowler and Fowler positions both place the patient at risk for aspiration.

While receiving tracheostomy care, the patient's oxygen saturation drops to 87%. What action should be the nurse's next intervention? A. Administering 100% oxygen to the patient B. Calling the practitioner immediately C. Suctioning the tracheostomy tube with high negative pressure D. Removing the tracheostomy tube and replacing it with a new one

A. Administering 100% oxygen to the patient Rationale: When the patient's oxygen saturation level drops during tracheostomy care, the nurse should administer 100% oxygen the patient to increase the oxygen saturation level. The practitioner does not need to be called as the first action, but may need to be notified if the saturation does not improve. High negative pressure may increase tracheal mucosal damage and should not be used. The tracheostomy tube may eventually need to be replaced, but this is not the first action.

The nurse is changing the infusion set on a patient with a continuous infusion of normal saline. A nursing student asks if the needleless connector should be cleaned before connecting the new line. Which of the response is the best? A. "Yes, the needleless connector should be vigorously scrubbed with an appropriate disinfecting agent." B. "No, the needleless connector has been covered with the old IV line, so there is no need to clean it as long as the new line is immediately connected." C. "Yes, the needless connector should be wiped off in a clockwise direction with a disinfecting agent for 2 minutes." D. "No, the needleless connector does not need to be cleaned unless the solution being infused is a lipid emulsion."

A. "Yes, the needleless connector should be vigorously scrubbed with an appropriate disinfecting agent." Rationale: The needleless connector should be disinfected using vigorous mechanical scrubbing for a minimum of 5 to 60 seconds, according to the organization's practice with an appropriate disinfecting agent. The other responses are incorrect.

When assessing the patient's IV site, the nurse detects pain with erythema and purulent drainage. Which score should the nurse assign on the phlebitis scale? A. 4 B. 3 C. 2 D. 1

A. 4 Rationale: Pain at the access site with erythema and purulent drainage is grade 4 on the phlebitis scale. Grade 3 is pain at the access site with erythema or edema, streak formation, and a palpable venous cord. Grade 2 is pain at the access site with erythema or edema. Grade 1 is erythema at the access site with or without pain.

When a patient undergoing a blood transfusion complains of flank pain and hematuria, which adverse reactions should be suspected? A. A hemolytic transfusion reaction B. Bacterial contamination of the blood C. An allergic transfusion reaction D. TACO

A. A hemolytic transfusion reaction Rationale: Back or flank pain and hematuria are signs of a hemolytic transfusion reaction. Fever, rigors, tachycardia, and hypotension suggest bacterial contamination of the blood. Rash, difficulty breathing with wheezing, and possibly hypotension would indicate an allergic reaction. TACO should be suspected in the presence of respiratory distress with crackles, hypertension, jugular venous distention, or pulmonary edema.

Which instruction should be included when educating the family about signs of severe respiratory distress while performing oropharyngeal suctioning in the home? A. "Pick up the phone and call 911." B. "Suction deeper and more vigorously." C. "Apply oxygen at the highest level available." D. "Notify your physician immediately."

A. "Pick up the phone and call 911." Rationale: Severe respiratory distress is a medical emergency, and the family should call 911 immediately for medical assistance. Deeper and more vigorous suctioning may cause further hypoxia and impair the gag reflex. High levels of oxygen may further impede the respiratory drive. Notifying the physician is important but should not be done first as it will delay the emergency personnel.

Which step should the nurse include when inserting an ONC? A. Advance the catheter until the hub rests at the venipuncture site. B. Anchor the vein above the insertion site while advancing the catheter. C. Insert the catheter bevel up at a 90-degree angle. D. Place a finger on the insertion site to anchor the newly placed catheter.

A. Advance the catheter until the hub rests at the venipuncture site. The catheter should be advanced until the hub rests at the venipuncture site to ensure greater stability and minimize the potential for contamination of the catheter. The vein should be anchored below the insertion site to facilitate IV insertion. Anchoring the vein above the site would occlude the vein. The catheter should be inserted bevel up at a 10- to 30-degree angle to minimize the risk of inserting it through the vein. The index finger can be used to stabilize the IV catheter until a dressing is applied, but the nurse should avoid touching the actual insertion site to minimize the risk of contamination.

Which action is appropriate for the nurse who is preparing to insert an IV catheter in a 9-year-old child? A. Allow the child to select the IV site. B. Consider using veins in the scalp or the foot. C. Ask the child's parents to leave the room. D. Perform the venipuncture in the child's room.

A. Allow the child to select the IV site. Allowing the older child to select the IV site helps increase cooperation, letting the child feel some control in the procedure. Veins in the scalp or the foot should be considered with infants, but not older children. Family members should be allowed to stay with the child to help him or her cope with the procedure. Venipuncture should be performed in a neutral space to allow the child's room to be a safe place.

Which step should the nurse include when preparing for IV catheter insertion? A. Apply a tourniquet above the selected site. B. Shave the hair from the selected site. C. Tap and massage the selected vein vigorously. D. Select a proximal site in an extremity.

A. Apply a tourniquet above the selected site. When choosing an IV insertion site, the nurse should apply a flat tourniquet around the patient's arm above the antecubital fossa or above the proposed insertion site. The arm hair is clipped with scissors, if necessary, but should not be shaved because shaving may cause microabrasions and predispose the patient to infection. Vigorous taps and massage may cause damage. The most distal site in the nondominant arm is used, if possible, because the nondominant arm is usually less used than the dominant arm and is therefore more stable. Distal sites are also used to allow more proximal venipunctures in the future.

The nurse is caring for a patient with multiple IV infusions including continuous infusions, intermittent infusions, and lipid emulsions. The nurse observes that it is time to change the lipid emulsion line, but not the others. Which of the intervention is the best practice? A. Change the lipid emulsion line only. B. Change all the IV lines now in order to be efficient with care tasks. C. Change all the IV lines now in order to make things easier for the oncoming shift. D. Leave the lipid emulsion line change for the oncoming shift because the patient is sleeping.

A. Change the lipid emulsion line only. Lipid emulsion lines need to be changed every 12 hours (6 to12 hours in the case of propofol) in order to reduce the risk of bacterial contamination. Changing the line should not be put off because the patient is sleeping. Although the desire to make things easier for the oncoming shift or clustering care to be efficient are admirable, changing IV lines more frequently than needed actually exposes the patient to greater chance for infection and may increase cost of supplies used.

What should the nurse do before administering an IV medication? A. Clean the access port with an antiseptic swab and allow it to dry completely. B. Instruct the patient that the IV route of administration will minimize any adverse effects. C. Dilute the medication to a total volume of 10 ml. D. Call the practitioner to verify the order for the IV medication.

A. Clean the access port with an antiseptic swab and allow it to dry completely. The access port should be cleaned with an antiseptic swab and then allowed to air dry completely before administration of an IV medication. Administering a medication by the IV route does not prevent adverse effects, and a patient should be provided information about all medications administered. IV push medications should not be diluted unless recommended by the manufacturer or the organization's practice or supported by the literature. The nurse is not required to call the practitioner for verification before administering an IV medication unless he or she has a question regarding the medication order.

Which action should the nurse include when providing tracheostomy care? A. Cleaning the inner cannula with normal saline solution B. Removing the old ties before applying new ones C. Suctioning the tracheostomy tube after the procedure D. Cleaning the inside of the outer cannula toward the stoma site

A. Cleaning the inner cannula with normal saline solution Rationale: Normal saline solution loosens secretions from the inner cannula and should be used to clean the inner cannula. The nurse should clean the area around the stoma starting at the stoma and working outward in order to pull contaminants to the periphery. New ties need to be applied before removing the old ties to prevent dislodgment. Suctioning after the procedure may cause the patient to cough secretions into the tube; tubes are usually suctioned before the procedure. There is no outer cannula to clean, only an inner cannula.

Which action should the nurse take after removing a short peripheral catheter? A. Control bleeding with gauze and pressure. B. Have the patient hold pressure at the site. C. Ensure the creation of an embolus. D. Elevate the extremity to prevent any bleeding.

A. Control bleeding with gauze and pressure. The priority nursing intervention when removing a short peripheral catheter is to control bleeding by keeping gauze in place and applying continuous pressure to the site until hemostasis is obtained. The nurse (not the patient) should hold pressure until the nurse is certain that the site forms a clot, not an embolus. When bleeding has stopped, the patient does not have to elevate the extremity.

A patient is receiving a blood transfusion. How often should the nurse change the IV tubing? A. Every 4 hours B. Every 6 hours C. Every 24 hours D. Every 96 hours

A. Every 4 hours Rationale: Blood tubing should be changed every 4 hours. Propofol infusions should be changed every 6 to 12 hours. Lipid infusions should be changed every 12 hours as they can promote bacterial growth. Intermittent infusion tubing should be changed every 24 hours, while continuous infusion tubing only needs to be changed every 96 hours.

When using a vacutainer to draw blood from a PICC, which tube order is correct? A. Fill tubes that form a clot first to prevent the vacutainer spike from being contaminated with additives. B. Fill tubes that form a clot last to prevent the vacutainer spike from being contaminated with additives. C. Lavender (ethylenediaminetetraacetic acid), blue (citrate), red (nonadditive tubes) D. Speckled, mottled, or gold top (gel separator) lavender (ethylenediaminetetraacetic acid), red (nonadditive tubes)

A. Fill tubes that form a clot first to prevent the vacutainer spike from being contaminated with additives. Rationale: Fill tubes that form a clot first to prevent the vacutainer spike from being contaminated with additives. The color order is red (nonadditive tubes); blue (citrate); lavender (ethylenediaminetetraacetic acid); and speckled, mottled, or gold top (gel separator).

When caring for a patient who recently began CPN therapy, the nurse reviews the initial laboratory results, knowing that the most common metabolic complication associated with CPN is which condition? A. Hyperglycemia B. Azotemia C. Serum aminotransferase level elevation D. Hyperammonemia

A. Hyperglycemia Rationale: Hyperglycemia is the most common metabolic complication that occurs with CPN. Attributed to insulin suppression, resistance, and gluconeogenesis from stress and infection, hyperglycemia is associated with overfeeding but can also occur in appropriately fed patients. Azotemia can be associated with protein overfeeding or renal or hepatic dysfunction. With the use of crystalline amino acids, hyperammonemia rarely occurs. Serum aminotransferase level elevations may occur within 2 weeks of CPN therapy and may return to normal even when CPN is continued.

Which technique should the nurse use while removing a short peripheral IV catheter? A. Keep the catheter hub parallel to the skin while withdrawing it. B. Remove the tape and catheter together using a slow, steady motion. C. Steady the catheter and pull it out with one quick tug. D. Instruct the patient to hold his or her breath during catheter removal.

A. Keep the catheter hub parallel to the skin while withdrawing it. The catheter should be removed with a slow, steady motion, keeping the hub parallel to the skin. The tape should be removed first; then the catheter can be removed. The motion for removal is slow and steady, not a quick tug. The patient does not need to hold his or her breath during catheter removal.

Which action should the nurse take next after obtaining a blood sample from a PICC? A. Label the specimen in the presence of the patient. B. Clean up the supplies and remove gloves. C. Immediately transport the specimen to the lab. D. Place the specimen into a biohazard bag filled with ice.

A. Label the specimen in the presence of the patient. After drawing a blood sample, the nurse should label the specimen in the presence of the patient; this ensures proper identification of the specimen and assists in appropriate treatment for that patient based on lab results. The specimen should be labeled before supplies are cleaned up or gloves removed. The specimen should be labeled in the presence of the patient and before transporting the specimen to the laboratory. The specimen should be labeled before placing it in a biohazard bag. If ice is required, the specimen should be placed in a biohazard bag, then this bag with the specimen should be placed into a second biohazard bag filled with ice slurry.

The nurse obtains a blood sample from an extremity with a peripheral access device in place. What technique should be used? A. Obtain the sample below the peripheral access device. B. Obtain the sample above the peripheral access device. C. Disconnect the peripheral access and draw directly from the hub. D. Select the vein on the underside of the wrist to avoid the peripheral access device.

A. Obtain the sample below the peripheral access device. Rationale: The sample should be obtained below the peripheral access device, if applicable. Obtaining a blood sample from an extremity with a peripheral access device in place may cause specimen contamination or hemolysis. The peripheral access device should not be disconnected to allow the draw at the site of the hub. This can lead to infection or contamination. The vein on the underside of the wrist should not be used for blood draw.

Before administering an IV push medication, what should the nurse do first? A. Perform hand hygiene. B. Identify the patient. C. Draw the medication into the appropriate syringe. D. Label all medications.

A. Perform hand hygiene. Rationale: To help prevent the spread of infection, the nurse should perform hand hygiene before preparing or administering medications. Identifying the patient is a requirement before medication administration; however, the first step is hand hygiene. To minimize the risk of infection, the nurse should always perform hand hygiene before drawing the medication into the appropriate syringe. While labeling all medications is an important step during medication administration, the nurse's first action must be to perform hand hygiene.

The nurse is removing and an IV catheter from a 3-year-old. Which intervention should the nurse plan to use? A. Remove the arm board before removing the catheter. B. Leave the arm board in place when removing the catheter. C. Ask the family members to leave the room during the procedure. D. Ask the child how he or she wants the catheter removed.

A. Remove the arm board before removing the catheter. Before removing the catheter, the nurse should remove the arm board or other stabilization device. Allowing family members to stay will help comfort the child during the procedure. A 3-year-old child does not have knowledge regarding how to remove the IV catheter but can participate in decision making about the procedure based on his or her developmental level.

4. Which action should br taken before performing oropharyngeal suctioning? A. Remove the oxygen mask and keep it near the patient's face. B. Apply petroleum-based lubricant to the rigid suction device. C. Set the vacuum regulator to the highest setting. D. Remove the nasal cannula.

A. Remove the oxygen mask and keep it near the patient's face. Rationale: When suctioning the oropharyngeal airway, the patient's oxygen mask should first be removed to expose the patient's mouth but it should be kept near the patient's face in case it is needed to prevent hypoxemia. Rigid devices are used only for the oral cavity, so lubrication is not needed. Setting the vacuum regulator to the highest setting may create hypoxic states and cause tissue trauma. Because a nasal cannula does not impede oral suctioning, it should remain in place during oropharyngeal suctioning.

The nurse is caring for patient on NPPV with a face mask interface. The patient keeps attempting to remove the mask. Which action by the nurse places the patient at risk for an adverse event? A. Restraining the patient's hands B. Assessing the fit of the interface C. Reassuring the patient D. Removing the interface after a short interval

A. Restraining the patient's hands Rationale: The patient's hand should never be restrained. The patient needs to be able to remove the mask in the event of vomiting as failure to do so can result in aspiration. Assessing the fit of the interface and reassuring the patient can facilitate the patient with becoming accustomed to the therapy. Removing the mask for short intervals can give the patient time to get used to the therapy.

Which complication of I.V. catheter removal is more prevalent in older adult patients? A. Skin tears B. Hematoma C. Infection D. Bleeding

A. Skin tears Many older adult patients have fragile skin, so tape must be removed carefully to avoid skin tears. Hematoma, infection, and bleeding can occur in any patient during I.V. catheter removal. These complications are not more prevalent in older adult patients.

The practitioner has ordered a variety of tests for a newly admitted patient. In preparation for drawing blood for the laboratory tests, what should the nurse keep in mind? A. Some laboratory specimens have special collection requirements. B. All laboratory specimens are treated in the same manner after collection. C. The patient needs to open and close his or her fist vigorously to create vein distention. D. Occasionally, the tourniquet must be maintained in position for 2 minutes to create vein distention.

A. Some laboratory specimens have special collection requirements. Rationale: Some laboratory specimens have special collection requirements before or after specimen collection to ensure accurate test results. Vigorously opening and closing the fist may cause erroneous laboratory results because of hemoconcentration and changes to the blood components. A tourniquet should not to be kept on a patient longer than 1 minute because of the potential for causing stasis.

1. While performing the initial assessment, gurgling is heard coming from the patient's throat and copious amounts of saliva is observed in the patient's mouth. Which action is the most appropriate? A. Suction the patient's mouth using a rigid suction device. B. Place the patient in the Trendelenburg position and turn him or her to the right side. C. Perform postural drainage. D. Suction the patient's nasopharynx using a flexible suction catheter.

A. Suction the patient's mouth using a rigid suction device. A rigid suction device is used to perform oropharyngeal suctioning and remove pharyngeal secretions via the mouth. Placing the patient in the Trendelenburg position and turning him or her to the side uses gravity to help clear the airway but is not as efficient as active suctioning. Postural drainage may help loosen respiratory secretions but is not as efficient as active suctioning for oral secretions. Suctioning the nasopharynx will not remove secretions effectively from the oropharynx.

The nurse is preparing to perform venipuncture on an older adult patient with fragile skin. Which consideration is most important regarding the use of a tourniquet with this patient? A. The tourniquet should be applied loosely or a tourniquet should not be applied. B. The tourniquet should be applied distal to the intended venipuncture site. C. The tourniquet should be applied more snugly on older adult patients. D. A tourniquet should not be applied and the intended area should be palpated to locate a rigid vein.

A. The tourniquet should be applied loosely or a tourniquet should not be applied. For a patient who has a history of bleeding, is easily bruised, has fragile skin, or has diminished circulation, apply a tourniquet loosely or do not use a tourniquet. A single-use tourniquet should be placed proximal to the insertion site. The selected vein should be firm and should rebound when palpated. A thrombosed vein is rigid, rolls easily, and is difficult to puncture.

After applying a tourniquet to the patient's arm, the nurse asks the patient to clench his or her fist. What is the purpose of this action? A. To cause distention of the veins B. To distract the patient from the pain C. To concentrate the blood D. To prevent muscle spasms

A. To cause distention of the veins Rationale: Forming a fist facilitates the distention of the veins by forcing blood up from the distal veins. Clenching the fist would not concentrate the blood. The purpose of clenching the fist is not to distract the patient. Muscle spasms are not associated with venipuncture.

What procedure should the nurse use to obtain more than one blood specimen from a PICC using the sterile syringe technique? A. Use a new sterile syringe to draw each specimen. B. Use one sterile syringe large enough to draw all specimens at the same time. C. Use the same sterile syringe, drawing one specimen at a time. D. Use a large sterile syringe and draw 1 ml more than the total blood volume needed.

A. Use a new sterile syringe to draw each specimen. Rationale: A new syringe should be used to draw up each specimen. Once the syringe is attached to the transfer device, it is no longer sterile. Using it again to draw blood risks contamination of the site and possible infection. Using only one syringe to draw all the blood can also lead to contamination of the specimens because the blood would be transferred to multiple vials.

When suctioning a tracheostomy tube, what should the nurse do? A. Use the dominant hand to maneuver the sterile suction catheter. B. Apply low level suction while inserting the suction catheter. C. Check the equipment for proper functioning by suctioning a small amount of tap water. D. Pass the suction catheter in and out within a 30-second interval.

A. Use the dominant hand to maneuver the sterile suction catheter. Rationale: When suctioning a tracheostomy, the nurse's dominant hand remains sterile and maneuvers the suction catheter. The unsterile nondominant hand is used to connect the suction catheter to the connecting tubing. Suction should be applied while withdrawing the catheter and never during insertion. The suction catheter must remain sterile, so the function of the suction equipment is tested using sterile solution. The entire suction pass should not last longer than 10 to 15 seconds in order to prevent a decrease in oxygen saturation.

The medication administration order states that 1 mg of medication should be given over 2 minutes. The medication comes in a prefilled syringe in 3-ml volume. How should the nurse administer this medication? A. Use the prefilled syringe and administer at a steady rate of 1.5 ml/min. B. Further dilute the medication with 3 ml of saline and administer at a rate of 3 ml/min. C. Administer 2 ml of the medication over the first minute and then give the last 1 ml over the second minute. D. Administer the 3 ml steadily over 3 minutes to avoid decimal calculations.

A. Use the prefilled syringe and administer at a steady rate of 1.5 ml/min. IV push medications are administered over a specified time to facilitate safe absorption of the medication. A medication with a volume of 3 ml to be delivered over 2 minutes should be administered at a steady rate of 1.5 ml/min. Medications in prefilled syringes should not be further diluted unless recommended by the manufacturer. The medication should be administered at a steady rate over the entire 2 minutes to facilitate safe absorption by the patient. The nurse should calculate administration rates according to the medication order; changing the time period for administration may affect the absorption of the medication.

A patient was involved in a motor vehicle crash, and paramedics at the scene placed a short peripheral catheter in the left antecubital space. When should the nurse replace this catheter? A. Within 48 hours of the catheter insertion B. As soon as the patient arrives at the organization C. When indicated by the organization's routine IV catheter practice D. When the practitioner orders the catheter to be replaced

A. Within 48 hours of the catheter insertion A short peripheral IV catheter placed in an emergency situation should be replaced within 48 hours of insertion because of the risk of site complications. When the patient arrives at the organization, the priority is stabilization and trauma resuscitation. The organization's routine IV catheter practice will likely allow catheters to remain in longer than 48 hours, but leaving the catheter in place longer than 48 hours could put this patient at risk. Practitioners do not normally order IV catheters to be replaced.

A nurse is teaching a new graduate nurse about tracheostomy tubes. Which statement by the new graduate nurse indicates understanding of the capabilities of a fenestrated tracheostomy tube? A. "A fenestrated tube allows the patient to take solid food by mouth." B. "A fenestrated tube allows the patient to speak." C. "With a fenestrated tube, the patient can drink thin liquids." D. "With a fenestrated tube, the patient does not require suctioning."

B. "A fenestrated tube allows the patient to speak." Rationale: A fenestrated tracheostomy tube allows speech when a fenestrated inner cannula is in place and the cuff has been deflated. Many patients with tracheostomy tubes of any sort have the ability to protect their airway enough to eat and drink normally. A fenestrated tracheostomy tube does not affect the production of mucus in the airway and thus does not change the necessary suctioning frequency for a patient.

The nurse preceptor is discussing peripheral IV management with the new graduate nurse. Which statement from the graduate demonstrates an understanding of when to change primary administration sets? A. "A primary administration set should be changed when blood has backed up in it." B. "A primary administration set should be changed when a new peripheral catheter is placed." C. "A primary administration set should be changed every 24 hours." D. "A primary administration set should be changed every 48 hours."

B. "A primary administration set should be changed when a new peripheral catheter is placed." Administration sets should be changed when a new central venous access device is placed or the peripheral catheter site is rotated. Blood backing up into the tubing is not a reason to change the administration set unless there is a leak causing the blood backup. Primary and secondary continuous administration sets should not be changed more frequently than every 96 hours.

The nurse has an order to draw blood for multiple laboratory tests. What are the most appropriate parameters for site selection when assessing the patient's arms? A. A stable vein that is rigid and cord-like B. A vein that is firm and rebounds when palpated C. Above or below the hemodialysis shunt D. The arm on the same side as the patient's mastectomy

B. A vein that is firm and rebounds when palpated Patent, healthy veins that are elastic and rebound on palpation are the best sites for blood draws without incurring complications. The nurse should assess each patient for contraindicated sites for venipuncture, such as the arm on the same side as a mastectomy or a current or planned hemodialysis device. Thrombosed veins are rigid and cord-like, roll easily, and make it difficult to perform successful venipuncture.

5. Which finding is an expected outcome of suctioning the patient's oropharynx? A. Wheezes that change to crackles on inspiration B. Absence of gurgling in the oropharyngeal area C. Blood tinged oral secretions immediately after suctioning D. Clearing of wheezes on expiration

B. Absence of gurgling in the oropharyngeal area Rationale: With oropharyngeal suctioning, expectations are that the oropharynx is cleared of secretions, which is evidenced by the absence of gurgling in the oropharyngeal area. Wheezes changing to crackles may indicate a worsening of the patient's respiratory status. Bloody secretions at any time after suctioning are indicative of tissue trauma requiring further investigation. Oropharyngeal suctioning has no impact on wheezes heard on expiration because these are the result of airway issues below the level of the oropharynx.

The nurse is preparing to remove a short peripheral catheter from a patient who is taking an anticoagulant medication and is to be discharged home. Which intervention should the nurse plan to do? A. Apply a greater than normal amount of pressure to the site. B. Apply pressure to the site for a longer period of time. C. Apply a tourniquet before removing the catheter. D. Apply a transparent dressing.

B. Apply pressure to the site for a longer period of time. If the patient has received anticoagulants (e.g., low-dose aspirin, warfarin sodium [Coumadin], or heparin) or has a low platelet count, the nurse should apply steady pressure for a longer period of time and assess the site for bleeding. Because clotting mechanisms are altered, pressure is required for a longer period than usual. A greater amount of pressure will not increase clotting and may damage tissue. A tourniquet is contraindicated when removing a short peripheral catheter. Transparent dressings are not used on old IV sites; a gauze bandage with tape is used.

A patient has been admitted for surgery with a history of OSA. The patient will be using his own NPPV device from home at night. Which action should the nurse take before initiating therapy? A. Tell the patient that he cannot use his own device during his inpatient stay. B. Ask biomedical engineering to check the device per the organization's practice. C. Tell the patient that he will not need the device during his inpatient stay. D. Plug the machine into an electrical outlet and ensure that it works.

B. Ask biomedical engineering to check the device per the organization's practice Rationale: Before using a medical device from home, the nurse should have biomedical engineering check the device to ensure it is working properly per the organization's practice. Telling the patient that he cannot use his own device or that he will not need the device is inappropriate in this situation. Unless the patient is having surgery that precludes the use of the device, the patient still needs treatment for OSA during his inpatient stay. A biomedical engineer, not the nurse, should ensure that the machine works.

Which action should be taken first when drawing blood cultures from a PICC? A. Disinfect the needleless connector with 70% isopropyl alcohol. B. Change the needleless connector. C. Disinfect the needleless connector with greater than 0.5% chlorhexidine in alcohol solution. D. Vigorous mechanical scrubbing for a minimum of 5 to 60 seconds with an appropriate disinfecting agent.

B. Change the needleless connector. Rationale: Change the needleless connector before drawing the blood sample when drawing blood cultures. For all other blood sampling disinfect the needleless connector using vigorous mechanical scrubbing for a minimum of 5 to 60 seconds with an appropriate disinfecting agent such as 70% isopropyl alcohol, an iodophor such as povidone-iodine, or greater than 0.5% chlorhexidine in alcohol solution.

Which action is correct when assessing the use of a tourniquet for venipuncture? A. Apply the tourniquet tight enough that the patient's distal pulse can no longer be palpated. B. Do not use a tourniquet on a patient with a history of bleeding. C. Apply the tourniquet for at least 2 minutes for best results. D. Substitute the tourniquet with a blood pressure cuff inflated to 60 mm Hg.

B. Do not use a tourniquet on a patient with a history of bleeding. A tourniquet should not be used on a patient with a history of bleeding, is easily bruised, has fragile skin, or has diminished circulation. The distal pulse should be palpated and the tourniquet released if the pulse is not palpable. The tourniquet should not be so tight that it impedes arterial blood flow. The tourniquet should not be left on the patient longer than 1 minute, and if a blood pressure cuff is used, it should be inflated less than 40 mm Hg.

When selecting a potential IV site on an older adult patient, the nurse should consider which information? A. Older adults have increased subcutaneous tissue that may obscure veins. B. Dorsal veins in the hands should be avoided if possible. C. The most distal site in the dominant arm is preferred. D. Slapping the IV site will cause the desired dilation of the veins.

B. Dorsal veins in the hands should be avoided if possible. The nurse should avoid using fragile dorsal veins in older patients. If possible, the nurse should use the most distal site in the nondominant, not the dominant, arm to minimize the impact on the older adult patient's independence. Older adults have decreased subcutaneous support tissue. Vigorous friction or tapping or slapping of veins may cause hematoma or venous constriction. Such venous alterations can increase the risk of complications (e.g., infiltration, decreased catheter dwell time).

6. While reviewing a patient's medication list before performing oropharyngeal suctioning, which medication raises concern as a risk for this procedure? A. Penicillin B. Enoxaparin C. Losartan D. Albuterol

B. Enoxaparin Rationale: Enoxaparin is a blood-thinning medication and raises concern for the risk of bleeding with oropharyngeal suctioning. Penicillin is an antibiotic used to treat infection, losartan is an angiotensin receptor blocker used to treat hypertension, and albuterol is a bronchodilator used to treat reactive airway disease. Although the medical conditions necessitating the use of these medications may pose a risk for oropharyngeal suctioning, the medications themselves do not pose a risk.

While preparing to administer an IV medication that is compatible only with normal saline, the nurse observes that the patient is receiving an infusion of D5 ½ normal saline. Which is the most appropriate nursing intervention? A. Insert a new IV line because the medication is incompatible with dextrose. B. Flush the IV line with normal saline before and after administering the IV medication. C. Administer the IV medication because the IV line has half-normal saline mixed with the D5W. D. Flush the IV line with normal saline before the medication is administered, administer the medication, and then restart the infusion at the same rate.

B. Flush the IV line with normal saline before and after administering the IV medication. When an IV medication is incompatible with the patient's IV fluids, the medication may be safely given if the nurse stops the infusion, clamps the IV line, and flushes with normal saline before and after administering the IV medication. Doing so adequately solves the issue of incompatibility between the medication and the dextrose. Inserting a new IV line is not necessary. The nurse must flush the IV line before administering the medication because D5 ½ normal saline contains dextrose and saline; the medication is compatible only with normal saline. The IV line should be flushed with normal saline before and after the medication to prevent incompatibilities.

A new graduate nurse hanging a 3-in-1 CPN admixture places a 1.2-micron filter inline and connects the infusion to the patient's CVC. The nurse observing the new graduate nurse should take which action? A. Explain that the lipids should be administered below the filter. B. Have the graduate nurse start the infusion. C. Point out that a 0.2-micron filter should be used. D. Have the graduate nurse check the infusion against the practitioner's order.

B. Have the graduate nurse start the infusion. Rationale: The infusion setup is correct, and the nurse should have the graduate nurse start the infusion. This 3-in-1 CPN admixture contains lipids and thus requires a 1.2-micron filter. Additional lipids would not be hung with CPN because the admixture already contains lipids. The nurse should have ensured that the graduate nurse checked the CPN against the practitioner's order before hanging the CPN and connecting it to the patient.

Which action should be performed to avoid the most common cause of fatal transfusion reactions? A. Establish vascular access. B. Have two qualified health care professionals check the blood component information and the patient's identification. C. Keep the blood refrigerated until the time of transfusion. D. Administer the blood over a 4-hour period.

B. Have two qualified health care professionals check the blood component information and the patient's identification. Rationale: The most common cause of fatal transfusion reactions is type mismatches due to clerical error, administration of blood to the wrong patient, or incorrect identification of the blood component. Having two qualified health care professionals check the blood component information and the patient's identification is the best way to avoid giving the wrong blood product to the wrong patient. Vascular access is required to administer blood products and does not influence transfusion reactions. All blood or blood components that are not used immediately should be returned to the blood bank or refrigerated until the time of transfusion and administered within 4 hours or less, but failure to adhere to these guidelines is not the most common cause of fatal transfusion reactions.

The nurse is making initial rounds. When assessing the patient, the nurse notices that the IV site is swollen and cool to the touch and that the flow rate is very slow. Which issue is the most likely cause? A. Positional IV catheter B. Infiltration C. Fluid volume excess D. Phlebitis

B. Infiltration Rationale: Swelling, pitting edema, pallor, coolness, pain at the insertion site, and a decreased flow rate may indicate an infiltration at the IV site. Fluid volume excess is indicated by crackles in the lungs, shortness of breath, and edema. Phlebitis is indicated by pain, increased skin temperature, and erythema along the path of the vein. Positional IV catheters are difficult to regulate because the rate changes according to the position of the patient's extremity, but positional IV catheters do not cause signs and symptoms of infiltration.

A patient who is receiving IV fluids wants the tubing changed every day. The nurse knows that the tubing should be changed no sooner than every 96 hours. What should the nurse tell the patient about more frequent tubing changes? A. More frequent tubing changes increase the risk of embolism. B. More frequent tubing changes increase the risk of infection. C. More frequent tubing changes cause undue strain on the nurse. D. More frequent tubing changes cause an extra expense for the patient.

B. More frequent tubing changes increase the risk of infection. Rationale: Repeated disconnection and reconnection of intermittent sets increases the risk of contamination of the IV system, which potentially increases the risk of a CLABSI. More frequent tubing changes do not increase the risk of embolism, cause undue strain on the nurse, or necessarily cause an extra expense for the patient.

When preparing to administer RBCs, the transfusionist notes that lactated Ringer solution is hanging on the IV pole. Which substance should be used to flush the line before hanging the blood? A. Lactated Ringer solution B. Normal saline C. Heparin by infusion pump D. Prophylactic antibiotics

B. Normal saline Only normal saline or Plasma-Lyte 148 may run in the same line with blood products. Other solutions may bind to components in the blood or may cause hemolysis.

After the short peripheral catheter is removed, the nurse suspects that the tip broke off. What is the first thing the nurse should do? A. Discard the used catheter and supplies in the trash. B. Save the used catheter. C. Clean the site with an alcohol pad. D. Bandage the site and apply a warm pack.

B. Save the used catheter. Although catheter embolism is a rare complication, when a short peripheral catheter is discontinued, the catheter tip can break off. The tip can embolize and travel proximally in the circulation. The used catheter should not be discarded; it is needed for inspection by the practitioner. Cleaning the site with alcohol or applying a bandage with a warm pack is important but not the first action.

A blood sample is to be obtained through the PICC. What action should the nurse take before entering the system? A. Replace the needleless connector with a new sterile device. B. Scrub the needleless connector with an antiseptic solution and allow it to dry. C. Gently disinfect the needleless connector and wipe it dry with sterile gauze. D. Open the clamp on the port of the tubing with the needleless connector.

B. Scrub the needleless connector with an antiseptic solution and allow it to dry. Rationale: Before the PICC is entered, the needleless connector should be scrubbed with an antiseptic solution and allowed to dry on its own rather than wiped dry. The needleless connector does not need to be changed unless there is visible blood or debris, or unless drawing blood cultures. The clamp on the port should be opened after the needleless connector is accessed with an appropriate device.

After spiking the blood bag and filling the drip chamber to cover the filter, the transfusionist observes air bubbles in the drip chamber. Which action should be taken next? A. Infuse the blood with no filter in the line. B. Tap the filter chamber lightly. C. Leave the existing air bubbles in the line. D. Change the entire tubing. Rationale: Tapping the filter chamber lightly causes the air bubbles to dissipate as they rise in the drip chamber. Blood is never administered without a filter or with visible air bubbles in the line. There is no need to change the entire tubing and waste the blood that is already in it when tapping will eliminate the problem.

B. Tap the filter chamber lightly. Rationale: Tapping the filter chamber lightly causes the air bubbles to dissipate as they rise in the drip chamber. Blood is never administered without a filter or with visible air bubbles in the line. There is no need to change the entire tubing and waste the blood that is already in it when tapping will eliminate the problem.

In which circumstance may the nurse administer an IV medication that he or she has not labeled? A. The nurse has given the medication to the patient before. B. The medication is prepared at the patient's bedside and immediately administered. C. The medication needs to be diluted and drawn up in a larger syringe. D. The medication requires a filter needle for administration.

B. The medication is prepared at the patient's bedside and immediately administered. Medications that are prepared at the patient's bedside and immediately administered without any break in the process do not need to be labeled. A history of giving the patient the same medication does not exclude the labeling of the medication. A medication should not be diluted in a syringe by the nurse. A filter needle does not exclude a medication from needing to be labeled.

8. What instruction should be given to a conscious patient before starting oropharyngeal suctioning? A. "Breathe deeply through your mouth" B. "Hold your breath while I am suctioning." C. "Try to cough before I begin." D. "Take quick, shallow breaths."

C. "Try to cough before I begin." Rationale: A patient should be instructed to cough before the suctioning procedure in order to move secretions from the lower airway into the mouth. The patient should be instructed to breathe deeply through the nose, not the mouth. Holding the breath and taking quick shallow breaths will limit the patient's respiratory effort and may contribute to hypoxia.

The nurse observes that a patient receiving CPN has fever, malaise, and chills. The nurse should suspect that the patient has developed which complication? A. An exit-site infection B. Fluid retention C. A systemic infection D. Hypoglycemia

C. A systemic infection Rationale: Fever, malaise, and chills indicate a systemic infection. An exit-site infection causes redness, swelling, and tenderness around the venous access site. Fluid retention produces weight gain, taut skin, turgor, and crackles heard over the lung fields. Signs and symptoms of hypoglycemia include shakiness, dizziness, nervousness, anxiety, and an increased sense of hunger.

After inserting an ONC through the skin and into the vein, the nurse should take which action? A. Advance the catheter and needle until the hub rests at the insertion site. B. Loosen the stylet for removal. C. Check for blood return in the flashback chamber. D. Stabilize the catheter and release the tourniquet.

C. Check for blood return in the flashback chamber. When inserting an ONC, the nurse should observe the flashback chamber for blood return, indicating that the bevel of the needle has entered the vein. The nurse should advance the catheter approximately ¼ inch into the vein before loosening the stylet. After checking for blood return, the nurse should continue to hold the skin taut and advance the catheter into the vein until the hub rests at the venipuncture site. Only after the catheter has been advanced should it be stabilized and the tourniquet released.

The nurse suctions the tracheostomy tube of a patient who received a tracheostomy the night before. When suctioning, the nurse notices a moderate amount of bloody secretions. The patient notices the blood and appears to be disturbed by it. What should the nurse do next? A. Call the practitioner immediately and calmly prepare for an emergency procedure. B. Suction more vigorously for 15-second intervals, providing oxygen between the suctioning intervals. C. Comfort the patient and explain that blood in the sputum is normal after tracheostomy tube insertion. D. Turn the lights down so that the patient cannot see the secretions and then promote relaxation techniques.

C. Comfort the patient and explain that blood in the sputum is normal after tracheostomy tube insertion. Rationale: For patients with a new tracheostomy, the nurse should explain that bloody secretions may occur after initial placement of the tracheostomy tube and after each tracheostomy tube change. Turning the lights down so that the patient has difficulty seeing the secretions may only increase the patient's anxiety and stress. Because this is an expected finding, there is no need to notify the practitioner. More vigorous suctioning may lead to more bleeding.

Which action should the nurse take to help reduce the risk of infection when drawing blood? A. Draw blood in the laboratory's recommended order. B. Label the laboratory tubes with two identifiers. C. Draw all ordered samples at the same time, if possible. D. Reinfuse the blood that was obtained as the discard volume.

C. Draw all ordered samples at the same time, if possible. Rationale: When possible, all ordered blood samples should be drawn at the same time to reduce the number of times the system is entered, thus helping to minimize the risk of infection. Drawing blood in the laboratory's defined order prevents contamination of subsequent tubes with preservatives, but it does not reduce the risk of infection. Laboratory tubes should be labeled per the organization's practice and include required patient identifying information; however, this does not prevent infection. Reinfusing the discard volume of blood may increase the risk of infection.

A patient is receiving parenteral nutrition. How often should the nurse change the IV tubing? A. Every 6 hours B. Every 12 hours C. Every 24 hours D. Every 96 hours

C. Every 24 hours Rationale: Parenteral nutrition tubing should be changed every 24 hours. Blood tubing should be changed every 4 hours. Propofol infusions should be changed every 6 to 12 hours. Lipid infusions should be changed every 12 hours as they can promote bacterial growth. Intermittent infusion tubing should be changed every 24 hours, while continuous infusion tubing only needs to be changed every 96 hours.

After removing a short peripheral catheter, which action should the nurse take? A. Turn the IV tubing roller clamp to the "off" position. B. Discard the used catheter and supplies in the trash. C. Examine the integrity of the catheter. D. Clean the site with an alcohol pad.

C. Examine the integrity of the catheter. After removing a short peripheral catheter, the nurse must inspect the integrity of the catheter to ensure that the catheter tip has not broken off. The used IV catheter should be discarded in the biohazard container, not the trash. The IV tubing should have been turned to the "off" position before removal and should remain off. The site should now be covered with a dressing, and no additional cleansing is indicated.

An obese patient who had a right mastectomy several years ago has better veins in her right hand but is left handed. Where should the nurse place the IV catheter? A. In her right hand B. Wherever the patient wants C. In her left lower arm D. In her left antecubital site

C. In her left lower arm Rationale: Although placing an IV catheter in the patient's nondominant hand (in this case, her right hand) is preferred, this patient has a medical condition that dictates that the IV catheter be placed in her dominant (left) hand or arm because venipunctures are contraindicated in arms on the same side as a mastectomy. Although the nurse should try to accommodate a patient's wishes, medical conditions and nursing judgment may require the nurse to choose sites other than the one the patient prefers. The antecubital site should be avoided because it limits the patient's mobility.

Which action should the nurse take when administering CPN with lipids? A. Infuse the solution over no more than 12 hours. B. Infuse the solution over no less than 48 hours. C. Initiate and maintain the infusion at the prescribed rate. D. Increase the infusion rate gradually over 4 hours.

C. Initiate and maintain the infusion at the prescribed rate. Rationale: The CPN infusion should be initiated and maintained at the prescribed rate. The rate should not be gradually increased over 4 hours. CPN infusions should be administered over 24 hours.

Which is the nurse's highest priority to prevent life-threatening complications related to a PICC? A. Monitor arterial blood pressure. B. Obtain correct central venous pressure readings. C. Maintain aseptic care of the access device and system. D. Ensure that medications continue infusing during blood sampling.

C. Maintain aseptic care of the access device and system. Rationale: Infection is a life-threatening complication of PICC use; therefore, aseptic catheter care is the highest priority. Arterial blood pressure is monitored using an arterial catheter. If the patient's hemodynamic status will not be compromised during blood sampling, infusions should be turned off for 3 to 5 minutes to prevent testing errors. Central venous pressure readings provide hemodynamic information, but they are not used to prevent CVAD complications.

Test View CE Information (Please select only one answer for each of the following questions) 1. While performing the initial assessment, gurgling is heard coming from the patient's throat and copious amounts of saliva is observed in the patient's mouth. Which action is the most appropriate? A. Suction the patient's mouth using a rigid suction device. B. Place the patient in the Trendelenburg position and turn him or her to the right side. C. Perform postural drainage. D. Suction the patient's nasopharynx using a flexible suction catheter. 2. A patient who is comatose but not intubated, requires frequent oral suctioning. After suctioning, in which position should the patient be placed? A. Fowler position B. Prone position C. Semi-Fowler position D. Sims position 3. After suctioning the oropharyngeal airway with a rigid suction device, which action should be performed? A. Place the device in an airtight container to prevent bacterial growth. B. Wrap the device in a rubber glove and discard it. C. Place the device in a container that is not airtight. D. Clamp the device onto the patient's pillowcase for easy accessibility.

C. Place the device in a container that is not airtight. Rationale: The rigid suction device should be kept in a container that is not airtight to ensure that it remains clean between suctioning. It is not necessary to discard the suction device between uses. Closure in an airtight container promotes bacteria growth. Placing the suction device on the patient's bedding exposes it to excretions, contaminants, and promotes bacteria growth.

What should the nurse do after drawing blood specimens for a coagulation profile? A. Store the specimens in the refrigerator until laboratory personnel pick them up. B. Place the specimens in the laboratory area of the nurses' station for processing. C. Send the specimens to the laboratory immediately after they have been obtained. D. Deliver the specimens personally to the laboratory before leaving at the end of the shift.

C. Send the specimens to the laboratory immediately after they have been obtained. Rationale: The nurse should send the specimens to the laboratory immediately. Timely delivery of blood samples for coagulation studies is essential because results may be distorted unless tests are performed immediately. Therefore, leaving a specimen in the refrigerator or at the nurses' station or waiting until leaving at the end of the shift could adversely affect the accuracy of the results.

If a patient develops a skin rash, edema, and wheezing during a blood transfusion, what should the transfusionist do? A. Discard the blood bag and tubing. B. Decrease the rate of the transfusion. C. Stop the transfusion immediately. D. Reassess the patient in 10 minutes.

C. Stop the transfusion immediately. Rationale: Rash, edema, and wheezing are signs of an anaphylactic reaction, and the transfusion should be stopped immediately. The transfusionist should continuously monitor the patient while summoning assistance and anticipating epinephrine administration. The blood bag and tubing should be saved to return to the blood bank.

1. A patient has IV crystalloid solutions infusing through a dual-lumen PICC line. The laboratory calls to let the nurse know that the patient's current laboratory results show a discrepancy from previous results. The nurse observes that there has been no change in the patient's condition. The blood sample was drawn from the PICC by another nurse. What is the most likely reason for the discrepancy in the laboratory results? A. The other nurse disinfected the hub for only 5 seconds. B. The other nurse discarded only 6 ml of blood before obtaining the blood sample. C. The other nurse turned off the IV fluid in only one lumen of the PICC. D. The other nurse stopped the infusions for only 5 minutes before obtaining the blood sample.

C. The other nurse turned off the IV fluid in only one lumen of the PICC. The other nurse likely turned off the IV fluid in only one lumen of the PICC. All IV solutions infusing in the PICC need to be discontinued before sampling blood from a PICC. The discard volume of 6 ml is normal and should not be an issue. Disinfecting the hub for only 5 seconds is wrong but would not affect the laboratory results. Stopping the infusion for 5 minutes is fine.

An unidentified male trauma patient requires an emergent transfusion. What is the correct transfusion option? A. Type AB-negative, uncrossmatched blood B. Type AB-positive, uncrossmatched blood C. Type O-positive, uncrossmatched blood D. Crossmatched blood only Rationale: In emergency situations, male patients and postmenopausal female patients may receive uncrossmatched, O-positive blood until crossmatched blood is available. (Other patients in this situation may receive uncrossmatched, O-negative blood.) A patient should receive type AB blood only if that is his or her known blood type; in this situation, the patient's blood type is not yet known.

C. Type O-positive, uncrossmatched blood Rationale: In emergency situations, male patients and postmenopausal female patients may receive uncrossmatched, O-positive blood until crossmatched blood is available. (Other patients in this situation may receive uncrossmatched, O-negative blood.) A patient should receive type AB blood only if that is his or her known blood type; in this situation, the patient's blood type is not yet known.

While preparing to administer an IV push medication, the nurse sees that the patient's IV site is slightly puffy, yet the IV solution continues to infuse at a slow rate. What should the nurse do next? A. Administer the IV push medication through the IV site. B. Flush the IV line with normal saline and then administer the medication. C. Use another IV site for the medication or insert a new IV line, if necessary. D. Place the medication in an IV piggyback and infuse it over the recommended time.

C. Use another IV site for the medication or insert a new IV line, if necessary. Rationale: An IV push medication should not be administered if the insertion site appears puffy or edematous. These signs indicate infiltration. Administering a medication into an infiltrated IV site can cause pain, necrotic sloughing of tissues, and abscesses. Flushing an infiltrated IV site increases the infiltration area and increases tissue damage. The medication order specifies IV push administration, not via IV piggyback.

2. An IV cardiac medication to treat tachycardia is prescribed for a patient in the telemetry unit. Which action should the nurse take? A. Administer the medication at a steady rate over at least 5 minutes to decrease the potential adverse effects and ensure that all medication is absorbed. B. Double-check with another nurse regarding the appropriate rate of administration. C. Verify that the rate of administration is recommended by the manufacturer or the organization's practice or supported by the literature. D. Call the practitioner who prescribed the medication to clarify the rate of administration.

C. Verify that the rate of administration is recommended by the manufacturer or the organization's practice or supported by the literature. The nurse must verify that the rate of administration is recommended by the manufacturer or the organization's practice or supported by the literature to ensure correct medication administration and patient safety. The safe administration rate varies from medication to medication, and administering a medication at an arbitrary rate may harm the patient. Consulting another nurse is neither safe nor acceptable. Consulting the practitioner to verify a medication's recommended rate is neither necessary nor appropriate.

9. Which condition is an expected outcome of effective oropharyngeal suctioning? A. Adventitious breath sounds B. Thickened secretions in the oropharynx C. Increased heart rate D. Absence of vomitus in the mouth

D. Absence of vomitus in the mouth Rationale: Expected outcomes of effective oropharyngeal suctioning include absence of vomitus in the mouth. Thickened secretions in the oropharynx, an increased heart rate, and adventitious breath sounds all represent conditions where the suctioning was not effective.

The charge nurse is evaluating a new nurse's ability to insert an IV catheter. Which action by the new nurse may indicate the need for more education? A. Palpating the vein by pressing down and noting resiliency B. Placing the extremity in a dependent position C. Asking the patient if he or she is right or left handed D. Applying the tourniquet as tightly as possible

D. Applying the tourniquet as tightly as possible Rationale: The nurse should apply the tourniquet 10 to 15 cm (4 to 6 inches) above the anticipated insertion site and check for the presence of the distal pulse. Diminished arterial flow prevents venous filling; the tourniquet should be tight enough to cause the vein to dilate, but not so tight that it affects arterial flow. Using the most distal site in the nondominant arm; pressing down and noting a resilient, soft, bouncy feeling as pressure is released; and placing the extremity in a dependent position are all good techniques.

After two unsuccessful attempts to insert an IV catheter in an older adult patient, the nurse should take which action? A. Notify the practitioner that IV therapy cannot be started. B. Attempt a third and final time, using a site on the opposite arm. C. Place a PICC. D. Ask another nurse to attempt an insertion.

D. Ask another nurse to attempt an insertion. To prevent excessive trauma to the arm, a nurse should make no more than two attempts at gaining IV access. Many times, a different nurse can be successful. The practitioner should not be called unless all other options have been evaluated or attempted. In most organizations, a practitioner's order is required for the insertion of a PICC.

Which action should the nurse take before removing a short peripheral catheter? A. Place the patient's arm on an arm board to stabilize the IV device. B. Turn the IV roller clamp to the "on" position. C. Don sterile gloves, mask, and face shield. D. Assess the site for redness, swelling, tenderness, and temperature.

D. Assess the site for redness, swelling, tenderness, and temperature. Rationale: Before removing a short peripheral catheter, the nurse should observe the IV site for signs and symptoms of infection, infiltration, or phlebitis. The IV roller clamp should be in the "off" position to prevent fluid from running out of the catheter when it becomes disconnected. Clean gloves, rather than sterile gloves, are worn for removal. Mask and face shields are usually not needed. Arm boards are used to stabilize IV devices after they are inserted.

When preparing to administer blood products, what is the most appropriate action? A. Open the tubing clamp when squeezing the drip chamber. B. Hang the blood bag slightly below the normal saline bag. C. Prime the tubing with the blood product. D. Completely prime the tubing and cover the filter with normal saline.

D. Completely prime the tubing and cover the filter with normal saline. Rationale: The blood filter functions more effectively when saturated with fluid, and dripping directly onto an exposed filter can damage RBCs. The tubing should always be primed with normal saline to assure patency before introducing the blood product. The tubing clamp should be closed when the drip chamber is squeezed to prevent air entrapment in the filter. The blood bag should be hung slightly higher than the normal saline bag to allow fo

A nurse caring for a patient who has been receiving CPN for several weeks notes that the patient has developed dry, flaky skin; hair loss; coarse hair; and impaired wound healing. The nurse suspects the patient has developed which condition? A. Hypomagnesemia B. Iron-deficiency anemia C. Hypophosphatemia D. EFAD

D. EFAD Essential Fatty Acid Deficiency Rationale: EFAD occurs when patients do not receive any or adequate amounts of ILE (lipid injectable emulsion ) over an extended period of time. It is characterized by dry, scaly skin; sparse hair growth; and impaired wound healing. Hypomagnesemia causes weakness, muscle cramps, cardiac arrhythmia, and increased irritability of the nervous system with tremors, athetosis, jerking, nystagmus, and an extensor plantar reflex. Hypophosphatemia causes muscle dysfunction and weakness, diplopia, low cardiac output, dysphagia, and respiratory depression. Signs and symptoms of iron-deficiency anemia include brittle nails, swelling or soreness of the tongue, cracks in the sides of the mouth, an enlarged spleen, and frequent infections.

A patient is receiving a daily lipid infusion. How often should the nurse change the administration set? A. Every 6 hours B. Every 96 hours C. Every 48 hours D. Every 12 hours

D. Every 12 hours Administration sets for infusions containing fat emulsion are changed every 12 hours to prevent bacterial growth leading to infection.

Which sequence should the nurse follow to flush a positive fluid pressure needleless connector after drawing blood? A. Keep pressure on the syringe while flushing and clamping the port, then remove the syringe. B. Flush the port, close the clamp, open the clamp, and then remove the syringe. C. Keep pressure on the syringe while flushing the port then remove the syringe. D. Flush the injection port, remove the syringe, and then clamp the port.

D. Flush the injection port, remove the syringe, and then clamp the port. Rationale: The correct sequence for disconnecting a syringe from a positive fluid pressure needleless connector is to remove syringe from injection port and then clamp the port. The correct sequence for a negative fluid pressure needleless connector is to flush, keep pressure on syringe, close the clamp, and remove syringe from injection port. With a neutral displacement valve needleless connector there is no required sequence for disconnecting the syringe and clamping the catheter.

After a blood draw, the nurse fills a specimen tube that has an additive. What is the next action? A. Affix the patient identification label. B. Shake the specimen tube vigorously. C. Place the specimen tube in an ice slurry. D. Gently invert the specimen tube.

D. Gently invert the specimen tube. Rationale: Tubes with an additive should be inverted gently to allow the additive to mix with the specimen. Although affixing the patient's identification label to the test tube is essential, it is not the first priority. Shaking the tube vigorously may damage the specimen. Placing the tube in an ice slurry is not necessary unless required by a specific test, and this step would come after inverting the tube.

The nurse is preparing to perform venipuncture for routine blood sampling. What is an important part of the patient identification process? A. Ensuring that labels are sent with the specimen for laboratory application B. Verifying the patient's identity using the computer labels and laboratory requisitions C. Obtaining a witness verification of the blood samples obtained D. Identifying the patient using two identifiers

D. Identifying the patient using two identifiers Rationale: At the patient's side, laboratory requisitions and computer-generated labels are compared with the patient's identification band by confirming two identifiers including having the patient state his or her full name and date of birth whenever possible. Blood should not be drawn if there is any discrepancy. Labels are to be applied at the bedside and not sent separately to the lab for handling. Witness verification is not required for routine blood sampling.

The nurse prepares to perform venipuncture on a 6-year-old child. What action should the nurse take to calm the child's fears? A. Treat the child in the same manner as an adult patient. B. Administer the blood test in a public location so the child does not feel alone. C. Use any available vein for venipuncture. D. Include the child in the process.

D. Include the child in the process. Rationale: The child should be included in any medical procedure to eliminate the element of surprise and allow the child to develop trust with the caregivers. When treating children, procedures should be explained using age-appropriate methods. Drawing a child's blood should take place in a treatment room to provide the patient some privacy and to maintain the feeling that his or her room is a safe place. A variety of age-appropriate, organization-approved veins should be considered, such as the scalp, antecubital fossa, and saphenous and hand veins.

When securing the tracheostomy ties, the nurse should tie the ends in a double square knot, allowing for which outcome? A. Two loose or three snug finger widths of slack B. As much slack as possible to prevent pressure areas on the neck C. No slack in the ties D. One loose or two snug finger widths of slack

D. One loose or two snug finger widths of slack The nurse ties the ends securely in a double square knot, allowing space for only one loose or two snug finger widths in the tie. One finger width of slack prevents ties from being too tight when the tracheostomy dressing is in place and also prevents movement of the tracheostomy tube into the lower airway. Two loose or three snug finger widths is too loose and can lead to dislodgment of the tube. Securing the ties too tightly can cause excessive pressure on the tissue and cause skin breakdown along with interrupting blood flow because it can place pressure on vessels in the neck. No slack in the ties can lead to tissue compression and breakdown in the trachea or other internal structures and to areas of irritation around the insertion site.

7. Which monitoring parameter is most important to use when assessing for effectiveness of oropharyngeal suctioning? A. Patient weight B. Respiratory rate C. Blood pressure D. Oxygen saturation

D. Oxygen saturation Rationale: The patient should be assessed before and after oropharyngeal suctioning. The most important parameter to assess is oxygen saturation, as this will indicate the change in effectiveness of breathing before and after secretions are cleared from the airway. The patient's weight is not a factor. Respiratory rate may decrease after the procedure, but this is not the guiding parameter. Blood pressure may remain unaltered or may decrease after suctioning, but the oxygen saturation is the most effective parameter to assess effectiveness of the suctioning.

A patient on NPPV has developed eye irritation. Which situation contributes to the development of this condition? A. Using a nasal mask instead of an oronasal mask B. Failing to apply a skin barrier under the mask C. Initiating the therapy in a patient with pneumonia D. Placing the interface too high on the patient's face

D. Placing the interface too high on the patient's face Rationale: Placing the mask too high on the patient's face may create a leak in the system that can cause eye irritation. If properly fitted to the patient's face and nose, neither a nasal mask nor an oronasal mask should leak and create eye irritation. Failure to apply a skin barrier under the mask would increase the patient's risk for pressure injury but not eye irritation. Initiating the therapy in a patient with pneumonia is appropriate and would have no effect on the patient developing eye irritation.