NMNC 4335

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next? - Run a solution of 5% dextrose in water - Obtain a culture of the tip of the catheter device removed from the client - Remove the intravenous (IV) line - Run normal saline at a keep-vein-open rate

Run normal saline at a keep-vein-open rate If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-vein-open rate pending further health care provider prescriptions. This maintains a patent IV access line and aids in maintaining the client's intravascular volume. The nurse would not remove the IV line because then there would be no IV access route Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First, the catheter should not be removed. Second, cultures are performed when infections, not transfusion reaction, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump.

The nurse has a prescription to give a client salmeterol, 2 puffs, by metered-dose inhaler. The nurse should administer the medication using which procedure? - salmeterol first and then the beclomethasone - alternating a single puff of each, beginning with beclomethasone - alternative a single puff of each, beginning with salmeterol - beclomethasone first and then the salmeterol

Salmeterol first and then beclomethasone Salmeterol is an adrenergic type of bronchodilator, and beclomethasone dipropionate is a glucocorticoid. Bronchodilators are always administered before glucocorticoids when both are to be given on the same time schedule.

While changing the client's dressing, the nurse observes the wound's drainage is pale red/pinkish. What does the nurse describe the drainage as - Sanguineous - Serous - Serosanguineous - Purulent

Serosanguineous This answer is correct because pale red/pinkish drainage from the surgical wound is serosanguineous. This is a normal drainage in the healing process of the surgical incision. If the drainage becomes redder, it is a sign of active bleeding

A client has been hospitalized for 10 days in the intensive care unit on the ventilator and has been NPO. The nurse is giving the client a bath and notices skin breakdown on the sacrum exposing the dermis. When documenting in the medical record, what stage pressure injury will the nurse record? - stage 1 - stage 2 - stage 3 - stage 4

Stage 2 A stage 2 pressure injury is skin damage through two layers of skin, the epidermis and the dermis. A stage 2 pressure injury is open, red, and moist extending to the dermis of the skin.

The nurse is starting a client's 3rd unit of PRBCs. The client begins complaining of severe back pain, becomes apprehensive, and VS: T 100.9F, P 126, RR 28, BP 80/54. Which intervention should the nurse perform as priority? - Administer Tylenol and Benadryl and continue the infusion - Stop the infusion - Slow the infusion - Call for help

Stop the infusion The client is having a blood transfusion reaction and the nurse must stop the infusion immediately.

The nurse is planning to teach a client with COPD how to cough effectively. Which instruction should be included? - Lie flat on the back, splint the thorax, take two deep breaths, and cough - Take a deep abdominal breath, bend forward, and cough three or four times on exhalation - assume a side-lying position, extend the arm over the head, and alternate deep breathing and coughing. - Take several rapid, shallow breaths, and then cough forcefully

Take a deep abdominal breath, bend forward, and cough three or four times on exhalation The goal of effective coughing is to conserve energy, facilitate removal of secretions, and minimize airway collapse. The client should assume a sitting position with feet on the floor if possible. The client should bend forward slightly and, using purse-lip breathing, exhale. After resuming an upright position, the client should use abdominal breathing and to slowly and deeply inhale. After repeating this process three or four time, the client should take a deep abdominal breath, bend forward, and cough three or four times upon exhalation ("huff" cough)

A nurse is assessing a sacral pressure injury on a client and evaluates that the wound base has yellow stringy slough noted. How should the nurse document this assessment? - the client has a stage 3 - the client has a stage 4 - the client has an unstageable pressure injury - the client has a deep tissue injury

The client has an unstageable pressure injury An unstageable pressure injury is a full-thickness injury where the base of the wound is covered by slough or necrotic tissue. Once the slough is removed, the tissue damage will likely be a stage 3 or 4 pressure injury.

The nurse observes a client using a metered-dose inhaler (MDI) to aid in management of asthma. Which actions indicate that the client needs further instruction? SATA - cleans the inhaler and canister in soapy water before using agin in rapid succession - exhales before starting the use the MDI - inspires rapidly when dispensing the medication from the MDI - shakes the MDI before using - holds breath for 3 seconds after inhaling with the MDI

- cleans the inhaler and canister in soapy water before using agin in rapid succession - inspires rapidly when dispensing the medication from the MDI - hold breath for 3 seconds after inhaling with the MDI Utilization of an MDI requires the following actions: shaking the MDI before use; exhaling prior to dispensing the medication; taking a deep breath to ensure the medication is distributed int he lungs and holding it for 10 seconds or as long as possible to disperse the medication into the lungs; and allowing 30 seconds between puffs to provide an adequate amount of inhalation medication. The client should rinse the plastic parts of the MDI and wipe them dry; the canister should not become wet.

The nurse is caring for a client who has been placed on droplet precautions. Which protective gear is required to take care of this client? Select all that apply. - gloves - respirator - surgical mask - gown - glasses

- gloves - surgical mask - gown - glasses

A client with newly diagnosed chronic obstructive disease is to be discharged home w/ O2 per nasal prongs. Which teaching points should the nurse include in this client's discharge plan? SATA: - place gauze between the ears and oxygen tubes to prevent skin irritation - apply Vaseline or petroleum jelly on lips and nose to prevent dryness and irritation - increase oxygen flow at night during hours of sleep - avoid areas where people are smoking cigarettes or cigars - avoid use of microwave oven when using oxygen - request a large, pressurized oxygen take for use during car travel

- place gauze between the ears and oxygen tubes to prevent skin irritation - avoid areas where people are smoking cigarettes or cigars

330 mL = ____ L?

0.33

A health care provider's prescription reads morphine sulfate, 8mg stat. The medication ampule reads morphine sulfate, 10mg/mL. The nurse prepares how many milliliters to administer the correct dose?

0.8 mL

A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain with intravenous (IV) solution from the IV storage area to hang with the blood products at the client's bedside? - 0.9% sodium chloride - 5% dextrose in 0.9% sodium chloride - 5% dextrose in 0.45% sodium chlorid - Lactated Ringer's

0.9% sodium chloride

Solumedrol 4 mg/kg is ordered for a child weighing 64.8 lbs. Solumedrol is available as 500 mg/4mL. How many mL will the nurse administer?

0.942 mL

Order: Hydrochlorothiazide 0.05 g Available: hydrochlorothiazide 50 mg How many tablets will be administered to the patient?

1 tablet

List complications that can arise from a peripheral IV

1. Infection - IV site will present as red with swelling. Patient may experience fever. 2. Phlebitis - Inflammation of the vein. IV site would be red, swollen, warm to touch, patient would complain of pain. 3. Extravasation - solutions leak into tissue at IV causing irritation, maybe necrosis 4. Infiltration - solutions leak into tissues causing edema 5. Air embolism

A health care provider's prescription reads to administer an IV dose of 400,000 units of penicillin G benzathine (Bicillin). The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine (Bicillin), 300,000 units/mL. The nurse prepares how much medication to administer the correct dose? Record your answer using one decimal place.

1.3 mL

A healthcare provider's prescription reads levothyroxine (Synthroid), 150mcg orally daily. The medication label reads Synthroid, 0.1mg/tablet. The nurse administers how many tablet(s) to the client?

1.5 tablets

The nurse is suctioning a client who had a laryngectomy. What is the maximum amount of time the nurse should suction the client? - 25 seconds - 20 seconds - 10 seconds - 30 seconds

10 seconds Suctioning for longer than 10 seconds may reduces the client's oxygen level so much that the client becomes hypoxic

A healthcare provider's prescription reads potassium chloride 30mEq to be added to 1000mL NS and to be administered over a 10-hour period. The label on the medication bottle reads 40mEq/20mL. The nurse prepares how many milliliters of potassium chloride to administer the correct dose of medication?

15 mL

The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. Approximately how long will the nurse need to stay with the client to ensure that a transfusion reaction is not occurring? - 30 minutes - 5 minutes - 45 minutes - 15 minutes

15 minutes The nurse must remain with the client for the first 15 minutes of a transfusion, which is usually when a transfusion reaction may occur. This enables the nurse to detect a reaction and intervene quickly. The nurse engages in safe nursing practice by obtaining coverage for the other assigned clients during this time. Therefore, the remaining options re incorrect time frames.

A healthcare provider prescribes heparin sodium, 1300 units/hour by continuous IV infusion. The pharmacy prepares the medication and delivers an IV bag labeled heprain sodium 20,000 units/250mL D5W. An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters per hour to deliver 1300 units/hour? Record the answer to the nearest whole number.

16 mL/hour

The same IV orders above (500 mL NS over 5 hours) will have how many mL left in the IV bag after 3 hours?

200 mL

A health care provider's prescription reads 1000mL of NS to infuse over 12 hours. The drop factor is 15 drops (gtt)/1mL. The nurse prepares to set the flow rate at how many drops per minute? Record your answer to the nearest whole number.

21

Which respiratory rate is classified as tachypnea? - 20 breaths/min - 14 breaths/min - 17 breaths/min - 23 breaths/min

23 breaths/min

Cefuroxime sodium, 1g in 50mL normal saline, is to be administered over 30 minutes. The drop factor is 15gtt/mL. The nurse sets the flow rate at how many drops per minute?

25 gtt/minute

A nurse is teaching a new nurse how to remove a midline catheter. The nurse asks the new nurse what the minimum amount of time is to hold pressure on the site after the catheter is removed. Which of the following responses would indicate the new nurse understood the teaching? - 30 seconds - 15 seconds - 1 minute - 2 minutes

30 seconds Applying pressure for 30 seconds is an adequate amount of time for clotting to occur and stop bleeding. Pressure should be held longer in patients taken anti-coagulants or anti-platelets.

Based on knowledge of areas at greatest risk for development of a pressure ulcer in a bedridden patient, the nurse identifies which position to minimize the risk - 30-degree side lying - 90-degree side lying - sitting with the head of the bed elevated 75-degrees - lying supine with the bed flat at all times

30-degree side lying A 30-degree side lying position puts the least amount of pressure on bony prominences. The others will increase pressure in at risk areas for a pressure ulcer to form

Gentamicin sulfate, 80mg in 100mL normal saline, is to be administered over 30 minutes. The drop factor is 10gtt/mL. The nurse sets the flow rate at how many drops per minute? Record your answer to the nearest whole number.

33 gtt/minute

Order for 500 mL of 0.45NS is to infuse over 8 hours. Calculate the flow rate

63 mL/hour

Guaifenesin 300 mg four times a day has been prescribed as an expectorant. The dosage strength of the liquid is 200 mg/5mL. How many milliliters should the nurse administer for each dose? ________________mL - 7.5 mL - 7.0 mL - .75 mL - 8 mL

7.5 mL

A health care provider prescribes 1000mL D5W to infuse at a rate of 125mL/hr. The nurse determines that it will take how many hours for 1L to infuse?

8 hours

A health care provider prescribes regular insulin, 8 units/hour by continuous IV infusion. The pharmacy prepares the medication and then delivers an IV bag labeled 100 units of regular insulin in 100mL normal saline. An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters per hour to deliver 8 units/hour?

8 mL/hour

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

A gauze dressing placed over catheter exit site A gauze dressing should be used with a patient who perspires excessively because it wicks the moisture away from the catheter exit site.

An 89-year-old client had right hip surgery a week ago. The rehab nurse assesses a purple maroon-colored blood-filled blistered area to the client's right heel. How should the nurse document her findings? - a right heel deep tissue injury - a stage 1 right heel pressure injury - a stage 2 right heel pressure injury - a stage 3 right heel pressure injury

A right heel deep tissue injury A deep tissue injury involves tissue loss to the muscle and appears as a maroon, purple or red injury that may be a blood-filled blister or bulla. The tissue damage may not be visible at first, but the tissue damage is extensive and involves bone, tendon, and ligament

When assessing the client that presents with a pressure injury, what description best describes an unstageable pressure injury? - A wound that is full thickness through to the bone, muscle and tendon - A wound that appears red, shiny, and dry with injury to the dermis - Dark purple tissue with injury to the subcutaneous tissue - A wound that presents with full thickness loss as well as Escher and sloughing

A wound that presents with full thickness loss as well as Escher and sloughing A wound that presents with full thickness loss as well as eschar and sloughing is a presentation of an unstageable pressure injury. The wound is classified as unstageable when there is full skin thickness loss and there is a presence of eschar and sloughing, as these will interfere with the ability to objectively determine the stage.

What is the correct order of the steps for starting an IV on a client? Place steps in appropriate order. A. Perform hand hygiene, don gloves, open the IV extension set and prime the set with sterile saline. B. Apply the tourniquet above the site chosen and clean the site. C. Open the catheter and hold it securely while inserting the catheter into the chosen vein. D. When a flash of blood is observed, insert the catheter fully into the vein, and remove the cannula. E. Attach the IV extension set and assure placement by drawing blood into the IV extension set via the saline syringe, then flush. F. Continuing to hold the catheter in place, apply a clear transparent dressing so the site is visible .G. Place initials, date, and time on the IV transparent dressing

A, B, C, D, E, F, G

A patient recovering from surgery in the postoperative area suddenly becomes confused, pulse ox reading shows a drop from 98% to 90% on room air. What is the most appropriate intervention? - apply nasal cannula - apply non-rebreather - raised the head of the bed - apply simple face mask

Apply nasal cannula A short-term drop in oxygen saturation can be solved with a short-term solution.

What is the nurse's initial action when preparing to change a patient's colostomy pouching system? - Applying clean gloves - Draping the patient appropriately - Assessing the surrounding skin for signs of irritation - Emptying the colostomy

Applying clean gloves Applying gloves first will protect the nurse while checking the stoma for leakage and assessing the patient's skin for irritation. Although it is appropriate to drape the patient, FIRST put on gloves. The nurse will need to empty the pouch, but this is not the best initial action. Although it is appropriate to assess the skin, doing so would not be the nurse's first action.

Following nasal surgery, what should the nurse do first? - measure intake and output - assess respiratory status - assess the client's pain - inspect the area for periorbital ecchymosis

Assess respiratory status Rationale: Immediately after nasal surgery, ineffective breathing patterns may develop as a result of the nasal packing and nasal edema. Nasal packing may dislodge, leading to obstruction. Assess for airway obstruction is a priority.

A nurse is teaching a new nurse about midline catheters. The nurse is asked about which intravenous infusions can be administered through a midline catheter. Which of the following responses would indicate the nurse needs more teaching? - Central parental nutrition - Fresh frozen plasma - Long-term antibiotic therapy - RBC's

Central parental nutrition Rationale: Central parenteral nutrition needs to be given through a central line. Administering through a midline line will cause phlebitis due to the osmolality of the CPN

Which nursing action minimizes a patient's risk for injury during removal of an indwelling urinary catheter? - Checking the documentation for the volume of fluid used to inflate the balloon - Use a 5-mL syringe to deflate the balloon - Using sterile scissors to cut the valve to deflate the balloon - Tugging gently on the catheter to pull the balloon through the urethra

Checking the documentation for the volume of fluid used to inflate the balloon Checking the amount of fluid used to inflate the balloon will tell the nurse how much needs to come out BEFORE removing the catheter to prevent injury to the urinary tract.

The nurse inserts an indwelling Foley catheter into the distended bladder of a postoperative client who has not voided for 8 hours. After the tubing is secured and the collection bag is hung on the bed frame, the nurse notices that 900 mL of urine has drained into the collection bag. What is the appropriate nursing action for the safety of this client? - Clamp the tubing for 30 minutes and then release - Provide suprapubic pressure to maintain a steady flow of urine. - Raise the collection bag high enough to slow the rate of drainage. - Check the specific gravity of the urine.

Clamp the tubing for 30 minutes and then release Rapid emptying of a large volume of urine may cause engorgement of pelvic blood vessels and hypovolemic shock, prolapse of the bladder, or bladder spasms. Clamping the tubing for 30 minutes allows for equilibration to prevent complications. Specific gravity is an assessment and would not affect the flow of urine or prevent possible hypovolemic shock. Applying suprapubic pressure would increase the flow of urine, which could lead to hypovolemic shock. Raising the collection bad could cause backflow of urine. Infection is likely to develop if urine is allowed to flow back into the bladder.

After changing the intravenous tubing on a patient's primary infusion, the nurse notes air bubbles in the tubing. How should the nurse remove them? - Add more fluid to the drip chamber - Begin the process again - Inject a syringe of saline into the tubing to vent the air bubbles. - Close the clamp, stretch the tubing downward, and flick the tubing

Close the clamp, stretch the tubing downward, and flick the tubing Closing the clamp is a preventative action to keep the air bubbles from going into the patient's IV. Flicking the tubing will create small vibrations to remove the bubbles from the tubing.

Why should PICC lines be changed every 7 days and prn? - The dressing begins to irritate the skin of the client after a week - The client is at a high risk for infection at the insertion site - Tests have proven that no infection will begin before a week - The nurse supervisor mandates a weekly dressing change

The client is at a high risk for infection at the insertion site The client is at a high risk of infection at the insertion site. PICC lines should be changed weekly due to the risk of infection that can get into the bloodstream of the client. Signs/symptoms of infection may include redness, edema at the site, pain at the site, pyrexia, rigors, and fluid leaking from the site. Infection may occur within 48-72 hours after insertion.

The nurse assesses the client's stoma during the initial postoperative period. What observation should the nurse report to the healthcare provider (HCP) immediately? - The stoma is dark red to purple - The stoma is slightly edematous - The stoma oozes a small amount of blood - The stoma does not expel stool

The stoma is dark red to purple A dark red to purple stoma indicates inadequate blood supply. Mild edema and slight oozing of blood are normal in the early postoperative period. The colostomy would typically not begin functioning until 2 to 4 days after surgery.

Which is an expected outcome of pursed-lip breathing for clients with emphysema? - to promote oxygen intake - to strengthen the diaphragm - to promote carbon dioxide elimination - to strengthen the intercostal muscles

To promote carbon dioxide elimination Purse-lip breathing prolongs exhalation and prevents air trapping in the alveoli, thereby promoting carbon dioxide elimination. By prolonging exhalation and helping the client relax, pursed-lip breathing helps the client learn to control the rate and depth of respiration. Pursed-lip breathing does not promote the intake of oxygen, strengthen the diaphragm, or strengthen intercostal muscles

The registered nurse (RN) is aware of what primary benefit of the prescription of a drug classified as a glucocorticosteroid? - weakens the overall immune system - relieves body irritation - prevents the spread of infection - treats total body inflammation

Treats total body inflammation Glucocorticosteroids are a specific group of drugs that work to treat total body inflammation. Drugs that fall into the class of glucocorticosteroids include: prednisone, dexamethasone, and hydrocortisone. The presence of an active fungal infection is a contraindication for taking glucocorticosteroids. This drug, when administered orally, should not be discontinued abruptly, but should be tapered. Prednisone and dexamethasone can also suppress the immune system, requiring caution for infection exposures when the drug is taken long-term.

True or False. A standard surgical mask is used as part of droplet precautions to protect the nurse from acquiring the client's infection.

True

True or False. Noninvasive ventilation delivers ventilatory support without an artificial airway (endotracheal or tracheostomy tube) to patients who can breath spontaneously.

True

True or False. Simple face masks are used in patients who require short term, higher oxygen concentration, such as FiO2 35% to 60%.

True

True or False. The NRB non-breather mask delivers 10-15 L/min and is used for medical emergencies.

True Ex) it is used for people who have carbon monoxide poisoning

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

Use a 10-mL syringe for the flush A 10-mL syringe would be used during the flush to minimize pressure on the device. Clamping the device would hinder the nurse's ability to flush the catheter. A 3-mL syringe would not reduce pressure on the device during the flush.

Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.60 F orally. Which action should the nurse take? - Begin the transfusion as prescribed - Administer two tablets of acetaminophen (Tylenol) and begin the transfusion - Delay hanging the blood and notify the health care provider (HCP) - Administer an antihistamine and begin the transfusion

Delay hanging the blood and notify the health care provider (HCP) If the client has a temperature higher than 1000 F, the unit of blood should not be hung until the HCP is notified and has the opportunity to give further prescriptions. The HCP likely will prescribe that the blood be administered regardless of teh temperature, but the decision is not within the nurse's scope of practice to make. The nurse needs an HCP's prescription to administer medication to the client.

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

Discard the first 6-9 mL of blood drawn Discarding the first sample reduces the risk of drug concentrations or a diluted specimen. Allowing fluid infusions to continue to flow right up to the time of the sample could alter the sample. Flushing the catheter after aspirating for blood return would have no effect on the quality of the sample. The patient need not be asked to rest before the sample is taken.

A nurse is beginning a foley catheter insertion on a client with urinary retention. Which hand is sterile and what should it hold? - Non-dominant hand, the tip of the Foley catheter with the rest coiled in hand - Dominant hand, holding the clients labia open - Non-dominant hand, holding the clients labia open - Dominant hand, the tip of the Foley catheter with the rest coiled in the hand

Dominant hand, the tip of the Foley catheter with the rest coiled in the hand The dominant hand holds the foley catheter for insertion. Being able to maneuver the catheter in case it becomes difficult during insertion is extremely important. The non-sterile hand has to keep the labia open to help keep the field of vision as clear as possible

Which term is used to document the presence of difficulty breathing noted in the provision of client care? - eupnea - tachypnea - dyspnea - bradypnea

Dyspnea

How often should the IV tubing be changed on a primary IV line? - Every week - Every shift - 12 hours - Every 24 hours - Every 72 hours

Every 72 hours IV tubing change should be changed every 72 hours on a primary IV line. Also tubing should be replaced whenever the sterile pathway could be compromised. Primary IV fluids are utilized for clients with dehydration, electrolyte imbalances, severe burns, and to administer nutrients as well as medications

The nurse who is about to begin a blood transfusion knows the blood cells start to deteriorate after a certain period of time. Which item is important to check regarding the age of blood cells before the transfusion is begun? - Blood identification number - Presence of clots - Expiration date - Blood group and type

Expiration date The nurse notes the expiration date on the unit of blood to ensure that the blood is fresh. Blood cells begin to deteriorate over time, so safe storage usually is limited to 35 days. Careful notation of the expiration date by the nurse is an essential part of the verification process before hanging a unit of blood. The nurse also notes the blood identification (unit) number, blood group and type, and client's name. The nurse also inspects the unit of blood for leaks, abnormal color, clots, and bubbles and returns the unit to the blood bank if clots are noted.

True or False. Nasal cannulas are the LEAST common type of low-flow oxygen delivery system.

False

True or False. The nurse's best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago is to notify the surgeon of the bleeding

False Bloody drainage 7 hours after surgery is still normal so the provider does not need to be contacted. If drainage increases and dressings become heavily saturated, then the surgeon should be notified as internal bleeding could be present.

True or False. To prevent exhaled carbon dioxide accumulation within a face mask, the flow rate must be set at 2 L/min - 5 L/min.

False To prevent exhaled carbon dioxide accumulation within a face mask, the flow rate must be set at MORE THAN 6 L/min

What is the proper procedure when cleaning the female perineal area with iodine? - First make sure the client is not allergic to betadine or iodine, then always clean from the meats downward (front to back) - First make sure the client is not allergic to iodine, then circle out from the meatus then back - First make sure the client is not allergic to betadine or iodine, then circle up to the meatus - First make sure the client is not allergic to betadine or iodine, then always clean from the anus out

First make sure the client is not allergic to betadine or iodine, then always clean from the meats downward (front to back) The first thing to do is making sure the client isn't allergic to betadine or iodine. Once that is done, always clean from the meatus down. Never return the iodine swab to the meatus. This would be contaminating the sterilized area and may introduce bacteria that can cause infection.

When administering an IV piggyback medication to infuse by gravity, how can the nurse ensure that the medication will infuse properly? - Hang the piggyback medication higher than the primary fluid - Use an infusion pump to regulate the flow of the piggyback medication - Attach the piggyback medication to the most proximal insertion port on the primary tubing. - Use a secondary infusion set for the piggyback tubing

Hang the piggyback medication higher than the primary fluid When a medication or any fluid is infused by gravity a pump is not necessary to run the infusion. Placing the secondary bag higher than the primary fluid will allow for the fluid to infuse at a faster rate than the primary bag with the help of gravity.

The nurse is instructing a client with COPD how to do pursed-lip breathing. In which order from first to last should the nurse explain the steps to the client? 1. "Breathe in normally through your nose for two counts (while counting to yourself, one, two.)" 2. "Relax your neck and shoulder muscles." 3. "Pucker your lips as if you were going to whistle." 4. "Breathe out slowly through pursed lips for four counts ("one, two, three, four.)"

In the following order: 2 1 3 4

Which activity is important to include in the plan of care of a patient with a peripherally inserted central catheter (PICC)? - Use a sterile technique when changing the PICC dressing - Take blood pressure in the arm with the PICC line - Change the IV tubing every 72 hours - Use only macro-drip tubing with IV infusions through the PICC line.

Use a sterile technique when changing the PICC dressing Using sterile technique is the most important to include because it decreases risk of bacteria entering the body, going directly to heart, and causing infection (endocarditis or myocarditis). Changing IV tubing is important but not a priority over maintaining a sterility during dressing change. You would NOT place a blood pressure cuff on the arm with the PICC line.

The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client's intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which complication has occurred? - Infiltration - Infection - Thrombosis - Phlebitis

Infiltration An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, and swelling are the results of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and start a new IV line at another site. Infection, phlebitis, and thrombosis are likely to be accompanied by warmth at the site, not coolness.

A client is admitted to the emergency department following a fall from a horse, and the primary health care provider (PHCP) prescribes insertion of a urinary catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take with action? - Notify the PHCP before performing the catheterization - Administer parenteral pain medication before inserting the catheter - Clean the meatus with soap and water before opening the catheterization kit - Use a small-sized catheter and an anesthetic gel as a lubricant

Notify the PHCP before performing the catheterization The presence of blood at the urinary meatus may indicate urethral trauma or disruption. The nurse notifies the PHCP, knowing the the client should not be catheterized until the cause f the bleeding is determined by diagnostic testing. The other options include performing the catheterization procedure and therefore are incorrect

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

Notify the practitioner Redness, swelling, and drainage at the catheter exit site are signs of infection, and the practitioner should be notified to make a decision regarding blood and catheter exit site cultures for further evaluation.

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action? - Wipe the spike end of the tubing with Betadine - Obtain new IV tubing - Scrub the spike end of the tubing with an alcohol swab - Obtain a new IV bag

Obtain new IV tubing The nurse should obtain new IV tubing because contamination has occurred and could cause systemic infection to the client. There is no need to obtain a new IV bag because the bag was not contaminated. Wiping with Betadine or alcohol is insufficient and is contraindicated because the spike will be inserted into the IV bag.

A client had a central venous line placed 15 minutes ago. What priority intervention should the nurse implement next? - Administer ordered IV fluids - Order a state chest x-ray - Administer IV antibiotics ordered - Order a stat ultrasound of the chest

Order a state chest x-ray When a central venous catheter is inserted, placement must be confirmed before using the line. Placement is confirmed by a stat chest x-ray. The tip of the catheter should lie in the superior vena cava.

A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient's pain? - Pre-medicate the patient with a prescribed analgesic 30 minutes before the intervention. - Thoroughly explain the procedure to the patient -Position the patient comfortably before the intervention. - Use a distraction technique to divert the patient's attention during the procedure

Pre-medicate the patient with a prescribed analgesic 30 minutes before the intervention By pre-medicating the patient before the intervention, it allows for the patient's pain to be controlled and for a comfortable state during dressing change. Distracting, re-positioning and explaining the procedure to the patient does not prevent or diminish the patient's pain.

When pouching a patient's colostomy, which action reduces the patient's risk for injury? - Protecting the skin from irritation caused by fecal drainage - Measuring output when emptying the contents of the pouch - Maintaining the patient's bowel elimination function - Promoting the patient's autonomy with bowel elimination care

Protecting the skin from irritation caused by fecal drainage Protecting the skin from irritation caused by fecal drainage ensures correct pouching and prevents injury associated with skin breakdown

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

Remove the transparent dressing or tape and gauze in the direction of catheter insertion The old dressing should be removed in the direction of catheter insertion. Positioning the patient with his or her head lower will not reduce the risk of dislodging the catheter during a dressing change. Skin protectant should be applied before placing a new catheter stabilization device.

Match: - Ventilation - Respiration - Low-flow devices - Moderate-flow devices - High-flow devices - Venturi mask, HFNCs - Nasal cannulas, face masks and NRB masks - Partial non-breather masks - The movement of air in and out of the lungs. Controlled by the Neurologic and musculoskeletal system. - Oxygen and carbon dioxide exchange in the lungs. Controlled by pulmonary and cardiovascular systems.

Ventilation - The movement of air in and out of the lungs. Controlled by the Neurologic and musculoskeletal system. Respiration - Oxygen and carbon dioxide exchange in the lungs. Controlled by pulmonary and cardiovascular systems. Low-flow devices - nasal cannulas, face masks and NRB masks Moderate-flow devices - Partial non-breather masks High-flow devices - Venturi mask, HFNCs

Which of the following oxygen delivery devices is most precise oxygen delivery device? - nasal cannula - non-rebreather mask - venturi mask - face tent

Venturi mask

The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which priority item? - Urine Output - Vital Signs - Latest hematocrit level - Skin Color

Vital Signs A change in vital signs during the transfusion from baseline may indicate that a transfusion reaction is occurring. This is why the nurse assesses vital signs before the procedure and again after the first 15 minutes. The other options do not identify assessments that are a priority just before beginning a transfusion.

Which nursing action demonstrates proper procedure in the collection of a wound culture specimen? - Wear clean gloves to remove soiled dressings - Using a circular motion to cleanse the wound before collecting the specimen. - Sending the specimen to the lab within 30 minutes of collecting it - Completing the lab requisition form in a timely manner after collecting the specimen

Wear clean gloves to remove soiled dressings Wearing clean gloves to remove soiled dressings minimizes the risk of cross contaminating the wound. The proper procedure is to wipe away old exudate by swabbing outward from the wound.

Which skin preparation would be best to apply around the client's colostomy? - adhesive skin barrier - petroleum jelly - cornstarch - antiseptic cream

adhesive skin barrier An adhesive skin barrier is effective for protecting the skin around a colostomy to keep the skin healthy and prevent skin irritation from stoma drainage. Petroleum jelly, cornstarch, and antiseptic creams do not protect the skin adequately and may prevent an adequate seal between the skin and the colostomy bag

Recognizing that the client prescribed theophylline for the treatment of bronchitis is at risk for toxicity, which clinical manifestation will alert the registered nurse (RN) to this occurrence? Select all that apply. - restless - drowsiness - loss of appetite - onset of seizures - insomnia

Restlessness Loss of appetite Onset of seizures Insomnia Theophylline has a narrow therapeutic range of 10 to 20 mcg/mL, of which any value greater than 20 mcg/mL is considered toxic. Frequent blood testing is indicated to monitor for toxicity. Early indicators of toxicity include the occurrence of anorexia, nausea/vomiting, insomnia, and/or restlessness. A critical sign of toxicity is the occurrence of tonic clonic seizures. Drugs that increase the occurrence of toxicity with theophylline include cimetidine and ciprofloxacin. These drugs are not administered to the individual prescribed theophylline.

The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride and needs to add the medication to the IV bag. The nurse should plan to take which action immediately after injecting the potassium chloride into the port of the IV bag? - Rotate the bag gently - Check the solution for yellowish discoloration - Prime the tubing with the IV solution - Attach the tubing to the client

Rotate the bag gently After adding a medication to a bag of IV solution, the nurse should agitate or rotate the bag gently to mix the medication evenly in the solution. The nurse should then attach a completed medication label. The nurse can them prime the tubing. The IV solution should have been checked for discoloration before the medication was added to the solution. The tubing is attached to the client last.

The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question? - "Do you know the complications and risks of a transfusion?" - "Have you ever gone into shock for any reason in the past?" - "Have you ever had a transfusion before?" - "Why do you think that you need the transfusion?"

"Have you ever had a transfusion before?" Asking the client about personal experience with transfusion therapy provides a good starting point for client teaching about this procedure. Questioning about previous history of shock and knowledge of complications and risks of transfusion are not helpful because they may elicit a fearful response from the client. Although determining whether the client knows the reason for the transfusion is important, it is not an appropriate statement in terms of eliciting information from the client regarding an understanding of the need for the transfusion.

The nurse is caring for a client receiving an albuterol/ipratropium nebulized breathing treatment. Which report from the client should the nruse note as an expected side effect of this combination medication? - "My eyes have been watering lately." - "I feel like my heart is racing." - "I feel more bloated than usual." - "I haven't had a bowel movement in 4 days."

"I feel like my heart is racing." Albuterol/ipratropium is a combination agent. One is a B -adrenergic agonist and the other is an anticholinergic medication, and in combination they produce an overall bronchodilation effect. Common side and adverse effects include headache, dizziness, dry mouth, tremors, nervousness, and tachycardia

A nurse instructs a client with allergic rhinitis about the correct technique for using an intranasal inhaler. Which statement indicates that the client understands the instructions? - "I should limit the use of the inhaler to early morning and bedtime use." - "I should hold one nostril closed while I insert the spray into the other nostril." - "The inhaler tip is inserted into the nostril and pointed toward the inside nostril wall." "It is important to not shake the canister because than can damage the spray device."

"I should hold one nostril closed while I insert the spray into the other nostril." When using an intranasal inhaler, it is important to close off one nostril while inhaling the spray into the other nostril to ensure the best inhalation of the spray. Use of the inhaler is not limited to mornings and bedtime. The canister should be shaken immediately before use. The inhaler tip should be inserted into the nostril and pointed toward the outside nostril wall to maximize inhalation of the medication.

The nasal cannula delivers how many liters per minute? - 1-10 L/min - 1-6 L/min - 1-7 L/min - 1-4 L/min

- 1-6 L/min

Which respiratory rate is classified as bradypnea for an adult? - 17 breaths/min - 15 breaths/min - 19 breaths/min - 21 breaths/min

- 15 breaths/min

Which steps help to manage infection control with PICC line dressing changes? Select all that apply - Ensure the client and nurse wear a mask prior to the beginning the dressing change - Don sterile gloves after removing previous dressing - Scrub skin with chlorhexidine using sterile gauze to hold the line in place - Use soap and water to clean skin around Statlock

- Ensure the client and nurse wear a mask prior to the beginning the dressing change - Don sterile gloves after removing previous dressing - Scrub skin with chlorhexidine using sterile gauze to hold the line in place sterile gloves should be donned after removing the previous PICC line dressing. Steps to help prevent infection when changing a PICC line may include: masking the client and the nurse prior to starting the dressing change; don sterile gloves after removing the previous PICC line dressing; and scrub the skin with chlorhexidine (antimicrobial) using sterile gauze to hold the line steady and in place. The dressing is a sterile dressing change

Which of the following are primary risk factors for pressure ulcers? Select all that apply. - Fever - Low-protein diet - Insomnia - Sleeping on a waterbed - Lengthy surgical procedures

- Fever - Low-protein diet - Lengthy surgical procedures Protein is needed for adequate skin health and healing. During surgery the patient is on a hard surface for a long period of time and their body is not well protected from pressure on bony prominences. Fever causes diaphoresis so the patient's skin is moist leading to skin breakdown, and the stress on the body can cause their circulation to be impaired leading to a decrease in skin integrity.

Which actions would the nurse take when obtaining a sputum culture from a client with a diagnosis of pneumonia? Select all that apply. - Have the client brush his teeth before expectoration - Explain the procedure to the client - Instruct the client to take deep breaths before coughing - Obtain the specimen early in the morning - Place the lid of the culture container face down on the bedside table

- Have the client brush his teeth before expectoration - Explain the procedure to the client - Instruct the client to take deep breaths before coughing - Obtain the specimen early in the morning

Which area of the body will the client have an increased risk of developing a pressure injury? Select all that apply. - Knees and thighs - wrists and hands - heels and ankles - sacrum and coccyx - bilateral hip bones

- Knees and thighs - heels and ankles - sacrum and coccyx - bilateral hip bones Sacrum and coccyx are areas of the body that have an increased risk of developing pressure injury. A pressure injury occurs when there is damage to the skin and the underlying soft tissue. This occurs as a result of the compression of the skin and skin tissue between a bony prominence and an external surface. The most common areas this can occur include the sacrum, coccyx, hips, heels, and ankles.

The nurse is teaching a class on strategies of pressure injury prevention. What should be included in the information? Select all that apply - Pressure redistribution turn every 1-2 hour - Encourage a diet high in protein and calories - Keep clients clean and dry by managing incontinence - Rub and massage the clients pressure injuries

- Pressure redistribution turn every 1-2 hour - Encourage a diet high in protein and calories - Keep clients clean and dry by managing incontinence Pressure redistribution and turning every 1-2 hours helps prevent pressure injuries. This answer is correct because a diet high in protein and calories will help prevent skin breakdown and pressure injuries. When a client has a low albumin and protein is low, the client has a much higher risk of skin breakdown. The client should be checked every 1-2 hours and changed if incontinent. Mild soaps and skin moisturizers should be utilized to help prevent breakdown. . Dry intact skin breaks down much faster than dry intact moisturized skin.

Which of the following describes the function of wound dressings? Select all that apply. - Protects surgical incision from infection - Absorbs excess drainage - To dry out the incision - Creates a sterile field for the incision -Allows for wound friction

- Protects surgical incision from infection - Absorbs excess drainage - Creates a sterile field for the incision Without the dressing, the client is a risk for cross contamination as well. The nurse must follow the orders of the healthcare provider to properly take care of the clients needs. This answer is correct because the dressing absorbs excess drainage. The dressing helps to promote healing by keeping the incision moist. Without the dressing it causes the incision to become dry and hinders the healing process and causes the client excess pain. A sterile dressing protects the incision and promotes healing. The dressing protects the incision from trauma and infection. The nurse will use aseptic technique when taking care of the clients incision

Which signs alert the nurse to a potential complication of an IV push? Select all that apply. - The nurse assesses that the insertion catheter will not flush - The client presents with labored breathing after the push - The client says, "Stop, this is taking too long." - The nurse observes clear liquid ooze from the IV insertion site

- The nurse assesses that the insertion catheter will not flush - The client presents with labored breathing after the push - The nurse observes clear liquid ooze form the IV insertion site Clear fluid oozing around the IV catheter insertion site indicates something is wrong with the IV site. If the nurse assesses that the catheter will not flush, she should check for kinks in the catheter tubing and do not forcefully flush the IV catheter. Labored breathing after a push of med can mean an adverse reaction is occurring.

When choosing a site for the IV catheter, which statement(s) is/are true? Select all that apply. - The nurse will choose a vein that is not visibly hard or scarred - The nurse and client will collaborate on choosing an appropriate site - The nurse will attempt to choose a site to maximize client mobility - The vein should be visible or easily palpated above the antecubital site - The client will need to have the site in an area that can be easily cared for by the client

- The nurse will choose a vein that is not visibly hard or scarred - The nurse and client will collaborate on choosing an appropriate site - The nurse will attempt to choose a site to maximize client mobility The client knows which veins are easily accessible and can advise the nurse. The collaboration between the client and the nurse can increase access to a functional site. Many clients prefer the IV not be placed in the dominant hand, so they can continue to maximize mobility as much as possible while hospitalized. The nurse should choose a vein that is not visibly hard or scarred. Patients should not care for their own IV site.

A client is admitted to the hospital with a diagnosis of right lower lob pneumonia. The nurse auscultates the affected lung area, expecting to note which type of breath sounds? - vesicular - Bronchovesicular - absent - bronchial

- bronchial Bronchial sounds are normally heard over the trachea. The client w/ pneumonia will have bronchial breath sounds over area(s) of consolidation because the consolidated tissue carries bronchial sounds to the peripheral lung fields. The client may also have crackles in the affected area resulting from fluid in the interstitium and alveoli. Absent breath sounds are not likely to occur unless a serious complication of pneumonia occurs. Vesicular sounds are normally heard over the lesser bronchi, bronchioles, and lobes. Bronchovesicular sounds a re normally heard over the main bronchi

What technique will the registered nurse (RN) educate the client to implement when administering the beclomethasone inhalation therapy? - place the beclomethasone inhaler in the refrigerator as it works better chilled - place the beclomethasone inhaler under warm water as it works better warmed - administer the inhalation therapy through a space attached to the inhaler mouthpiece - position the mouthpiece of the inhaler one inch away from the open mouth as the drug is dispersed out

administer the inhalation therapy through a space attached to the inhaler mouthpiece The RN will educate the client to implement a specific intervention when administering the beclomethasone inhalation therapy. The intervention the RN will educate the client to implement is to administer the inhalation therapy through a spacer attached to the inhaler mouthpiece. Corticosteroids are a group of drugs that help reduce inflammation specifically in the respiratory system. Specific drugs in this drug class include: fluticasone, beclomethasone, and methylprednisolone. The drugs are administered using inhalation therapy as part of the treatment plan for asthma. Because of the risk of the individual developing oral thrush (Candida albicans) it is beneficial for the individual to use a spacer to administer this inhalation drug. The inhaler device mouthpiece is attached to the spacer. This will allow delivery of the drug without residual drug collecting in the oral cavity

For a client with asthma, the HCP prescribes albuterol, two puffs twice a day via MDI, and beclomethasone, two puffs twice a day via MDI. The nurse should instruct the client to administer: - medications 1 hour apart, two times a day - beclomethasone inhaler first and follow with albuterol - albuterol on awakening and alternate the medications every 4 hours - albuterol first and follow with beclomethasone two times a day.

albuterol first and follow with beclomethasone two times a day. The nurse instructs the client to administer the bronchodilator first in order to open the airway and allow for improved delivery of the corticosteroid to the lung tissue, which follows after 1 minute between puffs. Using a spacer device with an MDI provides the best delivery of medication to the lungs

The nurse team leader is making rounds and observes the client who had a tracheostomy tube inserted 2 days ago. ( see figure on back) The nursing policy manual recommends use of the gauze pad. The nurse should: - ask a registered nurse (RN) to change the ties and position another gauze pad around the stoma. - ask the unlicensed assistive personnel (UAP) to tie the tracheostomy tube ties in the back of the client's neck. - reposition the gauze pad around the stoma with the open end downward. - make sure the gauze pad is dry and the client is in a comfortable position.

make sure the gauze pad is dry and the client is in a comfortable position. The tracheostomy tube, ties, and gauze pad are positioned correctly; the nurse team leader should be sure the client is comfortable. The tracheostomy tube ties should be tied in a square knot on the side of the neck and alternate sides of the neck when the ties are changed. The full part of the gauze square should be placed under the tracheostomy tube to absorb drainage. There is no indication the ties need to be changed; an addition gauze pad is not necessary; if necessary, the current gauze square should be changed rather than adding an additional pad.

A client who had an appendectomy for a perforated appendix returns from surgery with a JP drain inserted in the incisional site. The purpose of the drain is to; - promote drainage of wound exudates - provide access for wound irrigation - minimize development of scar tissue - decrease postoperative discomfort

promote drainage of wound exudates JP Drains are inserted postoperatively in appendectomies when an abscess was present, or the appendix was perforated. The purpose is to promote drainage of exudate from the wound and facilitate healing. A drain is not used for irrigation of the wound. The drain will not minimize scar tissue development or decrease postoperative discomfort.

When suctioning a tracheostomy tube 3 days following insertion, what should the nurse do? - use a sterile catheter each time the client is suctioned - use a clean catheter with each suctioning, and disinfect it in hydrogen peroxide between uses - protect the catheter in sterile packaging between suctioning episodes - Clean the catheter in sterile water after each use, and reuse from no longer than 8 hours

use a sterile catheter each time the client is suctioned The recommended technique is to use a sterile catheter each time the client is suctioned. There is a danger of introducing organisms into the respiratory tract when strict aseptic technique is not used. Reusing a suction catheter is not consistent with aseptic technique. The nurse does not use a clean catheter when suctioning a tracheostomy or a largyngectomy; it is a sterile procedure