UWorld Fundamentals Skills and Procedures

Prior to discharge, the nurse must evaluate the client's ability to perform home wound care. When performing a simple dry dressing change, the client should:

- Don clean gloves and perform hand hygiene before and after removing the old dressing - Cleanse the wound bed using sterile saline (or a prescribed cleanser) by moving from "clean" to "dirty," or from the center of the wound outward (Option 3) - Thoroughly dry the wound and surrounding skin using sterile gauze to prevent maceration (breakdown) of underlying tissues - Monitor the site for signs of infection (eg, redness, warmth, purulent drainage) (Option 4) - Apply dry, sterile gauze over the wound bed - Cover the gauze with an occlusive sterile dressing to keep gauze in place and maintain asepsis. The covering should be applied without touching the wound bed (Option 1)

Ten minutes after an infusion of packed RBCs is initiated through a triple lumen central venous catheter (CVC), the client reports shortness of breath and slight chest tightness. Which of the following initial actions would be appropriate for the nurse to perform? Select all that apply. If a transfusion reaction is suspected, the nurse should immediately stop the transfusion, disconnect the blood IV tubing, connect new tubing, and infuse 0.9% sodium chloride. The nurse should then remain with and frequently assess the client and notify the health care provider from the bedside.

1) Assess the patient's breath sounds 2) Notify HCP 3) Stop the infusion Signs of a transfusion reaction include chills, fever, flushing, itching, shortness of breath, and chest tightness. If signs of a transfusion reaction occur, the nurse should:

The nurse is reinforcing instructions to a client on collection of a sputum specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective? Select all that apply.

1. "I should rinse my mouth with water before collecting the sputum." 2."I will be careful not to touch the inside of the specimen cup or lid." 3. "I will inhale deeply a few times and then cough forcefully." 5. "It is helpful if I am sitting upright when I collect the sputum."

A 2-year-old is admitted to the emergency department for anaphylactic reaction to a bee sting. The nurse teaches the parent about emergency use of epinephrine injection. Which statement indicates that the parent understands the instruction? Select all that apply. The injection should be given in the mid-outer thigh and can be given through clothing (Options 3 and 4)

1. "I will keep an epinephrine injection in close proximity to my child at all times." -The EpiPen should always be available for emergency use and so should be taken along (in purse, pocket, backpack) when the client leaves home (Option 1 2."I will give the injection if my child has trouble breathing after a bee sting." -The EpiPen should be given when the client first notices any anaphylactic symptoms, such as tightening or swelling of the airway, difficulty breathing, wheezing, stridor, or shock (Option 2) 4."The injection can be given through clothing." 5."If I give the injection, I'll still take my child to the emergency room."

The nurse has attended a staff education program about obtaining blood specimens from newborns via heel stick. Which of the following statements by the nurse would require follow-up? Educational objective:A heel stick is used to collect a blood specimen from a newborn. The nurse should warm the heel prior to the procedure, select a location on the outer aspect (eg, medial or lateral) of the newborn's heel, provide comfort measures (eg, nonnutritive sucking), and wipe away the first drop of blood.

1. "I will obtain the blood specimen from the center of the newborn's heel Proper technique involves obtaining the specimen from the outer lateral or medial aspect of the newborn's heel using an automatic lancet. The nurse should avoid puncturing the center of the heel to prevent injury to the calcaneus or nerves in that area (Option 1).

A school nurse observes a 3-year-old begin to choke and turn blue while eating lunch. What should be the nurse's initial action?

1. Abdominal thrusts (Option 2) Back blows and chest thrusts are appropriate interventions for a choking infant under age 1. Older children require abdominal thrusts to clear an obstructed airway.

The nurse is preparing to irrigate the wound of a 7-year-old client who sustained a laceration while on a playground. Which of the following actions should the nurse take? Select all that apply. Fill a 30- to 60-mL sterile irrigation syringe with the prescribed irrigation solution. Attach an 18- or 19-gauge needle to the syringe and hold it 1 inch (2.5 cm) above the wound. Wounds should be cleansed from the least to the most contaminated area to prevent recontamination.

1. Administer a prescribed analgesic 30 minutes before irrigating the wound 4. Review the client's vaccination record 5. Use continuous pressure to flush the wound and repeat until the drainage is clear - Dry the surrounding wound area to prevent skin breakdown and irritation.

The nurse is preparing to change the wound dressing for a client who is receiving negative pressure wound therapy. Which of the following actions should the nurse take? Select all that apply

1. Administer pain medication 30 minutes before the procedure 2.Apply skin protectant to intact skin surrounding the wound 3.Cut the foam dressing to the shape and size of the wound 4.Ensure that the prescribed negative-pressure setting is applied 5.Verify that the occlusive film dressing is free of air leaks When changing a negative pressure wound therapy dressing, the nurse should administer analgesics, apply a skin protectant to intact skin around the wound, cut the foam dressing to the shape and size of the wound, ensure the prescribed pressure is applied, and verify that the occlusive dressing is free of air leaks.

The nurse is preparing to administer an intermittent enteral feeding to a client who has a nasogastric tube. The client has a gastric residual volume of 75 mL. Which of the following actions should the nurse take? Select all that apply. Aspirated GRV should be returned to the stomach. If repeatedly discarded, there is risk for hypokalemia and metabolic alkalosis. Gastric residual pH should be acidic (pH ≤5)

1. Administer the scheduled feeding as prescribed - Per facility policy, enteral feedings may need to be held for a high GRV (eg, >500 mL) to reduce the risk of aspiration. A low GRV indicates that the client is tolerating the feedings well and the feeding may be administered as prescribed (Option 1) 2.Check the pH of the residual and hold the feeding for a pH of 6 4. Flush the nasogastric tube before and after administering the feeding 5. Place the client in the semi-Fowler position during the feeding

The nurse is performing open endotracheal suctioning for a client with a tracheostomy tube. Which of the following actions by the nurse are appropriate? Select all that apply.

1. Administers 100% oxygen prior to suctioning the client 2.Applies suction while withdrawing the catheter from the airway 5.Uses sterile gloves and technique throughout the procedure - Limit suctioning to ≤10 seconds on each suction pass

One unit of packed RBCs (PRBCs) is prescribed for a client experiencing complications of sickle cell anemia. Which of the following actions by the nurse are appropriate? Select all that apply. Click the exhibit button for additional information. ) Blood products should be administered within 4 hours to reduce the risk of bacterial contamination.

1. Administers type A-negative blood 4. Uses filtered Y-type tubing with 0.9% sodium chloride 5. Verifies client identifiers and blood product with another nurse before administration

The charge nurse observes a new staff nurse collecting a urine sample for urinalysis and culture as pictured. What is the charge nurse's best action? Click on the exhibit button for additional information.

1. Advise the staff nurse to discard the collected urine specimen and record the output A urine specimen is collected aseptically from the specimen port in an indwelling urinary catheter. Urine that has been collected from the collection bag does not yield accurate urinalysis and culture results.

The nurse is suctioning the artificial airway of a conscious client. Which actions demonstrate correct technique? Select all that apply. (Option 2) The suction catheter should be no more than half the width of the artificial airway and inserted without suction. Apply intermittent or continuous suction while withdrawing the catheter. Suction should be set at medium pressure (100-120 mm Hg for adults, 50-75 mm Hg for children) as excess pressure will traumatize the mucosa and can cause hypoxia. Clients usually cough as the catheter enters the trachea, and this helps loosen secretions. The catheter should be advanced until resistance is felt and then, to prevent mucosal damage, retracted 1 cm before applying suction.

1. Apply suction for no longer than 5-10 seconds 4. Wait at least 1 minute between suction passes The process of suctioning a client's airway removes oxygen in addition to the secretions; therefore, the client should be preoxygenated with 100% O2, and suction should be applied for no more than 10 seconds during each pass to prevent hypoxia (Option 1). The nurse must wait 1-2 minutes between passes for the client to ventilate to prevent hypoxia (Option 4). In addition, deep rebreathing should be encouraged.

The nurse is caring for a postoperative client who has D5W/0.45% normal saline with 10 mEq potassium chloride infusing through a peripheral IV catheter. What are appropriate reasons for the nurse to change the site? Select all that apply. (Option 2) Potassium is a known irritant to veins. Discomfort is not a sign of infiltration, although the site should be regularly monitored for complications. ) Locations where flexion occurs (eg, antecubital region) are generally avoided; however, these sites may be required for certain medications or situations. Unless a problem develops, PIV sites are not changed based solely on location.

1. Area around the insertion site feels cool to touch 3. Edema is observed on the dependent side of the involved arm Serous fluid leaking from the site despite secure connections Peripheral IV catheter sites should be changed no more frequently than every 72-96 hours unless signs of complications develop. The nurse should check for signs of infiltration by assessing the insertion site and areas dependent from it (ie, edema, cool skin).

The nurse is assessing urine dipstick results in a client with right flank area pain for the past 24 hours. According to the dipstick results, what is the nurse's best action? Click on the exhibit button for additional information. ) Glucose in the urine is suspicious for diabetes mellitus. This client's glucose test strip result is negative. Nurse should obtain more information and assess before reporting to the HCP.

1. Ask the client about any recent illnesses The results of point-of-care testing, such as using urine test strips, are often interpreted by the nurse. Occasional loss of up to 150 mg/day of protein in the urine is typically considered normal and usually does not require further evaluation. Common benign causes of transient proteinuria include fever, strenuous exercise, and prolonged standing.

The spouse of a client calls the nurse at the clinic and reports that the client is not feeling well and is concerned that something is seriously wrong. How should the nurse respond initially?

1. Ask the spouse to further describe the client's symptoms The first step in the nursing process is assessment. In this situation, additional information is needed before the nurse can determine the next course of action (Option 1). It is not a violation to obtain information about a client from a knowledgeable source.

The nurse is assisting a client who has a bedside needle liver biopsy scheduled. Which are the essential actions? Select all that apply. full bladder is a concern with paracentesis when a trocar needle is inserted into the abdomen to drain ascites. A he client must lie on the right side for a minimum of 2-4 hours to splint the incision site. The liver is a "heavy" organ and can "fall on itself" to tamponade any bleeding. The client stays on bed rest for 12-14 hours.

1. Assess for rising pulse and respirations afterward 2.Check PT/INR and PTT values before the procedure 3.Ensure that the client's blood is typed and crossmatched The client's coagulation status is checked before the liver biopsy using PT/INR and PTT. The liver ordinarily produces many coagulation factors and is a highly vascular organ. Therefore, bleeding risk should be assessed and corrected prior to the biopsy (Option 2). Blood should be typed and crossmatched in case hemorrhage occurs (Option 3).After the procedure, frequent vital sign monitoring is indicated as the early signs of hemorrhage are rising pulse and respirations, with hypotension occurring later (Option 1).

The nurse prepares to administer a cleansing enema to a client with constipation. Which of the following interventions are appropriate? Select all that apply. Enemas should be administered at room temperature or warmed, because cold enema solutions cause intestinal spasms and painful cramping. Enemas may be warmed by placing the container of solution in a basin of hot water.

1. Assist the client into left lateral position with right knee flexed (ie, Sims position) to promote flow of the enema into the colon (Option 1). 2.Encourage the client to retain the enema after administration (5-10 mins) 3.Insert tubing into the rectum with the tip directed toward the umbilicus (ie, anteriorly) to prevent intestinal perforation (Option 3). 5.Stop administration briefly if the client reports abdominal cramping Hanging the enema bag no more than 12 inches (30 cm) above the rectum to avoid overly rapid administration. Lubricating the enema tubing tip and gently inserting 3-4 inches (7.5-10 cm) into the rectum.

The nurse is caring for a 6-month-old client who has a new tracheostomy. Which of the following findings would indicate that the client's airway requires suctioning? Select all that apply. Findings that indicate a need for suctioning include: Adventitious breath sounds (eg, rhonchi, wheezes, crackles) (Option 1) Altered mental status (eg, irritability, lethargy) (Option 3) Decreased oxygen saturation (Option 4) Increased heart rate Increased respiratory rate Increased work of breathing (eg, flared nostrils, use of accessory muscles) Pallor, mottling, or cyanosis of the skin

1. Audible gurgling 3. Increased irritability 4.Oxygen saturation of 88%

Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test? Select all that apply. An arm without IV infusion is preferred. If it is necessary to use the arm with the IV infusion, the specimen should be collected from a vein several centimeters below (distal to) the point of IV infusion, with the tourniquet placed in between. The finger specimen should be obtained from the third or fourth finger on the side of the fingertip, midway between the edge and midpoint.

1. Avoid the arm on the affected side after a mastectomy 2.Do not make further attempts to draw blood if unsuccessful on first 2 attempts - The Infusion Nurses Society (INS) identifies the standard of care as no more than 2 attempts by any 1 individual. If the nurse is unable to successfully draw blood after 2 attempts, a phlebotomist or a different nurse should be asked to complete the blood draw. 4. Insert the needle bevel up at a 15-degree angle to the skin

The nurse is documenting the assessment of a client's peripheral pulses. The nurse palpates the top portion of the client's feet and notes that the right pulse is full and strong, and the left pulse is diminished but still palpable. Which of the following would be correct documentation to include in the client's medical record?

1. Bilateral dorsalis pedis pulses palpable. Right pulse 3+, left pulse 1+ The dorsalis pedis pulse is located on the top or dorsal part of the foot. The force of the pulse should be rated as 0, absent; 1+, diminished; 2+, normal; 3+, full and strong; or 4+, bounding.

A client arrives in the emergency department on a cold winter day. The client is calm, alert, and oriented with a respiratory rate of 20/min and a pulse oximeter reading of 78%. The nurse suspects that the client's pulse oximeter reading is inaccurate. Which factors could be contributing to this reading? Select all that apply.

1. Black fingernail polish 2. Cold extremities 4. Hypotension 5. Peripheral arterial disease Any factor that affects light transmission or peripheral blood flow can cause a falsely low reading for oxygen saturation on pulse oximeter. Common causes include dark nail polish, hypotension, low cardiac output, vasoconstriction (eg, hypothermia, vasopressor medications), and peripheral arterial disease.

A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-mL balloon inserted to relieve postoperative urinary retention. The nurse observes urine leaking from the insertion site, past the catheter. What is the nurse's first action?

1. Check the urethral catheter and drainage tubing If leakage of urine is observed from the insertion site of an indwelling urinary catheter, the nurse should assess for obstruction, kinking, or compression of the catheter or drainage tubing; bladder spasms; and improper catheter size. - Remove kinking or compression of the catheter or tubing. - Attempt to dislodge a visible obstruction by milking the tubing. This involves squeezing and releasing the full length of the tubing, starting from a point close to the client and ending at the drainage bag. If these interventions fail, the nurse should then notify the health care provider (HCP) (Option 3).

The nurse prepares to draw up regular and NPH insulins into one syringe. Place in order the steps the nurse should take when mixing the insulins. All options must be used. cloudy--> clear --> clear--> cloudy The nurse can recall the mnemonic RN (Regular before NPH).

1. Clean the vial tops with alcohol swabs 4. Inject air into the NPH insulin vial 5. Inject air into the regular insulin vial 3. Draw up the regular insulin solution 2. Draw up the NPH insulin solution

The nurse observes a client who is postoperative left total knee replacement use a cane. Which action by the client indicates an understanding of the correct technique when walking down the stairs?

1. Descends with the cane on the step first, followed by the left leg, and then the right leg To remember the order, use the mnemonic "up with the good and down with the bad." The cane always moves before the weaker leg.

The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions? Select all that apply. The veins on the ventral aspect of the wrist are located near nerves, resulting in painful venipuncture and a higher risk of nerve injury.

1. Do not leave a tourniquet on more than 1 minute while looking for a vein 3. If pulsating red blood is noted, withdraw the needle and apply pressure for 5 minutes When performing phlebotomy for a laboratory specimen, allow the cleansed area to air dry, do not use the veins on the ventral side of wrist, position the tourniquet for no more than 1 minute at a time, and invert the tube gently 5-10 times to mix the solution with blood. Insertion in an artery will cause pulsation; if this happens, immediately remove the needle and apply pressure for 5 minutes

Which interventions should the nurse perform when assisting the health care provider with removal of a client's chest tube? Select all that apply. The client should be placed in semi-Fowler's position or on the unaffected side to promote comfort and facilitate access for tube removal.

1. Ensure the client is given an analgesic 30-60 minutes before tube removal 2.Instruct the client to breathe in, hold it, and bear down while the tube is being removed 4.Prepare a sterile airtight petroleum jelly gauze dressing 5. Provide the health care provider with sterile suture removal equipment

The nurse is inserting an indwelling (Foley) urinary catheter into a male client. After inserting the catheter about 6 in (15.2 cm), the nurse notes drops of urine in the tubing. What action should the nurse take next? ) The client should be told to take slow, deep breaths to help relax the external sphincter and provide a distraction.

1. Further insert the catheter 1-2 in (2.5-5.1 cm) In the male client, it is recommended that the catheter be inserted 7-9 in (17-22.5 cm) or until urine flows out, due to the longer urethra. The catheter should then be inserted at least an additional 1 in (2.5 cm) or to catheter bifurcation.

The student nurse verbalizes the procedure for obtaining a wound culture to the nurse preceptor. Which of the following statements by the student indicate a correct understanding? Select all that apply. (Option 3) Pooled purulent exudate likely contains skin flora different from the pathogen(s) responsible for the infection. Microorganisms responsible for infection are most likely found in viable tissue.

1. I will apply the prescribed bacitracin ointment after collecting the wound culture." 2."I will cleanse the wound by gently flushing it with normal saline." "4."I will perform hand hygiene and apply new gloves before obtaining the wound culture." Wound cultures are used to identify microorganisms and select appropriate antibiotics. The nurse should assess and clean the wound, swab from the wound center toward the outer margin, and avoid contamination (eg, hand hygiene, not touching intact skin with swab) to prevent misidentification of microorganisms.

The nurse is changing the dressing, injection caps, and IV tubing of a client who is receiving total parenteral nutrition through a right peripherally inserted central venous catheter. The nurse should implement what actions to prevent complications during this procedure? Select all that apply. When performing the dressing change, the client should be instructed to turn the head away from the PICC site to prevent potential contamination of the insertion site by microorganisms from the client's respiratory tract. ) During dressing, injection caps, and tubing changes, the client is placed in the supine position. If an air embolism is suspected, the client should be placed in the Trendelenburg position (head down) on the left side, causing any existing air to rise and become trapped in the right atrium.

1. Instruct the client to hold the breath when changing the injection caps and tubing 3.Perform hand hygiene before and after the procedure 5.Wear sterile gloves and a surgical mask when changing the dressing Prior to a central line dressing change, the nurse performs hand hygiene (Option 3). The central line dressing change is performed using sterile technique with the nurse wearing a mask to prevent contamination of the site with microorganisms or respiratory secretions (Option 5). During injection cap and tubing changes, the client is instructed to hold the breath (or perform the Valsalva maneuver) to prevent air from entering the line, traveling to the heart, and forming an air embolism (Option 1).

The nurse is assessing a client for orthostatic hypotension. Which of the following actions should the nurse take? The first set of vital signs is obtained while the client is in the supine position. The nurse can place the client in Trendelenburg position to encourage blood flow to the head if the client reports dizziness. Reverse Trendelenburg position causes blood to pool in the extremities in the dependent position. The nurse should check the client's blood pressure and heart rate at 1 minute after the client changes position, and again at 3 minutes after.

1. Notify the health care provider If the client's systolic blood pressure decreases ≥20 mm Hg Assessing a client for orthostatic hypotension involves checking the client's blood pressure and heart rate in the supine, sitting, and standing positions. The nurse should notify the health care provider if any position change produces a decrease of systolic blood pressure ≥20 mm Hg (Option 1).

The nurse assesses the breath sounds of a 2-day postoperative total laryngectomy client and determines that suctioning is needed to clear secretions. The client is off the mechanical ventilator and is receiving humidified oxygen via a tracheostomy mask. Place the steps for suctioning the tracheostomy tube in the correct order. All options must be used.

1. Place client in semi-Fowler's position 5. Preoxygenate (hyper-oxygenate) with 100% oxygen 3. Insert catheter the length of the airway without applying suction 2. If resistance is felt, withdraw the catheter 0.4-0.8 in (1-2 cm) 1. Apply intermittent suction while rotating the suction catheter while withdrawing

A charge nurse is monitoring a newly licensed registered nurse. What action by the new nurse would warrant intervention by the charge nurse? (Option 2) Occasional premature ventricular contractions (PVCs) in the normal heart are not significant. PVCs in the client with coronary artery disease or myocardial infarction indicate ventricular irritability and may lead to life-threatening dysrhythmia such as ventricular tachycardia.

1. Prepares to administer IVPB potassium chloride via gravity infusion for a client with hypokalemia Treatment of hypokalemia may require an IV infusion of potassium chloride (KCL). The infusion rate should not exceed 10 mEq/hr (10 mmol/hr). Therefore, IVPB KCL must be given via an infusion pump so the rate can be regulated. IV KCL should be diluted and never given in a concentrated amount. Furthermore, too rapid infusion can cause cardiac arrest. The charge nurse would need to intervene if the new nurse was attempting to administer IVPB KCL via gravity infusion instead of a pump.

The nurse working in an intensive care unit receives a prescription from the primary health care provider to discontinue a triple-lumen subclavian central venous catheter. Which interventions will help prevent air embolism on removal? Select all that apply. To prevent air embolism when discontinuing a central venous catheter, it is important for the nurse to pull the line cautiously, have the client in a supine position, have the client bear down or exhale, and apply an air-occlusive dressing.

1.Applying an air-occlusive dressing 2.Instructing the client to bear down 3.Instructing the client to lie in a supine position - Pull the line cautiously and never pull harder if there is resistance. Doing so could cause the catheter to break or become dislodged in the client's vessel (Option 4).

The nurse has a prescription to infuse 2 units of packed RBCs to a client with gastrointestinal bleeding. Which of the following actions are appropriate? Select all that apply.

1.Assess the client's vital signs 2.Infuse the 2 units simultaneously 3.Obtain a Y-type tubing infusion set 4.Plan to remain with the client for the first 15 minutes of the transfusion Appropriate steps for safe blood transfusion include checking vital signs before, throughout, and after the transfusion; using a Y-type tubing set; and remaining with the client for at least the first 15 minutes to monitor for a transfusion reaction.

The nurse is caring for a client who is having a thoracentesis. Following the procedure, the nurse monitors for complications. The initial postprocedure monitoring plan should include what? Select all that apply. Thoracentesis is commonly used to treat pleural effusion. The health care provider (HCP) will prepare the skin, inject a local anesthetic, and then insert a needle between the ribs into the pleural space where the fluid is located. A complication of thoracentesis is pneumothorax, which occurs when the needle goes into the lung and causes the lung to slowly deflate, like a balloon with a small hole in it. Bleeding is another, yet less common, complication of the procedure. Infection would be a later complication (occurring a few days after the procedure), so monitoring temperature is not required during the initial postprocedure period. - Urine output not affe ted

1.Level of alertness 2.Lung sounds 3.Oxygen saturation 4.Respiratory pattern Signs of pneumothorax include increased respiratory rate, increased respiratory effort, respiratory distress, low oxygen saturation, and absent breath sounds on the side where the procedure was done (where the lung is collapsed) (Options 2, 3, and 4). Tension pneumothorax may also develop, with tracheal shift to the unaffected side, severe respiratory distress, and cardiovascular compromise. Altered level of consciousness may occur due to decreased oxygenation and blood flow to the brain (Option 1). A tension pneumothorax may be prevented by early detection of pneumothorax through appropriate monitoring.

The health care provider prescribes a continuous IV infusion of regular insulin at 5 units/hr. The infusion bag contains 50 units of regular insulin in 100 mL of normal saline solution. At what rate in milliliters per hour (mL/hr) does the nurse set the IV pump? Record your answer using a whole number.

10 ml/hr

A client with hypokalemia is prescribed IV potassium chloride (KCl) to infuse at 10 mEq/hr. The pharmacy sends 20 mEq of KCl in 250 mL of D5W. To deliver the prescribed dose, the nurse sets the infusion pump at how many milliliters per hour (mL/hr)? Record your answer using a whole number.

125 ml/hr

A client with ascites had 5400 mL of fluid removed during paracentesis. The health care provider prescribes 8 g of albumin IV per 1000 mL of fluid removed. If the albumin is supplied as 25 g in 100-mL bottles, how many mL will the nurse administer? Record your answer using one decimal place.

172.8 ml Albumin may be given after paracentesis to prevent volume depletion in a client with cirrhotic ascites.

The nurse cares for an 11-lb (5-kg) infant admitted with dehydration and prepares to calculate intake and output over an 8-hour shift. Using the data in the exhibit, calculate the total output in milliliters for the 8-hour shift. Record your answer as a whole number. Click on the exhibit button for additional information. One (1) gram of weight is equal to one (1) milliliter of fluid. Adequate urinary output for an infant is 2 mL/kg/hr.

178 ml

A child with congenital heart disease weighing 44 lb is prescribed furosemide 1 mg/kg PO every 8 hours. It is available as an oral solution of 10 mg/mL. How many milliliters (mL) of furosemide should the nurse administer to the client each dose? Record your answer using a whole number.

2 ml

The nurse is preparing a client for a magnetic resonance cholangiopancreatography. Which statements by the client would require the nurse to obtain further assessment data? Select all that apply. Many clients should be NPO for 4 hours prior to the procedure to allow better visualization of the anatomical features. (Option 5) Smoking does not affect MRI visualization and is not a contraindication.

2. "I got a rash the last time I had IV contrast." 3."I had my last period 6 weeks ago." 4."I have a hearing aid implanted in my ear." Magnetic resonance cholangiopancreatography uses MRI to visualize the biliary and hepatic ductal system. Contraindications, including pregnancy, the presence of certain metal implants, and an allergy to gadolinium (ie, noniodine contrast agent), should be assessed before the procedure.

The nurse plans to start an IV line to infuse 2 units of packed red blood cells for a stable 42-year-old client with a gastrointestinal bleed. Which IV catheter size is best? A 20-22-gauge catheter is sufficient for administering general IV fluids and medications to adult clients; a 20-gauge is acceptable for blood transfusion. However, 20-22-gauge is not preferred for blood administration. A 24-gauge catheter is recommended for children and some older adults with small, fragile veins.

2. 18-gauge A lower IV catheter gauge number corresponds to a larger bore IV catheter. A 14-gauge (large-bore) catheter is used to administer fluids and drugs in a prehospital or emergency setting, or for hypovolemic shock. An 18-gauge catheter is typically indicated for infusing blood or large amounts of fluid in adults.

The nurse is reinforcing education about ascending stairs using a modified 3-point gait to a client prescribed crutches after a left ankle sprain. Place the instructions for ascending the stairs in the correct order. All options must be used. Using a modified three-point gait to ascend the stairs, the client should place body weight on the crutches and step up with the unaffected leg. Body weight should then be transferred from the crutches to the unaffected leg. The client should raise the body to align with the unaffected leg, followed by the affected leg and crutches together.

2. Assume the tripod position, then bear body weight on the crutches 3. Place the unaffected leg onto the stair 4. Transfer body weight to the unaffected leg and raise the body onto the stair 1. Advance the affected leg and crutches up the stair

An elderly client is brought to the emergency department with lethargy, chills, and sharp chest pain with deep breathing. Pulse oximeter shows 93% on room air and respirations are 24/min. What is the nurse's initial action? Although the saturation is decreased (93%) and the respiratory rate is increased (24/min), both are adequate to support oxygenation at this time. Nasal oxygen at 3 L/min should be initiated to improve oxygenation. Even though this is an appropriate intervention, it is not the best initial action.

2. Auscultate the client's lung sounds Assessment is the first step in the nursing process that is used to gather information. Lung auscultation is the nurse's initial action with this client. Before intervening, the nurse should assess respiratory status and vital signs to obtain the baseline data that will be compared to subsequent changes.

The nurse is assisting the health care provider with a lumbar puncture for a 6-year-old client with suspected meningitis. Place in order the steps the nurse should take. All options must be used. A lumbar puncture is a sterile procedure used to gather a specimen of cerebrospinal fluid (CSF) for diagnostic purposes (eg, meningitis). A needle is inserted into the vertebral spaces between L3 and L4, and a sample of CSF is obtained. When assisting with a lumbar puncture, the nurse should

2. Check the medical record for a consent form signed by the parent 3. Have the client empty the bladder 1. Assist the client into a side-lying position with the knees drawn up 5. Label the vials as the specimens are collected 6. Place a bandage over the needle insertion site 4. Instruct the client to report development of a headache

The nurse is performing a central line tubing change when the client suddenly begins gasping for air and writhing. Order the interventions by priority. All options must be used.

2. Clamp the catheter tubing 4. Place the client in Trendelenburg position on the left side 1. Administer oxygen as needed 3. Notify the health care provider (HCP) 5. Stay with the client and provide reassurance Any delay in treatment of an air embolism could prove fatal. There is no time to call the HCP. Seal off the source of the leak, and ensure stabilization of the air bubble via left lateral positioning.

The nurse is evaluating a return demonstration by the client of a dry dressing change. Which action by the client would cause the nurse to intervene?

2. Client applies sterile gauze moistened with sterile saline to wound surface When performing a dry dressing change, the client must make sure that the bandaging materials applied (ie, gauze) are dry. Sterile gauze moistened with sterile saline is used for wet-to-dry dressing changes and is not appropriate for a dry dressing change.

The nurse is planning postmortem care for a client who died during the shift. Which of the following client situations might cause the nurse to delay or not perform postmortem care? Select all that apply.

2. Client died in the emergency department following a suicide attempt 5. Client's religious beliefs require special ceremonial treatment of the body Postmortem care may be delayed or not performed if the family has certain cultural or religious beliefs or if the death is considered nonnatural, traumatic, or associated with criminal activity. Nurses should provide opportunities to support the families of clients and involve them in postmortem care as much as is desired and possible.

The nurse is preparing to administer several medications through a client's feeding tube. None of the medications are extended release. Which of the following actions should the nurse implement? Select all that apply.

2. Crush each medication separately before administration 3.Determine if the medications are available in liquid form 4.Flush the tube before and after medication administration When using a feeding tube, medications should be crushed, dissolved, and administered separately to prevent interactions. Feeding tubes should be flushed before and after each medication is given. Liquid medications should be used if possible.

The nurse is assigned to care for a hospitalized confused client with an indwelling urinary catheter. On entering the client's room, the nurse notes the client pulling at the catheter and grimacing in pain. Blood is trickling from the client's meatus and the urine in the drainage bag is pink. Which action should the nurse take first? (Option 4) The meatus should be cleaned after balloon deflation

2. Deflate the balloon on the urinary catheter Steps for removing an indwelling catheter include the following: Perform hand hygiene Ensure privacy and explain the procedure to the client Apply clean gloves Place a waterproof pad underneath the client Remove any adhesive tape or device anchoring the catheter Follow specific manufacturer instructions for balloon deflation - Loosen the syringe plunger and connect the empty syringe hub into the inflation port - Deflate the balloon by allowing water to flow back into the syringe naturally, removing all 10 mL, or applicable amount (note the size of the balloon labeled on the balloon port). If water does not flow back naturally, use only gentle aspiration. - Remove the catheter gently and slowly; inspect to make sure it is intact and fragments were not left in the client. If any resistance is met, stop the removal procedure and consult with the urologist for removal - Empty and measure urine before discarding the catheter and drainage bag in the biohazard bin or according to hospital policy Remove gloves and perform hand hygiene

A client started a 24-hour urine collection test at 6:00 AM. The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 mL at 10:00 AM by mistake but adding all specimens to the collection container before and after that time. What action should the nurse take?

2. Discard urine and container, and restart the 24-hour urine collection tomorrow morning Not all of the client's urine was saved during the collection period. Therefore, the nurse or UAP must discard the urine and container and restart the specimen collection procedure. Although a 24-hour urine collection can begin at any time of the day after the client empties the bladder, it is common practice to start the collection in the morning after the client's first morning voiding and to end it at the same hour the next morning after the morning voiding (Option 2).

The nurse initiates a norepinephrine infusion through a client's only IV access into a large peripheral vein. The client reports severe pain at the IV site shortly after the infusion is started, and blanching is visible along the vein pathway. Which nursing interventions are appropriate? Select all that apply.

2. Elevate the affected extremity above the level of the heart 4. Notify the health care provider and prepare phentolamine (Regitinie) 5. Stop the infusion immediately and disconnect the IV tubing Use a syringe to aspirate the drug from the IV catheter; remove the IV catheter while aspirating.

The home health nurse is visiting a client who underwent a left total knee replacement seven days ago. The client is using a cane to go up and down the stairs. Which client action indicates an understanding of the correct technique when using a cane? Option 3) The cane should always move before the weaker leg moves.

2. Leads with the right leg when going up stairs Clients using a cane should hold the cane on the stronger side and face forward when going up and down stairs. To ascend stairs, the client should step up with the stronger leg first, then move the cane, and finally move the weaker leg up. To descend stairs, the client should lead with the cane, then bring the weaker leg down, and finally step down with the stronger leg. To remember the order, use the mnemonic "up with the good and down with the bad."

The nurse is caring for a client with newly prescribed hearing aids. Which of the following actions by the client indicate proper use and care of hearing aids? Select all that apply. Each aid must be cleaned with a soft cloth. Hearing aids should not be immersed in water, as this can damage the electrical component Store hearing aids in a safe, dry place when not in use. This will help prevent the hearing aids from becoming lost or damaged.

2. Lowers television volume when talking with nurse 4. Turns volume completely down prior to insertion of aid into the ear 5.Verifies that battery compartment is closed before insertion

The nurse prepares to insert an indwelling urinary catheter in a client who is disoriented to time, place, and person and cannot follow directions or commands. Which intervention is most important when inserting the urinary catheter?

2. Maintain a sterile field and keep the urinary catheter sterile (Option 1) The procedure should be explained to the client; however, this client is confused and likely will not understand.

The 70-year-old client with type 2 diabetes and hypertension is scheduled for ureteral stent removal in 2 hours. The preoperative protocol ECG is done in the inpatient unit, and results indicate a "possibly acute" ST segment elevation. What action is most important for the nurse to take?

2. Notify the health care provider about the test result This is a high-risk client (eg, older age, hypertension, diabetes), and the acute, new, significant finding needs further evaluation and possible intervention before undergoing the stress of surgery. In addition, clients with a long history of diabetes often have associated neuropathy and may not experience the chest pain typical of myocardial infarction (MI), known as silent MI. As a result, the nurse must ensure that the health care provider (HCP) is made aware of this client's new findings in a timely manner.

Which of the following are correct nursing actions related to client positioning? Select all that apply. ption 1) Fowler position places the client's head of the bed >30 degrees and is contraindicated following femoral artery cardiac catheterization because of the risk for hemorrhage. Instead, the client should be positioned supine. After liver biopsy, the client should lie on the right side for a minimum of 2 hours (to apply pressure and splint the puncture site) and then supine for an additional 12-14 hours.

2. Position client in Trendelenburg position (head of the bed lowered) on the left side if air embolism is suspected - which will cause the air to rise to the right atrium. The health care provider should be notified immediately (Option 2). 4.Position client on the side with head, back, and knees flexed during lumbar puncture Side-lying with the head, back, and knees flexed for clients undergoing lumbar puncture. A small pillow may be placed between the legs and under the head for comfort and to maintain the spine in a horizontal position (Option 4). 5.Position client with the arm raised above the head for chest tube placement -The arm should be raised above the head on the affected side for clients undergoing chest tube insertion. If possible, the head of the bed should be raised 30-45 degrees to reduce risk of injury to the diaphragm (Option 5).

A client with a dislocated shoulder is prescribed a shoulder sling. The nurse applies the sling and evaluates the fit before discharge from the emergency room. Which assessment finding indicates an incorrect fit?

2. The hand is held slightly below elbow level - To ensure proper shoulder sling fit, the nurse should assess for the following: - Elbow is flexed at 90 degrees Hand is held slightly above the level of the elbow - Bottom of the sling ends in the middle of the palm with the fingers visible - Sling supports the wrist joint

The charge nurse is observing the nurse apply a condom catheter for a client who is uncircumcised. The charge nurse should intervene if the nurse Paraphimosis occurs when the uncircumcised male foreskin cannot be returned (reduced) to its original position, after being pulled back (retracted) behind the glans penis, resulting in pain, progressive swelling of the foreskin, and impaired lymph and blood flow. Paraphimosis can occur when the foreskin is in the retracted position for an extended period (eg, under a condom catheter sheath) The drainage tubing may be attached to a leg collection bag to enable ambulation, prevent tube kinking, and facilitate gravity drainage. A 1- to 2-inch (2.5- to 5-cm) space should be left between the tip of the penis and the end of the condom to prevent penile irritation and pooling of urine in the condom.

2. retracts the foreskin before applying the condom sheath Before applying a condom catheter, the nurse should ensure the client's foreskin is fully reduced (not retracted) to avoid impairing circulation and causing permanent damage to the glans penis (Option 2). If the condom catheter is not self-adhesive, elastic adhesive may be used to secure the device to the penis, and should be applied in a spiral, not circular, manner to prevent restricting circulation.

The nurse is teaching a client with suspected Cushing syndrome who has a prescription for a 24-hour urine collection. Which of the following information should the nurse include? Select all that apply. . An elevated urine cortisol level is indicative of Cushing syndrome. Although cortisol levels are higher in the morning, it is essential that all urine is collected over the entire 24-hour collection period, regardless of the time of day.

2."Discard your first void in the toilet and then record the start time of the urine collection so the start time coincides with an empty bladder." 3."Keep the collection container in the refrigerator or a cooled ice chest when it is not in use." 5. "You will be given an opaque plastic container to collect your urine in order to protect it from light."

While preparing to insert a peripheral venous access device (VAD), the nurse notes scarring near the client's left axilla. The client reports a history of breast cancer and a modified left radical mastectomy. Which of the following actions should the nurse take? Select all that apply.

2.Ensure history of a mastectomy is documented in the medical record 3.Insert the peripheral VAD into the client's right arm 4.Place an appropriate precaution sign above the client's bed Insertion of a peripheral venous access device is contraindicated on the operative side of clients who have had a modified radical mastectomy due to the risk of lymphedema. The nurse should ensure that the history of the procedure is documented in the medical record and signage should be placed above the bed alerting staff of necessary precautions.

The nurse prepares to insert an indwelling urinary catheter for a female client. The nurse assesses for allergies, explains the procedure to the client, gathers equipment, and then performs perineal care. Place in order the steps the nurse should take when inserting the urinary catheter. All options must be used.

2.Perform hand hygiene and open a sterile urinary catheterization kit 1. Apply sterile gloves and place sterile drape under the client's buttocks 6. Use the nondominant hand to gently spread the labial folds 3. Use the dominant hand to cleanse the labial folds with antiseptic swabs 4. Use the dominant hand to cleanse the urethral meatus with antiseptic swabs 5. Use the dominant hand to insert the catheter until urine return is observed

The nurse is preparing to flush a client's central venous catheter. Which size syringe is best for the nurse to choose?

3. 10 mL A 10-mL syringe is generally preferred for flushing the lumen of a CVC (Option 3). The smaller the syringe, the greater the amount of pressure per square inch exerted during injection, increasing the risk for damage to the CVC. The "push-pause" method involves slowly injecting normal saline into the CVC catheter and stopping for any resistance. Injecting against resistance can damage the CVC, which may result in complications, including embolism and malfunction. The

The nurse is caring for a client with hypokalemia who has a new prescription to infuse potassium chloride 10 mEq (10 mmol) in 100 mL D5W over 30 minutes. The client has a peripheral venous access device (VAD). Which of the following actions should the nurse take first? nd no greater than 40 mEq/hr (40 mmol/hr) when infused through a central line (follow facility guidelines and policy) Prior to administering KCl, the nurse should flush the VAD to verify patency and minimize the risk for extravasation.

3. Clarify the prescription with the health care provider Potassium chloride (KCl) is commonly prescribed to correct or prevent hypokalemia. KCl is a high-alert medication that can cause life-threatening dysrhythmias if administered inappropriately. The recommended rate for an intermittent infusion of KCl is no greater than 10 mEq/hr (10 mmol/hr) when infused through a peripheral venous access device (VAD). If administered over 30 minutes as prescribed, the rate (20 mEq/hr [20 mmol/hr]) would exceed the recommended rate. Therefore, the nurse should first clarify the prescription with the health care provider (Option 3).

The nurse is feeding a confused client via a small-bore nasoenteric tube. The nurse observes the client pulling at the tube and then notices an increase in external tube length from the original exit mark. After immediately stopping the feeding, which action is appropriate for the nurse to take next?

3. Contact the health care provider to request an x-ray to verify tube placement A feeding tube is marked with indelible ink at the exit site (nare). If the external length of the tube changes, the nurse should contact the health care provider and request a prescription for a repeat x-ray to determine tube location before resuming administration of enteral feedings and medications.

The nurse is preparing to administer a unit of packed red blood cells to a 16-year-old with blood loss anemia. The client currently has D5W infusing through a 20-gauge IV catheter. What action should the nurse take? Although an 18-gauge IV catheter is preferred for blood administration, a 20-gauge catheter is acceptable. The nurse can start a second IV catheter if required, but there is no need to discontinue the original one. ) Blood should not be run with any other fluid except NS. Blood can be infused with an IV pump if the fluid in the tubing is compatible.

3. Discontinue the D5W, flush the IV catheter with normal saline, and start the transfusion Normal saline (NS) is the only fluid that can be given with a blood transfusion. Dextrose solutions may lyse the red blood cells. All other IV solutions and medications may cause precipitation and are incompatible with blood. Blood transfusions should be infused through a dedicated IV line. If a transfusion must be started in an IV catheter currently in use, the nurse should discontinue the infusion(s) and tubing, and then flush the catheter with NS prior to connecting the blood administration tubing. After transfusion, the catheter should be cleared with NS before any other IV fluids are administered.

The nurse is assessing a client with suspected kidney disease who is scheduled for a kidney biopsy today. Which of the following findings may cause the procedure to be delayed? Percutaneous kidney biopsy is a diagnostic procedure that involves inserting a needle through the skin to obtain a renal tissue sample that is used to determine the cause of certain kidney diseases. Bleeding from the biopsy site is a major complication because the kidney is a highly vascular organ. Expected with kidney disease: decreased calcium level, decreased urinary output, elevated creatinine

3. Elevated blood pressure Hypertension increases renal arterial pressure, which increases the risk for postprocedure bleeding. Therefore, blood pressure must be lowered and well controlled (goal: <140/90 mm Hg) before performing a kidney biopsy (Option 3). Additional findings that increase the risk for bleeding include clotting disorders and thrombocytopenia (ie, decreased platelet level).

A child on the playground is experiencing an anaphylactic reaction. The school nurse arrives with an EpiPen. The weather is cold and the child is wearing several layers of clothing. How should the nurse proceed with the EpiPen?

3. Inject through the clothing into thigh and hold in place for 10 seconds The EpiPen is designed to be administered through clothing with a swing and firm push against the mid-outer thigh until the injector clicks. The position should be held for 10 seconds to allow the entire contents to be injected (Option 3). The site should be massaged for an additional 10 seconds. Timing is essential in the delivery of epinephrine during an anaphylactic reaction. The nurse should administer the medication immediately on the playground without removing the child's clothing. Any delays can cause client deterioration and make maintenance of a patent airway difficult (Option 4).

The nurse prepares equipment for insertion of a large-bore nasogastric (NG) tube for a hospitalized client. Which actions should the nurse take to measure and mark the tube? Select all that apply.

3. Measure from tip of nose to earlobe to xiphoid process 4.Place a small piece of tape at the point of measurement Traditional Method: Using the end of the tube that will eventually rest in the stomach, measure from the tip of the nose, extend the tube to the earlobe and then down to the xiphoid process (Options 1, 2, and 3). Mark the distance with a small piece of tape that can be easily removed (Options 4 and 5).

The nurse plans to start an IV line on a female client hospitalized with pneumonia. The nurse reviews the electronic medical record for relevant information and learns that the client is right-handed and has a history of a left-sided mastectomy with lymph node removal. Which site is best for the nurse to select for the client's IV line? The client's medical history should be reviewed prior to starting an IV line so that the nurse can identify any contraindications to specific anatomical sites. Lymph node removal during a mastectomy may affect lymphatic fluid drainage on the affected side and cause lymphedema or other complications such as infection, venous thromboembolism, or trauma to the affected arm. The nurse must avoid any needlesticks, IV insertions, or blood pressure measurements in the affected arm (Options 1 and 4). The antecubital space should be avoided when possible (except for emergency insertion) as it inhibits mobility and may be positional.

3. Median vein of the right forearm The nondominant side is preferred when no medical contraindications exist. However, in this case, the right forearm is best because the client had a left-sided mastectomy (Option 3). Other considerations when selecting IV sites include avoidance of areas that have obstructed blood flow, dialysis sites, areas distal to old puncture sites, bruised areas, painful areas, or areas with skin conditions or signs of infection. arteriovenous fistula or graft (used for hemodialysis),

The nurse is inserting an indwelling urinary catheter into a female client who has urinary retention. The client has not voided in 6 hours, and bladder scan reveals 400 mL of urine. During the first attempt of placing the urinary catheter, no urine is returned. What action should the nurse take? A brief delay in urine flow may occur initially from the water-based lubricant partially blocking the opening. Thirty minutes is too long of a delay without additional intervention.

3. Obtain a new kit and insert the catheter higher up in the perineal area When attempting indwelling urinary catheter (IUC) insertion, the nurse would expect for urine to be present in the catheter on successful insertion because this client has not voided for 6 hours and bladder scan reveals 400 mL of retained urine. The most common explanation is that the IUC was unintentionally inserted into the vagina. The nurse can leave the misplaced IUC as a landmark and insert a new sterile IUC into the urethra, which is located above the vagina (Option 3). On successful insertion, the misplaced IUC should be removed

The nurse is instructing a female client how to collect a clean catch urine specimen. Place in order the steps indicating that client teaching has been effective. All options must be used.

3. Performs hand hygiene and removes container lid, with sterile side placed upward 5. Spreads labia using index finger and thumb of nondominant hand 1. Cleanses vulva from front to back with single-use antiseptic towelettes 2. Initiates urinary stream before passing container into stream for collection 4. Removes specimen container from stream before stopping urinary flow - Replace the sterile cap without contaminating it and repeat hand hygiene.

A nurse is caring for a 2-year-old child diagnosed with nephrotic syndrome who is in diapers and has red, edematous genitals. Which collection technique is appropriate for the nurse to obtain daily urine specimens for proteinuria testing with a urine dipstick?

3. Place cotton balls in a dry diaper; when wet, squeeze urine onto dipstick Nephrotic syndrome is characterized by massive proteinuria and hypoalbuminemia, which results in severe edema most evident in the abdomen, face, and perineum. Daily dipstick urinalysis determines the presence and pattern of urine protein loss to monitor for exacerbations. To collect a nonsterile urine specimen from a child who is not toilet trained, the nurse can place several cotton balls in a dry diaper and later squeeze urine onto a dipstick. The diaper is checked frequently and the sample collected and tested within 30 minutes of urination for the most accurate result

The registered nurse observes a graduate nurse who is inserting a small-bore nasojejunal feeding tube. Which action by the graduate nurse requires intervention by the registered nurse? (Options 1 and 4) The client should sip water during insertion to close the airway and open the esophagus. With each swallow the nurse should advance the tube a little. The nurse should stop advancing when the client is inhaling or coughing to avoid inserting the tube into the airway and then continue advancing when the client is able to swallow again.

3. Removing the stylet before the x-ray is performed After placing a new, small-bore nasoenteric (eg, nasoduodenal, nasojejunal) feeding tube, the nurse should obtain an x-ray to verify tube placement and should leave the stylet (guide wire) in place until tube placement is verified. The nurse should never reinsert a stylet into a nasoenteric tube. To avoid perforating the gut, the nurse should never reinsert the stylet when a feeding tube is in place.

The nurse is administering a cleansing enema to a client the night before bowel surgery. When administering the enema, the client reports cramping and pain. Which of the following actions should the nurse take? The height of the solution container should be lowered if the client reports discomfort during installation.

3. Temporarily stop instilling the solution, then resume at a slower rate Enema administration can be uncomfortable for clients because instilling enema solution into the bowel may produce abdominal cramping and discomfort. If the client experiences discomfort during a cleansing enema, the instillation should be stopped temporarily (eg, 15-30 sec) and then resumed at a slower rate (Option 3). Slowing the installation decreases the likelihood of premature ejection of the solution, which would not allow for adequate bowel evacuation and preparation.

The nurse is to administer prescribed heparin 70 units/kg IV bolus before initiating the continuous infusion as prescribed. Heparin 1,000 units/mL is available. The client weighs 108 lb. How many milliliters of heparin bolus should the nurse administer? Record your answer using one decimal place. 1 kg = 2.2 lb

3.4 mL

The health care provider prescribes a continuous heparin infusion at 18 units/kg/hr for a client who has a pulmonary embolus and weighs 198 lb. The infusion bag contains 25,000 units of heparin in 500 mL of D5W. At what rate in milliliters per hour (mL/hr) does the nurse set the IV infusion pump? Record your answer using a whole number.

32 ml/hr

An experienced nurse precepts a graduate nurse in the intensive care unit while caring for a client with a right subclavian triple-lumen central venous catheter (CVC). Which statement by the graduate nurse indicates understanding of the CVC? Proper hand hygiene should be performed when caring for a CVC to prevent infection, and nonsterile gloves should be worn to protect the nurse from blood or body fluids at the port site as one or more lumens are often used to draw blood (Option 3). Enteral nutrition is given only through the GI tract (orally or through a feeding tube). Parenteral nutrition is administered through the IV route via a central vein.

4. "The lumen hub should be cleaned thoroughly with antiseptic prior to drug administration." he Centers for Disease Control and Prevention recommend that catheter hubs always be handled aseptically to prevent catheter-associated infections. The hubs should be disinfected with a hospital-approved antiseptic (eg, 70% alcohol sterile pads; > 0.5% chlorhexidine with alcohol; 10% povidone-iodine). Always allow the antiseptic to dry before using the hub/port (Option 4).

A student nurse is preparing to administer the hepatitis B vaccine to a newborn. Which statement by the student nurse requires the preceptor to provide further teaching? he vastus lateralis muscle in the anterolateral middle portion of the thigh is the preferred site for IM injections in newborns (age <1 month) and infants (age 1-12 months). The deltoid muscle is an inappropriate injection site for newborns due to inadequate muscle mas

4. "The medication should be administered into the deltoid muscle The preferred site for intramuscular (IM) injection in newborns is the vastus lateralis muscle in the anterolateral portion of the middle thigh. A 1-mL syringe should be used, and medication dosages should be calculated to two decimal places. A ⅝-inch, 22- to 25-gauge needle is appropriate for IM injection in a newborn.

The occupational health nurse administers an intradermal tuberculin skin test (TST) to a health care worker (HCW). The site must be assessed for a reaction afterward. The nurse instructs the HCW to return in how many hours? The QuantiFERON-TB (QFT) blood test is an alternative to TST that measures how the immune system reacts to TB bacteria. Like TST, a positive QFT test only indicates that the individual has been infected with TB bacteria. Although the test is more expensive, it requires only a single visit to the health care provider and results are available in 24 hours.

4. 72 hours TST (Mantoux) is the standard method for conducting tuberculosis (TB) surveillance of HCWs and involves 2 steps: - Injection of purified protein derivative solution under the first layer of skin of the forearm Evaluation of the injection site 48-72 hours later

A client with type 1 diabetes has a prescription for 20 units of NPH insulin daily at 7:30 AM and regular insulin before meals, based on a sliding scale. At 7:00 AM, the client's blood glucose level is 220 mg/dL (12.2 mmol/L), and the client's breakfast tray has arrived. What action should the nurse take? Click on the exhibit button for additional information. Intermediate-acting insulins (NPH) can be safely mixed with short-acting (regular) and rapid-acting (lispro, aspart) insulins in one syringe ( Most long-acting insulins (eg, glargine, detemir) are not suitable for mixing and typically are packaged in prefilled injection pens.

4. Administer 26 units of insulin: 20 units of NPH mixed with 6 units of regular insulin in the same syringe, drawing up the regular insulin first NPH insulin and regular insulin may be safely mixed and administered as a single injection. Regular insulin should be drawn into the syringe before intermediate-acting insulin to decrease the risk of cross-contaminating multidose vials (mnemonic - RN: Regular comes before NPH).

A nurse preparing to insert a peripheral IV catheter dons clean gloves, applies a tourniquet to the client's arm, and immediately identifies a site for venipuncture. Place in order the remaining steps that the nurse should take. All options must be used When initiating IV therapy, the nurse should wash hands thoroughly and don clean gloves, identify the appropriate venipuncture site, apply the tourniquet, select the venipuncture site after palpating the vein, clean the site, stretch skin taut, insert the IV ONC until blood returns, thread the cannula, apply firm pressure above the catheter tip, release the tourniquet, and retract the stylet safely

4. Cleanse selected site using an antiseptic swab 2. Anchor vein by holding skin taut 5. Insert needle bevel-side up until blood return is observed 1. Advance catheter hub while retracting stylet 6. Remove stylet and attach extension or infusion set 3. Apply a transparent dressing

The nurse performs tracheostomy care for a client with a disposable inner cannula and tracheostomy dressing. Place the steps in the correct order. All options must be used.

4. Gather supplies and position client 2. Don mask, goggles, and clean gloves 5. Remove soiled dressing & also remove clean gloves. 3. Don sterile gloves; remove old disposable cannula and replace with a new one 1. Clean around stoma with sterile water or saline; dry and replace sterile gauze pad

The nurse performs nasogastric (NG) tube insertion using a large-bore NG tube on a hospitalized client with a gastrointestinal bleed. During insertion, after the tube passes the nasopharynx, the client begins to cough and gag. Which action should the nurse take first?

4. Pull back on the tube slightly and then pause to give the client time to breathe During NG tube insertion, the tube sometimes slips into the larynx or coils in the throat, which can result in coughing and gagging. The nurse should withdraw the tube slightly and then stop or pause while the client takes a few breaths. After the client stops coughing, the nurse can proceed with advancement (Option 2), asking the client to take small sips of water to facilitate advancement to the stomach (Option 1). The client should not be asked to swallow during coughing or aspiration may occur. If resistance or obstruction occurs during tube advancement, the nurse should rotate the tube while trying to advance it. If resistance continues, the tube should be withdrawn and inserted into the other naris if possible (Option 3)

The nurse attempts to flush a client's subclavian vein central venous access device with normal saline using a 10-mL syringe, but meets resistance, is unable to aspirate blood, and suspects an occlusion. What should the nurse do next?

4. Reposition the client Catheter occlusion is the most common complication of central venous access devices. Kinked tubing, catheter malposition, medication precipitate, or thrombus can occlude the lumen, preventing the ability to flush or aspirate blood. The nurse should first assess for mechanical, nonthrombotic problems by: Repositioning the client (eg, head, arm) as the catheter tip may be resting against a vessel wall (Option 4) Assessing IV tubing for clamps, kinks, and precipitate The nurse should then attempt to flush the device again. If the occlusion remains, the nurse should not flush against resistance as applying force may damage the catheter or dislodge a thrombus. Instead, the nurse should contact the health care provider (HCP), who may prescribe medication (ie, alteplase) to dissolve a thrombus or fibrin sheath.

A client is receiving a blood transfusion. Fifteen minutes after the transfusion starts, the nurse notes a drop in blood pressure from 110/70 to 84/50 mm Hg. The client reports "feeling a little cold." Based on this assessment, in what order should the nurse complete the following actions? All options must be used.

4. Stop the blood transfusion 5. Using new tubing, infuse normal saline into the vein Continue to monitor hemodynamic status and notify the health care provider and blood bank. 1. Administer prescribed vasopressor 2. Collect urine specimen 3. Document the occurrence If signs or symptoms of a blood transfusion reaction occur, the nurse should stop the infusion immediately and use new tubing to keep the vein open with normal saline. The nurse should continue to monitor the client's hemodynamic status, and administer prescribed drugs. The nurse should also collect a urine specimen to be assessed for a hemolytic reaction.

The graduate nurse (GN) is inserting an oropharyngeal airway into a client emerging from general anesthesia. Which action by the GN causes the nurse preceptor to intervene? Appropriate OPA size should be measured prior to insertion because an inappropriate size could push the tongue back and cause airway obstruction. The OPA should be measured with the flange next to the client's cheek. With correct sizing, the OPA curve reaches the jaw angle. When inserting an OPA, the nurse should initially suction the upper airway to remove secretions. The OPA is then inserted with the distal end pointing upward toward the roof of the mouth to prevent tongue displacement and tracheal obstruction. Once the OPA reaches the soft palate, the nurse rotates the OPA tip downward toward the esophagus, which pushes the tongue forward and maintains airway patency.

4. Tapes the external portion of the inserted oropharyngeal airway to the client's cheek An OPA should never be taped in place because of the risk of choking and aspiration when the client awakens.

The nurse is assisting with procedural moderate sedation (conscious sedation) at a client's bedside. The unlicensed assistive personnel (UAP) comes to the door and indicates that the client in the next room needs the nurse right now. How should the nurse respond? The UAP has already communicated that the client's need is urgent. The client should not be kept waiting without further assessment to evaluate the situation.

4. Tell the UAP to tell the charge nurse about the needs of the client in the next room With procedural moderate sedation at the bedside, the nurse takes on the role of an anesthetist. The nurse's role is to monitor the client's condition while the health care provider focuses on performing the procedure. The nurse should never leave the client during the procedure. The best response is to have an available nurse (the charge nurse) go assess and deal with the needs of the client next door.

The nurse helps the health care provider perform a thoracentesis at the bedside. In which position does the nurse place the client to facilitate needle insertion and promote comfort?

4. Upright leaning forward over the bedside table, with arms supported on pillow During a thoracentesis, a needle is inserted into the pleural space to remove fluid for diagnostic or therapeutic purposes. Before the procedure, the nurse places the client in an upright sitting position on the side of the bed, leaning forward over the bedside table, with arms supported on pillows. This position ensures that the diaphragm is dependent, facilitates access to the pleural space through the intercostal spaces, and promotes client comfort.

The nurse inserts a small-bore nasogastric (NG) tube and prepares to initiate enteral feedings for a hospitalized client with laryngeal cancer. Which action should the nurse take first? Verification by auscultating air is not an evidence-based method of placement verification.

4. Verify tube placement with an x-ray Imaging - visualization of tube placement by x-ray is the standard protocol to ensure proper placement prior to initiating enteral tube feedings Gastric content pH testing - although testing the pH of aspirated contents is an evidence-based method, it is typically used to assess for displacement after initial x-ray verification. It can also be used to test the position of the tube prior to each feed as the frequent x-rays expose the client to radiation. Gastric pH is usually acidic (<5) because of acid secretion. pH ≥6 indicates bronchial secretions and incorrect placement.

The nurse is drawing a blood specimen from the client's right basilic vein. The client cries out, retracts the arm, and reports feeling "pins and needles" in the right arm. Which action by the nurse is appropriate?

4. Withdraw the needle and reattempt in a different site with new equipment The preferred site for venipuncture when collecting blood specimens is the antecubital fossa's median cubital vein. The basilic vein lies close to the brachial nerve and artery. When severe, shooting pain radiates down a client's arm during venipuncture, nerve injury may be occurring. The client may also report feelings of "pins and needles" or numbness at and/or near the venipuncture site. If this occurs, the nurse should promptly withdraw the needle, obtain new equipment, and choose a different site for specimen collection (Option 4).

The nurse is assisting with the care of a newborn during circumcision. Which intervention is appropriate? A loose-fitting diaper is put on the newborn after circumcision to avoid irritation to the penis. Sterile, not clean, technique is used during the surgical procedure of circumcision.

4. Wrap the newborn's upper body in a blanket for the circumcision Application of a blanket can provide comfort to the newborn as well as act as a restraint to prevent injury during circumcision (Option 4). Swaddling and the use of nonnutritive sucking (eg, pacifier) are nonpharmacologic approaches to manage pain during circumcision.

A continuous regular insulin IV infusion of 0.2 units/kg/hr is prescribed for a 10-year-old client who weighs 51 lb and has diabetes mellitus. How many units per hour (units/hr) would the nurse administer to this client? Record your answer using one decimal place

4.6

A health care provider prescribes cefuroxime 30 mg/kg/day PO divided in equal doses every 12 hours for a child with a urinary tract infection. The child weighs 34 lb. Based on the available concentration of cefuroxime, how many mL would the nurse administer per dose? Click the exhibit button for additional information. Record your answer using one decimal place.

4.6 mL

The school nurse is assisting a student with type 1 diabetes mellitus to calculate the insulin dosage needed based on the student's lunch menu selections. Using the prescribed carbohydrate-to-insulin ratio, how much insulin should the student receive? Record your answer using a whole number. Click on the exhibit button for additional information.

5 U calculate the required dosage of insulin, the nurse should first identify the client's individually prescribed carbohydrate-to-insulin ratio (eg, 1 unit insulin/15 g carbohydrates), calculate the total carbohydrate content in the meal (eg, 75 g), and then convert to units per meal (eg, 5 units).

The nurse prepares to insert a large-bore nasogastric tube for gastric decompression. After obtaining equipment, the nurse identifies the client, performs hand hygiene, applies clean gloves, assesses nares, and selects a naris. Place the remaining steps in the correct order. All options must be used. Perform hand hygiene and apply clean gloves (no need for sterile gloves) Place client in high Fowler's position

5. Measure, mark, and lubricate tube 4. Instruct client to extend neck back slightly 3. Gently insert tube just past nasopharynx 2. Ask client to flex head forward and swallow 1. Advance tube to the marked point 6. Verify tube placement and anchor Key steps when inserting a large-bore nasogastric tube include using clean gloves; inspecting nares; measuring, marking, and lubricating tube; instructing client to extend the neck back slightly; inserting tube past the nasopharynx and continuing advancement until just above oropharynx; asking the client to flex the head forward and swallow; advancing tube to marked point; and verifying tube placement using abdominal x-ray and anchoring

The nurse is preparing to suction secretions from the airway of an unconscious client whose lungs are mechanically ventilated with an endotracheal tube. Place the steps for suctioning the endotracheal tube in the correct order. All options must be used.

5. Perform hand hygiene and don clean gloves 6. Suction the oropharynx and perform oral care 4. Hyperoxygenate the lungs (100% FiO2) 1. Advance catheter into the trachea 3. Gently rotate the catheter while suctioning 2. Evaluate client tolerance and document

The nurse is assessing the abdomen of a client experiencing gastrointestinal distress. Place the answer choices in the correct order of assessment. All options must be used.

5. Placement of client in supine position 2. Inspection 1. Auscultation 4. Percussion 3. Palpation Abdominal examination is performed with the client in the supine position using the following sequence: inspection, auscultation, percussion, and palpation.

The nurse is preparing to administer an antibiotic to a child with pneumonia. The prescription reads: 7.5 mg/kg every 24 hours divided into 2 doses, PO in liquid form. The client weighs 78 lb. The pharmacy has supplied the drug in 125 mg/5 mL. How many milliliters (mL) should the client receive for each dose? Record your answer using one decimal place.

5.3 mL

The nurse is to administer an albuterol nebulizer treatment to a client with acute bronchospasm. The prescribed dosage is 5 mg every 4 hours. The available solution is albuterol (0.083%) inhaled, 2.5 mg/3 mL. How many milliliters (mL) should the nurse administer with each dose? Record your answer as a whole number.

6 mL

The nurse is calculating IV fluid resuscitation for a client weighing 85 kg with visible partial-thickness burns covering 40% of the body. Using the Parkland Formula, how many liters of IV fluid resuscitation are needed during the first 8 hours? Record your answer using one decimal place. Click the exhibit button for additional information.

6.8 L

The nurse is caring for a client with gastroenteritis and dehydration who is prescribed strict intake and output monitoring with calculation of net fluid balance each shift. Calculate the client's net fluid balance for the shift.

655 ml Net fluid balance is calculated by subtracting total output from total intake. All values must first be converted to milliliters.

A pediatric client weighing 66 lb is prescribed ibuprofen 5 mg/kg by mouth every 6 hr PRN for fever. It is available as an oral solution of 20 mg/mL. How many milliliters (mL) of ibuprofen should be given to the client per dose? Record your answer using one decimal place.

7.5

A client with heart failure is prescribed an IV infusion of dobutamine. The concentration of dobutamine is 250 mg in 500 mL D5W. At what rate in milliliters per hour (mL/hr) should the nurse program the IV pump? Record your answer as a whole number. Click the exhibit button for additional information.

84 To calculate the infusion rate of dobutamine, the nurse should first identify the prescribed dose (eg, 10 mcg/kg/min) and available medication (eg, 250 mg/500 mL) and then convert to milliliters per hour (eg, 84 mL/hr).

The nurse cares for a client receiving intermittent peritoneal dialysis who is prescribed strict intake and output monitoring with calculation of net fluid balance each shift. Calculate the total net fluid balance for the shift. Record the answer using a whole number. Click the exhibit button for additional information.

890 ml. For clients on peritoneal dialysis, fluid balance should be tracked closely with daily weights and strict intake and output monitoring. Net fluid balance is calculated by subtracting total output from total intake. The following steps are used to calculate the net fluid balance: Calculate the net fluid balance Total intake−total output=net fluid balance 2290 mL−1400 mL=890 mL

A client postoperative from a transurethral prostatectomy has a triple-lumen, indwelling urinary catheter and is receiving continuous bladder irrigation of sterile normal saline solution at 175 mL/hr. The nurse empties the urine drainage bag for a total of 2300 mL at the end of the 8-hour shift. How many milliliters (mL) should the nurse document as the net urine output for the shift? Record your answer using a whole number. A transurethral prostatectomy (TURP) is a surgical prostate-removal procedure commonly performed for male clients with prostate cancer. Following a TURP, clients typically receive continuous bladder irrigation (CBI) with a sterile, isotonic solution (eg, normal saline) via indwelling urinary catheter. CBI prevents bladder obstruction by large blood clots in the bladder or urethra.

900 ml To calculate the net urine output in a client with continuous bladder irrigation, the nurse should subtract the total amount of irrigating solution infused from the total amount of catheter output.

The nurse is teaching a client who had surgery how to use a volume-oriented incentive spirometer. Select, in the correct order, the steps the client should take. All options must be used.

Assume a sitting or high Fowler position, which optimizes lung expansion. 1. Exhale normally and place the mouthpiece in the mouth 5. Seal the lips tightly on the mouthpiece 4. Inhale deeply, until the piston is elevated to the predetermined level 3. Hold the breath for at least 2-3 seconds 2. Exhale slowly around the mouthpiece - Breathe normally for several breaths before repeating the process. - Cough at the end of the session to help with secretion expectoration.

The nurse is preparing to administer digoxin to a client. Prior to administering the medication, the nurse should obtain the client's apical heart rate. Click on the best location to auscultate the client's apical pulse. Left-clicking the mouse will put an X to show the answer before submitting the question.

The apical pulse is best assessed by placing the diaphragm of the stethoscope at the apex of the heart/mitral area. This is located at the fifth intercostal space on the midclavicular line. For a client who is receiving digoxin, the apical heart rate should be assessed for 1 full minute. If the heart rate is <60/min, the nurse should consider holding the dose of digoxin based on the health care provider's instructions. In addition to the apical heart rate, digoxin and potassium levels should be monitored. Digoxin has a very narrow therapeutic range (0.8-2.0 ng/mL [1.02-2.56 nmol/L]), and hypokalemia (serum potassium <3.5 mEq/L [<3.5 mmol/L] can potentiate digoxin toxicity (>2.0 ng/mL [>2.56 nmol/L]).

The nurse is caring for a client who has deep venous thrombosis and is prescribed a continuous IV infusion of heparin 25,000 units in 500 mL of D5W at 1300 units/hr. After 6 hours of the heparin infusion, the client's PTT is 44 seconds. The nurse must adjust the infusion rate according to the heparin drip protocol (shown in the exhibit). According to the protocol, at what rate in milliliters per hour (mL/hr) should the nurse set the IV infusion pump? Click on the exhibit button for additional information. Record your answer using a whole number.

The original heparin dose is 1300 units/hr. This client's PTT is 44 seconds, which is below the therapeutic range of 55-70 seconds (as shown in the exhibit), indicating that the client requires a higher dose of heparin for adequate anticoagulation. According to the heparin drip protocol (protocols vary per institution), the rate should be increased by 100 units/hr, or to an infusion rate of 1400 units/hr, which converts to 28 mL/hr.

The nurse has received a prescription from the health care provider to administer 94 mg of methylprednisolone via IV push. The available vial contains 125 mg in 2 mL. Select the syringe containing the appropriate amount of medication to be administered.

The volume of medication to be administered is 1.504 mL, which should be rounded to the first decimal place for administration. Therefore, the nurse should draw the medication to the 1.5-mL mark on the syringe (Option 3).

The nurse is caring for a client who has a chest tube attached to a closed-chest drainage system. Click on the area of the drainage system the nurse should observe to assess for tidaling. Left-clicking the mouse will put an X to show the answer before submitting the question. A. This is the suction control chamber, which is usually set at -20 cm H2O to maintain negative pressure in the system. Bubbling will occur when suction is applied. C. The air leak gauge (part of the water seal chamber) allows for assessment of air leaks. Continuous bubbling indicates an air leak in the system. D. This is the drainage collection chamber in which fluid from the client's pleural cavity will collect; the nurse will assess the color and amount of drainage and record the output.

The water seal chamber (Section B) of the closed-chest drainage system is filled with sterile water and acts as a one-way valve preventing air from entering the client's chest cavity. The water level in the water seal chamber rises and falls with inspiration and expiration, a process known as tidaling. This movement indicates that the system is functioning properly and maintaining appropriate negative pressure.

Pleural effusion is an abnormal collection of fluid (>15 mL) in the pleural space that prevents the lung from fully expanding and leads to ineffective gas exchange. A chest tube is often placed to remove the fluid and promote reexpansion of the compressed lung.

The water seal chamber of a chest tube acts as a one-way valve, allowing air and fluid to exit the pleural space but not to enter it. Continuous bubbling in the water seal chamber indicates an air leak in the system and requires immediate intervention to prevent development of a tension pneumothorax, a life-threatening emergency that develops as air becomes trapped in the pleural space.

The nurse cares for a client with aortic stenosis who was admitted due to syncope on exertion and dyspnea. Identify the area where the nurse would best auscultate the client's heart murmur. Left-clicking the mouse will place an X to show the answer before submitting the question. Aortic stenosis (AS) is a type of valvular heart disease characterized by narrowing of the aortic valve opening, which limits the left ventricle's ability to eject blood into the aorta. AS may occur from hardening (ie, calcification) of the valves, congenital heart disorders, or inflammation. If left untreated, AS may result in heart failure and pulmonary hypertension as compensatory mechanisms fail.

When assessing a client with AS, the nurse should auscultate in the aortic area (ie, second intercostal space at the right sternal border) for a loud, systolic ejection murmur heard following the first heart sound. The aortic area, rather than directly over the heart valve, is the preferred location for auscultation as the heart sounds travel in the direction the blood flows. Additional clinical manifestations of aortic stenosis include chest pain, shortness of breath, and/or syncope that are worsened by exertion.