Advanced skills exam
IV therapy with a hypotonic fluid is ordered for the patient. the nurse would plan to start which solution?
0.45%
What nursing action will limit hypoxia when suctioning a client's airway?
Apply suction only after catheter is removed
The nurse is preparing to start a hypodermoclysis treatment on a patient. What is a preferred insertion site?
Area under the clavicle
The nurse is adding a filter to an IV administration setup. Where is the best place to add the filter to the IV line?
As close as possible to the catheter hub
A nurse is analyzing how a hyperglycemic client's blood glucose can be lowered. The nurse considers that the chemical that buffers the client's excessive acetoacetic acid is:
Bicarbonate
Which illnesses can be treated by an intrathecal infusion?
Cancer of the central nervous system Reflex sympathetic dystrophy Multiple sclerosis Anoxic acquired brain injury
Which characteristics apply to IV infusion pumps?
Deliver fluids under pressure Can be pole-mounted or ambulatory and portable Are best for accurate infusion Decrease drug errors through smart technology
A patient has an endotracheal tube and requires frequent suctioning for copious secretions. Which is a major complication of tracheal suctioning?
Hypoxia
A client reports vomiting and diarrhea for 3 days. What clinical finding will most accurately indicate that the client has a fluid deficit?
Loss of body weight
The nurse is suctioning the secretions from a patient's endotracheal tube. The patient demonstrates a vagal response by a drop in heart rate to 54/min and a drop in BP to 90/55 mm Hg. After stopping suctioning, what is the nurses priority action?
Oxygenate with 100% oxygen and monitor the patient
Which statement by a client with hypovolemia related to dehydration is the best indicator to the nurse of the need for additional teaching?
"I will drink coffee and cola drinks throughout the day."
The home health nurse is adjusting the rate for a hypodermoclysis treatment. What is the usual MAXIMUM rate for this therapy?
120 ml/hr
What is the minimum size peripheral IV catheter through which a blood transfusion can be infused
22 gauge
The nurse is flushing a patient's short peripheral IV catheter. What does the nurse typically use for this procedure?
3 ml of normal saline
1000 ml - 15drops/mL - 8 hours
31 gtt/min
The intake and output of a client over an 8-hour period (8 an to 4 pm) is:
495 mL
The patient has an order for 0.45% normal saline 1000 mL to infuse over 15 hours. At what rate in mL/hr would the nurse set the infusion pump?
67 ml/hr
How many mL's of IV fluid did the client receive during the shift?
950 mL's
A patient has a PICC placed by an IV therapy nurse at the bedside. Before using the catheter, how is its placement verified?
A chest x-ray is taken, which shows the catheter tip in the lower superior vena cava
A client's potassium level is 6.7 mEq/L (6.7 mmol/L). Which intervention should the nurse delegate to the first-year student nurse whom he or she is supervising?
Administer sodium polystyrene sulfonate 15 g orally
A nurse is reviewing the lab report of a client with a tentative diagnosis of kidney failure. What mechanism does the nurse expect to be maintained when ammonia is excreted by healthy kidneys?
Acid-base balance of the body
A client is diagnosed with a spontaneous pneumothorax. Which physiologic effect of a spontaneous pneumothorax should the nurse include in a teaching plan for the client?
Air will move from the lung into the pleural space.
A patient who is breathing on his own has a fenestrated trach tube with a cuff. Which precaution must the nurse instruct the student about when caring for this patient?
Always deflate the cuff before capping the tube with decannulation cap.
A patient with a tracheostomy is unable to speak. He is not in acute distress, but is gesturing and trying to communicate with the nurse. Which nursing intervention is the best approach in this situation?
Ask questions that can be answered with a "yes" or "no" response
A patient has a cuffed trach tube without a pressure relief valve. To prevent tissue damage of the tracheal mucosa, what does the nurse do?
Assess and record cuff pressures each shift using minimal leak technique
The nurse is assessing a short peripheral catheter after removal and it appears that the catheter tip is missing. What does the nurse do next?
Assess the patient for symptoms of emboli
A patient with a trach tube is currently alert and cooperative but seems to be coughing more frequently and producing more secretions than usual. The nurse determines there is a need for suctioning. Which nursing intervention does the nurse use to prevent hypoxia for this patient?
Avoid prolonged suctioning time.
Which nursing interventions are implemented when caring for a patient with an implanted port?
Before puncture, palpate the port to locate the septum Flush the port before each use Use a noncoring needle to access the port Check for blood return before giving any drug through a port
A patient with a trach who receives unnecessary suctioning can experience which complications? Select all that apply
Bronchospasm Mucosal damage Bleeding
A 65-year-old patient has been receiving IV D5 1/2 NS at 100mL/hr for the past 3 days, along with IV antibiotic therapy. The patient reports chills and a headache. On assessment, the patient's temperature is elevated. What complication do these assessment finding suggest?
Catheter-related infection in the blood
The patient has an order for a unit of packed red blood cells PRBCs. Which priority action must the nurse complete before starting the infusion?
Check patient identification with another RN using two identifiers
During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What initial action should the nurse take?
Check the tube to ensure that it is not kinked
A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful?
Clear breath sounds
The unlicensed assistive personnel (UAP) reports to the nurse that a client's urine output for the past 24 hours has been only 360 mL. What is the nurse's priority action at this time?
Contact and notify the health care provider immediately.
When a client suffers a complete pneumothorax, there is danger of a mediastinal shift. If such a shift occurs, what potential effect is a cause for concern?
Decreased filling of the right heard
A nurse is caring for a client with albuminuria resulting in edema, what pressure change does the nurse determine as the cause of the edema?
Decrease in plasma colloid oncotic pressure
Two hours after a subtotal gastrectomy, the nurse identifies that the drainage from the client's nasogastric tube is bright red. What should the nurse do first?
Determine that this is an expected finding
What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply.
Diarrhea Weakness Dysrhythmias
A patient has been on prolonged steroid therapy. In assessing the patient for IV insertion, what finding does the nurse expect to see?
Ecchymosis and possibly a hematoma
An older adult patient sustained a stroke several weeks ago and is having difficulty swallowing. To prevent aspiration during mealtimes, what does the nurse do?
Encourage "dry swallowing" after each bite to clear residue from the throat
A nurse is concerned that a client is at risk for developing hyperkalemia. Which disease does the client have that had caused this concern?
End-stage renal
A patient is receiving IV therapy via an infusion pump. What is the priority nursing responsibility related to the therapy and equipment?
Ensure the IV pump is programmed correctly
When using an intermittent administration set to deliver medications, how often does the Infusion Nurses Society recommend that the set be changed?
Every 24 hours
A patient's central venous IV site is covered with a transparent membrane dressing. How often does the nurse change this dressing?
Every 5 to 7 days
A patient has a chest tube in place. What does the water in the water seal chamber do when the system is functioning correctly?
Fluctuates with the patient's respirations
Which priority concept is of concern to the nurse when performing infusion therapy?
Fluid and electrolyte balance
The nurse is assessing a patient's vascular access for phlebitis. The IV site shows erythema with swelling and pain. Based on Infusion Nurse Society standards, which grad oh phlebitis would the nurse document?
Grade 2
A nurse administers an intravenous solution of 0.35% sodium chloride. In what category of fluids does this solution belong?
Hypotonic
A patient with a tracheostomy is being discharged to home. In patient teaching, what does the nurse instruct the patient to do?
Increase the humidity in the home.
Which dis advantage accompanies the placement of a large-bore peripheral IV catheter?
Increased occurrence of phlebitis
For what clinical indicator should a nurse assess a client who is having a gastric lavage?
Increased serum bicarbonate
A nurse is receiving an IV infusion of 5% dextrose in water. The client loses weight and develops a negative nitrogen balance. What nutritional problem prompts the nurse to notify the health care provider?
Lack of protein supplementation
A patient is receiving epidural medication therapy. The nurse assesses for which potential problem specific to this type of therapy?
Meningitis
A patient with an implanted port is discharged home and will receive long term therapy on an outpatient basis. How frequently must the port be flushed between courses of therapy?
Monthly
The nurse has removed the dressing from a patient's central venous catheter site. In order to monitor the cath position what does the nurse do?
Note the length of the catheter external to the insertion site
Which site is most commonly used for intraosseous therapy
Proximal tibia
The nurse is selecting a site for peripheral IV insertion. Which patient condition influences the choice of left versus right upper extremity?
Regular renal dialysis with a shunt in the left upper forearm
A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish?
Remove the air that is present in the intrapleural space.
The nurse is supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause the nurse to intervene?
Removing the inner cannula and cleaning using standard precautions
A client with emphysema experiences a sudden episode of shortness of breath and is diagnosed with a spontaneous pneumothorax. The client asks, "How could this have happened?" What likely cause of the spontaneous pneumothorax should the nurse's response take into consideration?
Rupture of a subpleural bleb
In what position does the nurse place a patient before stating intraperitoneal therapy?
Semi-fowlers
The RN is reviewing the clients labs which is of most concern?
Serum magnesium level of 0.8 mEq/L (0.4)
What clinical indicators should the nurse expect to identify when assessing an individual with a spontaneous pneumothorax? Select all that apply.
Shortness of breath Unilateral chest pain
A patient returns from the OR after having a tracheostomy. While assessing the patient, which observations made by the nurse warrant immediate notification of the provider?
Skin is puffy at the neck area with a crackling sensation
A nurse is caring for a client with ascites who is receiving albumin. What infusion rate and oral fluid intake should the nurse expect to have the greatest therapeutic effect?
Slow IV rate and restricted fluid intake
The charge nurse is reviewing IV therapy orders. What information must be included in each order?
Specific type of solution Rate of administration Specific drug dose to be added to the solution Specific type of administration equipment Frequency of drug administration
The nurse is attempting to insert a peripheral IV when the patient reports tingling and a feeling like "pins and needles." What does the nurse do next?
Stop immediately, remove the catheter, and choose a new site.
The physician's prescription indicate an increase in the suction to -20 cm for a patient with a chest tube. To implement this, the nurse performs which interventions?
Stops the suction, adds sterile water to level of -20 cm to the water seal chamber, and resumes the wall suction
The client has a nasogastric tube connected to intermittent wall suction. The student nurse asks why the client's respiratory rate and depth has decreased. What is the nurse's best response?
The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory mechanism
The nurse is caring for a patient with a chest tube. What is the correct nursing intervention for this patient?
The patient is encouraged to cough and do deep-breathing exercises frequently
The nurse is supervising a student nurse who is preparing an IV bag with IV administration tubing. For which action by the student nurse must the nurse intervene?
The student touches the tubing spike.
The nurse is caring for a patient with a tracheostomy who has recently been transferred from the ICU. but he has no unusual occurrences related to the tracheostomy or his oxygenation status. What does the routine care for this patient include?
Thorough respiratory assessment at least every 2 hours
A patient with a tracheostomy stoma in place develops increased coughing, inability expectorate secretions, and difficulty breathing. What are these assessment findings related to?
Tracheal stenosis
Which complication is the result of constant pressure exerted by a tracheostomy cuff causing tracheal dilation and erosion of cartilage?
Tracheomalacia
A patient requires long-term airway maintenance following surgery for cancer of the neck. The nurse is using a piece of equipment to explain the procedure and mechanism that are associated with this long-term therapy. Which piece of equipment is the nurse most likely use for this patient teaching session?
Tracheostomy tube
The nurse is assessing a patient after surgery for placement of tracheostomy tube and notes these findings: difficulty breathing; noisy respirations; difficulty inserting a suction catheter; and thick, dry secretions. Which complication of a tracheostomy does the nurse suspect?
Tube obstruction
A client is admitted to the surgical unit from the postanesthesia care unit with a Salem sump nasogastric tube that is to be attached to wall suction. Which nursing action should the nurse implement when caring for this client?
Use normal saline to irrigate the tube
The nurse is preparing to administer IV infusion therapy to a patient. When is the choice of using a glass container appropriate?
When the drug is incompatible with a plastic container
Under what circumstances does the nurses elect to use one secondary to administer multiple medications instead of a secondary set for each medication?
When the medications are compatible
The home health nurse is caring for a patient receiving hypodemoclysis meds. How often are the subcutaneous sites changed?
at least once a week
The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse clearly instruct the nursing student to report immediately?
continuous bubbling in the water-seal chamber
a nurse is caring for a client with ascites. What does the nurse consider to be the cause of ascites?
diminished plasma protein level
What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume?
distended jugular veins
A patient was intubated for acute respiratory failure, and there is an endotracheal tube in place. Which nursing interventions are appropriate for this patient? Select all that apply.
ensure that the oxygen is warmed and humidified suction the airway, then the mouth, and give oral care Position the tubing so it does not pull on the airway apply suction only when withdrawing the suction catheter Keep a resuscitation bag at the bedside at all times
the nurse is preparing to start an infusion of dextrose 10% in water (d10w). why would the nurse infuse the solution through a central line?
osmolarity of the solution could cause phlebitis or thrombosis
To prevent accidental decannulation of a tracheostomy tube, what does the nurse do?
secure the tube in place using ties or fabric fasteners
A nurse is caring for a client with diarrhea. In which clinical indicator does the nurse anticipate a decrease?
tissue turgor
A patient with an endotracheal tube in place has dry mucous membranes of the mouth and lips related to the tube and the partial open mouth position. What technique does the nurse use to provide this patient with frequent oral care?
uses oral swabs or a soft bristled brush moistened in water
50 mL X 15 gtt / 20 minutes
38
A patient has a local complication from a peripheral IV access with 0.9% normal saline infusing at 100 mL/hr. What does the nurse assess at the insertion site?
A red streak is present proximal to the site Edema is present proximal to the site The IV fluids are not infusing The patient reports numbness and tingling at the site
Which nursing interventions are essential to prevent infection in a patient with a central line?
Assess the dressing and insertion site of the central line Employ aseptic technique when administering medication and changing tubing Use sterile technique when assisting the HCP with insertion of a central line Use proper handwashing and nonsterile gloves before coming into contact with a central line
The nurse must insert a short peripheral IV catheter. In order to decrease the risk of deep vein thrombosis or phlebitis, which vein does the nurse choose for the infusion site?
Forearm
A patient has a central line inserted in the vena cava. The nurse assess the patient for which potential complications related to the procedure? select all
Hemothorax Air embolism Bloodstream infection
The nurse is preparing to give the patient IV drug therapy. What information does the nurse need before administering the drug? (Select all that apply.)
Indications, contraindications, and precautions for IV therapy Rate of infusion and dosage of drugs Compatibility with other IV medications Appropriate dilution, pH, and osmolarity of solution Parameters to monitor related to immediate drug effects
What are possible complications that can occur with suctioning from an artificial airway? Select all that apply
Infection Hypoxia Tissue trauma Vagal stimulation Bronchospasm
A patient returns from the OR and the nurses assesses for subcutaneous emphysema, which is a potential complication associated with tracheostomy. How does the nurse assess for this complication?
Inspecting and palpating for air under the skin
The nurse is attaching an administration set to the central venous cath. Which type of equipment decreases the risk of accidental disconnection or leakage?
Luer-Lok connector
A patient requires an infusion of packed red blood cells (PRBCs) . Which factor allows the nurse to infuse the PRBCs through the patient's PICC?
Lumen size of PICC is a 4 Fr or larger
A chest tube is inserted into a client who was stabbed in the chest and is attached to a closed-drainage system. Which is an important nursing intervention when caring for this client?
Observe for fluid fluctuations in the water-seal chamber
A client has chest tubes attached to a chest tube drainage system. What should the nurse do when caring for this client?
Palpate the surrounding area for crepitus
A nurse is reviewing the health care provider's orders for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which order should the nurse question?
Parenteral albumin (Albuminar)
A nurse assesses a client's serum electrolyte levels in the lab report. What electrolyte in intracellular fluid should the nurse consider most important?
Potassium
An older adult patient is at risk for aspirating food or fluids. Which are the most appropriate nursing actions to prevent this problem? Select all that apply.
Provide close supervision when the patient is self-feeding Instruct the patient to tuck the chin down when swallowing Place the patient in an upright position. Keep emergency suctioning equipment at hand and turned on
The nurse is assessing a patient's IV insertion site. What features must the nurse look for during the assessment?
Redness and swelling Check that dressing is clean and dry Observe yellow discoloration Observe for hardness or drainage
During intraperitoneal therapy, a patient reports nausea and vomiting. What does the nurse do next?
Reduce the flow rate and give antiemetics
While assessing a patient's IV site and identifies signs and symptoms of infiltration. What is the first action that the nurse implements for this patient?
Stop the IV infusion
While attempting to remove a PICC line, the nurse feels resistance. What technique does the nurse use first to attempt to resolve this problem?
Use simple distraction techniques and deep breathing
Which task would the nurse delegate to unlicensed assistive personnel for a patient receiving intraperitoneal therapy?
Assist the patient to move from side to side to distribute fluid evenly
While the nursing student changes a patients trach dressing, the nurse observes the student using a pair of scissors to cut a 4X4 gauze pad to make a split dressing that will fit around the trach tube. What is the nurses best action?
Direct the student in the correct use of materials and explain rationale
Which statements are correct about intraperitoneal infusion?
IP can be accomplished by a catheter with an implanted port and large internal lumens Strict aseptic technique is used with IP access and supplies IP is used for patient who are receiving chemotherapy agents
Which nursing action is important when suctioning the secretions of a client with a tracheostomy?
Initiate suction as the catheter is being withdrawn
A patient is ordered to receive peripheral parenteral nutrition (PPN). What type of access device is appropriate for this patient?
PICC
A patient requires a two month course of IV antibiotics to treat a resistant infection. Which device is chosen for this therapy?
PICC
a patient with lung cancer is to receive his first chemotherapy treatment. which IV access methods are appropriate for this pt. select all.
PICC Tunneled central venous catheter Implant port
The charge nurse assigned the care of a client with acute kidney failure and hypernatremia to a new-graduated RN. Which actions can the new-graduate RN delegate to the unlicensed assistive personnel (UAP)? Select all that apply.
Providing oral care every 3-4 hours Record urine output when client voids Help the client change position every 2 hours
The client has fluid volume deficit related to excessive fluid loss. Which action related to fluid management should be delegated by the RN to unlicensed assistive personnel (UAP)?
Providing straws and offering fluids between meals
A patient has a recent tracheostomy. What necessary equipment does the nurse ensure is kept at the bedside? Select all that apply.
Resuscitation bag Oxygen tubing Suction equipment Tracheostomy tube with obturator
A client's serum potassium level has increased to 5.8 mEq/L. What action should the nurse implement first?
Take vital signs and notify the health care provider
Which safety measures does the nurse apply to reduce the risk of catheter related bloodstream infection related to needleless systems?
Tape connections between tubing sets Clean all needleless connections vigorously for at least 60 seconds before connecting Use evidence-based hand hygiene guidelines from the CDC and OSHA
A patient has an intraosseous needle in place. Why does the nurse advocate for removal of the device within 24 hours after insertion?
There is an increased risk for osteomyelitis
Which content must the nurse be sure to teach a patient before central line insertion, specific to prevention of catheter-related bloodstream infection
Type of catheter use Hand hygiene and aseptic technique for care of the catheter Activity limitations Signs and symptoms of complications
After completing the insertion of a peripherally inserted central catheter (PICC), which entries does the nurse make in the documentation? Select all that apply
Type of dressing applied Type of IV access device used Location and vein that was used for insertion
After a partial gastrectomy is performed, a client is returned from the postanesthesia care unit to the surgical unit with an IV solution infusing and a nasogastric tube in place. The nurse identifies that there is no nasogastric drainage for 30 minutes. There is an order for instillation of the nasogastric tube prn. The nurse should instill:
30 mL of normal saline and continue the suction
Which activities are performed by infusion nurses? select all that apply.
Develop evidence based policies and procedures. Insert and maintain peripheral and central venous catheters Consult on product selection and purchasing decisions Monitor patient outcomes of infusion therapy. Provide education to staff, patients, and families
A nurse is assigned to change a central line dressing, the agency policy is to clean the site with Betadine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede Betadine in a dressing change. In addition, an article in a nursing journal stated that a new product was more effective antibacterial than alcohol then Betadine. The nurse had a sample of the new product. How should the nurse proceed?
Follow the agency's policy unless it is contradicted by a health care provider's order
A patient requires IV therapy via a peripheral line. What factors does the nurse use when inserting the peripheral IV?
For active adults start with more proximal sites, such as the forearm Choose the patient's nondominant arm Do not use the arm if the patient had a mastectomy on that side Avoid placing an IV on the anterior surface of the wrist
A patient required emergency intubation and currently has an artificial airway in place. Oxygen is being administered directly from the wall source. Why would warmed and humidified oxygen be a more appropriate choice for this patient?
Helps prevent drying damage to mucous membranes
A client is to have gastric lavage. In which position should the nurse place the client when the nasogastric tube is being inserted
High-Fowler
The patient is ready for discharge. Which actions must the nurse follow to remove the patient's peripheral cath?
Hold pressure on the site until hemostasis is achieved Assess the catheter tip to make sure it is intact and completely removed Remove the peripheral catheter dressing Document catheter removal and the appearance of the IV site
The RN is providing care for a client diagnosed with dehydration and hypovolemic shock. Which prescribed intervention from the health care provider should the RN question?
IV 5% dextrose in water (D5W) to run at 250 mL/hr
A patient is brought to the ED after a serious motor vehicle accident. Which factor makes the patient a candidate for intraosseous therapy?
IV access cannot be achieved within a few minutes
Hypodermoclysis can be used for a patient under which types of circumstances?
If the patient requires palliative care For IV fluid replacement that is less than 2000 ml When subcutaneous IV infusion is warranted
A nurse explains to an obese client that the rapid weight loss during the first week after initiating a diet is because of the fluid loss. The weight of extracellular body fluid is approximately 20% of the total body weight of an average individual. Which component of the extracellular fluid contributes the greatest proportion to this amount?
Interstitial
A triple-lumen catheter central line is inserted in a patient. What does the nurse do immediately after the procedure?
Obtain a portable chest x-ray and hold IV fluids until results are obtained
A patient is receiving preoperative teaching for a partial laryngectomy and will have a tracheostomy postoperatively. How does the nurse define a tracheostomy to the patient?
Opening in the trachea that enables breathing
How should the nurse monitor for the complication of subcutaneous emphysema after the insertion of chest tubes?
Palpate around the tube insertion sites for crepitus
The nurse is preparing to deliver IV infusion therapy through an implanted port. What technique does the nurse use to access the port?
Palpate the port, scrub skin, and access with a noncoring (Huber) needle
Which patient is the most likely candidate for a tunneled Central venous catheter?
Patient in need of permanent parenteral nutrition
The nurse is caring for the patient receiving arterial therapy via the carotid artery. What important nursing action is specific to this therapy?
Perform frequent neurologic assessments
A patient requires a nontunneled percutaneous central catheter. What is the nurse's role in this procedure?
Place the patient in Trendelenburg position
When providing care for an older patient receiving IV fluids through a central line at 150 ml/hr, the nurse finds that patient has shortness of breath, cough, puffiness around the eyes, and crackles. What does the nurse do next?
Place the patient in an upright position, administer oxygen, slow the IV rate, and notify the care provider.
The nurse is caring for a patient with a central venous cath. when changing the administration set or connectors, what measures will the nurse use to prevent air emboli?
Position the patient flat so the catheter site is below the heart Uses the pinch clamp that can be closed during the procedure Asks the patient to perform the valsalva maneuver by holding the breath and bearing down Times the IV set change to the the expiratory cycle when the patient is spontaneously breathing
Patients with a tracheostomy or endotracheal tube need suctioning. Which nursing interventions apply to proper suctioning technique? Select all that apply
Preoxygenate the patient for at least 30 seconds before suctioning Instruct the patient that he or she is going to be suctioned Quickly insert the suction catheter until resistance is met Apply suction only when withdrawing the suction catheter
A patient has a temporary tracheostomy following surgery to the neck area to remove a benign tumor. Which nursing intervention is performed to prevent obstruction of the tracheostomy tube?
Provide tracheal suctioning when there are noisy respirations
Which clinical finding in a patient with a recent tracheostomy is the most serious and requires immediate intervention?
Pulsating tracheostomy tube in synchrony with the heartbeat
A patient sustained a serious crush injury to the neck and had a trach tube placed 3 days ago. As the nurse is performing trach care, the patient suddenly sneezes forcefully and the tube falls out onto the bed linens. What does the nurse do?
Quickly and gently replace the tube with a clean cannula kept at the bedside
The nursing care plan for an older client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/LVN being supervised by a nurse?
Reminding the client to avoid commercial mouthwashes Encouraging mouth rinsing with warm saline Observing the lips, tongue, and mucous membranes Providing mouth care every 2 hours while the client is awake
A nurse adds 20 mEg of potassium chloride to the IV solution of a client with diabetic ketoacidosis. What is the primary purpose for administering this drug?
Replace excessive loss
An experienced LPN/LVN reports to the RN that a client's blood pressure and heart rate have decreased, and when his face was assessed, one side twitches. What action should the RN take at this time?
Review the client's morning calcium level
An external long term IV catheter is required for hemodialysis of a hospitalized patient. Which statements are true about this venous access device?
Should not be used for administration of other fluids or medications except in an emergency Is required for hemodialysis because it has a large lumen Can often cause a common problem of venous thrombosis Is a tunneled catheter with large lumen needed for long-term hemodialysis Requires aspiration of the previously instilled heparin before being used
After assessing the patency of a patient's IV catheter, the nurse attempts to flush the catheter and meets resistance. What does the nurse do next?
Stop the flush attempt and discontinue the IV
A patient with a permanent trach is interested in developing an exercise regime. Which activity does the nurse advise the patient to avoid?
Swimming
A patient is to be discharged home with an implanted port and needs discharge instructions on prescribed medication administration. Which instructions must the nurse give to the patient and family member who will be assisting the patient?
The skin will be punctured over the port when the port is accessed When the port is not accessed, no dressing needs to be applied The port must be flushed after each use
Upon observation of a chest tube setup, the nurse reports to the physician that there is a leak in the chest tube and system. How has the nurse identified this problem?
There was onset of vigorous bubbling in the water seal chamber
A nurse if reviewing a client's serum electrolyte labs report. What is a comparison between blood plasma and interstitial fluid?
They both contain the same kinds of ions
The nurse is caring for a patient with a tracheostomy. Which interventions for bronchial and oral hygiene should the nurse delegate to the unlicensed assistive personnel (UAP)? select all that apply
Turn and reposition the patient every 2 hours Elevate the head of the bed for mouth care Assist the patient to the bathroom as needed Help the patient rinse mouth with saline every 4 hours while awake
After the respiratory therapist preform suctioning on a patient who is intubated, the unlicensed assistive personnel (UAP) measures vital signs for the patient. Which vital sign value should the UAP be instructed to report to the RN immediately?
Tympanic temperature of 101.4 (38.6)
The nurse is caring for a patient with a peripherally inserted central catheter line. according to recommendations by the Infusion Nurses Society, which technique does the nurse us in maintaining this type of catheter?
Use 10 mL of sterile saline to flush before and after medication
How should a nurse prepare an IV piggyback (IVPB) medication for administration to a client receiving an IV infusion? Select all that apply.
Wear clean gloves to check the IV site Rotate the bag after adding the medication Use a sterile technique when preparing the medication.
