Level 2 Nursing Skills

Which statements made by the student nurse shows effective learning about securing an intravenous (IV) catheter? Select all that apply. "I will use strips of clean tape." "I will use the tape from tape roll." "I will use the tape from the IV starter kit." "I will use the tape from my uniform pocket." "I will use the tape that I placed on the patient's bedrail."

"I will use strips of clean tape." "I will use the tape from the IV starter kit." Rationale Using a clean piece of tape will reduce the risk of infection. Using the tape from the IV starter kit also reduces the risk for infection. Rolls of tape are used for all patients, so using the tape from the tape roll increases the risk for infection. Since the uniform is not sterile, the tape in a uniform pocket is contaminated, which may lead to infection. Because the patient's bedrail is not sterile, using the tape that is placed on it also increase the chance of infection. p.212

Which of these statements demonstrate that a student nurse properly understands the training about how to use a simple facemask for providing low-flow oxygen delivery? Select all that apply. "Monitor the patient closely for risk for aspiration." "Provide skin care to the area covered by the mask." "The mask should be loosely fitted near the nose and mouth." "Claustrophobic patients are not to be provided this treatment." "Ask the primary health care provider to switch the patient to a nasal cannula during eating."

"Monitor the patient closely for risk for aspiration." "Provide skin care to the area covered by the mask." "Ask the primary health care provider to switch the patient to a nasal cannula during eating." Rationale While providing low-flow oxygen delivery using a simple facemask, the student nurse should monitor the patient closely for risk for aspiration. This is because the mask limits the patient's ability to clear the mouth, especially if vomiting occurs. Pressure and moisture in the area under the mask may cause skin breakdown, so it is important for the nurse to keep the area moisturized by applying water-soluble jelly. If the patient wants to eat, the nurse should convey this to the primary health care provider, who will switch the patient to a nasal cannula to prevent hypoxemia during eating. The mask should not be poorly fitted because this would result in reduced fraction of inspired oxygen (FiO 2) delivery. Claustrophobic patients must be provided emotional support to reduce anxiety. p. 532, Table 28-1

Which of these are valuable instructions for the nurse regarding best practices for patient safety during oxygen therapy? Select all that apply. "Position the tubing so it does not pull on the patient's face or the artificial airway." "Mouth care should be infrequent to prevent irritation to the nasal cannula." "The presence of smoking, lit matches, or candles in the immediate area is considered safe." "Lubrication of the patient's nostrils, face, and lips is essential to prevent drying." "Ensure that the oxygen and humidification equipment are functioning properly."

"Position the tubing so it does not pull on the patient's face or the artificial airway." "Lubrication of the patient's nostrils, face, and lips is essential to prevent drying." "Ensure that the oxygen and humidification equipment are functioning properly." Rationale During oxygen therapy, lubrication of the patient's nostrils, face, and lips with nonpetroleum cream is essential to relieve the drying effects of oxygen. For effective oxygen therapy, the oxygen and humidification equipment should be functioning properly. The tubing should be positioned in such a way that it does not pull on the patient's face or artificial airway. Mouth care is an integral part of caring for a patient who is undergoing oxygen therapy and should be provided every 8 hours or as needed. Care should be taken that smoking, lit matches, and candles are not present in the immediate vicinity of the oxygen therapy room or area because oxygen is combustible. p. 530, Chart 28-1

Which patient does the medical-surgical unit charge nurse assign to an LPN/LVN? 41-year-old who needs assistance with choosing a site for a colostomy stoma 47-year-old who needs to receive "whole gut" lavage before a colon resection 56-year-old who has obstipation and a recent emesis of foul-smelling liquid 51-year-old who has recently arrived on the unit after having an open herniorrhaphy

47-year-old who needs to receive "whole gut" lavage before a colon resection Rationale Because administration of medications is within the LPN/LVN scope of practice, this preoperative patient can be assigned to the LPN/LVN. Assistance with choosing a site for a colostomy stoma is an intervention that should be provided by an RN. The recent postoperative patient and the critically ill patient will need assessments and interventions that can only be done by an RN. p. 1130

A patient who is receiving long-term intravenous therapy experiences edema around the intravenous insertion site, along with fluid leakage from the punctured site. The patient reports blanching and skin tightness. The nurse should perform what interventions? Select all that apply. Apply a sterile dressing Apply a cold compress Clean the exit site with alcohol Temporarily slow the infusion rate Encourage the patient to elevate the extremity

Apply a sterile dressing Apply a cold compress Encourage the patient to elevate the extremity Rationale Edema around the intravenous insertion site, leakage of fluid from the punctured site, and blanching and skin tightness are characteristics of infiltration. Applying a sterile dressing will be useful in case of weeping from the tissue. Applying a cold compress may help relieve discomfort and reduce swelling. Elevating the extremity will also reduce the swelling at the site. Cleaning the exit site of the wound is appropriate if the patient has an intravenous insertion site infection. Temporarily slowing the infusion rate is appropriate for patients with venous spasm. p. 217

A patient has a new colostomy after a partial colectomy for colon cancer in which the surgeon was able to completely remove the colorectal tumor. The patient is crying and keeps saying, "Nothing will ever be the same." Which action by the nurse is best? Ask the patient to describe feelings about having a colostomy. Teach the patient how to care for and manage the colostomy. Provide information about colon cancer survivor support groups. Reassure the patient that the surgery was successful and that cure is likely.

Ask the patient to describe feelings about having a colostomy. Rationale Patients' reactions to colostomy surgery often include fears about not being accepted by others, grieving over disturbances in body image, and concerns about sexuality; therefore, the nurse should help the patient explore feelings about the colostomy. Reassuring the patient that the surgery was successful and giving information about support groups assumes that the patient is worried about the cancer. Providing teaching about the colostomy will be necessary for home management but is not appropriate while the patient is expressing feelings of grief. p. 1134

During shift report, the nurse learns the assigned patient with chronic lung disease is receiving oxygen at 4 L/min per nasal cannula. When entering the patient's room, what is the nurse's initial action? Auscultate the lung sounds. Reduce the rate of oxygen to 3 L/min. Request an order for arterial blood gases. Assess oxygen saturation with a pulse oximeter.

Assess oxygen saturation with a pulse oximeter. Rationale A patient with chronic lung disease and hypercarbia loses sensitivity to elevated carbon dioxide levels as a stimulus for breathing. Instead, low oxygen levels become the primary stimulus. Patients with hypercarbia and hypoxemia usually require 1-2 L/min (no more than 2-3 L/min) to keep them from losing their hypoxic drive and developing oxygen-induced hypoventilation. In a patient receiving 4 L/min, oxygen-induced hypoventilation may be a concern, although inadequately treated hypoxemia is a greater priority. The lowest level of oxygen needed to maintain adequate oxygenation should be given. The nurse should evaluate oxygen saturation with a pulse oximeter before making a decision to reduce the O 2 rate or requesting an order for arterial blood gasses (ABGs). Auscultating lung sounds does not provide definitive assessment data on oxygenation. p. 530

The nurse who is starting the shift finds a patient with an IV that is leaking all over the bed linens. What does the nurse do initially? Assess the insertion site. Check connections. Check the infusion rate. Discontinue the IV and start another.

Assess the insertion site. Rationale Assessing the insertion site to check for patency is the priority. IV assessments typically begin at the insertion site and move "up" the line; that is, from the insertion site to the tubing, to the tubing's connection to the bag. Checking the IV connection is important, but is not the priority in this situation. Checking the infusion rate is not the priority. Discontinuing the IV to start another may be required, but it may be possible to "save" the IV, and the problem may be positional or involve a loose connection. p. 217

The nurse encourages a patient who has undergone total joint arthroplasty to use the incentive spirometer every 2 hours. The nurse also encourages the patient to breathe deeply and cough frequently. Which complication is the nurse seeking to prevent by using this intervention? Infections Atelectasis Pressure ulcers Postural hypotension

Atelectasis Rationale The partial collapse or incomplete inflation of the lung is called atelectasis. To prevent atelectasis, the nurse encourages the patient to use the incentive spirometer every 2 hours, to take deep breaths, and to cough frequently. An incentive spirometer is a medical device used to help the patient improve the function of his or her lungs. Infections can be prevented by maintaining hygienic conditions. Observing for fever and decreased mental status can help identify infection. The nurse encourages the patient to keep his or her heels off the bed to prevent pressure ulcers. When assisting the patient out of bed, the nurse moves him or her slowly to prevent orthostatic or postural hypotension. p. 311

The nurse is caring for a patient with a total knee arthroplasty. What action does the nurse take when the patient is using a continuous passive motion (CPM) machine? Allows the patient to take control of the machine Encourages the use of CPM whenever awake Checks the cycle and range of motion settings at least once every 8 hours Stores the machine on the floor when not in use

Checks the cycle and range of motion settings at least once every 8 hours Rationale The nurse should check the cycle and range of motion settings at least once every 8 hours for safety. When caring for a confused patient, the nurse should place the machine's control out of reach. The machine is turned off during meal times. The machine is generally used on an intermittent schedule or designated number of hours per day. The machine is not stored on the floor when not in use; it must be placed on a chair or table. p. 315

The nurse is caring for a patient diagnosed with vancomycin resistant enterococcus (VRE) infection. What type of precaution is most appropriate when providing patient care? Standard Precautions Contact Precautions Airborne Precautions Droplet Precautions

Contact Precautions Rationale Patients with infection or colonization by multidrug resistant organisms such as VRE are placed on Contact Precautions because it spreads by direct contact. VRE can live on any surfaces such as toilet seats, door handles, and other objects for days to weeks and still cause an infection. Therefore, Contact Precautions (gloves, mask, gown, or protective eyewear as appropriate) are used whenever direct contact with body fluids is expected. Standard Precautions are recommended while caring for all patients in the healthcare setting, which involves hand hygiene, personal protective equipment (PPE), needle handling, patient placement, and so forth. VRE-infected patients are not placed under Airborne or Droplet Precautions because VRE is not transmitted by these routes. p. 420, Table 23-3

A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen with a Venturi mask at a rate of 3 L/min. Prior to initiating oxygen therapy, the patient appeared anxious with gray skin, a respiratory rate of 24 breaths/min, and an oxygen saturation of 87%. After 15 minutes of oxygen therapy, the nurse observes the patient resting with closed eyes, pink coloration, a respiratory rate of 12 breaths/min, and an oxygen saturation of 95%. Which action by the nurse is correct? Decrease the oxygen to 2 L/min to improve respiratory rate. Increase the oxygen to 4 L/min to improve oxygen saturation. Request an order for arterial blood gases to evaluate for hypercarbia. Change the Venturi mask to a nasal cannula to further reduce anxiety.

Decrease the oxygen to 2 L/min to improve respiratory rate. Rationale Patients with chronic hypercarbia are at risk for oxygen-induced hypoventilation. Patients with COPD are more likely to have chronic hypercarbia. This patient has a slowed respiratory rate and an altered level of consciousness indicating hypoventilation, which can occur within the first 30 minutes of oxygen therapy. The nurse should reduce the oxygen flow to see if the respiratory rate improves. Although many patients with COPD become anxious with a facemask, this patient is currently not demonstrating signs of anxiety. Increasing the oxygen flow will only increase the risk for hypoventilation. An arterial blood gas will be a part of the ongoing assessment but will not distinguish between acute and chronic hypercarbia. p. 530

During an intravenous drug infusion, the patient reports lightheadedness. On further examination, the nurse finds that the patient has a flushed face and an irregular pulse. The nurse should perform which intervention? Slow the infusion rate Discontinue the drug infusion Administer diuretics as prescribed Help the patient to an upright position

Discontinue the drug infusion Rationale Signs and symptoms such as lightheadedness, flushed face, and irregular pulse after an intravenous infusion[1][2] are caused by speed shock. Speed shock results from rapid infusion of drugs or bolus infusion, which causes the drug to reach toxic levels quickly. Therefore, the nurse discontinues the drug infusion for this patient. Slowing the infusion rate is beneficial for patients who have circulatory overload. Administering diuretics as prescribed will help reduce edema in patients with circulatory overload. Raising the patient to an upright position is beneficial to alleviate symptoms of shortness of breath or edema in case of circulatory overload. p. 220

What does the nurse do first when setting up a safe environment for the new patient on oxygen? Uses a pulse oximetry unit Ensures that staff members wear protective clothing Ensures that no combustion hazards are present in the room Sets the oxygen delivery to maintain no fewer than 16 breaths per minute

Ensures that no combustion hazards are present in the room Rationale Oxygen is highly flammable. The nurse must ensure that no open flames or combustion hazards are present in a room where oxygen is in use. Protective clothing is not necessary for a patient who requires oxygen therapy other than the use of Standard Precautions. The oxygen delivery setting is usually determined in conjunction with the respiratory therapy care partner. Although the setting is important for safe administration, it is not necessary for a safe environment. Pulse oximetry would be useful for monitoring the patient's oxygenation status but is not necessary for a safe environment. p. 571

Which is the most important strategy the nurse implements for preventing the transmission of infection from patients to other people? Disinfection Sterilization Hand hygiene and gloves Private rooms and cohorting

Hand hygiene and gloves Rationale The nurse must perform hand hygiene and wear gloves to preventing infection transmission. Health care workers' hands are the primary way in which infection is transmitted from patient to patient or staff to patient. Sterilization is a process where all items that invade the patient's tissue are removed of microorganisms and spores. It helps only invasive procedures to become safe. Disinfection is a process where all items that invade the patient's tissue are removed of microorganisms, but it does not kill spores. Using private rooms for patients and cohorting patients with the same infections reduces the transmission of infections, but they are not the best ways. pp. 417-418

Incentive spirometry for the treatment of pneumonia has which outcome objective? Reduced sputum production and increased cough Reduced crackles and wheezes and improved oxygenation Improved expiratory air flow and increased respiratory effort Increased inspiratory muscle action and decreased atelectasis

Increased inspiratory muscle action and decreased atelectasis Rationale Incentive spirometry helps improve inspiratory muscle action and prevents or reverses atelectasis. It does not increase respiratory effort, reduce crackles and wheezes, or reduce sputum production. p. 604

Which condition indicates infiltration? Inflammation of the vein Blood clot inside the vein Leakage of nonvesicant intravenous (IV) solution into extravascular fluids Leakage of vesicant intravenous (IV) solution or medication into extravascular fluids

Leakage of nonvesicant intravenous (IV) solution into extravascular fluids Rationale Leakage of nonvesicant IV solution into extravascular fluids is called infiltration. It occurs due to obstruction of blood flow, causing back flow through the insertion site. Inflammation of the vein is called phlebitis. It occurs due to improper insertion of the catheter and extreme pH and osmolarity of the fluid medication. A blood clot inside the vein is called thrombosis. It occurs due to a traumatic vein puncture or multiple vein puncture attempts. Leakage of vesicant IV solution or medication into extravascular fluids is called extravasation. It is an inflammatory process causing fluid leakage at the capillary level. p. 217

A patient is admitted with peritonitis due to a perforated appendix. Which intervention can be delegated to unlicensed assistive personnel (UAP)? Measuring intake and output Assessing for signs of sepsis Administering pain medication Performing nasogastric tube suctioning

Measuring intake and output Rationale UAPs can measure intake and output. Administering pain medication, performing nasogastric tube suctioning, and assessing for signs of sepsis would be beyond the scope of practice for UAP and should be performed by a registered nurse. p. 1146

Which type of tube is commonly used in the surgical process to promote GI rest? T- tube Levin tube Nasogastric (NG) tube Penrose drain

Nasogastric (NG) tube Rationale NG tubes are used for the prevention of gastric bleeding and intestinal obstruction. They also promote gastrointestinal (GI) rest and heal the lower GI tract. Levin tubes are less often used in surgeries; they have a single lumen with no air vent. T-tubes are used to drain bile in a cholecystectomy. Penrose drains are used for the dressing of wounds. p. 277

Which patient does the charge nurse on a medical-surgical unit assign to the LPN/LVN? Cardiac patient who has a diltiazem IV infusion being titrated to maintain a heart rate between 60 and 80 beats/min Diabetic patient admitted for hyperglycemia who is on an IV insulin drip and needs frequent glucose checks Older patient admitted for confusion who has a heparin lock that needs to be flushed every 8 hours Postoperative patient receiving blood products after excessive blood loss during surgery

Older patient admitted for confusion who has a heparin lock that needs to be flushed every 8 hours Rationale The older patient admitted for confusion with a heparin lock is the most stable and requires basic monitoring of the IV site for common complications such as phlebitis and local infection, which would be familiar to an LPN/LVN. The cardiac patient with a diltiazem IV infusion, the diabetic patient on an IV insulin drip, and the postoperative patient receiving blood products all are not stable and will require ongoing assessments and adjustments in IV therapy that should be performed by an RN. p. 206

The nurse is discharging a patient with a prescription for continuous oxygen therapy via nasal cannula at home. What does the nurse include in the discharge teaching? Provide mouth care daily. Pad the tubing behind the ears. No family members or visitors may smoke within three feet of the patient. Petroleum jelly may be applied to dry nostrils and chapped lips.

Pad the tubing behind the ears. Rationale Because the tubing creates pressure that may lead to skin breakdown (especially behind the ears), padding the tubing prevents this complication. Smoking is prohibited in a room where oxygen therapy is being administered. Petroleum jelly is flammable and should not be used on the patient's face, nose, or lips; a nonpetroleum cream should be used. p. 530, Chart 28-1

The nurse is documenting peripheral venous catheter insertion for a patient. What does the nurse include in the note? Select all that apply. Patient's name and hospital number Patient's response to the insertion Date and time inserted Type and size of device Type of dressing applied Vein used for insertion

Patient's response to the insertion Date and time inserted Type and size of device Type of dressing applied Vein used for insertion Rationale The patient's ability to adapt to interventions, such as IV insertion, should be noted when the intervention is performed. The date and time of the insertion are important data. IV sites need to be routinely monitored and changed at prescribed intervals per facility policy. It is important to note the device used (often the brand name is given), as well as all specifics such as needle or cannula length, gauge, and material (Teflon). It is necessary to describe the dressing applied, and the vein used should be noted. The patient's name and hospital number should be on the medical record, but the nurse makes certain that the information is recorded in the correct medical record. p. 216

Which interventions should the nurse provide during the postoperative care of a patient who underwent a colostomy formation? Select all that apply. Place a colostomy pouch over the stoma. Establish and maintain an intravenous line. Advance the diet slowly from solids to liquids. Assess the color and integrity of the stoma frequently. Assess for a dry stoma during initial postoperative period.

Place a colostomy pouch over the stoma. Establish and maintain an intravenous line. Assess the color and integrity of the stoma frequently. Rationale A colostomy pouch, called an appliance, should be placed over the stoma for collection of stools. After the surgery, the intravenous (IV) line should be maintained so that the patient can receive pain medication through the IV line for 24 to 36 hours. Color and integrity of the stoma should be assessed frequently. A healthy stoma should be reddish pink, moist, and protrude 2 cm from the abdominal wall. The diet should slowly progress from liquids to solids for easy bowel formation and elimination. During the initial postoperative period, the stoma may be slightly edematous. A small amount of bleeding at the stoma site is common. p. 1132

The nurse notes that a patient sitting in a waiting area has a wound that is draining profusely. What actions should the nurse take? Select all that apply. Place the patient in an examination room. Perform hand hygiene prior to wearing gloves. Apply gloves and wear a gown when touching the patient. Transfer the patient to an airborne infection isolated room. Use a fit-tested N95 respirator provided by the health care facility.

Place the patient in an examination room. Perform hand hygiene prior to wearing gloves. Apply gloves and wear a gown when touching the patient. Rationale The nurse follows contact transmission-based precautions when caring for a patient with excessive wound drainage. The nurse moves the patient to an examination room for further assessment of the wound. Before touching the patient, the nurse performs hand hygiene prior to wearing gloves to avoid the spread of infection. The nurse uses gloves and wears a gown when touching the patient to prevent cross infection. The nurse does not transfer the patient to an isolated room, as the patient is not infected with an airborne contagious disease. The nurse does not use a fit-tested N95 respirator because the patient does not have an airborne or droplet infection. p. 414

A postoperative patient has a Jackson-Pratt drain in place. After the nurse empties and compresses the reservoir to restore suction, the drain is secured to the patient's gown. What is this action meant to prevent? Select all that apply. Pulling Skin irritation Slipping of the drain Wound contamination Stress on the surgical wound

Pulling Stress on the surgical wound Rationale After emptying and compressing the reservoir of a Jackson-Pratt drain to restore suction, the drain is secured to the patient's gown. This helps to prevent pulling and stress on the surgical wound. Absorbent pads are placed under Penrose drains to prevent skin irritation or wound contamination. A safety pin is also used to prevent a Penrose drain from slipping. p. 282

After changing the wound dressing of a patient, the nurse plans to administer medication. What action does the nurse perform next? Rub hands with chlorhexidine with gloves on, then administer the medication. Ask the patient to take the medication himself/herself to avoid removing gloves. Remove gloves and perform hand hygiene just before leaving the room. Remove gloves and perform hand hygiene before administering the medication.

Remove gloves and perform hand hygiene before administering the medication. Rationale The nurse should perform hand hygiene after removing gloves and administer the medication. The gloves are contaminated after the wound dressing change and should be removed followed by hand hygiene. This avoids transmission of infection from the wound to the patient and the nurse. Chlorhexidine is an antiseptic solution used for handwashing when caring for people with a high risk for infection or infected with multidrug-resistant organisms. Further, hand hygiene is performed after removing the contaminated gloves and before administering medication to the patient, not with the gloves on. The nurse should personally give the medication to the patient to ensure proper adherence to the prescribed medication. The nurse should not remove the gloves and perform hand hygiene just before leaving the room; it should be done before administering the medication to the patient. p.418

Which nursing interventions will bring relief to a patient reporting tingling, feeling pins and needles in the extremities, and numbness during vein puncture? Select all that apply. Removing the catheter Continuing the insertion procedure Informing the primary health care provider Choosing a new site for the catheter insertion Stopping the intravenous insertion procedure immediately

Removing the catheter Choosing a new site for the catheter insertion Stopping the intravenous insertion procedure immediately Rationale Symptoms of tingling, feeling pins and needles in the extremities, or numbness during vein puncture indicates nerve puncture. The catheter must be removed if the patient experiences these symptoms and a new site for catheter insertion should be selected. The intravenous insertion procedure should be stopped immediately because it may result in permanent loss of the nerve function. The procedure should not be continued because it may lead to nerve damage. There is no need to inform the primary health care provider. p. 204

Test-Taking Tip: Stay away from other nervous students before the test. Stop reviewing at least 30 minutes before the test. Take a walk, go to the library and read a magazine, listen to music, or do something else that is relaxing. Go to the test room a few minutes before class time so that you are not rushed in settling down in your seat. Tune out what others are saying. Crowd tension is contagious, so stay away from it.

Test-Taking Tip: Stay away from other nervous students before the test. Stop reviewing at least 30 minutes before the test. Take a walk, go to the library and read a magazine, listen to music, or do something else that is relaxing. Go to the test room a few minutes before class time so that you are not rushed in settling down in your seat. Tune out what others are saying. Crowd tension is contagious, so stay away from it.

The nurse assessing a patient's peripheral IV site obtains and documents information about it. Which assessment data indicate the need for immediate nursing intervention? Patient states, "It really hurt when the nurse put the IV in." The vein feels hard and cordlike above the insertion site. Transparent dressing was changed 5 days ago. Tubing for the IV was last changed 72 hours ago.

The vein feels hard and cordlike above the insertion site. Rationale A hard, cordlike vein suggests phlebitis at the IV site. The IV should be discontinued and restarted at another site. It is common for IVs to cause pain during insertion. An intact transparent dressing requires changing only every 7 days. Tubing for peripheral IVs should be changed every 72-96 hours. p. 218

A patient is receiving oxygen therapy. What are potential sources of infection the nurse should address? Select all that apply. Oxygen tubing pulling on the airway Use of nonpetroleum lotion for dry skin Use of a heated humidifier or nebulizer Use of an oral suction catheter in the endotracheal tube Rising white blood cell count noted on recent blood work

Use of a heated humidifier or nebulizer Use of an oral suction catheter in the endotracheal tube Rationale Humidifiers and nebulizer containers can harbor organisms, which can lead to infections in patients receiving oxygen therapy. Organisms in the oral cavity can cause respiratory infections when transferred to the trachea via a suction catheter. Although oxygen tubing tension on an airway can cause pressure and potential breakdown, the more immediate concerns are the heated fluid in the containers and transference via suction catheters. The nonpetroleum lotions are preferred for dry skin that can result from oxygen therapy. A rise in the white blood cell count may indicate the presence of an infection, but it is not a source of infection. p. 531