NMNC 4335 Midterm Practice Question

A client is admitted to the emergency department following a fall from a horse, and the primary health care provider (PHCP) prescribes insertion of a urinary catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take which action? 1. Notify the PHCP before performing the catheterization. 2. Use a small-sized catheter and an anesthetic gel as a lubricant. 3. Administer parenteral pain medication before inserting the catheter. 4. Clean the meatus with soap and water before opening the catheterization kit.

1. Notify the PHCP before performing the catheterization. Rationale: The presence of blood at the urinary meatus may indicate urethral trauma or disruption. The nurse notifies the PHCP, knowing that the client should not be catheterized until the cause of the bleeding is determined by diagnostic testing. The other options include performing the catheterization procedure and therefore are incorrect.

Potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply. 1. Obtain an intravenous (IV) infusion pump. 2. Monitor urine output during administration. 3. Prepare the medication for bolus administration. 4. Monitor the IV site for signs of infiltration or phlebitis. 5. Ensure that the medication is diluted in the appropriate volume of fluid. 6. Ensure that the bag is labeled so that it reads the volume of potassium in the solution.

1. Obtain an intravenous (IV) infusion pump. 2. Monitor urine output during administration. 4. Monitor the IV site for signs of infiltration or phlebitis. 5. Ensure that the medication is diluted in the appropriate volume of fluid. 6. Ensure that the bag is labeled so that it reads the volume of potassium in the solution.

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action? 1. Check for an air leak. 2. Document the findings. 3. Notify the primary health care provider. 4. Change the chest tube drainage system.

2. Document the findings.

The nurse is assessing the functioning of a chest tube drainage system in a client with a chest injury who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. 1. Excessive bubbling in the water seal chamber 2. Vigorous bubbling in the suction control chamber 3. Drainage system maintained below the client's chest 4. 50 mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

3. Drainage system maintained below the client's chest 4. 50 mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

A patient on anticoagulant therapy needs an IV catheter to be removed. What nursing intervention is most appropriate after the nurse removes the catheter? A. Apply pressure to the IV site for 5 minutes B. Leave the IV in place and attach a saline lock for 24 hours C. Elevate the extremity for 10 minutes D. Use a warm compress at the site for several minutes

A. Apply pressure to the IV site for 5 minutes

The nurse is getting ready to administer an IV push medication. What is the most important action for the nurse to take before administering the med? A. Assess the condition of the IV insertion site. B. Stop the maintenance of IV fluids. C. Dilute the medication to decrease irritation. D. Ensure that the correct-size filter needle is applied to the syringe.

A. Assess the condition of the IV insertion site.

What is the removal of devitalized tissue from a wound called? A. Debridement B. Pressure distribution C. Negative-pressure wound therapy D. Sanitization

A. Debridement

Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) A. Frequent position changes B. Keeping the buttocks exposed to air at all times C. Using a large absorbent diaper, changing when saturated D. Using an incontinence cleaner E. Applying a moisture barrier ointment

A. Frequent position changes D. Using an incontinence cleaner E. Applying a moisture barrier ointment

The nurse is caring for a patient with a chest tube for treatment of a right pneumothorax. Which assessment finding necessitates immediate notification of the health care provider? A. New, vigorous bubbling in the water seal chamber. B. Scant amount of sanguineous drainage noted on the dressing. C. Clear but slightly diminished breath sounds on the right side of the chest. D. Pain score of 2 one hour after the administration of the prescribed analgesic.

A. New, vigorous bubbling in the water seal chamber.

Which action would the nurse take *first* when a client who is receiving a blood transfusion develops fever, chills, and low back pain? A. Stop the blood transfusion and infuse saline B. Administer the prescribed antipyretic C. Obtain a prescription for an antihistamine D. Notify blood bank about symptoms

A. Stop the blood transfusion and infuse saline

While the nurse is giving an IV infusion of a piggyback medication, the patient's IV site becomes cool, pale, and swollen. The nurse should take which action? A. Stop the current infusion and change to another site. B. Slow down the rate of the infusion. C. Flush the IV line with normal saline. D. Retape the IV catheter to decrease the pressure.

A. Stop the current infusion and change to another site.

Ten minutes after the initiation of a blood transfusion, a client reports chills and flank pain. Which nursing action would be performed first? A. Stop the transfusion B. Obtain vital signs C. Notify health care provider D. Maintain flow with normal saline

A. Stop the transfusion

The nurse is caring for a patient with an artificial airway. What are reasons to suction the patient? (Select all that apply.) A. The patient has visible secretions in the airway. B. There is a sawtooth pattern on the patient's EtCO2 monitor. C. The patient has clear breath sounds. D. It has been 3 hours since the patient was last suctioned. E. The patient has excessive coughing.

A. The patient has visible secretions in the airway. B. There is a sawtooth pattern on the patient's EtCO2 monitor. E. The patient has excessive coughing.

Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) 1. Use a transfer device (e.g., transfer board) 2. Have head of bed elevated when transferring patient 3. Have head of bed flat when repositioning patient 4. Raise head of bed 60 degrees when patient positioned supine 5. Raise head of bed 30 degrees when patient positioned supine

A. Use a transfer device (e.g., transfer board) C. Have head of bed flat when repositioning patient E. Raise head of bed 30 degrees when patient positioned supine

A nurse notes blanching, coolness, and edema at a client's peripheral intravenous site. Which nursing action is most appropriate? A. Check for a blood return. B. Discontinue the intravenous line. C. Apply a warm compress. D. Measure the area of infiltration.

B. Discontinue the intravenous line.

The nurse is caring for a patient with pneumonia. On entering the room, the nurse finds the patient lying in bed, coughing, and unable to clear secretions. What should the nurse do first? A. Start oxygen at 2 L/min via nasal cannula. B. Elevate the head of the bed to 45 degrees. C. Encourage the patient to use the incentive spirometer. D. Notify the health care provider.

B. Elevate the head of the bed to 45 degrees.

Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)? A. Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution B. Hanging the urinary drainage bag below the level of the bladder C Emptying the urinary drainage bag daily D. Irrigating the urinary catheter with sterile water

B. Hanging the urinary drainage bag below the level of the bladder

An left-handed patient who had a right mastectomy several years ago has good veins in her right hand. Where should the nurse place the IV catheter? A. Right hand B. Left lower arm C. The patient's preferred location D. Right antecubital site

B. Left lower arm

The nurse is performing tracheostomy care on a patient. What finding would indicate that the tracheostomy tube has become dislodged? A. Clear breath sounds B. Patient speaking to nurse C. SpO2 reading of 96% D. Respiratory rate of 18 breaths/minute

B. Patient speaking to nurse

Which assessment findings indicate that the patient is experiencing an acute disturbance in oxygenation and requires immediate intervention? (Select all that apply.) A. SpO2 value of 95% B. Retractions C. Respiratory rate of 28 breaths per minute D. Nasal flaring E. Clubbing of fingers

B. Retractions C. Respiratory rate of 28 breaths per minute D. Nasal flaring

During a blood transfusion a client develops chills and a headache. Which intervention is the *priority* nursing action? A. Cover the client B. Stop the transfusion C. Take the client's vital signs D. Notify the health care provider

B. Stop the transfusion

What is a critical step when inserting an indwelling catheter into a male patient? A. Slowly inflate the catheter balloon with sterile saline. B. Secure the catheter drainage tubing to the bedsheets. C. Advance the catheter to the bifurcation of the drainage and balloon ports. D. Advance the catheter until urine flows, then insert ¼ inch more.

C. Advance the catheter to the bifurcation of the drainage and balloon ports.

During assessment of the IV site the nurse observes redness and tenderness on palpation. The nurse discontinues the IV and documents that the IV was discontinued and restarted because of which complication? A. Clotting of the IV catheter B. Infiltration C. Phlebitis D. Puncturing of the opposite side of the vein

C. Phlebitis

A patient is admitted to the hospital with severe dyspnea and wheezing. Arterial blood gas levels on admission are pH 7.26; PaCO2, 55 mm Hg; PaO2, 68 mm Hg; and HCO3- 24. How does the nurse interpret these laboratory values? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

C. Respiratory acidosis

Which of the following describes a hydrocolloid dressing? A. A seaweed derivative that is highly absorptive B. Premoistened gauze placed over a granulating wound C. A debriding enzyme that is used to remove necrotic tissue D. A dressing that forms a gel that interacts with the wound surface

D. A dressing that forms a gel that interacts with the wound surface

Which skills can the nurse delegate to assistive personnel (AP)? (Select all that apply.) A. Initiate oxygen therapy via nasal cannula. B. Perform nasotracheal suctioning of a patient. C. Educate the patient about the use of an incentive spirometer. D. Assist with care of an established tracheostomy tube. E. Reposition a patient with a chest tube.

D. Assist with care of an established tracheostomy tube. E. Reposition a patient with a chest tube.

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? A. A local skin infection requiring antibiotics B. Sensitive skin that requires special bed linen C. A stage 3 pressure injury needing the appropriate dressing D. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

D. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

The nurse assesses pain and redness at a vascular access device (VAD) site. Which action is taken first? A. Apply a warm, moist compress. B. Aspirate the infusing fluid from the VAD. C. Report the situation to the health care provider. D. Discontinue the intravenous infusion.

D. Discontinue the intravenous infusion.

Which patients are at most risk for pressure injuries? Select all that apply. a. A patient with right sided-paralysis and fecal incontinence b. An older adult who is alert and needs assistance to ambulate c. A young adult patient with paraplegia after a gunshot wound d. A morbidly obese patient who has an open abdominal wound e. An ambulatory patient who has occasional stress incontinence f. A young adult with a tibial fracture from a motor vehicle accident

a. A patient with right sided-paralysis and fecal incontinence c. A young adult patient with paraplegia after a gunshot wound d. A morbidly obese patient who has an open abdominal wound

The nurse notes tidaling of the water level in the water-seal chamber in a patient with closed chest tube drainage. The nurse should: a. continue to monitor the patient. b. check all connections for a leak in the system. c. lower the drainage collector further from the chest. d. clamp the tubing at a distal point away from the patient.

a. continue to monitor the patient.

Which patient has the greatest risk for experiencing delayed wound healing? a. A 65-yr-old woman with stress incontinence b. A 52-yr-old obese woman with type 2 diabetes c. A 78-yr-old man who has a history of hypertension d. A 30-yr-old man who drinks 2 alcoholic beverages per day

b. A 52-yr-old obese woman with type 2 diabetes

What are appropriate reasons for insertion of a straight or indwelling catheter? Select All That Apply. a. Substitute for routing nursing care b. Urinary retention c. Urine measurement of critically ill patients d. End of life care e. Immobilization f. Patient who is voiding 80 cc of urine per hour

b. Urinary retention c. Urine measurement of critically ill patients d. End of life care e. Immobilization

Which order should a nurse question in the plan of care for an older adult that is immobile after a stroke and has a pink, clean stage 3 pressure injury? a. Pack the wound with foam dressing. b. Turn and position the patient every 2 hour. c. Clean the wound every shift with Dakin's (sodium hypochlorite) solution. d. Assess for pain and medicate before dressing change.

c. Clean the wound every shift with Dakin's (sodium hypochlorite) solution.

An 82 year-old patient is being cared for at home by their family. A pressure injury on the patient's right buttock measures 1 × 2 × 0.8 cm, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

c. Stage 3

Which nursing action would be of *highest priority* when suctioning a patient with a tracheostomy? a. Auscultating lung sounds after suctioning is complete b. Giving antianxiety medications 30 minutes before suctioning c. Instilling 5 mL of normal saline into the tracheostomy tube before suctioning d. Assessing the patient's oxygen saturation before, during, and after suctioning

d. Assessing the patient's oxygen saturation before, during, and after suctioning

A patient has the following arterial blood gas results: pH 7.52, PaCO2 30 mm Hg, HCO3− 24 mEq/L. The nurse determines that these results indicate a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

d. respiratory alkalosis.