Lev3 lab midterm
Which intervention reduces the risk for skin breakdown in a patient with a new tracheostomy? A. Cleaning the stoma with hydrogen peroxide and drying thoroughly B. Cleaning and assessing the skin around the stoma C. Assessing temperature and reporting skin breakdown immediately D. Allowing the patient to re-oxygenate after each tracheal suctioning
B
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? "My eyes have been watering lately." "I feel more bloated than usual." "I haven't had a bowel movement in 4 days." "I feel like my heart is racing."
"I feel like my heart is racing." Albuterol/ipratropium is a combination agent--one is a B -adrenergic agonist and the other is an anticholinergic medication, and in combination the produce an overall bronchodilation effect. Common side and adverse effects include headache, dizziness, dry mouth, tremors, nervousness, and tachycardia.
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." "The inhaler tip is inserted into the nostril and pointed toward the inside nostril wall." "It is important to not shake the canister because than can damage the spray device." "I should limit the use of the inhaler to early morning and bedtime use."
"I should hold one nostril closed while I insert the spray into the other nostril."
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? 5% dextrose in 0.9% sodium chloride 5% dextrose in 0.45% sodium chlorid 0.9% sodium chloride Lactated Ringer's
0.9% sodium chloride Sodium chloride 0.9% (normal saline) is a standard isotonic solution used to precede and follow infusion of blood products. Dextrose is not used because it could result in clumping and subsequent hemolysis of red blood cells.
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 15 seconds 1 minute 2 minutes
30 seconds
Which action might the nurse perform to ensure that the wound drainage tubing does not pull on the insertion site? A. Attach the tubing to the patient's gown with a safety pin. B. Tape the tubing to the patient's bed. C. Attach the tubing to the nearest side rail. D. Loop the tubing through the bed frame.
A
Which action would the nurse perform to best ensure effective insertion of a venous access device into a patient's arm? A. Anchor the vein by placing a thumb 1 to 2 inches below the site. B. Insert the device tip at a 45-degree angle distal to the proposed site. C. Place the patient's left arm in a dependent position for 5 minutes before assessment. D. Apply a tourniquet to the left antecubital fossa 8 to 12 inches above the proposed site.
A
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? Raise the head of the bed Apply simple face mask Apply non-rebreather Apply nasal cannula
Apply nasal cannula This is a newly postoperative patient recovering from surgery. A short-term drop in oxygen saturation can be solved with a short-term solution. Applying a nasal cannula will assist the patient.
Which nursing action shows the most effective planning for emergency care of a patient with a tracheostomy? A. Having a spare oxygen mask at the patient's bedside B. Keeping an obturator and a tracheostomy tube at the patient's bedside C. Reviewing the agency's policy regarding tracheostomy care D. Instructing the family to call immediately if the patient has difficulty breathing
B
Which observation indicates that instruction given to nursing assistive personnel (NAP) in caring for a patient with an indwelling urinary catheter has been effective? A. The collection bag has been placed on the side rail of the bed. B. The excess catheter tubing has been coiled beside the patient's inner thigh. C. The collection bag has been placed on the bed. D. The collection bag is held above the level of the bladder while ambulating the patient.
B
Which nursing action minimizes a patient's risk for injury during removal of an indwelling urinary catheter? Use a 5-mL syringe to deflate the balloon Tugging gently on the catheter to pull the balloon through the urethra Checking the documentation for the volume of fluid used to inflate the balloon Using sterile scissors to cut the valve to deflate the balloon
Checking the documentation for the volume of fluid used to inflate the balloon
Which term is used to document the presence of difficulty breathing noted in the provision of client care? Bradypnea Dyspnea Tachypnea Eupnea
Dyspnea
Nasal cannulas are the least common type of low-flow oxygen delivery system. T or F
F
Noninvasive ventilation delivers ventilatory support without an artificial airway (endotracheal or tracheostomy tube) to patients who can breathe spontaneously. T or F
F
A patient is recovering from a pneumothorax and has a chest tube present. Which of the following is an appropriate finding when assessing the chest tube drainage system? 200 cc of drainage per hour is expected during recovery of a pneumothorax. All of these options are appropriate findings. Intermittent bubbling may be noted in the water seal chamber. The chest tube is positioned at the patient's chest level to facilitate drainage.
Intermittent bubbling may be noted in the water seal chamber.
What can the nurse do to help ensure an accurate result when collecting a midstream urine sample for a patient who is menstruating? Do nothing other than follow normal procedure, since menstruation will not affect the results. Make a note on the lab slip that the patient is menstruating. Notify the health care provider. Postpone the specimen collection until menses has ceased.
Make a note on the lab slip that the patient is menstruating.
Low flow devices include
Nasal cannulas, face masks, NRB
Respiration is
Oxygen and carbon dioxide exchange in the lungs. Controlled by pulmonary and cardiovascular systems
Moderate flow devices include
Partial NRB
The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next? Run a solution of 5% dextrose in water Run normal saline at a keep-vein-open rate Remove the intravenous (IV) line Obtain a culture of the tip of the catheter device removed from the client
Run normal saline at a keep-vein-open rate This maintains a patent IV access line and aids in maintaining the client's intravascular volume. The nurse would not remove the IV line because then there would be no IV access route
When drawing blood from a patient's peripherally inserted central catheter (PICC), what can the nurse do to minimize pressure on the device during flushing? Use a 10-mL syringe for the flush Cleanse the catheter hub with an alcohol swab Clamp the device Use 3-mL syringe for the flush
Use a 10-mL syringe for the flush. Rationale: A 10-mL syringe would be used during the flush to minimize pressure on the device. Clamping the device would hinder the nurse's ability to flush the catheter. A 3-mL syringe would not reduce pressure on the device during the flush. Cleansing the catheter hub with alcohol will not affect the amount of pressure being placed on the device.
High flow devices include
Venturi, HFNCs
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. Scroll down to see the 5 answer choices. inspires rapidly when dispensing the medication from the MDI shakes the MDI before using holds the breath for 3 seconds after inhaling with the MDI exhales before starting to use the MDI cleans the inhaler and canister in soapy water before using again in rapid succsion
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
To prevent exhaled carbon dioxide accumulation within a face mask, the flow rate must be set at 2 L/ min - 5 L/min. T or F
F To prevent exhaled carbon dioxide accumulation within a face mask, the flow rate must be set at more than 6 L/min.
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 nurse is irrigating a patient's abdominal wound 2 days postoperatively. Which finding would need to be reported to the health care provider? A. Drainage that was not present previously B. Redness at the abdominal suture line C. Granulation tissue in the wound bed D. The patient reports less pain
A
Which action(s) would minimize the patient's risk for injury during insertion of an indwelling urinary catheter? A. Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances B. Thoroughly cleansing the patient's perineal area with povidone-iodine solution before inserting the catheter C. Performing proper hand hygiene and applying gloves before inserting the catheter D. Terminating the insertion if the patient reports pain at any time during the procedure
A
What is the nurse's initial action when preparing to change a patient's colostomy pouching system? Applying clean gloves Draping the patient appropriately You Answered Assessing the surrounding skin for signs of irritation Emptying the colostomy
Applying clean gloves
What type of chest tube system does this statement describe? This chest drainage system has no water column to control suction but uses a suction monitor bellow that balances the wall suction and you can adjust water suction pressure using the rotary suction dial on the side of the system. It allows for higher suction pressure levels, has no bubbling sounds, and water does not evaporate from it as with other systems. A. Mediastinal chest tube system B. Dry suction chest tube system C. Wet suction chest tube system D. Dry-Wet suction chest tube system
B
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 Vesicular Bronchovesicular Absent
Bronchial Bronchial sounds are normally heard over the trachea. The client with pneumonia will have bronchial breath sounds over area(s) of consolidation because the consolidated tissue carries bronchial sounds to the peripheral lung fields. The client may also have crackles in the affected area resulting from fluid in the interstitium and alveoli. Absent breath sounds are not likely to occur unless a serious complication of pneumonia occurs. Vesicular sounds are normally heard over the lesser bronchi, bronchioles, and lobes. Bronchovesicular sounds are normally heard over the main bronchi.
A female patient placed in the dorsal recumbent position for the insertion of an indwelling urinary catheter tells the nurse that she "doesn't feel comfortable in this position" and that her "back really hurts." What is the nurse's best response? A. Reassure the patient that the procedure will take only a few minutes. B. Promise to reposition the patient as soon as the catheter has been inserted. C. Reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip. D. Explain to the patient that the position will allow the catheter insertion to be more efficient.
C
The nurse is inserting an over-the-needle catheter into a newly admitted patient. What will the nurse do after confirming blood return? A. Loosen or remove the tourniquet. B. Advance the catheter 1 inch into the vein. C. Lower the catheter until it is flush with the skin. D. Thread the catheter into the vein up to the hub.
C
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 parental nutrition Fresh frozen plasma Long-term antibiotic therapy RBC's
Central parental nutrition Central parenteral nutrition needs to be given through a central line. Administering through a midline line will cause phlebitis due to the osmolality of the CPN.
The nurse is using chlorhexidine to prepare the site before inserting a venous access device into the median cubital vein of a 60-year-old patient. Which action is correct? A. Wash the site with soap and water. B. Allow the site to dry 1 to 2 minutes after cleansing it with chlorhexidine. C. Cleanse the site using a circular motion, starting at the insertion site and working outward. D. Cleanse the area by first swabbing horizontally, then vertically with the applicator for about 30 seconds.
D
The patient in room 2569 calls on the call light to tell you something is wrong with his chest tube. When you arrive to the room you note that the drainage system has fallen on its side and is leaking drainage onto the floor from a crack in the system. What is your next PRIORITY? A. Place the patient in supine position and clamp the tubing. B. Notify the physician immediately. C. Disconnect the drainage system and get a new one. D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.
D
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. T or F
F Bloody drainage 7 hours after surgery is still normal so the provider does not need to be contacted. If drainage increases and dressings become heavily saturated, then the surgeon should be notified as internal bleeding could be present.
Chest tubes are used to drain fluid, blood, or air from the pleural space within the lung in order to re-expand a collapsed lung and restore the normal positive pressure in the pleural space. T or F
F Chest tubes are used to drain fluid, blood, or air from the pleural space BUT they are used to restore the normal NEGATIVE pressure.
When irrigating a wound, how would the nurse know the right amount of pressure to apply? A. Calculate the wound size. B. Follow the general rule of keeping the pressure between 4 and 15 psi. C. Keep the pressure strong enough to cause moderate pain. D. Gentle enough that is does not create a splash off of the wound.
B
The Nasal Cannula delivers how many liters per minute? 1-10 Liters per minute 1-4 Liters per minute 1-7 Liters per minute 1-6 Liters per minute
1-6 Liters per minute
During intermittent open bladder irrigation, a patient complains of pain. Which action would the nurse take first? A. Examine the drainage tubing for clots, sediment, and kinks. B. Notify the health care provider. C. Leave the irrigation drip wide open. D. Monitor the patient's vital signs.
A
Which action would the nurse take to manage continuous urinary catheter irrigation for a patient whose urine is bright red and contains clots? A. Increase the irrigation drip rate. B. Notify the patient's health care provider of the blood and clots in the urine. C. Encourage the patient to increase fluid intake. D. Apply ice to the patient's lower abdominal area.
A
Which statement best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) when inserting an indwelling urinary catheter in a female patient? A. "Please direct the light to better illuminate the patient's perineal area." B. "You need to be comfortable inserting a catheter in a patient of her size." C. "See if a size 14-French catheter is big enough." D. "Find out if the patient has any allergies to latex or iodine." Rationale: This is the correct answer. No aspect of the skill of indwelling urinary catheter insertion may be delegated to NAP, but the nurse may delegate related tasks, such as redirecting the lighting during the procedure. Neither indwelling urinary catheter insertion, catheter selection, assessment of the patient for allergies, nor any other aspect of the skill may be delegated to NAP, although related tasks may be delegated.
A
While discontinuing a midline catheter, the nurse meets resistance and the catheter appears stuck. What action should the nurse take next? A. Stop the procedure and notify the practitioner B. Switch hands and try to remove the catheter again C. Ask another more experienced nurse to try to remove the catheter D. Have the patient take several deep breaths and cough
A
You're assessing a patient who is post-opt from a chest tube insertion. On assessment, you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of water in the water seal chamber when the patient breathes in and out, and bubbling in the suction control chamber. Which of the following is the most appropriate nursing intervention? A. Document your findings as normal. B. Assess for an air leak due to bubbling noted in the suction chamber. C. Notify the physician about the drainage. D. Milk the tubing to ensure patency of the tubes.
A
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 20 seconds 30 seconds 25 seconds
A client should be suctioned for no longer than 10 seconds at a time. Suctioning for longer than 10 seconds may reduce the client's oxygen level so much that the client becomes hypoxic.
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 Antibacterial ointment applied at the exit site and covered with a gauze dressing A transparent dressing placed over the gauze dressing at the catheter exit site A transparent dressing applied over catheter exit site
A gauze dressing placed over catheter exit site A gauze dressing should be used with a patient who perspires excessively because it wicks the moisture away from the catheter exit site.
The nurse is concerned that a patient's central venous access device (CVAD) may have become dislodged. How might the nurse assess for this complication? A. Check for blood return. B. Palpate the skin for coiling. C. Listen for gurgling sounds. D. Assess for pain at the site.
B
Upon removal of a midline catheter, the nurse notices that the catheter length is less than the original insertion length. What should the nurse do first? A. Notify the physician immediately B. Place the patient on his or her right side C. Initiate oxygen therapy at 2 L via a nasal cannula D. Remove the dressing from the catheter exit site
B
When caring for a patient who has a CVAD, which sign may indicate infection at the insertion site? A. Occlusion alarm sounds on infusion pump B. Patient's oral temperature gradually increases C. Patient's neck veins become distended D. The nurse cannot achieve blood return
B
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. Scroll down to review all 6 answer choices. Request a large, pressurized oxygen tank for use during car travel. Apply Vaseline or petroleum jelly on lips and nose to prevent dryness and irritation. Avoid areas where people are smoking cigarettes or cigars. Avoid use of microwave oven when using oxygen. Place gauze between the ears and oxygen tubing to prevent skin irritation Increase oxygen flow at night during hours of sleep.
Avoid areas where people are smoking cigarettes or cigars. Place gauze between the ears and oxygen tubing to prevent skin irritation
Which discharge instruction would help to ensure that the patient achieves maximum therapeutic delivery of the medication when using a pressurized metered-dose inhaler (pMDI)? A. Make sure to report any adverse effects after using your inhaler. B. Prime the inhaler if it is new or has not been used for several days. C. Hold your breath for 60 seconds after the medication is delivered. D. Use the inhaler while sitting up in a chair at 90-degree angle.
B
Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with an intravenous access device? A. "Assess the IV site frequently for signs of inflammation." B. "Be sure not to obscure the insertion site with the dressing." C. "Let me know when you notice that the IV bag contains less than 100 milliliters." D. "Explain the symptoms of infection to the patient."
C
The nurse is preparing to administer a unit of blood to a patient in the emergency department and discovers that he is not wearing an identification bracelet. What should the nurse do? A. Identify the patient by asking him to produce a photo ID, such as a driver's license. B. Administer the blood only if you have been caring for the patient and can be certain of his identity. C. Return the unit to the blood bank. D. Identify the patient by asking a family member to identify him.
C
Which action minimizes the patient's risk for injury when inserting a venous access device into the arm? A. Wearing clean gloves during the procedure B. Using a larger vein found on the palmar (ventral) side of the wrist C. Checking for a radial pulse once the tourniquet has been applied D. Priming the extension tubing after attaching it to the newly placed venous access device
C
Which action would the nurse take to reduce the risk for a catheter-associated urinary tract infection (CAUTI) in a patient with an indwelling urinary catheter? A. Wear clean gloves when inserting the catheter. B. Inflate the balloon on the catheter before using it. C. Use the smallest-size catheter possible. D. Empty the urine by disconnecting the catheter from the collection bag.
C
What is the nursing action to set up suction for a Hemovac drainage system? A. Set the suction to lowest level possible. B. Hemovacs are always set to medium suction. C. Connect to the wall on intermediate suction. D. Compress the hemovac, creating suction.
D Compress for suction!!
When administering an IV piggyback medication to infuse by gravity, how can the nurse ensure that the medication will infuse properly? Use an infusion pump to regulate the flow of the piggyback medication Use a secondary infusion set for the piggyback tubing Attach the piggyback medication to the most proximal insertion port on the primary tubing. Hang the piggyback medication higher than the primary fluid
Hang the piggyback medication higher than the primary fluid Placing the secondary bag higher than the primary fluid will allow for the fluid to infuse at a faster rate than the primary bag with the help of gravity.
Which actions would the nurse take when obtaining a sputum culture from a client with a diagnosis of pneumonia? Select all that apply. Scroll down to view the 5 answer choices. Place the lid of the culture container face down on the bedside table Have the client brush his teeth before expectoration Explain the procedure to the client Instruct the client to take deep breaths before coughing Obtain the specimen early in the morning
Have the client brush his teeth before expectoration Explain the procedure to the client Instruct the client to take deep breaths before coughing
Ventilation is
Movement of air in and out of the lungs. Controlled by neurologic and musculoskeletal systems
A primary health care provider is inserting a chest tube to treat pneumothorax. Which materials should the nurse have available to be used as the first layer of the dressing at the chest tube insertion site? Absorbent gauze dressing Petrolatum jelly gauze Sterile 4 X $ gauze pad Gauze impregnated with providine-iodine
Petrolatum jelly gauze
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? Prime the tubing with the IV solution Check the solution for yellowish discoloration Attach the tubing to the client Rotate the bag gently
Rotate the bag gently
Simple face masks are used in patients who require short-term, higher oxygen concentration, such as FiO2 35% to 60%. T or F
T
True or False. A standard surgical mask is used as part of droplet precautions to protect the nurse from acquiring the client's infection.
T
The NRB non-breather mask delivers 10-15 Liters per minute and is used for medical emergencies. T or F
T The NRB non-breather mask delivers 10-15 Liters per minute and is used for medical emergencies. For example, it is used for patients who have had carbon monoxide poisoning.
The nurse assists the primary health care provider with the removal of a chest tube inserted to treat a client who experienced a pneumothorax. During the procedure, the nurse instructs the client to perform which action? Breathe out forcefully Take a deep breath and hold it Inhale deeply Breathe normally
Take a deep breath and hold it
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 dark red to purple The stoma is slightly edematous The stoma oozes a small amount of blood The stoma does not expel stool
The stoma is dark red to purple A dark red to purple stoma indicates inadequate blood supply. Mild edema and slight oozing of blood are normal in the early postoperative period. The colostomy would typically not begin functioning until 2 to 4 days after surgery.
When suctioning a tracheostomy tube 3 days following insertion, what should the nurse do? Use a sterile catheter each time the client is suctioned. Use a clean catheter with each suctioning, and disinfect it in hydrogen peroxide between uses. Protect the catheter in sterile packaging between suctioning episodes. Clean the catheter in sterile water after each use, and reuse for no longer than 8 hours.
Use a sterile catheter each time the client is suctioned.
Which nursing action demonstrates proper procedure in the collection of a wound culture specimen? Wear clean gloves to remove soiled dressings Using a circular motion to cleanse the wound before collecting the specimen. Sending the specimen to the lab within 30 minutes of collecting it Completing the lab requisition form in a timely manner after collecting the specimen
Wear clean gloves to remove soiled dressings
Which skin preparation would be best to apply around the client's colostomy? adhesive skin barrier petroleum jelly cornstarch antiseptic cream
adhesive skin barrier An adhesive skin barrier is effective for protecting the skin around a colostomy to keep the skin healthy and prevent skin irritation from stoma drainage. Petroleum jelly, cornstarch, and antiseptic creams do not protect the skin adequately and may prevent an adequate seal between the skin and the colostomy bag.
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 gloves surgical mask respirator gown
gloves surgical mask gown
