ICS Quiz #2 Review

What should be done when a medication error occurs?

-Check the patient's condition immediately and check for adverse effects -Notify nurse manager and PCP -Write description of error and remedial steps on medical record -Complete form used for reporting errors as dictated by facility policy

What steps should be taken to identify a patient?

-Checking the ID bracelet -Validating the patient's name (first identifier) -Validating the patient's ID#, EMR#, or DOB (second identifier) -Comparing with the cMAR or MAR -Asking the patient to state their name if possible

"Rights" of Medication Administration

-Right Medication -Right Patient -Right Dosage -Right Route -Right Time -Right Reason -Right assessment data -Right documentation -Right response -Right to eduction -Right to refuse

A nurse is preparing to administer methylprednisolone 10mg by IV bolus. The amount available is methylprednisolone 40mg/mL. How many mL should the nurse administer? Round the answer to the nearest tenth. Do not use a trailing zero.

0.3 mL

Adequate Urine Output

0.5 mL/kg/hr Ex: 140lb person (64 kg) - adequate UO is 32-64 mL/hr

A nurse is preparing to administer ketorolac 0.5mg/kg IV bolus every 6 hr to a school-age child who weighs 66lb. The amount available is ketorolac injection 30mg/mL. How many mL should the nurse administer per dose? Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.

0.5mL

Steps of Medication Administration

1) Check the MAR for physician orders 2) Assess for any contraindications (NPO, BP, HR, allergies, etc.) 3) Perform the six rights of med administration (ID patient, drug/indication, dose, route, time, documentation) 4) Open the medication on the MAR 5) Scan the barcode on the patient ID band 6) Scan the barcode on the medication 7) Provide teaching regarding medication purpose and utilize the teach-back method

Nasogastric (NG) Tube - Insertion Steps

1) Put patient in high Fowler's position (90°) 2) Measure from nose to earlobe to diploid process and mark tube at appropriate length 3) Lubricate tube with water-based lubricant 4) Have patient tilt head forward to close epiglottis to ensure tube doesn't go down trachea 5) Have patient sip water as you feed the tube down or have them dry-swallow if NPO 6) Anchor tube to nose using tape, secure to patient gown using safety pin and/or tape - keep end above head 7) To ensure it is in the stomach, the standard is to have a stat X-ray

When should the nurse read the label during medication administration checks?

1) When the nurse reaches for the container or the unit dose package 2) After retrieval from the drawer and compared with the eMAR/MAR 3) Before giving the unit dose medication to the patient or when replacing the multi-dose container in the drawer or shelf

A nurse is preparing to administer acetaminophen 320mg PO every 4 hr PRN for pain. The amount available is acetaminophen liquid 160mg/5mL. How many mL should the nurse administer per dose? Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.

10 mL

A nurse is preparing to administer dextrose 5% in water (D5W) 1,000mL IV to infuse over 10 hr. The nurse should set the IV infusion pump to deliver how many mL/hr? Round the answer to the nearest whole number. Do not use a trailing zero.

100 mL/hr

A nurse is preparing to administer metoprolol 200mg PO daily. The amount available is metoprolol 100mg/tablet. How many tablets should the nurse administer? Round the answer to the nearest whole number. Do not use a trailing zero.

2 tablets

A patient is to receive 1,000 mL of 5% dextrose in lactated Ringer's over 8 hours. Using tubing with a drop factor of 15 gtt/mL, the nurse should regulate the fluid to infuse at how many drops per minute? Round the answer to the nearest whole number.

31 gtt/min

A nurse is preparing to administer lactated Ringer's (LR) IV 100mL over 15 min. The nurse should set the IV infusion pump to deliver how many mL/hr? Round the answer to the nearest whole number. Do not use a trailing zero.

400 mL/hr

A nurse is preparing to administer dextrose 5% in lactated Ringer's (D5LR) 1,000 mL to infuse over 6 hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? Round the answer to the nearest whole number. Do not use a trailing zero.

42 gtt/min

A patient has finished a 16-oz container of orange juice. The intake and output sheet documents fluid in milliliters. What should the nurse document as intake?

480 mL

A nurse is preparing to administer 0.9% NaCl 250mL IV to infuse over 30 min. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? Round the answer to the nearest whole number. Do not use a trailing zero.

83 gtt/min

A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? Select all that apply. A.) Review a signal the client can use if feeling any distress B.) Lay a towel across the client's chest C.) Administer oral pain medications D.) Obtain a Dobhoff tube for insertion E.) Have a petroleum-based lubricant available

A & B

A nurse is discussing direct and indirect contact modes of transmission of infection at a staff education session. Which of the following incidents should the nurse include as examples of the direct mode of transmission? Select all that apply. A.) Blood spurting from an arterial wound splashes into a nurse's eye. B.) A nurse has a needlestick injury. C.) A mosquito bites a hiker in the woods. D.) A nurse finds a hole in their glove while handling a sterile dressing. E.) A person fails to wash their hands after using the bathroom and touches a client.

A & E

A nurse is reviewing a client's prescribed medications at the beginning of the day shift. Which of the following 0900 medications can be given anytime between 0700 and 1100? Select all that apply. A.) A once-daily multivitamin B.) Eye drops prescribed every 3 hours C.) An antibiotic prescribed every 8 hours D.) A blood pressure pill prescribed twice daily E.) A subcutaneous injection prescribed once weekly

A & E

A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? Select all that apply. A.) Older adults are more prone to dehydration than younger adults are. B.) Older adults need the same amount of most vitamins and minerals as younger adults do. C.) Many older men and women need calcium supplementation. D.) Older adults need more calories than they did when they were younger. E.) Older adults should consume a diet low in carbohydrates.

A, B, C

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? Select all that apply. A.) Auscultate bowel sounds B.) Assist the client to an upright position C.) Test the pH of gastric aspirate D.) Warm the formula to body temperature E.) Discard any residual gastric contents

A, B, C

Which of the following are appropriate choices for a patient prescribed a full liquid diet? Select all that apply. A.) Plain yogurt B.) Custard C.) Ice cream D.) Mashed potatoes E.) Pureed meat F.) Gelatin

A, B, C, F

A nurse is preparing medications for patients in the ICU. The nurse is aware that there are patient variables that may affect the absorption of these medications. Which statements accurately describe these variables? Select all that apply. A.) Patients in certain ethnic groups obtain therapeutic responses at lower doses or higher doses than those usually prescribed. B.) Some people experience the same response with a placebo as with the active drug used in studies. C.) People with liver disease metabolize drugs more quickly than people with normal liver functioning. D.) A patient who receives a pain medication in a noisy environment may not receive full benefit from the medication's effects. E.) Oral medications should not be given with food as the food may delay the absorption of the medications. F.) Circadian rhythms and cycles may influence drug action.

A, B, D, F

A nurse educator is teaching newly licensed nurses about safe medication administration. Which of the following statements indicates understanding? Select all that apply. A.) "I will observe for adverse effects." B.) "I will monitor for therapeutic effects." C.) "I will prescribe the appropriate dose." D.) "I will change the dose if adverse effects occur." E.) "I will refuse to give a medication if I believe it is unsafe."

A, B, E

A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should identify which of the following findings as a manifestation of dehydration? Select all that apply. A.) Hct 55% B.) Blood osmolarity 260 mOsm/kg C.) Blood sodium 150 mEq/L D.) Urine specific gravity 1.035 E.) Blood creatinine 0.6 mg/dL

A, C, D

A nurse in a residential care facility is assessing an older adult client. Which of the following findings should the nurse identify as atypical indications of infection in this client? Select all that apply. A.) Urinary incontinence B.) Malaise C.) Acute confusion D.) Fever E.) Agitation

A, C, E

A nurse is teaching a patient how to use a meter-dosed inhaler to control asthma. What are appropriate guidelines for this procedure? Select all that apply. A.) Shake the inhaler well and remove the mouthpiece covers from the MDI and spacer. B.) Take shallow breaths when breathing through the spacer. C.) Depress the canister releasing one puff into the spacer and inhale slowly and deeply D.) After inhaling, exhale quickly thorough pursed lips E.) Wait 1 to 5 minutes as prescribed before administering the next puff F.) Gargle and rinse with salt water after using the MDI

A, C, E

A nurse on the IV team is conducting an in-service education program amount the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? Select all that apply. A.) "The temperature around the IV site is cooler." B.) "The rate of the infusion increases." C.) "The skin at the IV site is red." D.) "The IV dressing is damp." E.) "The tissue around the venipuncture site is swollen."

A, D, E

A nurse who is administering medications to patients in an acute care setting studies the pharmacokinetics of the drugs being administered. Which statements accurately describe these mechanisms of action? Select all that apply. A.) Distribution occurs after a drug has been absorbed into the bloodstream and is made available to body fluids and tissues B.) Metabolism is the process by which a drug is transferred from its site of entry into the body to the bloodstream C.) Absorption is the change of a drug from its original form to a new form, usually occurring in the liver D.) During first-pass effect, drugs move from the intestinal lumen of the liver by way of the portal vein instead of going into the system's circulation E.) The gastrointestinal tract, as well as sweat, salivary, and mammary glands, are routes of drug absorption F.) Excretion is the process of removing a drug, or its metabolites (products of metabolism), from the body

A, D, F

A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into a syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make? A.) "Water helps clear the tube so it doesn't get clogged." B.) "Flushing helps make sure the tube stays in place." C.) "This will help you get enough fluids." D.) "Adding water makes the formula less concentrated."

A.) "Water helps clear the tube so it doesn't get clogged."

A nurse is discontinuing an IV infusion. For which of the following reasons is it important to verify and document the integrity and condition of the IV catheter? A.) A broken-off catheter tip indicates the risk for an embolus B.) Catheter erosion indicates that is was left in place too long C.) Blood within the catheter could indicate clot formation D.) Discoloration of the catheter could be as sign of phlebitis

A.) A broken-off catheter tip indicates the risk for an embolus

A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia? A.) A client who has nasogastric suctioning B.) A client who has chronic constipation C.) A client who has syndrome of inappropriate antidiuretic hormone D.) A client who took a toxic dose of sodium bicarbonate antacids

A.) A client who has nasogastric suctioning

A nurse should recognize that which of the following is correct regarding albumin level as a diagnostic marker for nutritional status? A.) Albumin level is a poor short-term indicator of protein status B.) Hydration status does not affect a patient's albumin level C.) An albumin level of 3.2 g/dL is within the normal reference range D.) Albumin level is calculated by keeping a 24-hr record of protein intake

A.) Albumin level is a poor short-term indicator of protein status

A nurse is administering a pain medication to a patient. In addition to checking his identification bracelet, the nurse correctly verifies the patient's identify by performing which action? A.) Asking the patient his name and birthdate B.) Reading the patient's name on the sign over the bed C.) Asking the patient's roommate to verify his name D.) Asking, "Are you Mr. Brown?"

A.) Asking the patient his name and birthdate

To assess a stroke patient for complications secondary to inadequate swallowing, the nurse should do which of the following? A.) Auscultate the patient's lungs B.) Place the tip of the tongue depressor on the patient's posterior tongue C.) With a penlight, inspect the patient's uvula and soft palate D.) Place fingers on the patient's throat at the level of the larynx and ask him to swallow

A.) Auscultate the patient's lungs

A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as a risk factor for the development of this electrolyte imbalance? A.) Crohn's disease B.) Postoperative following appendectomy C.) History of bone cancer D.) Hyperthyroidism

A.) Crohn's disease

A nurse is administering phenytoin via a gastric tube to a patient who is receiving tube feedings. What would be an appropriate action of the nurse in this situation? A.) Discontinue the tube feeding and leave the tube clamped for required period of time before and after medication administration B.) Notify the primary care provider that medication cannot be given to the patient at this time via the gastric tube C.) Remove the tube in place and replace it with another tube prior to administering the medication D.) Flush the tube with 60mL of water prior to administering the medication

A.) Discontinue the tube feeding and leave the tube clamped for required period of time before and after medication administration

An older adult patient in a long-term care facility is receiving intermittent enteral feedings in his room. His affect is flat, and the nurse suspects that he is feeling isolated. Which of the following interventions is appropriate for this patient? A.) Encourage him to go to the dining room at meal times to talk with other patients. B.) Suggest that he watch television while his feedings are being administered. C.) Remind him that he can have visitors after his feeding administration times. D.) Ask the facility chaplain to speak with the patient.

A.) Encourage him to go to the dining room at meal times to talk with other patients.

Which of the following interventions should a nurse use at mealtimes for a patient who has visual deficits? A.) Identify the food location as though the plate were a clock B.) Direct the order in which food items are consumed C.) Have the patient tilt her head forward while eating D.) Avoid talking to the patient during mealtime

A.) Identify the food location as though the plate were a clock

A nurse is preparing to admit a client who is suspected to have pulmonary tuberculosis. Which of the following actions should the nurse plan to perform first? A.) Implement airborne precautions B.) Obtain a sputum culture C.) Administer antituberculosis medications D.) Recommend a screening test for family members

A.) Implement airborne precautions

A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse include in the plan of care? A.) Infuse hypotonic IV fluids B.) Implement a fluid restriction C.) Increase sodium intake D.) Administer sodium polystyrene sulfonate

A.) Infuse hypotonic IV fluids

A nurse is performing a nasogastric intubation. Which of the following actions should the nurse take immediately after inserting the tube to the predetermined length? A.) Inspect the oropharynx with a penlight and a tongue blade B.) Obtain an X-ray examination of the chest and abdomen C.) Tape the tube securely in place with a tube holder device D.) Aspirate gastric contents

A.) Inspect the oropharynx with a penlight and a tongue blade

A nurse prepares an injection of morphine to administer to a client who reports pain, then asks a second nurse to give the injection because another assigned client needs to use a bedpan. Which of the following actions should the second nurse take? A.) Offer to assist the client who needs the bedpan. B.) Administer the injection the other nurse prepared. C.) Prepare another syringe and administer the injection. D.) Tell the client who needs the bedpan to wait while the nurse gives someone else medication.

A.) Offer to assist the client who needs the bedpan.

A nurse is caring for a patient who has a newly inserted nasogastric tube. Which of the following methods is appropriate for verifying the initial placement? A.) X-ray examination of the chest and abdomen B.) Auscultation of injected air C.) pH measurement of gastric aspirate D.) Color of gastric contents

A.) X-ray examination of the chest and abdomen

A nurse inserting a nasogastric tube asks the patient to flex her head toward her chest after the tube passes through the nasopharynx. This action facilitates proper insertion of the tube by A.) closing off the glottis. B.) preventing curling of the tube in the mouth. C.) allowing the patient to breathe through her mouth. D.) opening the lower esophageal sphincter.

A.) closing off the glottis.

A nurse has just inserted a peripheral IV catheter for a continuous infusion. To secure the catheter, the nurse should A.) leave the connection between the hub and the tubing uncovered. B.) wrap tape around the circumference of the patient's arm. C.) tape the IV catheter's hub securely to the patient's skin. D.) place a piece of paper tape over the insertion site.

A.) leave the connection between the hub and the tubing uncovered.

To prevent a common application of continuous enteral tube feedings, a nurse should A.) limit the time the formula hangs to 4 hr. B.) chill the formula prior to administration. C.) deliver the formula at a brisk rate. D.) allow the feeding bag to empty before refilling it.

A.) limit the time the formula hangs to 4 hr.

A nurse is collecting data from a client who has hypercalcemia as a result of long-term use of glucocorticoids. Which of the following findings should the nurse expect? Select all that apply. A.) Hyperreflexia B.) Confusion C.) Positive Chvostek's sign D.) Bone pain E.) Nausea and vomiting

B, D, E

PRN Order

As needed; order will specify dose, frequency, and conditions under which patient can have the medication

A nurse is providing teaching to a patient who is receiving intermittent nasogastric feedings. Which of the following should the nurse instruct the patine to report immediately? A.) A feeling of fullness B.) Persistent coughing C.) Discomfort in the naris D.) Postfeeding belching

B.) Persistent coughing

A nurse is caring for a client receiving dextrose 5% in 0.9% sodium chloride IV at 120 mL/hr. Which of the following statements by the client should alert the nurse to suspect fluid overload? Select all that apply. A.) "I feel lightheaded." B.) "I feel as though my heart is racing." C.) "I feel a little short of breath." D.) "The nurse technician told me that my blood pressure was 150 over 90." E.) "I think my ankles are less swollen."

B, C, D

A nurse orienting a newly licensed nurse is reviewing the procedure for taking a telephone prescription. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands the process? A.) "A second nurse enters the prescription into the client's medical record." B.) "Another nurse should listen to the phone call." C.) "The provider can clarify the prescription when they sign the health record." D.) "I should omit the 'read back' if this is a one-time prescription."

B.) "Another nurse should listen to the phone call."

A nurse is demonstrating how to insert an IV catheter. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure? A.) "I will thread the needle all the way into the vein until the hub rests against the insertion site after I see a flashback of blood." B.) "I will insert the needle into the client's skin at an angle of 10 to 30 degrees with the bevel up." C.) "I will apply pressure approximately 1.2 inches below the insertion site prior to removing the needle." D.) "I will choose a vein in the antecubital fossa for IV insertion due to its size and easily accessible location."

B.) "I will insert the needle into the client's skin at an angle of 10 to 30 degrees with the bevel up."

A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction? A.) A client who has a new diagnosis of adrenal insufficiency B.) A client who has heart failure C.) A client who is receiving treatment for diabetic ketoacidosis D.) A client who has abdominal ascites

B.) A client who has heart failure

When checking for nasogastric tube placement, the nurse should conduct which of the following procedures? A.) Instill 20 mL of air into the tube and listen for a whooshing sound B.) Aspirate stomach contents and check the pH C.) Aspirate stomach contents and check their color D.) Auscultate lung sounds

B.) Aspirate stomach contents and check the pH

Ms. Hall has an order for hydromorphone, 2 mg, intravenously, q 4 hours PRN pain. The nurse notes that according to Ms. Hall's chart, she is allergic to hydromorphone. The order for medication was signed by Dr. Long. What would be the correct procedure for the nurse to follow in this situation? A.) Administer the medication; the doctor is responsible for medication administration. B.) Call Dr. Long and ask that the medication be changed. C.) Ask the supervisor to administer the medication. D.) Ask the pharmacist to provide a medication to take the place of hydromorphone.

B.) Call Dr. Long and ask that the medication be changed.

A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? A.) Administer antihypertensive on schedule B.) Check the client's weight each morning C.) Notify the provider of a urine output greater than 30 mL/hr D.) Encourage independent ambulation four times a day

B.) Check the client's weight each morning

A health care provider orders a pain medication for a postoperative patient that is a PRN oder. When would the nurse administer this medication? A.) A single dose during the postoperative period B.) Doses administered as needed for pain relief C.) One dose administered immediately D.) Doses routinely administered as a standing order

B.) Doses administered as needed for pain relief

Which of the following dietary modifications should an adolescent engaging in sports implement? A.) Increase fats to 30% to 40% of daily kilocalories B.) Drink water before and after sports activities C.) Keep protein intake at the same level D.) Decrease carbohydrates to 30% to 40% of daily kilocalories

B.) Drink water before and after sports activities

Which of the following formulas is appropriate to administer to a patient who has a dysfunctional gastrointestinal tract? A.) Modular B.) Elemental C.) Polymeric D.) Specialty

B.) Elemental

A patient requires 40 units of NPH insulin and 10 units of regular insulin daily subcutaneously. What is the correct sequence when mixing insulins? A.) Inject air into the regular insulin vial and withdraw 10 units; then, using the same syringe, inject air into the NPH vial and withdraw 40 units of NPH insulin. B.) Inject air into the NPH insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the regular insulin vial and withdraw 10 units; then, withdraw 40 units of NPH insulin. C.) Inject air into the regular insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the NPH insulin vial and withdraw 40 units; then, withdraw 10 units of regular insulin. D.) Inject air into the NPH insulin vial and withdraw 40 units; then, using the same syringe, inject air into the regular insulin vial and withdraw 10 units of regular insulin.

B.) Inject air into the NPH insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the regular insulin vial and withdraw 10 units; then, withdraw 40 units of NPH insulin.

A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? A.) Give the client thin liquids B.) Instruct the client to tuck their chin when swallowing C.) Have the client use a straw D.) Encourage the client to lie down and rest after meals

B.) Instruct the client to tuck their chin when swallowing

A nurse initiating a peripheral IV infusion punctures the skin and selected vein and observes blood return in the flashback chamber of the IV catheter. Which of the following actions should the nurse perform next? A.) Secure the catheter to the skin with a transparent dressing B.) Lower the catheter until it is almost flush with the skin C.) Advance the catheter about 1/4 inch into the vein D.) Remove the stylet slowly from the lumen of the catheter

B.) Lower the catheter until it is almost flush with the skin

A patient with a gastric ileus postoperatively requires nutritional support for approximately 2 weeks. Which of the following types of feeding tubes is appropriate for this patient? A.) Nasogastric tube B.) Nasointestinal tube C.) Percutaneous endoscopic gastrostomy tube D.) Percutaneous endoscopic jejunostomy tube

B.) Nasointestinal tube

A patient recovering from gastric surgery remains NPO and has a nasogastric tube connected to suction. Which of the following actions should the nurse take to prevent dry mucous membranes? A.) Allow the patient to suck on ice chips B.) Provide frequent mouth care C.) Apply petroleum jelly to the patient's naris D.) Offer throat lozenges for the patient to use

B.) Provide frequent mouth care

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? A.) Auscultate breath sounds B.) Stop the feeding C.) Obtain a chest X-ray D.) Initiate oxygen therapy

B.) Stop the feeding

A nurse is caring for a patient who has sustained a head injury and whose level of consciousness fluctuates. The provider prescribes a full liquid diet progressing to a pureed diet as tolerated. Before initiating feedings, it is essential that this patient undergo which of the following? A.) Chest X-ray B.) Swallowing examination C.) Nasogastric tube insertion D.) Olfactory nerve evaluation

B.) Swallowing examination

A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse's highest assessment priority before performing this procedure? A.) Check ho long the feeding container has been open B.) Verify the placement of the NG tube C.) Confirm that the client does not have diarrhea D.) Make sure the client is alert and oriented

B.) Verify the placement of the NG tube

A patient in early stage renal failure is prescribed an infusion of 0.45% sodium chloride. This type of solution is appropriate because it A.) pulls fluid from the cells and increases vascular volume. B.) dilutes extracellular fluid and rehydrates the cells. C.) replaces extracellular volume and maintains intravascular volume. D.) draws fluid into blood vessels and reduces interstitial compartments.

B.) dilutes extracellular fluid and rehydrates the cells.

BMI Formula

BMI = weight (kg) / height (m^2) Obese = BMI 30 and above Overweight = BMI 25-20 Normal = BMI 18.5-25 Underweight = BMI < 18.5

A nurse is caring for a client who weighs 80kg (176lb) and is 1.6m (5ft 3in) tall. Calculate the body mass index (BMI) and determine whether this client's BMI indicates a health weight, underweight, overweight, or obese.

BMI = weight (kg) / height (m^2) Step 1: Client's weight (kg) and height (m) = 80kg and 1.6m Step 2: 1.6 x 1.6 = 2.56 m^2 Step 3: 80 / 2.56 = 31.25 A BMI greater than 30 identifies obesity. 25 is the upper boundary for a healthy weight 25 to 29.9 = overweight 30 to 34.9 = obesity class 1 35 to 39.9 = obesity class 2 40+ = obesity class 3

Digestion

Begins in mouth and ends in small and large intestines Intestine is primary area of absorption

A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? Select all that apply. A.) Distended neck veins B.) Hyperthermia C.) Tachycardia D.) Syncope E.) Decreased skin turgor

C, D, E

The nurse is administering a medication to a patient via an enteral feeding tube. Which are accurate guidelines related to this procedure? Select all that apply. A.) Crush the enteric-coated pill for mixing in a liquid B.) Flush open the tube with 60mL of very warm water C.) Use the recommended procedure for checking tube placement in the stomach or intestine D.) Give each medication separately and flush with water between each drug E.) Lower the head of the bed to prevent reflux F.) Adjust the amount of water used if patient's fluid intake is restricted

C, D, F

A charge nurse is teaching a newly licensed nurse about the care of a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements should the charge nurse identify as an indication that the newly licensed nurse understands the teaching? A.) "I should obtain a specimen for culture and sensitivity after the first dose of an antimicrobial." B.) "MRSA is usually resistant to vancomycin, so another antimicrobial will be prescribed." C.) "I will protect others from exposure when I transport the client outside the room." D.) "To decrease resistance, antimicrobial therapy is discontinued when the client is no longer febrile."

C.) "I will protect others from exposure when I transport the client outside the room."

A nurse should recognize that nasogastric intubation is indicated to relieve gastric distention for which of the following patients? A.) A 6-year-old child who drank a toxic substance B.) A 60-year-old patient admitted with gastrointestinal hemorrhage C.) A 40-year-old patient with postoperative bowel obstruction D.) A 20-year-old patient with malabsorption syndrome

C.) A 40-year-old patient with postoperative bowel obstruction

A nurse administers a dose of an oral medication for hypertension to a patient who immediately vomits after swallowing the pill. What would be the appropriate initial action of the nurse in this situation? A.) Readminister the medication and notify the primary care provider B.) Readminister the pill in a liquid form if possible C.) Assess the vomit, looking for the pill D.) Notify the primary care provider

C.) Assess the vomit, looking for the pill

A nurse discovers that a medication error occurred. What should be the nurse's first response? A.) Record the error on the medication sheet B.) Notify the physician regarding course of action C.) Check the patient's condition to note any possible effect of the error D.) Complete an incident report, explaining how the mistake was made

C.) Check the patient's condition to note any possible effect of the error

A nurse finds a patient's IV insertion site red, warm, and slightly edematous. Which of the following actions should the nurse perform first? A.) Check for a blood return B.) Elevate the extremity C.) Discontinue the IV line D.) Apply warm, moist heat

C.) Discontinue the IV line

A nurse is administering heparin subcutaneously to a patient. What is the correct technique for this procedure? A.) Aspirate before giving and gently massage after the injection. B.) Do not aspirate; massage the site for 1 minute. C.) Do not aspirate before or massage after the injection. D.) Massage the site of injection; aspiration is not necessary but will do no harm.

C.) Do not aspirate before or massage after the injection.

A nurse is caring for a patient who has impaired swallowing due to a cerebrovascular accident. Which of the following interventions should the nurse use to assist the patient with feeding? A.) Provide the patient with a straw B.) Offer the patient thin fluids C.) Elevate the head of the bed 45 to 90° D.) Place food in the weaker side of the mouth

C.) Elevate the head of the bed 45 to 90°

A nurse receives a laboratory report for a client indicating a potassium level of 5.2 mEq/L. When notifying the provider, the nurse should expect which of the following actions? A.) Starting an IV infusion of 0.9% sodium chloride B.) Consulting with dietitian to increase intake of potassium C.) Initiating continuous cardiac monitoring D.) Preparing the client for gastric lavage

C.) Initiating continuous cardiac monitoring Hyperkalemia

Which of the following strategies for enhancing the intake of healthful foods is appropriate for an adolescent? A.) Encouraging the adolescent to consume snack foods from the grains food group B.) Permitting the adolescent to skip breakfast to enhance appetite at later meals C.) Making healthful food choices more convenient and available for the adolescent D.) Allowing the adolescent complete autonomy in making food choices

C.) Making healthful food choices more convenient and available for the adolescent

A nurse is removing an IV catheter from a patient whose IV infusion has been discontinued. Which of the following actions is appropriate? A.) Apply firm pressure over the vein B.) Leave the roller clamp slightly open C.) Pull the catheter straight back from the insertion site D.) Lift the hub slightly upward away from the skin

C.) Pull the catheter straight back from the insertion site

A nurse reviewing a client's health record notes a new prescription for lisinopril 10mg PO once every day. The nurse should identify this as which of the following types of prescription? A.) Single B.) Stat C.) Routine D.) Now

C.) Routine

During report, a nurse is informed that a patient has a nasogastric tube connected to continuous suction. The nurse should recognize that this patient must have which of the following types of tube? A.) Levin B.) Sengstaken-Blakemore C.) Salem sump D.) Ewald

C.) Salem sump Levin - single-lumen tube, requires intermittent suction Sengstaken-Blakemore - ballon is inflated to apply internal pressure Salem sump - allows for continuous suction; two lumens Ewald - irrigate stomach in cases of active bleeding

A nurse who gives subcutaneous and intramuscular injections to patients in a hospital setting attempts to reduce discomfort for the patients receiving the injections. Which technique is recommended? A.) The nurse selects a needle of the largest gauge that is appropriate for the site and solution to be injected B.) The nurse injects the medication into contracted muscles to reduce pressure and discomfort at the site C.) The nurse uses the Z-track technique for intramuscular injections to prevent leakage of medication into the needle track D.) The nurse applies vigorous pressure in a circular motion after the injection to distribute the medication to the intended site

C.) The nurse uses the Z-track technique for intramuscular injections to prevent leakage of medication into the needle track

A nurse is performing a nutritional assessment. When obtaining and interpreting anthropometric values, the nurse should recognize which of the following? A.) Isolated measurements of height and weight are of greater significance than changes over time B.) A weight increase of 4lb in a patient with renal failure indicates retention of 1,000 mL of fluid C.) The patient should be weighed on the same scale at the same time each day D.) The ratio of height-to-wrist circumference is the most accurate way to identify obesity

C.) The patient should be weighed on the same scale at the same time each day

A medication order reads: "K-Dur, 20 mEq po BID." When and how does the nurse correctly give this drug? A.) Daily at bedtime by subcutaneous route B.) Every other day by mouth C.) Twice a day by the oral route D.) Once a week by transdermal patch

C.) Twice a day by the oral route

A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray? A.) Cooked barley B.) Pureed broccoli C.) Vanilla custard D.) Lentil soup

C.) Vanilla custard

Nasogastric tube feedings are an appropriate choice for a patient who A.) has a paralytic ileus. B.) has recently experienced facial trauma. C.) is postoperative following laryngectomy. D.) has pancreatitis.

C.) is postoperative following laryngectomy.

The most reliable method for verifying initial placement of a small-bore feeding tube is by A.) measuring the pH of gastric aspirate. B.) auscultating the epigastric area while injecting air. C.) obtaining an abdominal X-ray. D.) placing the open end of the tube in a cup of water.

C.) obtaining an abdominal X-ray.

During new employee orientation, a nurse is explaining how to prevent IV infections. Which of the following statements by an orientee indicates understanding of the preventive strategies? A.) "I will leave the IV catheter in place after the client completes the course of IV antibiotics." B.) "As long as I am working with the same client, I can use the same IV catheter for my second insertion attempt." C.) "If my client needs to use the rest room, it would be safer to disconnect their IV infusion as long as I clean the injection port thoroughly with an antiseptic swab." D.) "I will replace any IV catheter when I suspect contamination during insertion."

D.) "I will replace any IV catheter when I suspect contamination during insertion."

A nurse is providing education for a client who has severe hypomagnesemia and is prescribed oral magnesium sulfate. Which of the following information should the nurse include in the teaching? A.) "Avoid green, leafy vegetables while taking this medication." B.) "You should receive a prescription for a thiazide diuretic to take with the magnesium." C.) "You should eliminate whole grains from your diet until your magnesium level increases." D.) "Report diarrhea while taking this medication."

D.) "Report diarrhea while taking this medication."

A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy? A.) Fat B.) Protein C.) Glycogen D.) Carbohydrates

D.) Carbohydrates

A nurse who has just initiated an IV infusion explains to the patient that complications are possible and that she will monitor the infusion regularly. The nurse should teach the patient that which of the following findings is an indication of early infiltration? A.) Moisture B.) Bruising C.) Tingling D.) Coolness

D.) Coolness

A nurse is collecting data from a client who is receiving IV therapy and reports pain the arm, chills, and "not feeling well." The nurse notes warmth, edema, induration, and red streaking on the client's arm close to the IV insertion site. Which of the following actions should the nurse plan to take first? A.) Obtain a specimen for culture. B.) Apply a warm compress C.) Administer analgesics D.) Discontinue the infusion

D.) Discontinue the infusion

A medication order reads: "Hydromorphone, 2mg IV every 3 to 4 hours PRN pain." The prefilled cartridge is available with a label reading "Hydromorphone 2mg/1mL." The cartridge contains 1.2 mL of hydromorphone. What should the nurse do? A.) Give all the medication in the cartridge because it expanded when it was mixed and this is what the pharmacy sent B.) Call the pharmacy and request the proper dose C.) Refuse to give the medication and document refusal in the EHR D.) Dispose of 0.2 mL before administering the drug; verify the waste with another nurse

D.) Dispose of 0.2 mL before administering the drug; verify the waste with another nurse

When teaching the parents of a toddler about feeding and eating, the nurse should include which of the following safety measures? A.) Do not give the child peanut butter B.) Have the child drink 28 to 32 oz of milk daily C.) Give the child 9 to 12 oz of fruit juice daily D.) Do not offer the child raw vegetables

D.) Do not offer the child raw vegetables

A nurse has just initiated a new peripheral IV infusion with 5% dextrose in water for continuous infusion. How often should the nurse plan to replace the primary infusion tubing? A.) Every 24 hours B.) Every 48 hours C.) Every 72 hours D.) Every 96 hours

D.) Every 96 hours

Which of the following is an important nursing action when converting an IV infusion to a saline lock? A.) Open the roller clamp of the primary infusion to prime the saline lock B.) Apply pressure with a syringe to clear resistance in the IV catheter C.) Attach secondary tubing to allow mobility D.) Flush the IV catheter to confirm patency

D.) Flush the IV catheter to confirm patency

A nurse is caring for a patient who has a nasogastric tube connected to suction. Which of the following should indicate to the nurse that the tube has become occluded? A.) Active bowel sounds B.) Passing flatus C.) Increase in gastric secretions D.) Patient's report of nausea

D.) Patient's report of nausea

A nurse in a primary care is assessing a client who has a history of herpes zoster. Which of the following findings suggests that the client has postherpetic neuralgia? A.) Linear clusters of vesicles on the right shoulder B.) Purulent drainage from both eyes C.) Decreased white blood cell count D.) Report of continued pain following resolution of the rash

D.) Report of continued pain following resolution of the rash

Which of the following is the primary purpose for asking a patient to keep a 3-to-7 day food diary? A.) To allow the patient to rely on health professionals to identify the problem areas B.) To determine any changes in the patient's appetite C.) To evaluate any significant changes in body weight D.) To assess the pattern of intakes and compare with daily reference intakes

D.) To assess the pattern of intakes and compare with daily reference intakes

To prevent aspiration during the administration of an enteral tube feeding, a nurse should A.) flush the feeding tube with 30 mL of water. B.) add blue food coloring to the enteral formula. C.) ensure the formula is at room temperature. D.) place the patient in Fowler's position.

D.) place the patient in Fowler's position.

To determine how much the length of a nasoenteric tube to insert, a nurse should measure the distance from the tip of the patient's nose to the earlobe and from the earlobe to the A.) umbilicus. B.) xiphoid process. C.) manubrium plus 10 to 20 cm more. D.) xiphoid process plus 20 to 30 cm more.

D.) xiphoid process plus 20 to 30 cm more.

How do you check for residuals with an NG tube?

If they're continuous, you have to stop the feeding 30 mins before checking Should check residuals every 4-6 hours w/ continuous (for intermittent, check @ administration time) If volume exceeds 250mL, must report to physician and likely hold next feeding Below 250mL, residual can be returned to stomach After checking, flush tube either by gravity or with a syringe - use either tap or sterilized water

Ear Drops in Adults vs Children

In adults, pull auricle upward and outward. In children, pull auricle down and back.

Controlled Substances: Required Information

Name of patient receiving narcotic Amount of narcotic used How narcotic was given Name of prescribing physician Name of administering nurse

Parts of a Medication Order

Patient's Name Date and time order is written Name of drug to be administered Dosage of drug Route by which drug is to be administered Frequency of administration Signature of person writing the order

Gastrostomy Tube (G-Tube) Percutaneous Gastrostomy Tube (PEG Tube) Jejunostomy Tube (J-Tube, PEJ Tube) Gastrostomy Button (G-Button)

Placed surgically or laparoscopically into stomach or jejunum, sutured in place For long-term feedings

What should you do prior to each use of an NG tube for either medications or feedings?

You should check the gastric pH - it should be 5 or below - to do this, you draw up some of the gastric content You should check for residuals to ensure the patient is digesting

Oliguria

abnormally small amounts of urine

Dietary Reference Intakes (DRIs)

acceptable range of quantities of vitamins and minerals for each gender and age group

Single Order

administer the medication once at a specific time or as soon as possible; commonly used for presurgical patients

Now Order

administer the medication once but up to 90 minutes from when the nurse received the order

Resting Energy Expenditure (REE)

amount of energy needed to consume over a 24-hour period for the body to maintain internal working activities while at rest

Ventrogluteal Site

an injection landmark site for intramuscular injections when volume of medication exceeds 2 mL

Vastus Lateralis Site

an injection landmark site generally used fro infants 1 year or younger

Deltoid Site

an injection landmark site which has a small muscle mass and can only take in 1 mL of medication

Ovo-lactovegetarian Diet

avoids meat, fish, and poultry, but eats eggs and milk

MDI

medications administered through Metered Dose Inhalers

Stat Order

carried out immediately; one-time administration

Fruitarian

consumes fruit, nuts, honey, and olive oil

Vegan Diet

consumes only plant foods

Hypovolemia

dehydration; deficit fluid volume Dry skin/mucous membranes Confusion, weakness, fatigue Non-elastic skin turgor Decreased UO and hypotension Tachycardia Increase in temperature Oliguria Weight loss

Lactovegetarian Diet

drinks milk but avoids eggs, meat, fish, and poultry

Basal Metabolic Rate (BMR)

energy needed at rest to maintain life-sustaining activities for a specific amount of time

High Density Foods

fruits and vegetables high in nutrients, low in kilocalories

Instillation Route

generally used for eyes, ears, and nose

Spacers in MDIs

increase the amount of medication the device delivers

Oral Route

most common route; least expensive; tablets, capsules, liquids, suspensions, elixirs, lozenges

Topical Route

medication directly applied to the mucous membranes or skin

Transdermal Route

medication in a skin patch for absorption through the skin, producing systemic effects

Nasoenteric (NE) Tube

nasal passage --> duodenum or jejunum small, flexible tube preferred for feeding

Nasogastric (NG) Tube

nasopharynx --> esophagus --> stomach Levin (small-bore) for feedings, Salem sump (large-bore) to empty or lavage stomach

Hypervolemia

over hydrated; excess fluid volume Elevated BP, bounding pulse Tachycardia Tachypnea Pale/cool skin Edema/ascites Crackles Dyspnea

Electrolytes

regulate fluid balance, hormone production, strengthen skeletal structures, act as catalysis in nerve responses, muscle contraction, metabolism, etc.

Standing Order

routine order - carried out until cancelled by another order

Hypertonic Fluids

solutions that are more concentrated than blood; fluid that shifts back into circulation patient is dehydrated - expands intravascular space by pulling fluid from cells and tissues Ex: 0.45% ND, mannitol, TPN

Hypotonic Fluids

solutions that are more dilute than blood; fluid that moves into the cell expands intercellular volume by causing fluid shift from vascular compartment Ex: 0.25%, 0.45%, 0.5% dextrose in water

Isotonic Fluids

solutions that have the same tonicity as blood; fluid that stays where you put it patient in need of hydration - expands intravascular volume w/o affecting cellular volume Ex: 0.9% NA lactated Ringer's

Low Density Foods

sugars and alcohol high in kilocalories, nutrient poor