Skills Final student questions

Which of the following statements made by the nurse indicates the need for further teaching of the correct catheterization technique? "I will place the drainage bag on the bed next to the patient's arm, so they can grab it easily" "After I use my hand to spread the labia, I can no longer use that hand to touch the equipment" "Inserting a Foley catheter requires sterile technique" "I will position my patient in the dorsal recumbent or Sims' position"

"I will place the drainage bag on the bed next to the patient's arm, so they can grab it easily"

IM injection: The nurse is preparing to administer an intramuscular injection of pain mediaction to a new postoperative client. When the nurse walks into the client's room, the client asks why he is recieving an intramuscular form of the medicatoin instread of the oral form. What is the nurse's best response with regard to the absorption of the medication? "Your primary health care provider wants you have it this way." "Are you saying that you are not going to take this medication." "Medications given this way have fewer side effects than those given orally." "Medicatoins given this way are absorbed more quickly than other routes."

"Medications given this way are absorbed more quickly than other routes."

You are given the following needle gauges: 18-gauge, 25-gauge, 27-gauge, & 30-gauge; which would be the most appropriate needle gauge to use to administer a deltoid IM injection? 18-gauge 25-gauge 27-gauge 30-gauge

25-gauge

A nursing student is administering an injection of mixed insulin for patient with diabetes prior to mealtime. During the injection, the patient pulls away from the student nurse. What action by the student indicates the need for further instruction? a. the student immediately initiates injection again in the same spot with the same needle b. the student attaches a new needle to the syringe c. the student immediately removes the needle and discards it d. the student administers remaining medication in different location

A

An 80-year-old male is admitted to the cardiology unit with a diagnosis of congestive heart failure (CHF). To treat his condition, the physician ordered a continuous IV infusion of furosemide (Lasix) to manage fluid volume overload. The nurse notes that the patient's urine intake has not increased, but his output has increased. His blood pressure has decreased from 152/90 mmHg to 102/74 mmHg. The patient's heart rate is currently 88 beats per minute. Which action should the nurse prioritize at this time? A)Administer a bolus of normal saline to address the decreased blood pressure. B)Discontinue the furosemide infusion immediately. C)Assess the patient for signs and symptoms of hypokalemia. D)Notify the healthcare provider of the changes in the patient's vital signs.

A

The novice nurse provides care to neonates on the maternal-newborn unit with the assistance of a nurse preceptor. Which statement made by the novice nurse while preparing to give an intramuscular (IM) injection to a neonate requires the nurse preceptor to intervene? A. I will clean the deltoid muscle muscle in a circular motion and let it dry before injecting the medication. B. I will use an aseptic technique when preparing the site for administration of the injection C. I will draw up the medication using a small, tuberculin syringe." D. The appropriate needle gauge for this IM injection is 22."

A

When flushing a newly inserted peripheral intravenous catheter access the nurse notices that the site becomes cool to the touch and edematous. The nurse concludes that the IV has infiltrated. What would the nurse's next steps be? Select all that apply. a. Put on gloves and remove the catheter b. Leave the catheter in and observe for infiltration during the next flush. c. Outline the infiltrated area with a skin. marker. d. Restart the IV in a new location. e. Notify the healthcare team. f. Reflush the catheter.

A, C, D, E

When inserting a urinary catheter into a female, which of the following are best practices to take to prevent a catheter-associated urinary tract infection (CAUTI)? (select all that apply) a. Only use urinary catheters when absolutely necessary b. Use clean gloves when inserting the catheter c. Follow your facility's two-person protocol for urinary catheter insertion d. Keep urine drainage bag secured on the bed frame, positioned slightly above the patient's bladder e. Maintain an aseptic field by only using your dominant hand to insert the catheter

A, C, E

A 45-year-old female patient is admitted to the hospital. The healthcare provider orders the insertion of an indwelling urinary catheter due to increased urinary retention. Which nursing intervention is essential to prevent complications associated with catheters in female patients? A) Securing the drainage bag to the side rail B) Emptying the drainage bag when it is full C) Maintaining sterile technique during catheter insertion and care D) Insert the catheter another 3-4 in after urine return is noted

C

A nurse receives an order to give a patient 6 units of insulin subcutaneously in the abdomen. While preparing the medication for the patient, the nurse is teaching the patient how to mix regular and NPH insulins in the same syringe. Which action should the nurse do first? a. Remove all of the air from each vial b. Draw up the medication from the NPH vial c. Roll and agitate the NPH insulin vial d. Inject air into the NPH insulin vial

C

A nurse walks into a patient's room to administer medication through intermittent IV piggyback infusion. As the nurse begins to administer the medication, the patient complains of pain at the IV site. What is the most appropriate action for the nurse in this situation? A) Continue administering the medication because this is a normal reaction, and the pain will go away after a few minutes. B) Stop the medication and quickly flush the IV site with normal saline. C) Stop the medication and assess the site for any complications. Next, flush the IV with normal saline to check patency. If patency is normal, continue the medication but at a slower rate. D) Stop the medication and immediately contact the healthcare provider.

C

The nurse prepares to administer an intramuscular (IM) injection to an adolescent client. Which action by the nurse is developmentally appropriate? A. Asking the client's parent to assist with positioning. B. Asking the client's sibling if he or she would like to watch C. Providing the client with an explanation of the MI procedure D.Establishing a reward system to enhance the client's cooperation

C

Which of the following verbal instructions may the nurse give to nursing assistive personnel (NAP) during the care of a patient receiving IV piggy-back antibiotics? A. "Remember to hang the secondary medication higher than the primary medication." B. "Please let the physician know that the patient is allergic to the medication prescribed" C. "Please let me know if the patient complains of pain or tenderness at the IV site" D. "Could you please assess the IV site for any swelling, redness, or pain?"

C

A nurse is preparing to administer an intravenous piggyback (IVPB) medication to a patient. What action should the nurse prioritize to ensure the correct administration of the IVPB? Using a larger gauge needle for a faster infusion rate Connecting the IVPB tubing to the patient's existing IV line without verifying compatibility Hanging the IVPB bag at the same height as the primary infusion Checking the expiration date and compatibility of the IVPB medication with the primary infusion

Checking the expiration date and compatibility of the IVPB medication with the primary infusion

The nurse is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse should take which action? Position the client supine to assist in medication absorption. Aspirate the nasogastric tube after medication administration to maintain patency. Clamp the nasogastric tube for 30 to 60 minutes following-administration of the medication Change the suction setting to low intermittent suction for 30 minutes after medication administration.

Clamp the nasogastric tube for 30 to 60 minutes following-administration of the medication

A student nurse prepares to change a central line dressing. The student performs hand hygiene, identifies the patient, provides privacy, assembles equipment, adjusts the bed height, explains the procedure, then immediately begins to remove the old dressing change from the bottom with an adhesive remover. Why does the nurse need to correct the student nurse, before the student nurse begins removing the old dressing? A. The student nurse should ask the patient about their allergies. B. The student nurse should move a waste bin closer to the work site. C. The student nurse should clean the area around the old dressing. D. The student nurse should assess the site.

D

Which patient would benefit from a central line for their treatment? a. A patient receiving hemodialysis once a week. b. A patient on a morphine drip. c. A patient needing a bolus of normal saline. d. A patient receiving 8 weeks of antibiotic therapy.

D

The nurse is preparing to administer a subcutaneous insulin injection on the left arm but notices some redness and bruising. They notice the site is hard to the touch when palpating. The patient states their last injection was on the right arm. What is the correct nursing action? Administer the injection on the right arm Ask the patient how long it's been bruised and if it's been over 48 hours continue to administer there Find a new injection site on the abdomen Pinch up the skin of underlying fatty tissue to help with injection administration

Find a new injection site on the abdomen

The healthcare provider has ordered that 5,000 units of heparin be administered over the course of one minute, prior to administration, the nurse notes that there is swelling around the IV insertion site and the patient is complaining of pain, the next step of action is to: Immediately remove IV and reinsert in a different location with no grafts or fistulas present Proceed with medication administration and monitor IV insertion site for five minutes Immediately remove IV and reinsert in a different location on a different extremity with an arteriovenous fistula Wait at least fifteen minutes before reassessing IV site and administering medication

Immediately remove IV and reinsert in a different location with no grafts or fistulas present

The nurse is making rounds to assess the condition of his/her assigned patients on the unit. On one patient, the nurse notices that the IV site is cool to the touch, pale, and the skin around the insertion site is edematous. The nurse concludes that which complication has occurred at the IV site? Phlebitis Thrombosis Infection Infiltration

Infiltration

When inserting an indwelling catheter into the female bladder, the nurse advances the catheter until they get urine return. What is the next best action to be completed by the nurse? Inflate the balloon of the catheter with a 10 mL syringe Insert the catheter another 2-3 inches Insert the catheter another 7-8 inches Secure the tubing to the patients inner thigh with a securement device

Insert the catheter another 2-3 inches

A nurse needs to drain the bladder of a male patient by inserting a catheter for a few minutes. What type of catheter should the nurse use? Foley catheter Indwelling catheter Condom catheter Intermittent catheter

Intermittent catheter

A nurse is caring for a client with a new tracheostomy. The client's oxygen saturation is 91% and the dressing is soiled. Which of the following is the priority at this time? Infection Fall precautions Oxygen saturation Airborne precautions

Oxygen saturation

Which of the following are indications for using central venous access devices? Select all that apply. Prolonged antibiotic treatment Venipuncture on a client with a phobia of needles Prolonged total parenteral nutrition Patient receiving chemotherapy

Prolonged antibiotic treatment Prolonged total parenteral nutrition Patient receiving chemotherapy

The nurse is slowly advancing a NG tube when the client begins to gasp and is unable to talk. Which has likely occurred? The NG tube is curled in the back of the client's throat. The client is forcefully resisting the procedure The NG tube is in the client's airway. The client is experiencing a vasovagal reaction

The NG tube is in the client's airway

A nurse is teaching a patient how to administer a subcutaneous insulin injection. Which of the following patient actions indications they are performing this skill correctly? Select all that apply. The patient discards the needle in the regular trash The patient checks their blood sugar before the administration The patient cleans the lateral aspect of their arm in a circular motion moving out from the intended injection site The patient aspirates the needle to ensure it is not in the blood vessel The patient injects the medication in an area that is not painful and feels firm to the touch

The patient checks their blood sugar before the administration The patient cleans the lateral aspect of their arm in a circular motion moving out from the intended injection site

The nurse is caring for patient in room 101 in the ICU who has a central venous catheter. Which action is essential for the nurse to take to prevent infection from occurring? Select all that apply Use sterile gloves during dressing change Clean the site with >5 chlorhexidine Cleaning the site with alcohol before applying a new dressing Change dressing immediately if it becomes damp, loosen, or visibly soiled Perform site care and replace TSM dressing at least every seven days.

Use sterile gloves during dressing change Clean the site with >5 chlorhexidine Change dressing immediately if it becomes damp, loosened, or visibly soiled Perform site care and replace TSM dressing at least once every seven days

You have finished inserting a nasogastric tube, which of the following is the best way to assess for correct placement? pH Auscultate X-ray Marking on NG tube

X-ray