LAB MIDTERM L3

The nurse is planning to teach a client with chronic obstructive pulmonary disease how to cough effectively. Which instruction should be included?

Take a deep abdominal breath, bend forward, and cough three or four times on exhalation.

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

infiltration

The nurse observes a client using a metered-dose inhaler (MDI) to aid in management of asthma. Which actions indicate that the client needs further instruction? Select all that apply.

inspires rapidly when dispensing the medication from the MDI holds the breath for 3 seconds after inhaling with the MDI cleans the inhaler and canister in soapy water before using again in rapid succsion

The nurse team leader is making rounds and observes the client who had a tracheostomy tube inserted 2 days ago. ( see figure below) The nursing policy manual recommends use of the gauze pad. The nurse should:

make sure the gauze pad is dry and the client is in a comfortable position.

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

7.5mL

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

8 hours

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

8mL/hr

A nurse is preparing for a midline dressing change with a patient who is extremely diaphoretic. Which of the following dressings is most appropriate for this patient?

A gauze dressing placed over catheter exit site

T/F --Noninvasive ventilation delivers ventilatory support without an artificial airway (endotracheal or tracheostomy tube) to patients who can breathe spontaneously.

TRUE

T/F The NRB non-breather mask delivers 10-15 Liters per minute and is used for medical emergencies.

TRUE

The nurse is caring for a client receiving an albuterol/ipratropium nebulized breathing treatment. Which report from the client should the nurse note as an expected side effect of this combination medication?

"I feel like my heart is racing"

A nurse instructs a client with allergic rhinitis about the correct technique for using an intranasal inhaler. Which statement indicates that the client understands the instructions?

"I should hold one nostril closed while I insert the spray into the other nostril."

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

TRUE

The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question?

"have you had a transfusion before?"

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

30 seconds

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

0.8mL

A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain with intravenous (IV) solution from the IV storage area to hang with the blood products at the client's bedside?

0.9% NaCl

The Nasal Cannula delivers how many liters per minute?

1-6 Liters per Minute

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

1.3mL

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

1.5 tablets

The nurse is suctioning a client who had a largyngectomy. What is the maximum amount of time the nurse should suction the client?

10 seconds

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

15 mL

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

15 minutes

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

16 mL/hr

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

2 1 3 4

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

21

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

25gtt/min

Based on knowledge of areas at greatest risk for development of a pressure ulcer in a bedridden patient, the nurse identifies which position to minimize the risk?

30-degree side lying

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

33 gtt/min

A patient recovering from surgery in the postoperative area suddenly becomes confused, pulse ox reading shows a drop from 98% to 90% on room air. What is the most appropriate intervention?

Apply nasal cannula

What is the nurse's initial action when preparing to change a patient's colostomy pouching system?

Applying clean gloves

Following nasal surgery, what should the nurse do first?

Assess respiratory status

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

Bronchial

A nurse is teaching a new nurse about midline catheters. The nurse is asked about which intravenous infusions can be administered through a midline catheter. Which of the following responses would indicate the nurse needs more teaching?

Central Parenteral nutrition

After changing the intravenous tubing on a patient's primary infusion, the nurse notes air bubbles in the tubing. How should the nurse remove them?

Close the clamp, stretch the tubing downward, and flick the tubing so that the bubbles go back into the bag

Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.60 F orally. Which action should the nurse take?

Delay hanging the blood and notify the health care provider (HCP)

Which actions would the nurse take when obtaining a sputum culture from a client with a diagnosis of pneumonia? Select all that apply.

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

T/F Simple face masks are used in patients who require short-term, higher oxygen concentration, such as FiO2 35% to 60%.

FALSE

T/F The nurse's best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago is to notify the surgeon of the bleeding.

FALSE

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

FALSE

T/F Nasal cannulas are the least common type of low-flow oxygen delivery system.

FLASE

Which of the following are primary risk factors for pressure ulcers? Select all that apply

Fever Low-protein diet lengthy surgical procedures

The nurse is caring for a client who has been placed on droplet precautions. Which protective gear is required to take care of this client? Select all that apply. Scroll down to view all 5 answer choices.

Glasses Surgical mask Gown Gloves

low-flow devices

Nasal cannula facemasks NRBs

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action?

Obtain new IV tubing

List 4 complications that can arise from a peripheral IV

Phlebitis Infiltration Air embolism Extravasation infection hypervolemia

A client with newly diagnosed chronic obstructive disease is to be discharged home with oxygen per nasal prongs. Which teaching points should the nurse include in this client's discharge plan? Select all that apply.

Place gauze between the ears and oxygen tubing to prevent skin irritation Avoid areas where people are smoking cigarettes or cigars.

A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient's pain?

Pre-medicate the patient with a prescribed analgesic 30 minutes before the intervention.

A client who had an appendectomy for a perforated appendix returns from surgery with a JP drain inserted in the incisional site. The purpose of the drain is to;

Promote drainage of wound exudates

How can the nurse minimize the risk of dislodging the catheter when removing a dressing?

Remove the transparent dressing or tape and gauze in the direction of catheter insertion.

The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride and needs to add the medication to the IV bag. The nurse should plan to take which action immediately after injecting the potassium chloride into the port of the IV bag?

Rotate the bag gently

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next?

Run normal saline at TKO rate (15mL/hr)

The nurse has a prescription to give a client salmeterol, 2 puffs, and beclomethasone dipropionate, 2 puffs, by metered-dose inhaler. The nurse should administer the medication using which procedure?

Salmeterol first and then the beclomethasone Bronchodilators are always administered before glucocorticoids when both are to be given on the same time schedule.

Which activity is important to include in the plan of care of a patient with a peripherally inserted central catheter (PICC)?

Use a sterile technique when changing the PICC dressing

The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which priority item?

VITALS

Which of the following oxygen deliver devices is the most precise oxygen delivery device?

Venturi Mask

High- flow devices

Venturi mask HFNCs

Which nursing action demonstrates proper procedure in the collection of a wound culture specimen?

Wear clean gloves to remove soiled dressings

Which skin preparation would be best to apply around the client's colostomy?

adhesive skin barrier

When suctioning a tracheostomy tube 3 days following insertion, what should the nurse do?

use a sterile catheter every time the patient is suctioned

For a client with asthma, the healthcare provider (HCP) prescribes albuterol, two puffs twice a day via MDI, and beclomethasone, two puffs twice a day via MDI. The nurse should instruct the client to administe

albuterol first and follow with beclomethasone two times a day Bronchodilators are always administered before glucocorticoids when both are to be given on the same time schedule.

Which respiratory rate is classified as tachypnea?

any value greater than 20 or the largest value given

Which respiratory rate is classified as bradypnea for an adult?

anything less than 12bpm pick lesser value

Which action can the nurse take to ensure a quality blood sample when drawing blood from a patient's peripherally inserted central catheter (PICC) site?

discard the first 6-9 mL drawn

Which term is used to document the presence of difficulty breathing noted in the provision of client care?

dyspnea

The nurse who is about to begin a blood transfusion knows the blood cells start to deteriorate after a certain period of time. Which item is important to check regarding the age of blood cells before the transfusion is begun?

expiration date

When administering an IV piggyback medication to infuse by gravity, how can the nurse ensure that the medication will infuse properly?

hang the piggyback med higher than the primary fluid

Ventilation

movement of air in and out of the lungs, controlled by neurologic and musculoskeletal systems

When changing a midline dressing, the nurse notices redness, swelling, and drainage at the catheter exit site. Which of the following actions should the nurse take next?

notify the practitioner

Respiration

oxygen and carbon dioxide exchange in the lungs. controlled by pulmonary and cardiovascular systems.

Moderate flow devices

partial NRBs

When pouching a patient's colostomy, which action reduces the patient's risk for injury?

protecting the skin from irritation caused by fecal drainage

The nurse assesses the client's stoma during the initial postoperative period. What observation should the nurse report to the healthcare provider (HCP) immediately?

the stoma is red to purple since it indicates inadequate blood supply

Which is an expected outcome of pursed-lip breathing for clients with emphysema?

to promote carbon dioxide elimination

When drawing blood from a patient's peripherally inserted central catheter (PICC), what should the nurse do to minimize the pressure on the device during flushing?

use a 10-mL syringe for the flush