exam 1- practice questions

After reviewing a client's serum electrolyte levels, the provider prescribes an isotonic IV infusion. Which IV solution should the nurse plan to administer? 1) 5% dextrose in water 2) 10% dextrose in water 3) 3% sodium chloride solution 4) 0.45% sodium chloride solution

1 D5W

The nurse administers diphenhydramine (Benadryl) before a blood transfusion to: 1) prevent uticaria 2) avoid fever and chills 3) enhance clotting factors 4) expand the blood volume

1

A nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the IV of an assigned client who is receiving fluid replacement therapy at least every: 1. 1 hour 2. 2 hours 3. 3 hours 4. 4 hours

1 1 hr

A client has just undergone insertion of a central venous catheter at the bedside. The nurse would be sure to check the results of which of the following before initiating the flow rate of the client's IV solution at 100 mL/hr? 1. Serum osmolality 2. Serum electrolyte levels 3. Portable chest x-ray film 4. Intake and output record

3 chest x-ray

The nurse is preparing a continuous IV infusion at the medication cart. As the nurse goes to attach the distal end of the IV tubing to a needleless device,the exposed tubing drops and hits the top of the medication cart. Which of the following is the appropriate action by the nurse? 1. Obtain new IV tubing 2. Attach a new needleless device. 3. Wipe the distal end of the tubing with Betadine 4. Scrub the needleless device with an alcohol swab

1 obtain new IV tubing

Which of the following clients are most likely to develop circulatory overload? (select all that apply) 1. A premature infant 2. A 101-year-old man 3. The client on renal dialysis 4. The client with diabetes mellitus 5. A 29-year-old woman with pneumonia 6. The client with CHF

1,2,36 young, elderly, renal problems, cardiac problems

The nurse is monitoring a client who is receiving a blood transfusion when the client complains of diaphoresis, warmth, and a backache. The nurse suspects a transfusion retain and should take which actions? select all that apply 1) contact the physician 2) remove the IV catheter 3) document the occurrence 4) stop the blood transfusion 5) hang 0.9% NaCl solution

1,3,4,5

The nurse nostes that the site of a client's peripheral IV catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client experienced: 1. Phlebitis of the vein 2. Infiltration of the IV line 3. Hypersensitivity to the IV solution 4. Allergic reaction to the IV catheter material

1. phlebitis

A client involved in a motor vehicle crash presents to the ER with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which IV solution will most likely be prescribe to increase intravascular volume, replace immediate blood loss volume, and increase blood pressure? 1. 5% dextrose in lactated ringers 2. 0.33% sodium chloride (1/3 normal saline) 3. 0.225% sodium chloride (1/4 normal saline) 4. 0.45% sodium chloride (1/2 normal saline)

1. 5% dextrose LR--> normal saline used for REPLACEMENT

Which of the following is most likely to be effective in meeting a patient's teaching/learning needs preoperatively? A. Teaching only the patient B. Teaching the patient and family C. Using brief verbal instructions D. Using only written instructions

B teaching pt and family

An RN is teaching nursing students about the process of obtaining informed consent before a surgery. Which statement made by a nursing student indicates a need for further teaching? 1. "The informed consent given by a client who cannot physically sign, but is able to make his or her own care decisions needs to be witnessed by three people." 2. "Informed consent should generally be obtained in the presence of the client and one witness." 3. "Informed consent of the client is important if there is any need for blood product." 4. "Informed consent is mandatory even at the risk of death."

1. witnessed by 2 ppl

The nurse is assigned to a client receiving total parenteral nutrition (TPN) who had a blood glucose measurement done at 0600. The nurse documents on the client's clinical worksheet for the day that the blood glucose level should be checked next at which time? 1.0800 2.1200 3.1600 4.1800

1200

A client is going to be transfused with a unit of packed RBCs. The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started? 1. 5 minutes 2. 15 minutes 3. 30 minutes 4. 45 minutes

2 15 minutes

A nurse takes a client's temperature before giving a blood transfusion. The temperature is 100 degrees F orally. The nurse reports the finding to the RN and anticipates that which of the following actions will take place? 1. The transfusion will begin as prescribed 2. The blood will be held and the physician will be notified 3. The transfusion will begin after the administration of an antihistamine 4. The transfusion will begin after the administration of 600 mg of acetaminophen

2 blood held and HCP notified

A nurse is assisting with caring for a client who is receiving a unit of packed RBCs. The nurse tells the client that it is most important to report which of the following signs immediately? 1. Sore throat or earache 2. Chills, itching, or rash 3. Unusual sleepiness or fatigue 4. Mild discomfort at the catheter site

2 chills, itching, rash

A client with pancreatitis is being weaned from total parenteral nutrition (TPN). The client asks the nurse why the TPN cannot just be stopped. What is the nurse's best response? 1.Dehydration can result. 2.Hypokalemia may occur. 3.Hypernatremia will occur. 4.Rebound hypoglycemia is a risk.

4

A nurse is discussing the infusion of colloidal solutions with another nurse. Which statement indicates a need for further discussion? A. plasma volume expanders are colloidal slns B. colloidal slns are composed of electrolytes dissolved in water C. infusion of colloidal sln will prevent shock after major blood loss D. infusion of a colloidal sln can result in the drawing of fluid into the intravascular space

B

While performing preoperative teaching, the patient asks when she needs to stop drinking water before the surgery. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, the nurse tells the patient that: A. She must be NPO after breakfast. B. She needs to be NPO after midnight. C. She can drink clear liquids up to 2 hours before surgery. D. She can drink clear liquids up until she is taken to the OR.

C

Which of the following is most appropriate after administration of preoperative medications? A. Confirming that the patient has voided B. Monitoring vital signs every 15 minutes C. Placing the patient in bed with the rails up D. Transporting the patient immediately to the operating room

C bed rails up; anesthetics and sedatives can make pt dizzy or change LOC

What would be the most effective way for a nurse to validate "informed consent"? A. Ask the family whether the patient understands the procedure. B. Check the chart for a completed and signed consent form. C. Ask the patient what he or she understands regarding the procedure. D. Determine from the physician what was discussed with the patient.

C understanding of procedure

While a nurse is caring for a patient who is scheduled to have surgery in 2 hours, the patient states, "My doctor was here and told me a lot of stuff I didn't understand and then I signed a paper for her." To fulfill the role of advocate, what is the best nursing action? A. Reassure the patient that the surgery will go as planned. B. Explain the surgery and possible outcomes to the patient. C. Complete her first priority, the preoperative teaching plan. D. Call the physician to return and clarify information for the patient.

D call the physician

You observe a nurse priming tubing for a blood transfusion with D5W. What would you do?

Tell her to stop as D5W can cause clotting along with the transfusion. Normal saline is the only standard.

A nurse who has specialized training in placement of peripherally inserted central catheters (PICCs) is inserting a PICC for a patient in the perioperative phase. Which steps should the nurse follow to prevent any complications? Select all that apply. a. the nurse should confirm placement of the catheter by using ultrasound guidance b. the nurse should use the larger veins present in upper extremities c. the nurse should insert the PICC in the jugular of subclavian vein and the tip of the catheter is advanced into the superior vena cava d. the nurse should use a 10 mL syringe to flush or to administer medication through this catheter e. the nurse should insert the catheter in an emergency situation and should not keep it in for more than 48 hours

a- xray auscultation b- true vein in arm d. true

A nurse is caring for a patient who has dehydration and is needing a fluid challenge. Which isotonic IV solution should the nurse request from the primary healthcare provider? a. 0.33% sodium chloride b. 0.45% sodium chloride c. 0.9% sodium chloride d. 3% sodium chloride

c normal saline for replacement

In which situation should the nurse request medications to be delivered IV rather than orally? a. a patient with diabetes b. a patient with brochial asthma c. a patient with lung cancer d. a patient with uncontrolled vomiting

d

The nurse notes that a client's total parenteral nutrition (TPN) solution is 4 hours behind. Which action should the nurse take? 1.Assess the infusion pump to be sure it is functioning properly and is set at the correct rate. 2.Increase the infusion rate to a rate that allows the infusion volume to correct itself within a 2-hour period. 3.Replace the TPN solution with 10% dextrose, and restart the solution the following day. 4.Administer the TPN solution using gravity flow because the infusion pump is malfunctioning.

1. assess infusion pump

A nurse has just finished assisting the physician in placing a central IV line. Which of the following is a priority intervention after central line insertion? 1) prepare the client for a chest radiograph 2) assess the clients temperature to monitor for infection 3) label the dressing with the date and time of the catheter insertion 4) monitor the BP to asses for FVE

1. chest x-ray

A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and would avoid which of the following while changing the client's hospital gown? 1. Using a hospital gown with snaps at the sleeves 2. Disconnecting the IV tubing from the catheter in the vein 3. Checking the IV flow rate immediately after changing the hospital gown 4. Putting the bag and tubing thru the sleeve, followed by the client's arm

2 discontinuing IV tubing

A client began receiving an IV infusion of packed red blood cells 30 minutes ago. The client turns on the nurse call light and describes difficulty breathing, itching, and a tight sensation in the chest. Which of the following is the first action of the nurse? 1) call the physician 2) stop the transfusion 3) check the client's temperature 4) recheck the unit of blood for compatibility

2 stop the transfusion

Before inserting a perpheral IV catheter, the nurse notes that the female client's muscles are tense and she is fidgeting with the bed sheet. Which statement should the nurse verbalize to the client? 1) This will be finished before you know it 2) inserting the IV does not hurt very much 3) The IV adds fluid into your blood stream 4) The IV catheter is an 18-gauge angiocatheter

3 IV adds fluid to the bloodstream

The nurse hears that a client receiving total parenteral nutrition (TPN) at 100 mL/hr has bilateral crackles and 1+ pedal edema during shift report. When the nurse obtains a daily weight, the nurse notes that the client has gained 4 lb (1.8 kg) in 2 days. Which action should the nurse take first? 1.Administer the prescribed daily diuretic. 2.Encourage the client to cough and deep breathe. 3.Compare the intake and output records of the past 2 days. 4.Slow the TPN infusion rate to 50 mL/hr per infusion pump.

3 comapre intake/output--> circulatory overload

A client receiving PN via a central venous catheter (CVC) is scheduled to receive an IV antibiotic. Which should the nurse implement before administering the antibiotic? 1) Turn off the PN for 30 minutes 2) check for compatibility with PN 3) ensure a separate IV access route 4) flush the cvc with normal saline

3 ensure separate IV access route --> meds and feedings will NOT go together

The nurse assesses a peripheral IV dressing and notes that it is damp and the tape is loose. The best nursing action is to: 1) stop the infusion immediately 2) apply a sterile, occlusive dressing 3) ensure tight IV tubing connections 4) remove the IV and insert and new IV

3 ensure tight IV tubing connections

A nurse is doing a routine assessment of a client's peripheral IV site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which of the following has probably occurred? 1. Phlebitis 2. Infection 3. Infiltration 4. Thrombosis

3 infiltration

A client with total parenteral nutrition (TPN) infusing has disconnected the tubing from the central line catheter. The nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which position? 1.On the left side, with the head lower than the feet 2.On the left side, with the head higher than the feet 3.On the right side, with the head lower than the feet 4.On the right side, with the head higher than the feet

3 on right side with head lower than the feet--> trendelenburg

Which step followed by a nurse while caring for a diabetic client in the perioperative phase can prevent aspiration during intubation and extubation? 1. Checking heart rate, blood pressure, temperature and oxygen saturation level 2. Conducting a physical examination of the client 3. Confirming the last oral intake of the client 4. Confirming that appropriate skin prep and bowel prep has been carried out

3- last oral intake pt should be NPO for 8 hrs

An RN is teaching a nursing student about the genitourinary assessments that need to be performed before surgery. Which step, as stated by the nursing student, indicates a need for further teaching? 1. "The nurse should document the need for or use of any devices for urinary elimination." 2. "The nurse should have the client void before entering the operating suite." 3. "A nurse should discourage a client to discuss any concerns about urination postoperatively as the client may feel nervous." 4. "The nurse should document any perineal abnormalities on the chart."

3. the pt should feel encouraged to discuss concerns

The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter. The nurse determines that the client needs further instructions if the client made which statement? 1. I need to wear a medic-alter tag or bracelet 2. I need to have a repair kit available in the home for use if needed. 3. I need to keep the insertion site protected when in the shower or bath. 4. I need to keep my activity level to a minimum while this catheter is in place.

4 activity level

A patient has the following preoperative medication order: morphine 10 mg with atropine 0.4 mg IM. The nurse informs the patient that this injection will A. decrease nausea and vomiting during and after surgery. B. decrease oral and respiratory secretions, thereby drying the mouth. C. decrease anxiety and produce amnesia of the preoperative period. D. induce sleep, so the patient will not be aware during transport to the operating room.

B decrease oral and respiratory secretions (anti-cholinergic)

What step would you take if you have attempted IV access and are unsure of proper placement? A. Remove the catheter and try again. B. Attempt to flush the catheter. C. Pull the catheter back a few millimeters and check for blood return D. Go ahead and begin IV infusion.

B flush catheter

Which of the following may be left in place when a patient is sent to the operating room? A. Wig B. Hearing aid C. Engagement ring D. Well-fitting dentures

B hearing aid

A nurse is teaching about isotonic IV infusions. Which statement indicates a need for further teaching? a."Patients with mild dehydration are prescribed isotonic infusions." b. "Isotonic infusions are indicated in the management of hypernatremia." c."Isotonic solutions will cause no movement of fluid into or out of the cells." d. "The osmolality of isotonic solution ranges between 250 and 375 mOsm/L."

B hypotonic slns would manage hypernatremia because they would maintain fluid

A primary healthcare provider prescribes the administration of a crystalloid solution to a patient. Which infusion would the nurse most likely give to this patient? A. Dextran infusion. B. Albumin infusion C. Mannitol infusion D. dextrose infusion

d. dextrose sln only crystalloid sln

A client receiving total parenteral nutrition (TPN) is demonstrating signs and symptoms of an air embolism. What is the first action by the nurse? 1.Stop the TPN solution. 2.Place the client in the high-Fowler's position. 3.Notify the primary health care provider (PHCP). 4.Place the client on the left side in the Trendelenburg's position.

1 STOP TPN

A client receiving total parenteral nutrition (TPN) experiences sudden development of chest pain, dyspnea, tachycardia, cyanosis, and a decreased level of consciousness. What should the nurse suspect as a complication of the TPN? 1.Air embolism 2.Hyperglycemia 3.Catheter-related sepsis 4.Allergic reaction to the catheter

1 air embolism

The nurse administers midazolam hydrochloride (HCl) to a patient. Which symptom or condition is this used to address preoperatively? 1. anxiety 2.infection 3. vomiting 4. pneumonia

1 anxiety- benzo is a sedative

Before performing a venipuncture to initiate continuous IV therapy, a nurse should: 1) inspect the IV solution and exp date 2) apply a cool compress to the affected area 3) secure a padded arm board above the IV site 4) apply a tourniquet below the venipuncutre site

1 inspect IV sln

A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which of the following areas? 1. The pharmacy 2. The laboratory 3. The blood bank 4. The risk-management department

3 blood bank

A physician has written a prescription to discontinue an IV line. The nurse obtains which of the following supplies from the unit supply area for applying pressure to the site after removing the IV catheter? 1. Elastic wrap 2. Betadine swab 3. Adhesive bandage 4. Sterile 2x2 gauze

4 sterile gauze

The nurse is inserting an IV line into a client's vein. After the initial stick, the nurse continues to advance the catheter if: 1. The catheter advances easily 2. The vein is distended under the needle 3. The client does not complain of discomfort 4. Blood return shows in the backflash chamber of the catheter.

4 blood return shows in the back flash chamber of the catheter

The primary goal of the circulating nurse during preparation of the operating room, transferring and positioning the patient, and assisting the anesthesia team is A. avoiding any type of injury to the patient. B. maintaining a clean environment for the patient. C. providing for patient comfort and sense of well-being. D. preventing breaks in aseptic technique by the sterile members of the team.

A

The reason pts are sent to a PACU after surgery is: A. to be monitored while recovering from anesthesia. B. to remain near the surgeon immediately after surgery. C. to allow the medical-surgical unit time to prepare for transfer. D. to provide time for the pt to cope with the effects of surgery.

A

When administering low-molecular-weight heparin (LMWH) after an operation, a nurse should A. explain that the drug will help prevent clot formation in the legs. B. check the results of the partial thromboplastin time before administration. C. administer the dose with meals to prevent GI irritation and bleeding. D. inform the patient that blood will be drawn every 6 hours to monitor the prothrombin time.

A

In the operating room, a patient tells a circulating nurse that he is going to have the cataract in his left eye removed. If the nurse notes that the consent form indicates that surgery is to be performed on the right eye, what should be the nurse's first action? A. Ask the patient his name. B. Notify the surgeon and anesthesiologist. C. Check to see whether the patient has received any preoperative medications. D. Assume that the patient is a little confused because he is older and has received midazolam intramuscularly.

A ask the pt his name

The nurse is providing teaching to a patient regarding pain control after surgery. The nurse informs the patient that the best time to request pain medication is: A. Before the pain becomes severe. B. When the patient experiences a pain rating of 10 on a 1-to-10 pain scale. C. After the pain becomes severe and relaxation techniques have failed. D. When there is no pain, but it is time for the medication to be administered.

A before the pain becomes severe

Which of the following preoperative assessment findings should be reported to a surgeon for preoperative treatment? A. Excessive thirst B. Gradual weight gain C. Overwhelming fatigue D. Recurrent blurred vision

A excessive thirst- could be diabetic--> decrease wound healing--> BG complications during surgery

A patient is scheduled for a hemorrhoidectomy at an ambulatory day-surgery center. An advantage of performing surgery at an ambulatory center is a decreased need for A. laboratory tests and perioperative medications. B. preoperative and postoperative teaching by the nurse. C. psychologic support to alleviate fears of pain and discomfort. D. preoperative nursing assessment related to possible risks and complications.

A lab tests and medications

Select all that apply. A nurse is caring for a surgical patient in the preoperative area. The nurse obtains the patient's informed consent for the surgical procedure. Which statements are true regarding informed consent? A. Informed consent must be signed while the patient is free from mind-altering medications. B. Informed consent must be witnessed. C. Informed consent may be withdrawn at any time. D. Informed consent must be signed by patients age 16 and older. E. Informed consent must be obtained by the physician. F. Informed consent must be obtained from the family even in a life-threatening emergency.

A,B

A patient returning to the floor after orthopedic surgery is complaining of nausea. The nurse is aware that an appropriate intervention is to: A. Hold all medications. B. Avoid strong smelling foods. C. Avoid oral hygiene until the nausea subsides. D. Provide clear liquids with a straw.

B

The nurse would be alerted to the occurrence of malignant hyperthermia when the patient demonstrates: A. Hypocapnia B. Muscle rigidity C. Decreased body temperature D. Confusion upon arousal from anesthesia

B muscle ridgidity

The nurse is creating a plan of care for a client who is receiving total parenteral nutrition (TPN). Which assessment should be included in the plan of care? 1.Apical rate every hour 2.Continuous pulse oximetry 3.Blood glucose levels every 6 hours 4.Hemoglobin and hematocrit every 8 hours

Bg q 6 hrs

Which of the following nursing interventions should receive highest priority when a patient is admitted to the postanesthesia care unit? A. Positioning the patient B. Observing the operative site C. Checking the postoperative orders D. Receiving report from operating room personnel.

a positioning the pt--- ensures airway patency

The nurse notes redness, warmth, and a yellowish drainage at the insertion site of a central venous catheter in a client receiving total parenteral nutrition. What is the nurse's initial action? 1.Decrease the rate of infusion. 2.Administer diphenhydramine. 3.Evaluate for signs of septicemia. 4.Notify the primary health care provider (PHCP).

3 septicemia

The nurse prepares a client for discharge who needs intermittent antibiotic infusions through a peripherally inserted central catheter (PICC) line. Which should the nurse include in client teaching about daily infusion care in the home? 1) keep the affected arm immobilized 2) aspirate 3 mL of blood from the PICC line 3) maintain a continuous IV infusion 4) check the insertion site for redness and swelling

4 check for insertion site

A client has an order to receive 1000 mL of 5% dextrose in 0.45% NaCl. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing? 1. Uncaps the distal end of the tubing 2. Uncaps the spike portion of the tubing 3. Opens the roller clamp on the IV tubing 4. Closes the roller clamp on the IV tubing

4 closes the roller clamp on the IV tubing

A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse should next assess the client for the presence of which condition? 1.Thirst 2.Polyuria 3.Decreased blood pressure 4.Crackles on auscultation of the lungs

4 crackles/ fluid overload

A nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which of the following? 1. An increased Hct level 2. An increased Hgb level 3. A decline of the temperature to normal 4. A decrease in oozing from puncture sites and gums

4 decrease in blood loss--> increased clotting

A nurse evaluates the latency of a peripheral IV site and suspects and infiltration. Which does the nurse implement to determine if the IV has infiltrated? 1) strips the tubing and assesses for blood return 2) checks the regional tissue for redness and warmth 3) increases the infusion rate and observes for swelling 4) gently palpates regional tissue for edema and coolness

4 edema and coolness

The nurse prepares to administer an IV medication when the nurse notes that the med is incompatible with the IV solution. Which is the best intervention for the nurse to implement for safe medication administration? 1) ask the provider to prescribe a compatible IV solution 2) start a new IV cath for the incompatible medication 3) collaborate with the provider for a new admin route 4) flush tubing before and after admin the meds with NS

4 flush the tubing with NS

A client who is receiving a blood transfusion rings the call bell for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. The nurse interprets that the client is experiencing: 1. Bacteremia 2. Fluid overload 3. Hypovolemic shock 4. A transfusion reaction

4 transfusion rxn