Pharm final Mock exam

In a nursing unit, the RN delegates nursing tasks to the nursing assistant. Keeping in mind the delegation guidelines, which statement denotes the right communication for the nursing assistant?

"Dispose of the disconnected IV set."

Which statement by a registered nurse (RN) represents appropriate delegation to a nursing assistant?

"Dispose of the disconnected IV set."

A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate?

"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein."

The nurse is preparing to administer a medication through a peripheral intravenous line. What should the nurse do when administering the medication to ensure safe delivery? Select all that apply.

-Flush the access device before the infusion is begun and after the infusion is completed. -Don't start administering the medication until intravenous placement is confirmed. -Observe for signs of infiltration or phlebitis prior to administration.

A nurse who is administering a piggyback intermittent intravenous infusion of medication to a client observes that there is a cloudy, white substance forming in the IV tubing. Which actions should the nurse take in this situation? Select all that apply.

-Stop the IV from flowing and stop administering the medication. -Clamp the IV at the site nearest to the client. -Replace tubing on primary and secondary infusions.

The client has vancomycin 250 mL intravenously prescribed daily. The vancomycin is to be administered over 90 minutes through an IV administration pump. How many mL/hr would the nurse set the IV administration pump to administer the vancomycin? Record your answer using a whole number.

167

Client blood sugar is 152. How much insulin would you give according to the sliding scale below? blood glucose insulin 100-150 0 units 151-200 2 units 201-300 6 units 301-400 10 units > 400 call provider

2 units

Pt IV is ordered LR 2000cc ovr 8 hours. how many ml/r will the pt receive?

250 ml/hr

A postoperative home care client has developed thrombophlebitis in the right leg. What new plan of care will need to be added because of this complication?

Anticoagulant treatment and education about the increased risk of bleeding

A nurse flushing a capped peripheral venous access device finds that the IV does not flush easily. What is the most appropriate intervention in this situation?

Aspirate and attempt to flush the line again.

A postoperative client is experiencing decreased lung sounds, dyspnea, cyanosis, crackles, restlessness, and apprehension. Which condition would the nurse suspect?

Atelectasis

Which postoperative complications can be reduced by appropriate client teaching about deep-breathing exercises? Select all that apply.

Atelectasis Pneumonia Bronchitis Severe hypoxemia

A nurse is caring for a postoperative client. What intervention(s) will help prevent thrombophlebitis? Select all that apply.

Leg range of motion exercises Sequential compression devices (SCDs) and antiembolic stockings Early ambulation as tolerated Frequent turning and positioning

The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect?

Phlebitis

The nurse is caring for a client who has a prescription for a peripheral intravenous (IV) infusion of a liter of 0.9 sodium chloride solution over 10 hours by gravity infusion. The drop factor is 60 gtts/mL. After reviewing the image, what is best action by the nurse to provide the appropriate drops per minute of medication?

Regulate flow to allow 25 gtts every 15 seconds

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?

Remove the IV.

A nurse is caring for a 6-year-old client on the hematology-oncology floor. During a packed red blood cell (PRBC) transfusion, the client reports of pain at the peripheral IV site. The nurse assesses the site and notices that the site is purple. What is the nurse's best course of action?

Stop the transfusion and insert peripheral IV at a new site.

A nurse is instructing a client in how to perform leg exercises following surgery. The client asks the nurse, "Why do I have to do these exercises?" Which is the health reason the nurse should mention?

To increase venous return of blood to the heart

The nurse is preparing to administer fluid replacement to a client. Which action should the nurse take first?

Verify the prescription for type of solution and amount of infusion.

The nurse is preparing to administer a medication to a client when the client states, "Last time I took that medication, I broke out in hives." What is the priority action by the nurse?

Withhold the medication and notify the health care provider that ordered the medication

A physician orders a placebo for a client. What is a placebo?

an inactive substance given in place of a drug

A client scheduled for surgery has been taking aspirin since his heart attack in 1997. The client is at risk for:

hemorrhage.

The nurse has provided a client with a sublingual medication. Which is the most appropriate nursing intervention to ensure proper administration of this medication?

looking under the client's tongue to verify administration

Ibuprofen 200 mg is obtained:

over-the-counter.

A client with dehydration is being administered IV fluids. During rounds, the nurse noticed that the skin immediately surrounding the IV site was reddish in color and showing signs of inflammation. The nurse recognizes that what phenomenon is likely responsible?

phlebitis

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of:

phlebitis.

The primary reason for the Controlled Substances Act is:

to prevent drug use and dependence.

A client comes to the clinic for a routine visit. During the interview, the client tells the nurse, "I'd really like to try to use some herbs and supplements to stay healthy. Do you have any suggestions for what I should do?" Which response by the nurse would be appropriate? Select all that apply.

-"Use products from reputable companies that have tested their quality." -"Make sure to understand what you are taking and the reason why." -"Learn about the product you are planning to use."

The nurse is administering medication to a client through a drug-infusion lock using the saline flush. During the process, the client complains of pain at the site. Which interventions are appropriate in this situation? Select all that apply.

-Stop the medication and assess the site for signs of infiltration and phlebitis. -Flush the medication lock with normal saline again to recheck patency. -If site is within normal limits, resume medication administration at a slower rate.

What signs of complications and their probable causes may occur when administering an IV solution to a client? Select all that apply.

-Swelling, pain, coolness, or pallor at the insertion site may indicate infiltration of the IV. -Redness, swelling, heat, and pain at the site may indicate phlebitis. -Local or systemic manifestations may indicate an infection is present at the site.

The nurse is caring for a client diagnosed with an acute myocardial infarction requiring strict monitoring of intake and output. Calculate the intake for the shift. Record your answer using a whole number rounded to the nearest 10 mL. 550 mL of urine ¼ cup of grapes 200 mL of liquid stool 4 oz of Jell-O 250 mL of IV normal saline 1 cup of apple juice

610

The nurse is caring for a client following major surgery. Which intervention helps to prevent orthostatic hypotension in the postsurgical client?

Administer intravenous fluids per the health care provider's prescription.

A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation?

Discontinue the IV and relocate it to another site.

A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation?

Discontinue the IV and relocate it to another spot.

A nurse is caring for a client with phlebitis. The nurse notices that the client's forearm, which has the tubing, has become red and slightly warm. Which actions should the nurse perform to avoid further complications and provide relief to the client?

Discontinue the IV promptly.

While receiving a medication IV piggyback, the client reports discomfort at the IV site. Upon assessment, the site is cool to the touch and slightly swollen. What is the best action by the nurse?

Discontinue the IV site and restart IV in a new location.

A client asks the nurse whether the generic acetaminophen is as effective as the brand name product. Which is the nurse's best response?

Generic medication performs the same as the corresponding brand-name product.

The nurse is caring for an older adult with pneumonia. What action by the nurse will help the client prevent further pulmonary infections?

Immunize the client with the pneumococcal vaccination once in a lifetime

A nurse is monitoring a client post cardiac surgery. What action would help to prevent cardiovascular complications for this client?

Implement leg exercises and turn the client in bed every 2 hours.

A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which data collected can be classified as subjective data?

Nausea

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication?

Restart infusion in another vein and apply a warm compress.

The nurse is performing an assessment on a newly admitted client. The client states, "I feel really nervous." This is an example of which type of data?

Subjective

A nurse is inspecting the IV access site of a client receiving intravenous therapy. The nurse suspects that the IV has infiltrated based on which finding at the site? Select all that apply.

Swelling Pallor Coolness

The nursing instructor is discussing fluid and electrolyte balance with a group of students. One of the students asks the instructor how fluids move to maintain homeostasis. The instructor formulates her response based on her knowledge that fluid homeostasis can be maintained by which of the following? Select all that apply.

osmosis filtration diffusion active transport

Which consideration should a nurse prioritize relating to the use of herbs and supplements by a client?

potential interactions with drugs

The nurse recognizes the value of leg exercises in the prevention of postoperative thrombophlebitis. When should the nurse teach the correct technique for leg exercises to a client?

prior to surgery

A client has required frequent scheduled and breakthrough doses of opioid analgesics in the 6 days since admission to the hospital. The client's medication regimen may necessitate which intervention?

stool softeners and increased fluid intake

The wife of a client with cancer is concerned that her husband's breakthrough doses of morphine have recently needed to be larger and more frequent in order for him to achieve pain relief. The nurse would recognize that the client is likely showing the effects of:

tolerance.

A nurse is caring for a female client with an indwelling urinary catheter. Which action should the nurse take into consideration to reduce the client's risk of developing a urinary tract infection (UTI)?

Ensure that the catheter is removed as soon as possible.

When capping a primary line for intermittent use, a nurse notices local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. Which complication has most likely occurred?

thrombus