VN100 Exam 4 Review

A nurse administers the wrong medication to a client. What is the first step the nurse should take?

1. Assess the patient; check vital signs 2. Notify the provider/charge nurse 3. Fill out incident report 4. Document the client's condition in the EMR

Powdered Medication Administration

1. Check for allergies 2. Mix the medication 3. Monitor client/therapeutic response 4. Document

Six Rights of Medication Administration

1. Right medication 2. Right dose 3. Right patient 4. Right route 5. Right time 6. Right documentation

Occult blood test steps

1. The nurse should collect 2 stool specimens from different areas 2. The nurse should use a wooden applicator to transfer stool and avoid contamination 3. The nurse should apply 2 drops of solution to each sample 4. The nurse should wait 30-60 seconds for reading

Normal ranges for Potassium

3.5-5.0

Normal ranges for WBC?

5,000-10,000

What test is used to diagnose osteroporosis?

A dual-energy absorptiometry scan (DEXA Scan)

Which test would you use for macular degeneration?

Amster grid

Which test would you conduct to diagnose Heartburn?

An upper GI endoscopy

A nurse is planning to use the teach-back method to educate a client about a new antihypertensive medication. Which of the following should the nurse include to demonstrate this method?

Ask the client to explain the information using their own words.

A nurse administers the wrong medication to a client. Which of the following actions should the nurse take first?

Assess patient; check vital signs

A nurse is preparing to collect a specimen from a client for a guaiac test. The client asks what the test will detect in his stool. Which of the following responses should the nurse make?

Blood

A nurse is preparing the collect a specimen from a client for a guaiac test. The client asks what the test will detect in his stool. Which of the following should the nurse make?

Blood -- A FOBT measures occult blood in the stool and screens for colon cancer

Which actions should the nurse take when obtaining a wound drainage specimen culture?

Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen.

Which actions should the nurse take when obtaining a wound drainage specimen for culture?

Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen.

Urinary catheterization to obtain a urine specimen for a client. How would you provide privacy?

Closing the door and covering the client during the procedure will provide for her privacy.

Powdered medication to a client. Actions the nurse take first?

Confirm if any allergies with patient

Loop of bowel protruding from the surgical incision. What is this called?

Dehiscence - Surgical Emergency. Place a soaked sterile dressing on site and notify the provider.

The papanicolaou test is used for?

Detecting cervical cancer

Patient rights related to medication administration

Document, educate, notify your charge nurse/ provider

What is dye used for?

Dye is injected through an IV to visualize the vessels in the eye Flourescein angiography test

Preparing to administer a metered dose inhaler (MDI) medication

Educate patient, inhale slowly for 3-5 seconds to improve the absorption

If you have an assistive personnel and you ask them to take the specimen to the lab, and they refuse what do you do?

Educate them on what they are allowed to do

If you have an assistive personnel and you ask them to take a specimen to the lab, but they refuse what do you do?

Educate them on what they are allowed to do.

Urinary Catheterization to obtain a urine specimen for a client. How would you provide privacy?

Ensure the patient's privacy is maintained throughout the procedure and that they are kept warm

A nurse is collecting research to revise the protocol for specimen collection on their unit. From which of the following sources should the nurse retrieve information from?

Evidence-Based Practice

Key to reducing the risk of medication errors?

Following the 6 Medication Rights prior to administering medication.

Key for reducing the risk of medication errors?

Following the 6 rights of medication administration ; Confirmed prior to administering medication

A nurse is assisting with teaching a client about self-administration of insulin. Which of the following actions should the nurse take?

Have the client perform a return demonstration of the procedure.

Steps to collect a midstream urine specimen?

Have the patient urinate a small amount of urine before starting the collection

The nurse is removing staples from a surgical wound.

If the wound separates, then you stop removal and cover the site with a dry dressing.

Peripheral IV catheter site is cool and taunt, and there is IV fluid leaking. What is this called?

Infiltration

During the healing stage, at which point is the body sending more fluid into the site leading to swelling/edema?

Inflammatory Phase

A nurse is preparing to administer a metered dose inhaler medication (MDI). How should the nurse educate the patient?

Inhale slowly for 3-5 seconds to improve the absorption

If a patient has a rapid pulse, decreased blood pressure, urinary output and the dressing is dry then the diagnosis would most likely be?

Internal hemorrhage

Normal Ranges for Hematocrit (HCT)

M: 42-52% F: 37-47%

Refusal of Medication

Medication refusal - Clients have the right to refuse a medication. Determine the reason for refusal, provide information regarding the risk of refusal, notify appropriate health care personnel, and document the refusal and actions taken.

Food is transported through the GI tract in what order?

Mouth, Stomach, Small intestine (to large intestine), rectum (and then anus)

Serosanguineous

Pale, red, watery: mixture of clear and red fluid

Serosanguineous exudate

Pale, red, watery: mixture of clear and red fluid Mix of serous and sanguineous drainage

lecture method

Passive teaching method based on the cognitive domain of learning

A client who is pregnant and whose routine diagnostic testing results reveal a negative rubella titer. What is the next step?

Patient needs immunization/booster following delivery Patient also needs to wait 3 months to conceive after administration

A patient is scheduled for an arthroplasty, but WBC are elevated. What is the next step?

Patients with elevated WBCs should not undergo surgery. Elevated count can indicate infection. Immediately notify the surgeon.

Warfarin (anticoagulant). The nurse should used the results of which test to confirm this?

Prothrombin time (PT) — The clotting test used to measure the effect of warfarin is the prothrombin time (called pro time, or PT).

Collecting a 24-hour urine specimen.

Required for tests of renal function and urine composition Entire volume of urine from 24 hour period is collected If urine is accidentally discarded or contaminated or the patient is incontinent, restart the time period

Active teaching based on the cognitive domain of learning.

Role Playing

A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following?

Serosanguineous

EMG Test

Small needles inserted into the muscle, attached to a wire while it records electrical activity. Damage to a nerve will alter results.

IV Infiltration (Treatment)

Stop infusion, remove peripheral catheters, apply COLD compress, elevate extremity, insert new catheter in opposite extremity.

What test is used to diagnose Cystic Fibrosis?

Sweat chloride test

New prescription for antibiotic. What should the nurse instruct the patient?

The Nurse should instruct the patient to check with their provider before taking over-the-counter medications and herbal supplements. They may interact with certain antibiotics.

Preparing to administer an ophthalmic medication

The nurse should administer medication in the conjunctival sac.

A nurse is caring for a client who has cholelithiasis with bile duct obstruction. What should the nurse expect to find?

The nurse should expect this client to have dark or amber-colored urine. The client who has biliary obstruction will experience a backward flow of bile, which must be filtered out of the body by the kidneys.

A nurse is caring for a client who has cholelithiasis with bile duct obstruction. What should the nurse expect?

The nurse should expect this client to have dark or amber-colored urine. The patient will experience a backward flow of bile, which must be filtered out by the kidneys.

Preventing puncture injuries

The nurse should replace sharps containers when they are full to reduce the risk of a puncture injury

How can a nurse prevent puncture injuries?

The nurse should replace sharps containers when they are full to reduce the risk of a puncture injury.

A nurse is preparing to obtain a sputum specimen from a client.

The nurse should rinse the client's mouth with water to reduce contamination of the specimen

Collecting a 24 hour urine specimen

The time period for a 24-hr collection begins when the client urinates and the discards the urine. The client should collect urine for the following 24 hours (and then be stored in a refrigerator)

A nurse's patient had a diagnostic test. The patient's sibling asks the nurse to look up the results in the computer.

There is no legal or professional basis for a nurse-client relationship between them. Maintain HIPAA, otherwise it would be a breach of confidentiality.

A nurse is reviewing measurement systems to perform dosage calculations with a newly licensed nurse. Which of the following instructions should the nurse include?

To convert g to mg, move the decimal point 3 places to the right.

What is the purpose of a wet-to-dry dressing?

To debride a wound mechanically. Once it dries, it can cause more bleeding but removes all of the dead tissue. Also helps prevent infection.

A nurse is assisting with teaching a client about new medication. Which of the following strategies should the nurse plan to use?

Use the teach back method during the session to evaluate the client's understanding

What is a transvaginal ultrasound used for?

Used to detect endometrial cancer

What is a sickle Dex used for?

Used to diagnose sickle-cell anemia

What is an APTT test used for?

Used to measure the client's blood clotting time

Obtaining a urine specimen for a C&S via straight catheterization.

Utilizing sterile technique to collect specimen via catheter

A nurse is assisting with teaching a newly licensed nurse about administering a transdermal nitroglycerin patch to a client. Which of the following instructions should the nurse include?

Wear clean gloves to apply the transdermal medication.

teach back method

allows patient to repeat back key concepts from teaching session to confirm understanding

DEXA

bone density test

What is the schilling test used to determine?

cause of the Vitamin B12 deficiency

serous drainage

clear, watery plasma

sanguineous exudate

composed of serum and blood Indicates active bleeding

Substance in a clot that holds the wound together

fibrin

Phlebitis

inflammation of a vein; localized pain, heat, and swelling.

A charge nurse is reviewing routes of medication administration with a newly licensed nurse when providing care to a client. Which of the following routes of administration should the charge nurse include as having the slowest onset of action?

oral

What is CA 125 used for?

ovarian cancer

Tactile testing

simple touch test to check a client's perception of tactile stimulus

Electromyography (EMG)

the electrical recording of muscle activity Used to distinguish muscle disorders

purulent drainage

thick green, yellow, or brown drainage Indicates infection

purulent drainage

thick green, yellow, or brown drainage (infection)

sanguinous drainage

usually indicates bleeding and is bright red

Sites for IM injections

ventrogluteal, vastus lateralis, deltoid

What type of dressing does mechanical debridement require?

wet-to-dry dressing

An assistive personnel (AP) is collect a 24-hour urine specimen from a patient. Which of the following statements by the AP indicates that the specimen collection will have to be restarted?

"The patient just told me that he forgot to put the urine in the container."

A nurse is preparing to administer ophthalmic medication. What are the appropriate steps?

- Asking the client to look up at the ceiling -Dropping medication into the center of the client's conjunctival sac -Instructing the client to close the eye gently

The nurse is reviewing the data collection findings and diagnostic results. For each data collection finding, click to specify if the finding is consistent with Leukemia, sickle cell anemia or hemophilia.

- Hyperthermia is expected in Leukemia/Sickle cell anemia - Bruising is consistent with leukemia/Hemophilia - Bleeding is consistent with leukemia/hemophilia - Elevated WBC is consistent with Leukemia/sickle cell anemia - Pain is consistent will all of the above

The nurse is assisting with teaching a client about a new medication.

- Provide a quiet environment - Use easy to comprehend language - Provide educational material written at 5th/6th reading level - Begin with the most important information 1st

Which specimens can a nurse delegate to an Unlicensed Assistive Personnel?

- Routine Urine Analysis - Sputum Specimen - Stool Specimen

New prescription for an antibiotic

- The nurse should instruct the client to check with their provider before taking over-the-counter medications and herbal supplements, because these might interact with certain antibiotics. - The nurse should instruct the client that antibiotics are ineffective for viral infections. - The client should complete the course of the antibiotic to eradicate the infection.

A nurse is assisting with teaching a client about a new medication.

- The nurse should provide a quiet environment - The nurse should use simple/easy language - Provide educational material written in 5th/6th grade reading level - The nurse should begin with the most important information first, so patient does not forget

Creatinine Levels

0.5-1.2 mEq/L