NSG 352 exam 2 practice quetsions

The nurse reports to the provider that the client has polyuria. Which documentation in the chart supports this report? Per the Intake and Output, the client has voided 1500 mL urine in the past 8 hours Per the Intake and Output, the client has voided 75 mL of urine in the last 24 hours The previous nurse documented that client wakes up frequently during the night to urinate. Per the urinary assessment, the client has visible blood in their urine

Per the Intake and Output, the client has voided 1500 mL urine in the past 8 hours Rationale: Refer to Craven pp 1105. Oliguria--- Diminished amount of urine in a given time, typically less than 100-400 mL in 24 hours. Polyuria--- Large volume of urine in a given time. Hematuria--- Blood in the urine. Nocturia--- Frequency of urination at night

The client is prescribed a Fentanyl patch for pain. When giving medications via the transdermalroute, the nurse should do which of the following. Select all that apply. Remove the old Fentanyl patch before applying the new one Wear gloves so the medication doesn't absorb through the nurse's skin Ensure the patient doesn't have a fever Dispose the old patch according to the hospital's policy for controlled substance

Remove the old Fentanyl patch before applying the new one Wear gloves so the medication doesn't absorb through the nurse's skin Ensure the patient doesn't have a fever Dispose the old patch according to the hospital's policy for controlled substances

The nurse is teaching the client how to self-administer insulin. Which of the followingstatements by the client lets the nurse know that further education is required? "My insulin syringe and needle need to be disposed on in a red sharps container" "I should dispose of any unused insulin after 1 month" "Since I am using cloudy insulin, I should shake it first to mix it" "My syringe should always have an orange cap"

"Since I am using cloudy insulin, I should shake it first to mix it" Rationale: Insulin should only be rolled and not shaken. Shaking can damage theinsulin or create air bubbles which will alter the dose that is drawn up.

Which of the following statements by the female client would indicate that she is at high risk for recurrent urinary tract infections? "I can usually hold my urine 8-10 hours" "I take a warm plain water tub bath every evening" "I wipe from front to back after voiding" "I drink a lot of water during the day"

"I can usually hold my urine 8-10 hours" Not voiding frequently and holding urine in the bladder increases the risk of urinary tract infection.

The student nurse is watching the nursing instructor recap a needle. In which situation(s) would this be acceptable? Select all that apply. After the instructor draws up the insulin and is waiting for an independent double check from another nurse After the instructor injects subcutaneous heparin into the client's abdomen when there is no needle guard or sheath to engage After the instructor administers a flu shot to the client and the red sharps container is in the client's bathroom After the instructor reconstitutes the powder medication and draws it up to give to the client IV push

-After the instructor draws up the insulin and is waiting for an independent double check from another nurse -After the instructor reconstitutes the powder medication and draws it up to give to the client IV push It is never appropriate to recap a needle after it has been injected into a client as you risk blood contamination (HIV and hepatitis). It is appropriate to passively recap (recap after the medication is drawn up but before injection) when you are not ready to administer immediately. That could be when obtaining an independent double check by another nurse or when preparing to give an IVP medication.

The client with decreased blood pressure is ordered a "bolus of normal saline". The nurse goes into the supply closet to obtain the IV fluid and looks for a bag with which of the following printed on it? 0.9% Sodium Chloride 0.45% Sodium Chloride Dextrose 5% in Water Lactated Ringers

0.9% Sodium Chloride 0.9% sodium chloride is known as normal saline. 0.45% sodium chloride is known as 1/2 normal saline. Dextrose 5% in water is known as D5W.

A patient has fever and headache. Which option(s) is/are the best practice for medicationadministration orders? Select all that apply Acetaminophen 650 mg PO Q4 hours PRN fever Acetaminophen 650 mg PO Q4 hours PRN pain or fever Acetaminophen 650 mg PO Q4 hours PRN pain

Acetaminophen 650 mg PO Q4 hours PRN fever Acetaminophen 650 mg PO Q4 hours PRN pain Rationale: medications that are being used for multiple purposes require separate orders; onefor each purpose.

The patient is admitted with complaints of urinary dysfunction and is ordered to have a urinalysis. Which of the following urinalysis results would suggest the patient does not have a urinary tract infection (a normal urinalysis)? Amber color, no glucose, no ketones present, SG 1.010, 2 RBCs Amber color, no glucose, ketones present, SG 1.010, 2 RBCs Colorless, no glucose, ketones present, , SG 1.000, no RBCs Cloudy amber, no glucose, no ketones present, SG 1.020, no RBCs

Amber color, no glucose, no ketones present, SG 1.010, 2 RBCs Rationale: Please see Craven Table 34-3 for urinalysis normals and abnormals

The student nurse is going to administer an influenza vaccine. Which of the following actions by the student should concern the nursing instructor? The student chooses a 20-22 gauge needle The student chooses a 1 inch needle The student states that the correct site for administration is the abdomen The student rubs the injection site after administration

Correct Answer The student states that the correct site for administration is the abdomen The influenza vaccine is given intramuscular. For IM injections, a needle length of 1-1.5 inches and gauge of 20-22 is appropriate. It is appropriate, and often helpful, to rub IM injections to help absorption into the muscle. Appropriate sites are muscles like the deltoid, rectus femoris, vastus lateralis and ventrogluteal. The abdominal tissue is appropriate for subcutaneous injections.

The order on the MAR is for Amoxicillin 500 mg PO every 8 hours. The label on the bottle of Amoxicillin states 250 mg/5 mL. How much Amoxicillin should the nurse administer to the client? 5 mL 1.0 mL 10 ml 15 mL

Correct! 10 mL Med math doesn't go away after the medication safety test! What you know is 250 mg per 5 mL. What you need is how many mL in 500 mg. 250x=2500 . when you solve for X, you get 10.

When administering medications to an elderly client, which of the following should the nurseconsider? Select all that apply. Elderly clients take many different medications and they may have drug interactions Elderly clients can forget to take medications so they may need a calendar or system toremember Since elderly clients have a higher metabolism than younger clients, they will needhigher doses of medications Changes in mental status are an unusual side effect for elderly client

Elderly clients take many different medications and they may have drug interactions Elderly clients can forget to take medications so they may need a calendar or system to remember Rationale: Polypharmacy is common in the elderly. Nurses need to ensure that the medicationsthat have been prescribed by multiple providers are all safe to take together. Elderly clientscommonly omit doses and using a calendar or pill dispensing system is helpful to improvecompliance Elderly clients have slower metabolisms and this means that typically they needsmaller and less frequent doses to avoid accumulation. Changes in mental status are animportant consideration for all elderly patients and medications can cause these changes as sideeffects

Which of the following is considered an acceptable indication for the use of an indwelling urinary catheter? Select all that apply. Monitoring critically ill or acutely ill patients when accurate assessment of urinary output is necessary. Management of terminally or severely ill patients Urinary retention not manageable by intermittent catheterization or other means Management of urinary incontinence in patients with stage III or stage IV pressure injuries on the trunk of the body Convenience of the patient or the nurse

First 4: Monitoring critically ill or acutely ill patients when accurate assessment of urinary output is necessary. Management of terminally or severely ill patients Urinary retention not manageable by intermittent catheterization or other means Management of urinary incontinence in patients with stage III or stage IV pressure injuries on the trunk of the body Rationale: Indwelling catheters should never be used solely for the convenience of either the staff or patient. See Craven pp 1118 for Indication for Catheterization.

The client is ordered 650 mg Acetaminophen oral solution. The medication is provided in amulti-dose bottle with 160 mg/5 mL concentration. The nurse pours and and measures 25 mLinto a medication cup. How should the nurse proceed with medication administration? Give the client the 25 mL of Acetaminophen as ordered Give the client 20.3 mL of Acetaminophen and pour the rest back into the bottle Give the client 20.3 mL of Acetaminophen and dispose of the remaining dose into thesink Pour an additional 5 mL to give the client 30 mL of Acetaminophen

Give the client 20.3 mL of Acetaminophen and dispose of the remaining dose into the sink Rationale: Given the concentration of the medication provided, the client should receive 20.3mL of Acetaminophen. Since the nurse overpoured, the remaining medication should bediscarded and not returned to the original bottlle

The nurse plans to administer an isotonic IV solution for the patient. Which of the following istrue about isotonic IV solutions? 3% NaCl is an example of an isotonic IV solution Isotonic solutions are used for volume expansion and electrolyte replacement 0.45% NaCl is an example of an isotonic IV solution Isotonic solutions are used to draw fluid from the intracellular to the intravascular space

Isotonic solutions are used for volume expansion and electrolyte replacement Rationale: Normal saline and lactated ringers are examples of isotonic IV solutions. They areused for vascular expansion and fluid replacement. Isotonic solutions cause no fluid shifts. SeeCraven p. 519 table 22-1

The client is experiencing intermittent chest pain and receiving Nitroglycerin sublingually. The client is unfamiliar with this route of medication and asks to learn more about it. Which of the following statements by the nurse should be questioned? Medication given sublingually should be placed under the tongue and allowed to dissolve Medication given sublingually absorbs slowly into the bloodstream and takes longer to work than that given orally and swallowed into the stomach Medication given sublingually is not influenced by stomach acids and doesn't need to be broken down into the stomach The acceptable abbreviation for the sublingual route is SL

Medication given sublingually absorbs slowly into the bloodstream and takes longer to work than that given orally and swallowed into the stomach The question is asking which statement should be questioned, which means you are looking for the incorrect answer. Medication given sublingually absorbs more quickly because it avoids first pass.

Medication orders should include all of the following except.... Medication name Medication dosage Medication side effects Medication route

Medication name, Medication dosage, Medication route Rationale: Medication orders should include the medication name, dosage and route.Medication side effects are not part of a medication order.

The nursing student is reconstituting methylprednisilone powder to administer via thepatient's IV. The clinical instructor corrects the student when the student does which of the following? Wipes the vial with alcohol Mixes the powder and diluent in the vial by vigorously shaking together Checks to ensure the medication is free from clumping or particulate matterbefore drawing up Injects the diluent into the vial with the powder

Mixes the powder and diluent in the vial by vigorously shaking together Rationale: When mixing the powder and diluent, swirl the vial instead of shaking as somemedications foam up when mixed too vigorously and that foam contains medication. Seecraven p. 484 and PPT for reconstituting medications.

The nurse is assessing the client who has an indwelling/foley catheter. Previous documentation of the client's urine characteristics are that the urine was clear yellow with no foul smelling odor. Based upon the urine in the drainage bag now (pictured), what would be the priority action for the nurse? Bloody bag (image) Notify the provider Empty the bag and document the amount, color, clarity and odor Encourage the client to drink more oral fluids No action is needed at this time

Notify the provider This urine is very different from previous assessments. This could be indicative of blood which is a priority.

Match the following abnormal urinary system findings to the description. Each finding only matches to one description. Oliguria, Polyuria, Heamturia, Nocturia

Oliguria: Diminished amount of urine in a given time 100ml-400ml in 24 hours Polyuria: Large volume of urine in a given time Heamturia: Blood in the urine Nocturia: Frequency of urine at night

The nurse is caring for a client who has recently had an indwelling urinary catheter removed after being placed for surgery. It is 6 hours after removal and the client still has not voided. The bladder feels full upon palpation by the nurse. According to best practice, what intervention should the nurse perform first? Reinsert an indwelling urinary catheter and try to remove again tomorrow Perform a bladder scan Perform an in and out or straight catheterization Wait 3 more hours and see if the client can void on their own

Perform a bladder scan Although you may do all of these interventions, the question asks which one would you do FIRST. Based upon best practice, a bladder scan would be the first intervention to determine if the bladder is full or not. If the bladder is not full, then you may increase intake and wait a few more hours. If the bladder is full, you will want to empty the bladder using in and out catheterization. Neither of these is an immediate indication for an indwelling catheter placement due to the risk of infection.

Read the article "Improving Outcomes with the ANA CAUTI Prevention Tool" article and answer the question. Mr. T is 68 years old and has recently had an indwelling urinary catheter removed after being placed for surgery. It is 6 hours after removal and Mr. T still has not voided. His bladder feels full upon assessment by the nurse. What intervention should the nurse perform NEXT action according to the "Improving Outcomes with the ANA CAUTI Prevention Tool"? Reinsert an indwelling urinary catheter and try again tomorrow Wait another 2 hours and see if Mr. T can void on his own Perform a bladder scan Perform an in and out/straight catheterization

Perform a bladder scan Rationale: According the article that was assigned to read for lab prep, the NEXT intervention would be for the nurse to perform a bladder scan. If the scan revealed that Mr. T had 300-500 mL of urine, then the nurse would perform an in and out/straight catheterization and wait another 6 hours to see if he could void on his own. Replacement of an indwelling catheter is not best practice for the next step and waiting longer will only allow Mr. T's bladder to get more distended and harder to enable spontaneous voiding.

The nurse is ordered to give the patient a parenteral medication. The nurse knows thismeans which of the following are true? Select all that apply The parenteral route refers to medications that are given by injection or infusion. Medications given via the parenteral route are usually absorbed more completelyand begin acting more quickly that do medications given by the oral route Tissue damage can occur if the pH of the medication is not appropriate to thetissue where the medication is given Parenteral medications can be given using a syringe and needle

Rationale: All of these are correct. Please see Craven p. 482-Parenteral Medications.

The client is ordered a clear liquid diet. Which of the following would need to beremoved from their meal tray? Vanilla ice cream Cranberry juice Iced tea Apple juice

Rationale: Ice cream is considered a full liquid since you can't see through it. See diets in

The nurse is administering Morphine via the intramuscular route. Which of thefollowing indicates that the nurse is performing this medication administrationcorrectly? Select all that apply. The nurse administers the medication into the abdomen. The nurse injects 2-3 finger breadths below the lower edge of the acromion processin the shoulder The nurse documents the injection site in the MAR (Medication AdministrationRecord) The nurse injects into the side of the buttocks

Rationale: The abdomen site is not used for IM injections but instead for subcutaneous.The side of the buttocks is called the dorsogluteal site and due to the proximity tonerves and arteries, it is no longer used. The nurse injects 2-3 finger breadths below the lower edge of the acromion processin the shoulder The nurse documents the injection site in the MAR (Medication AdministrationRecord)

The order is for Morphine Sulfate 4 mg IV push. The patient does not have an existingIV line with fluids running so the nurse will administer into an intermittent infusion deviceor saline lock. Which of the following are steps in this process? Select all that apply. Check the patient's allergies to ensure they are not allergic to Morphine Sulfate Perform the 6 rights of medication administration Flush the IV site to ensure it is patent (flushes easily) Flush with normal saline after the Morphine Sulfate is administere

Rationale: These are all steps in the process. See Craven Procedure 21-8 and the adaptedprocedure in the Canvas lab preparation for this module.

The nurse is caring for an elderly client with altered mental status and urinary incontinence. What nursing interventions would be most appropriate? Encourage the client to increase their coffee intake Schedule toileting at least every 2 hours Provide medications to improve bowel function Request a provider order to insert indwelling/foley catheter

Schedule toileting at least every 2 hours Since coffee is a diuretic and urinary irritant, it will only increase frequency of urination. Meds for bowel function have no impact and a foley is not indicated for this problem. Scheduled toileting will help to reduce incontinent episodes.

The client is ordered Diphenhydramine (Bendadryl) 25 mg IV push stat. Which is the correct procedure for this type of administration? Scrub the injection port with alcohol, flush with normal saline and give Diphenhydramine over 2 minutes. Scrub the injection port with alcohol, flush with normal saline, give Diphenhydramine over 2 minutes and flush with normal saline. Scrub the injection port with alcohol, give Diphenhydramine over 2 minutes and flush with normal saline. Scrub the injection port with alcohol, give Diphenhydramine over 2 minutes

Scrub the injection port with alcohol, flush with normal saline, give Diphenhydramine over 2 minutes and flush with normal saline. You need to read each of these carefully. To give IV push correctly, you need to scrub the hub, flush with normal saline, give the medication at the correct rate and then flush again with NS at the same rate (remember how much medication is still in the IV tubing that needs to be flushed in).

The nurse is assessing the client's IV pump. The MAR states the patient should be receiving 0.9% sodium chloride at 200 mL/hr and Ceftriaxone 1000 mg IVPB in 100 mL over 30 minutes. The previous nurse states they started the Ceftriaxone at 0600. The current time is 0615. Based upon the picture of the IV pump, which action should the nurse take? Nothing, everything on the pump looks correct Change the rate of the 0.9% sodium chloride Start the Ceftriaxone at a rate of 100 mL/hr Start the ceftriaxone at a rate of 200 mL/hr

Start the ceftriaxone at a rate of 200 mL/hr The ceftriaxone runs as an IVPB so that is line B. In this picture, Line B is STOPPED, so the appropriate action is to start it. The rate should be 200 mL/hr because the volune is 100 mL to be infused over 30 minutes. 100 mL infused over 60 minutes would yield a rate of 100 mL/hr so infusing this over half the time means doubling the rate (200 mL/hr).

Which one of the following factors would be most important for the nurse to consider when determining the angle at which to insert the needle for a subcutaneous injection? size of the syringe the needle gauge amount of subcutaneous tissue position of the bevel

The amount of subcutaneous tissue is the most important factor to consider when deciding on the angle at which to insert the needle. Thin or emaciated patient with little subcutaneous tissue need to have the needle inserted at less of an angle. Patients who have large amount of subcutaneous tissue can tolerate up to a 90 degree angle. Gauge, size of the syringe, or position of the bevel has no bearing on the angle used.

The nursing student is administering an influenza vaccine to a client. The studentknows this vaccine is given via the intramuscular route. Which of the following wouldindicate that this student understands about giving IM medications? Use a 5/8 in needle Inject at a 45 degree angle Don't rub the site after the injection The deltoid in the upper arm is an appropriate injection sit

The deltoid in the upper arm is an appropriate injection sit rationale: IM injections use a 1 to 1.5 inch needle as they must be long enough to getthrough the subcutaneous layer and into the muscle. 5/8 inch needles would beappropriate for subcutaneous injections. IM injections require a 90 degree angle inorder to get the needle into the muscle. 45 degree angles are appropriate forsubcutaneous injections. It is helpful to rub the injection site after an IM injection(unless contraindicated per the medication) to increase absorption in to the muscle andalleviate some discomfort. The deltoid, rectus femoris, vastus lateralis andventrogluteal are appropriate intramuscular sites.

The client has an order for Heparin 5000 units Subcutaneous twice daily. Which of thefollowing indicates the nurse needs additional education about giving Heparin via thisroute? Select all that apply. A 5/8 inch needle is used The heparin is injected into the upper arm The nurse rubs the site after the injection The nurse avoids injecting into any scar tissue

The heparin is injected into the upper arm The nurse rubs the site after the injection Rationale: Heparin should be injected into abdomen since these sites are not near largemuscle groups and there is less risk of hematomas or bruising. Since it is ananticoagulant, rubbing the site after the injection is contraindicated to reduce the risk ofbleeding and bruising

The nursing student is completing their annual TB skin testing. The student shouldexpect which of the following during the visit to the TB clinic? The injection will be given in the subcutaneous tissue The injection site will be rubbed afterward The injection will be given in the thigh The injection will be performed at a 5-15 degree angle

The injection will be performed at a 5-15 degree angle Rationale: TB testing is performed through intradermal injection. With this it is givenvery superficially just below the dermal or skin layer. Common sites are the inner arm,upper back or scapula of the back with the inner arm being the most common for TBtesting. A short (1/2 inch) and fine gauge (26-28) needle is used to create a bleb orwheal which should not be touched or rubbed afterward. Injection angle is shallow,usually 5-15 degrees.

The nursing student comments to the nursing instructor that when drawing up medication from a vial, they keep getting too much air in the syringe. Which of the following can contribute to getting air into the syringe? The syringe is the wrong size The needle gauge is the wrong size The needle is not in fluid the whole time The student is drawing up the medication too slowly

The needle is not in fluid the whole time Getting air into the syringe usually isn't affected by the syringe or even the needle size. Air happens when the needle isn't in fluid the whole time. So when you draw up medication, always ensure the needle is low enough in the vial that is in fluid the whole time.

The elderly client is having difficulty hearing and it is discovered that the right ear has excessive wax buildup. The nurse obtains a prescription from the provider for Debrox ear wax removal. The client has had this done before and questions which of the following actions by the nurse? The client is instructed to turn on their left side The solution is warmed to body temperature prior to instilling The pinna of the ear is pulled down and back The tragus of the ear is gently massaged after releasing the pinna

The pinna of the ear is pulled down and back The pinna should be pulled and and back for adults and down and back for children under 3

Which of the following statements about CAUTI (Catheter Associated Urinary Tract Infection) is NOT true? -UTIs are the least common of all healthcare associated infections and 50% of those infections are caused by indwelling urinary catheters. -CAUTI is caused by a biofilm that develops on the catheter surface and leads to multi-drug resistant infections -Defined as a urinary tract infection that develops when an indwelling catheter is in place greater than 2 days prior to the onset of infection -CAUTIs can lead to gram-negative blood infections which are sometimes fatal

UTIs are the least common of all healthcare associated infections and 50% of those infections are caused by indwelling urinary catheters. Rationale: See Craven p. 1102. UTIs are the most common of all healthcare associated infections and 80% of those infections are caused by indwelling urinary catheters.