Final Exam Foundations 3
A patient has been using continuous positive airway pressure (CPAP), and now the health care provider is recommending bi-level positive airway pressure (BiPAP). The patient is asking the nurse to explain the difference again. Which response is appropriate?
"BiPAP delivers sufficient expiratory pressure to keep the airways open."
While assessing a client's peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?
"Grade 3 phlebitis at IV site"
The nurse is teaching a patient how to use a flow-oriented incentive spirometer (IS) the night before abdominal surgery. Which statement by the patient indicates an understanding of the procedure?
"I need to keep the balls elevated as long as possible."
A patient's order for IV fluid states that NS is to be infused. Which of the following IV fluids should be given?
0.9% Sodium Chloride
An LPN/LVN is asked by the RN to administer an IV chemotherapeutic agent to a patient in the acute care setting. What law should this nurse refer to before initiating this intervention?
Nurse practice act
The nurse caring for a patient in the acute care setting assumes responsibility for a patient's care. What is this legally binding situation?
Nurse-patient relationship
A patient has a peripherally inserted central catheter (PICC) line inserted to continue IV antibiotic therapy at home. With proper care, how long can this type of venous access device remain in place?
12 months
Acupuncture is a complementary therapy that uses fine needles placed in acupoints. What is the believed purpose of these acupoints?
Open meridians to release qi
When an older adult patient with chronic emphysema comes to the emergency department in respiratory distress, at what rate should the nurse begin oxygen per nasal cannula?
2 L/min
The student nurse is preparing to perform nasotracheal suctioning on an adult patient wearing a face mask. Which action by the student should the nursing instructor question?
Asking the patient to swallow while the catheter is being inserted
The nurse must keep an accurate intake and output record to assess kidney efficiency. In order for the kidneys to remove waste, what is the least amount of hourly urine output the kidneys must produce to remove waste?
30 mL
What percentage of an adult's body weight consists of water?
50% to 60%
A patient with COPD has carbon dioxide retention and is ordered oxygen therapy. The nurse anticipates the use of which oxygen delivery system?
Nasal cannula
What is the appropriate value for the venturi mask?Oxygen delivery devices with percent of oxygen delivered
4-10 L/min = 24%-55% O2
A patient is unable to obtain a sputum specimen by coughing and expectorating. What is the best way for the nurse to collect this specimen?
Perform tracheal suctioning.
A patient's order for IV fluid states the D5W is to be infused. Which of the following IV fluids should be given?
5% Dextrose
A patient's order for IV fluid states that D5NS with 20 KCL is to be infused. Which of the following IV fluids should be given to the patient?
5% Dextrose and 0.45% Sodium Chloride with 20 mEq of KCL/L
A patient's order for IV fluid states that D5NS is to be infused. Which of the following IV fluids should be given?
5% Dextrose with 0.9% Sodium Chloride
A patient's order for IV fluid states that D5LR is to be infused. Which of the following IV fluids should be given?
5% Dextrose with Lactated Ringer's Solution
A patient wants to use aromatherapy to treat pneumonia, but the hospital policy will not allow burning of eucalyptus-scented candles. What should the nurse suggest the patient use instead?
A topical eucalyptus product
A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the client's chart prior to administering the medication:
Administer the prescribed medication.
What role is the nurse who diligently works for the protection of patients' interests playing?
Advocate
The nurse is providing care to a patient with a tracheostomy tube that has an inner cannula. Which intervention by the nurse follows proper procedure for tracheostomy tube care?
After scrubbing the inner cannula, rinses it with normal saline
What is the importance of the nurse asking about the patient's use of alternative therapies when obtaining a health history?
Alternative therapies have unfortunate interactions with traditional therapies.
Which of the following steps is necessary when a patient is prepared for IV insertion?
Applying a tourniquet 4 to 6 inches above the selected site
A patient with a nasal cannula at 5 L/min has skin irritation around the nares and complains of a dry mouth and nose. Which action by the student nurse should be questioned by the nursing instructor?
Applying petroleum-based gel to the nares
What type of alternative therapy is the nurse practicing when using essential oils to provide inhalation treatments?
Aromatherapy
Herbs have not been approved for use as drugs. How are herbs allowed to be sold?
As diet supplements
The nurse has strong moral convictions that abortions are wrong. When assigned to assist with an abortion, what is the most appropriate action for the nurse to take?
Ask for another assignment
What should the nurse do upon noting bleeding around a dressing at an IV insertion site?
Assess the insertion site.
A patient with a tracheostomy tube has an order for oxygen. Which action by the nurse is appropriate?
Attach the T tube to a humidified oxygen source.
Why do people often choose complementary and alternative medicine (CAM)? (Select all that apply.)
CAM is within the control of the patient. CAM is less invasive. CAM is more holistic. CAM is dedicated to health maintenance.
The nurse is preparing an intravenous (IV) solution and tubing for a client who requires IV fluids. While preparing to prime the tubing, the tubing drops and hits the top of the medication cart. The nurse should plan to take which action?
Change the IV tubing.
While assessing the patient's IV infusion, the nurse notes that it is infusing more slowly than it should be. What should the nurse do first?
Check the position of the IV fluid and extremity.
What happens when there is a decrease in the oxygen level in the blood?
Chemoreceptors in the carotid body and aortic body stimulate the respiratory centers to modify respiratory rates.
In assessing a patient with a central venous access device, which sign or symptom indicates that the patient is experiencing an air embolism?
Chest pain
A client has a prescription to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing?
Closes the roller clamp on the IV tubing
The nurse is caring for a patient recovering from a hip replacement and is providing education regarding exercises in physical therapy. What type of therapy should the nurse call these exercises?
Complementary therapies
When a nurse protects the information in a patient's record, what ethical responsibility is the nurse fulfilling?
Confidentiality
While assessing the patient, the nurse recognizes that special caution should be taken with the IV infusion because of fluid volume excess when the nurse notes the presence of which condition?
Crackles in the lungs
The patient is on daily weights and is receiving intravenous therapy. The nurse notices that the patient has gained 2 kg since the previous morning. What else would the nurse expect to observe? (Select all that apply.)
Crackles or rhonchi in the lungs Distended neck veins
The student nurse is providing tracheostomy care to a patient who has intratracheal secretions and a damp tracheostomy dressing and ties. Which action by the student should the nursing instructor question?
Cutting gauze pads to place around the tracheostomy tube
Confusion and misinformation relative to herbal medicine can make patients reluctant to disclose their herbal use to health care providers. What should be the nurse's approach?
Nonjudgmental
When asked to perform a procedure that the nurse has never done before, what should the nurse do to legally protect himself or herself?
Discuss it with the charge nurse, asking for direction
Before administering a bag of intravenous (IV) fluid, a nurse should confirm the type and amount of solution in the medical record and then do which of the following?
Ensure the integrity of the bag.
How can the medical record be used in litigation? (Select all that apply.)
Evidence of omission of care Proof of adherence to standards Documentation of time lapses Public record
The nurse is caring for a patient receiving antineoplastic medications intravenously. The nurse discovers that the intravenous site is red, edematous, and painful. The nurse knows that antineoplastic medications are vesicant medications and documents that the patient has experienced which of the following events?
Extravasation
The nurse is educating a patient regarding reflexology. Information includes that reflexology is a therapy based on the theory that the entire body can be reached by applying pressure to specific areas. Where is pressure mainly applied?
Feet
What is the composition of hypotonic intravenous solutions such as 0.45% NaCl?
Fewer dissolved particles than blood
How would the nurse examining a patient with pleurisy document a low-pitched grating lung sound?
Friction rub
Which condition would the nurse expect to be treated with an isotonic solution?
Hemorrhagic shock
Which needle is used to access implanted infusion devices?
Huber
When administering intravenous (IV) fluids, the nurse ensures that the IV fluids are infusing as ordered to prevent dehydration in an adult. When could dehydration become lethal?
If the patient loses 20% of body fluid
The nurse is preparing the patient for a thoracentesis. What must be completed before the procedure may be performed?
Informed consent
The nurse assigns nursing assistive personnel (NAP) to care for several patients with continuous IV infusions. Which of the following can NAP assist with?
Informing the nurse if they notice anything abnormal
Which of the following is an appropriate nursing measure when performing tracheostomy care?
Insert the catheter without suction.
The nurse is providing nasotracheal suctioning for a 13-year-old patient with secretions in the throat and trachea. Which action by the nurse demonstrates proper technique?
Inserting the suction catheter 6 to 8 inches during inspiration
What should the nurse do when discontinuing a peripheral IV?
Inspect the catheter for intactness after removal.
During a lunch break, an emergency department (ED) nurse truthfully tells another nurse about the condition of a patient who came to the ED last night. What is the ED nurse guilty of? (Select all that apply.)
Invasion of privacy HIPAA violation
What is an appropriate technique for the nurse to implement when changing the dressing at a peripheral IV site?
Keep one finger over the IV catheter until the tape is replaced.
What are age-related changes in the older adult that make them at risk for respiratory diseases? (Select all that apply.)
Kyphosis Decrease in pulmonary blood flow Stasis pooling of secretions
A patient's order for IV fluid states that LR is to be infused. Which of the following IV fluids should be given?
Lactated Ringer's Solution
Which is a nursing care error that violates the Health Insurance Portability and Accountability Act (HIPAA)?
Leaving a copy of the patient's history and physical in the photocopier
Which important precaution should the nurse include when instructing an emphysema patient on the use of home oxygen?
Limit to 1 to 2 L oxygen flow.
What type of therapy is thought to increase circulation to the affected area, promote healing, and stimulate acupuncture points?
Magnetic therapy
A health care provider instructs the nurse to bladder train a patient. The nurse clamps the patient's indwelling urinary catheter but forgets to unclamp it. The patient develops a urinary tract infection. What do the nurse's actions exemplify?
Malpractice
The nurse is obtaining a throat culture. What area will the nurse swab with a cotton-tipped applicator?
Pharynx
The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of which?
Phlebitis of the vein
A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain?
Place warm compresses on the site.
The nurse needs to specifically prevent air emboli that may result from IV therapy. What should the nurse make sure to do to prevent air emboli?
Prime the tubing completely.
What is the best way for a nurse to avoid a lawsuit?
Provide compassionate, competent care.
Which independent nursing measures are effective in aiding a patient to expectorate? (Select all that apply.)
Providing hydration Suctioning Positioning in orthopneic position Assisting to cough
What should the nurse do when preparing the patient for a bronchoscopy?
Reassure the patient that he or she will be able to breathe during the procedure.
An older adult is admitted to the hospital with numerous bodily bruises, and the nurse suspects elder abuse. What is the best nursing action?
Report the bruises to the charge nurse.
What are the universal guidelines that define appropriate measures for all nursing interventions?
Scope of practice
The new LPN/LVN is concerned regarding what should or should not be done for patients. What resource will best provide this information?
Standards of care
The nurse has been instructed to remove an intravenous (IV) line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with which item?
Sterile 2 × 2 gauze
A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?
Stop the infusion of intravenous fluids.
What should the nurse do upon noting that the patient's IV site is pale, cool, and edematous? (Select all that apply.)
Stop the infusion. Start a new IV. Elevate the extremity.
What is the purpose of the cilia?
Sweep debris toward nasal cavity.
What training system may help prevent osteoporosis?
Tai chi
What is inspiratory capacity?
The amount of air that can be inhaled in one breath from the resting expiratory level
The nurse is caring for several patients receiving oxygen by various delivery systems. Which assessment finding by the nurse indicates proper use of the oxygen device?
The flow rate is between 1 and 6 L/min for a nasal cannula.
The nurse is performing nasotracheal suctioning on a patient. The nurse should discontinue the suctioning if which of the following occurs?
The heart rate decreases from 84 beats per minute to 60 beats per minute.
What is true about nurse practice acts?
The nurse must know the nurse practice act within his or her state.
A patient, age 22, is admitted with acute asthma. The patient shows a pulse oximetry level of SaO2 of 82%. How should the nurse interpret this?
There is only 82% of oxygen bound to the hemoglobin compared with the amount available.
A nurse failed to monitor a patient's respiratory status after medicating the patient with a narcotic analgesic. The patient's respiratory status worsened, requiring intubation. The patient's family claimed the nurse committed malpractice. What must be present for the nurse to be held liable? (Select all that apply.)
There was harm to the patient. A nurse-patient relationship exists. The nurse failed to perform in a reasonable manner.
What is true regarding manufacturers of herbal remedy products?
They do not have to demonstrate their safety.
The nurse is caring for a patient with a do-not-resuscitate (DNR) order. Although the nurse may disagree with this order, what is his or her legal obligation?
To follow the order
When adding medications to a bag of intravenous (IV) fluid, the nurse will use which method to mix the solution?
Turning the bag or bottle gently from side to side
A nurse working on an acute care medical surgical unit is aware that his or her first duty is to the patient's health, safety, and well-being. Given this knowledge, which of the following is most necessary for the nurse to report?
Unethical behavior of other staff members
A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention?
Upper extremity swelling is noted.
The nurse instructs a patient receiving home O2 therapy to drink plenty of fluids to help keep bronchial secretions liquefied. What is the recommended fluid?
Water
The young man who had a bronchoscopy 1 hour ago asks when he can eat. Which response would be most helpful?
When the gag reflex returns
What is a therapeutic treatment that joins the mind and body and increases muscle tone and flexibility?
Yoga therapy
Which Chinese healing technique incorporates the application of heat and needles to various body points to alter the energy flow?
acupuncture
A lumbar puncture was performed on a patient without a signed informed consent form. This patient might sue for
civil battery.
A nurse fails to irrigate a feeding tube as ordered, resulting in harm to the patient. This nurse could be found guilty of:
malpractice.
The nurse assessing an 11 year old who is having an asthma attack expects to hear adventitious sounds of:
sibilant wheezes.
When assessing the SaO2 with a pulse oximeter, the nurse will place the oximeter on a finger:
that is a normal temperature.
