Taylor's Clinical Nursing Skills

A client receiving epidural analgesia asks the nurse to put the head of the bed all the way down to sleep better. What is the correct response by the nurse? "It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to increase the effectiveness of the spinal analgesia." "It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to minimize the risk of respiratory depression." "It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to decrease the risk of severe migraine headaches." "It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to prevent accidental dislodgement of the catheter.

"It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to minimize the risk of respiratory depression." Rationale:The rationale for keeping the head of the bed elevated 30 degrees is that this position helps to minimize the upward migration of the opioid in the spinal cord, thereby minimizing the risk of respiratory depression. The nurse does not keep the head of the bed elevated to decrease the risk of migraines as migraines are not a common problem with epidural analgesia. Positioning of the client does not increase the effectiveness of the medication. Positioning also does not prevent accidental dislodgement of the catheter this is accomplished by a secure dressing and taping the tubing so that it is not pulled.

The client is to receive several medications via a gastric tube. How much water would the nurse flush the tube between the medications? 35 to 40 mL 15 to 20 mL 5 to 10 mL 25 to 30 mL

5 to 10 mL Rationale:When several medications are being administered via a gastric tube, the nurse would flush the tube with 5 to 10 mL of water after giving each medication. After the last dose of medication, the nurse would flush the tube with 30 to 60 mL to maintain tube patency.

The nurse is removing the needle from the implanted port of a central venous access device (CVAD). At what angle would the nurse remove the needle? 90-degree 30-degree 60-degree 45-degree

90-degree Rationale:To remove the needle from the septum, the nurse should grasp the needle/wings with the dominant hand, and then firmly and smoothly pull the needle straight up at a 90-degree angle from the skin. Pulling the needle at an angle less than 90 degrees may cause damage to implanted port.

The nurse prepares to provide gastrostomy insertion site care. The gastrostomy tube was placed this week. The client reports pain at the site. Which action does the nurse take next? Clean around the insertion site. Assemble bedside equipment. Provide for client privacy. Administer pain medication.

Administer pain medication. Rationale:Gastrostomy feeding tubes are uncomfortable for the first days after insertion. The client will tolerate site care better after analgesic administration. While waiting for the medication to take effect, the nurse can prepare the area. After the medication is working, the nurse provides for privacy and begins site care, carefully assessing for other reasons for site pain including excessive erythema or edema.

The nurse provides the client with a gravity feeding via a gastrostomy tube. Which action is correct? Assist the client to obtain a desired and comfortable position. Allow the feeding to infuse slowly from the feeding bag. Remove and waste gastric residual contents. Flush the gastrostomy tube with 60 mL of sterile water.

Allow the feeding to infuse slowly from the feeding bag. Rationale:The nurse allows the gravity feeding to infuse over about 30 minutes from the feeding bag. The tube is flushed before and after feedings with 30 mL of tap water. Gastric contents are replaced unless there is a large quantity according to institution policy. The nurse does assist the client to be comfortable, but the client must stay in an upright position for approximately 1 hour after feeding for safety.

The nurse is preparing to give an IV medication to a client through a drug-infusion lock. Which action would the nurse perform to ensure the right client receives the medication? Ask the client's family to identify the client. State the client's name and ask if this is correct. If the client cannot identify self, ask the client's roommate to identify the client. Ask the client to state his or her name and birth date.

Ask the client to state his or her name and birth date. Rationale: Usually, the client would be identified using two methods, based on facility policy, often by checking the name and ID number on the client's identification band, and by asking the client to state his or her name and birth date. If the client cannot self-identify, the nurse would verify the client ID with a second source, such as a staff member who knows the client.

A client has had a nasogastric tube inserted in preparation for tube feedings. When developing the client's plan of care, the nurse would anticipate checking the placement of the tube at which time? After administering an intermittent tube feeding Before administering a medication through the tube Every 8 hours during a continuous tube feeding At the beginning of each shift

Before administering a medication through the tube Rationale:The nurse would verify correct placement of the nasogastric tube after the initial insertion, before beginning a feeding or instilling medications or liquids, and at 4-hour intervals during continuous feedings. This ensures that the tip of the tube is situated in the stomach or intestine, preventing inadvertent administration of substances into the wrong place. A misplaced feeding tube in the lungs or pulmonary tissue places the client at risk for aspiration.

The nurse knows that monitoring the infusion rate and IV site is a nursing responsibility. When does the nurse routinely monitor client IVs? End of the work shift. Upon admission. Upon discharge. Beginning of the work shift.

Beginning of the work shift. Rationale:The nurse is responsible for monitoring the infusion rate and the IV site. This is routinely done as part of the initial client assessment and at the beginning of a work shift. In addition, IV sites would be checked at specific intervals and each time an IV medication is given, per the institution's policies.

Where should the nurse position the drain collection bag for the T-tube drain to facilitate proper drainage? Above the client's waist. Below the client's heart level. Below the level of the wound. Anywhere on the bedside rails

Below the level of the wound. Rationale:To best ensure proper drainage, the nurse should position the drain collection bag below the level of the wound, because drainage in the tubing drains via gravity. Placing the drain level with or higher than the wound prevents proper drainage. Using the guideline of placing the T-tube drain below the client's heart level or above the client's waist does not ensure it is below the level of the wound and can drain via gravity. For example, if a client had a drain from a hip surgery, the drain collection bag would need to be below the client's hip area. The nurse should never hang anything on the bedside rails as these are meant to be raised and lowered and do not ensure proper placement.

The nurse is assessing the pain of a neonate with altered respirations. Which pain assessment scale would be the best choice for this client? FLACC scale. CRIES pain scale. Wong-Baker Faces pain rating scale. COMFORT scale.

CRIES pain scale. Rationale:The CRIES pain scale would be the most appropriate scale to use for neonates. The COMFORT scale is used for infants, children, and adults who are unable to use the Numeric Rating Scale or Wong-Baker Faces pain rating scale. The FLACC scale is used for infants and children (2 months to 7 years) who are unable to validate the presence of or quantify the severity of pain. The Wong-Baker Faces pain rating scale is used for adults and children over three years old.

The nurse has just compared the label on the piggyback medication with the medication administration record (MAR), using the Rights of Medication Administration for a section check. What is the next step in the process? Check the medication prescription against the original prescription and check for allergies. Use the drug guide to check that the prescribed dose is safe, the administration rate is correct, and that the client has no contraindications. Calculate the drip rate for the prescribed infusion time. Choose the correct medication piggyback set from the client's medication drawer and check the expiration date.

Calculate the drip rate for the prescribed infusion time. Rationale: The correct procedure is to (1) check the medication prescription against the original prescription and check for allergies; (2) use the drug guide to check that the prescription dose is safe, the administration rate is correct, and that the client has no contraindications; (3) choose the correct medication piggyback set from the client's medication drawer and check the expiration date; (4) compare the label on the piggyback medication with the MAR; (5) calculate the drip rate.

The nurse is flushing a client's peripherally inserted central catheter (PICC). What action should the nurse perform first? Cap the infusion line. Flush the catheter using steady pressure. Swab the access cap with an alcohol wipe. Insert the saline syringe into the catheter port

Cap the infusion line. Rationale:The order in which the nurse should flush a PICC is (1) cap the infusion line, (2) swab the access cap with an alcohol wipe, (3) insert the saline syringe into the catheter port, and (4) flush the catheter using steady pressure

The nurse is conducting an initial assessment of the abdomen. When checking for vascular sounds in the abdomen, what should the nurse do? Select all that apply. Assess the lower region of the abdomen last. Expose only the region of the client being assessed. Evaluate the aortic region of the abdomen first. Listen for growling abdominal sounds in all quadrants. Use the diaphragm of the stethoscope.

Evaluate the aortic region of the abdomen first., Expose only the region of the client being assessed., Assess the lower region of the abdomen last. Rationale:When assessing the abdomen for vascular sounds, the nurse should use the bell, not the diaphragm of the stethoscope, expose only the region being assessed, and go from top to bottom in the artery areas. Listening for growling sounds would be assessing for Borborygmi, which is a bowel, not vascular sound.

To ensure the early detection of problems, at a minimum, how often should the nurse check the T-tube drain? Every shift Every 4 hours Every day Every hour

Every 4 hours Rationale:The nurse should check the T-tube drain status at least every 4 hours. Check all wound dressings every shift. Checking the drain ensures proper functioning and early detection of problems. Checking every hour is too frequent, unless there is a known problem. The other timeframes would not allow for early detection.

When monitoring a client with a continuous tube feeding, how often should the nurse confirm placement of the tube? Every 2 to 4 hours. Every shift. Every 24 hours. Every 4 to 6 hours.

Every 4 to 6 hours. Rationale:The nurse would confirm the tube placement for a client receiving a continuous tube feeding every 4 to 6 hours. Checking placement verifies that the tube has not moved out of the stomach.

In what position would the nurse place the client prior to removing a nasogastric tube? Flat with the side rails up. In an upright position with the bedrail nearest the nurse down. Sitting on the side of the bed. In a flat position with the bedrail nearest the nurse down.

In an upright position with the bedrail nearest the nurse down. Rationale:The nurse would place the client in an upright position in bed with the rail nearest the nurse down. Appropriate client positioning facilitates comfort for the client and the nurse, ensuring proper body mechanics for the nurse.

When administering an IV antibiotic to a client, where would the nurse hang the piggyback container? On the IV pole, lower than the primary IV solution container. On the IV pole, at the same height as the primary IV solution container. On the IV pole, higher than the primary IV solution container. On a separate IV pole at the same height as the primary IV solution container.

On the IV pole, higher than the primary IV solution container. Rationale: The nurse would hang the piggyback container on the same IV pole, positioning it higher than the primary IV solution according to manufacturer's recommendations. The position of containers influences the flow of IV fluid into the primary setup.

The nurse is preparing to administer a bolus of IV pain medication through a drug-infusion lock. Before flushing the lock with saline, there is no blood return with aspiration. What would be the initial recommended nursing intervention in this situation? Check the patency of the tubing by injecting 3 mL sterile water. Reassess the IV site for any infiltration or inflammation. Forcefully attempt to flush the drug-infusion lock with saline, observing the site for changes. Remove the device to another part of the arm.

Reassess the IV site for any infiltration or inflammation. Rationale: When there is no blood return upon aspiration of a drug-infusion lock, the nurse should first reassess the IV site for any infiltration or inflammation. Blood return does not always occur even though the IV lock is patent. If the lock is patent, the nurse should slowly and gently attempt to flush it with saline and observe the site for changes. If signs of infiltration are present, the nurse would remove the device and restart in another location.

Which is a normal finding upon assessment of a client's peripherally inserted central catheter (PICC)? a small amount of blood at the insertion site an insertion site free of blood and intravenous (IV) solution intravenous (IV) solution surrounding the catheter a crusted appearance at the insertion site

an insertion site free of blood and intravenous (IV) solution Rationale:The transparent dressing should allow the nurse to visualize that the catheter inserted into the arm is free of blood or IV solution. A small amount of blood or a crusted appearance at the insertion site would indicate the need for a dressing change. IV solution surrounding the catheter may indicate infiltration and would require further assessment.

A nurse would perform additional monitoring of the IV site and infusion according to facility policy for which client? A client who is unconscious. A client who is dehydrated. A client who has fluid imbalances. A client who is receiving IV medications.

A client who is receiving IV medications. Rationale:The nurse should monitor the IV infusion every hour or per agency policy, but more additional monitoring is necessary if the client is receiving IV medications. This promotes the safe administration of IV fluids and medications.

Which client would be an ideal candidate for receiving IV medication through a drug infusion lock? A client receiving a one-time fluid replacement for dehydration. A client who is receiving a dose of insulin. A client who is receiving a continuous infusion of pain medication. A client who is receiving medication for pain every four hours.

A client who is receiving medication for pain every four hours. Rationale: A drug infusion lock is best used for clients who require intermittent IV medication, but not a continuous infusion. It would not be used for a one-time fluid replacement or a single dose of insulin.

The nurse is reviewing prescriptions to irrigate an ostomy. Which clients can have their ostomy irrigated? Select all that apply. A client with diverticulitis A client with Crohn's disease A client with an ileostomy A client with a left-sided end colostomy A client with a peristomal hernia A client with a sigmoid colostomy

A client with a left-sided end colostomy, A client with a sigmoid colostomy Rationale:Colostomy irrigation may be indicated in clients who have a left-sided end colostomy in the descending or sigmoid colon. Contraindications to colostomy irrigation include irritable bowel syndrome, peristomal hernia, postradiation damage to the bowel, diverticulitis, and Crohn's disease. Ileostomies are not irrigated because the fecal content of the ileum is liquid and cannot be controlled.

A client is receiving a continuous tube feeding. Which accurately describes an aspect of this procedure? The procedure for inserting the tube is different from that for an intermittent feeding. The nurse should check for residual every 8 hours. The continuous feeding is administered over a 12-hour period. A feeding pump is used for a continuous feeding.

A feeding pump is used for a continuous feeding. Rationale:A continuous tube feeding is administered over a 24-hour period and a feeding pump is always used. The nurse would check for residual every four to six hours. Regardless of the type of tube used, the procedure for tube insertion is the same.

The nurse need to place a dressing under and around a Penrose drain. Which dressing would be best for the nurse to obtain? A precut 4 × 4 sterile drain sponge Roll of sterile prewoven gauze Nonadherent petrolatum dressing gauze Sterile 2 × 2 gauze sponge

A precut 4 × 4 sterile drain sponge Rationale:The nurse should obtain the presplit drain sponge to place under and around the drain. The sterile 2 × 2 gauze sponge is too small and does not have a precut split to allow it to go under and around the drain. Nonadherent petrolatum dressing gauze is medicated, which is not indicated. A roll of sterile prewoven gauze is also not precut and would not fit properly around the drain. Gauze should never be cut by the nurse to fit around a drain or stoma site, because this can cause fibers to get into the wound or stoma.

Which question, used for a pain assessment, would assess a client for the perception of pain? "Does the pain interfere with your sleep?" "What would you like to be doing now if your pain was controlled?" "What do you do to relieve stress?" "Do you find any meaning in your pain?"

"Do you find any meaning in your pain?" Rationale:The question about interference with sleep is related to the degree to which the pain interferes with the client's life. The question about stress relates to the client's use of adaptive mechanisms to cope with the pain. The question about meaning assesses the client's perception of pain, and the question about activity if pain were controlled refers to the outcomes of pain

The nurse has completed a preoperative teaching session with a client who will receive morphine via a patient-controlled analgesia (PCA) pump after surgery. Which statement by the client indicates the need for further teaching? "I can push the button whenever I feel pain." "I will use the PCA pump until oral pain medication controls my pain." "I will remind my family member to push the PCA pump button for me if I doze off during the day." "I will let my nurse know if the pain medication is not effective enough to help me move after surgery."

"I will remind my family member to push the PCA pump button for me if I doze off during the day." Rationale:Sedation occurs before clinically significant respiratory depression. Thus, if the client is too sleepy to push the button (or ask that it be pushed), the button should not be pushed. The other answers are all correct.

The nurse is caring for a client with a new sigmoid colostomy. The client expresses concern about how to anticipate when a bowel movement will pass into the bag. Which answer is most appropriate? "Once you recover from surgery, your bowel elimination pattern will become regular." "Irrigating the colostomy can help establish an elimination routine." "It is impossible to anticipate when a bowel movement will occur." "Increasing fiber in your diet will help promote regular bowel movements."

"Irrigating the colostomy can help establish an elimination routine." Rationale:Irrigations are used to promote regular evacuation of some colostomies. Left sided colostomies of the descending colon and sigmoid colon can be irrigated successfully for regulating bowel elimination. Telling the client that it is impossible to anticipate when a bowel movement will occur is appropriate for a client with an ileostomy, but not with a sigmoid colostomy. Increasing fiber in the diet will make the stool more solid, but it will not help establish an elimination pattern. Recovering from surgery does not help the bowel elimination pattern to become regular. Irrigating the colostomy is the best way to control when a bowel movement occurs.

The nurse is educating a preoperative client about gastric tubes. The client asks, "Why do I need to have a gastric tube?" How should the nurse respond? "Only so you can get the medications you need." "Your stomach isn't working, and this will help." "Your health care provider prescribed it for you." "To help you consume sufficient nutrition."

"To help you consume sufficient nutrition." Rationale:The gastric tube is usually placed for the client who cannot swallow or those who have had oral surgery to supplement feeding and allow the client to consume sufficient nutrition. Although the client will receive medications and the health care provider did prescribe placement of the gastric tube, the nurse must give clear and precise information to the client. In the client with a gastric tube the stomach is working, but the client may not be able to masticate or swallow.

A group of nurses are reviewing information about asepsis. Which statement by the group demonstrates the need for additional review? "Reaching over a sterile field contaminates the sterile field." "Any items coming into contact with a sterile field must be sterile." "Turning a back to a sterile field maintains the sterility of the field." "Items below waist level are considered contaminated."

"Turning a back to a sterile field maintains the sterility of the field." Rationale:A sterile field becomes contaminated if the nurse turns his or her back to it. Any item that comes into contact with a sterile field must be sterile. Reaching over a sterile field contaminates the sterile field. Any items below waist level are considered contaminated.

A client scheduled for the removal of a nasogastric tube asks the nurse, "Will taking out the tube hurt?" What is the nurse's best response? "We will give you pain medication since tube removal causes moderate pain." "Don't worry, I've done this procedure many times and no one has complained of pain." "We will numb your throat prior to removal so you will not experience any pain." "You may experience minor discomfort as the tube is being removed."

"You may experience minor discomfort as the tube is being removed." Rationale:The nurse would explain to the client that minor discomfort may be experienced for a few seconds but that the nose and throat will feel better once the tube is out. The procedure does not require pain medication or anesthetics.

The nurse is preparing to irrigate a client's NG tube. Which would the nurse include when teaching the client about this procedure? "You may feel cold solution going down your throat, but it should not hurt." "You may feel a slight burning sensation in the throat." "You may experience nausea or vomiting during the flush." "You will not experience any unusual sensations with this procedure."

"You may feel cold solution going down your throat, but it should not hurt." Rationale:The nurse should inform the client that when the tube is flushed with solution, it may feel cold going down the throat, but it will not hurt. The procedure may be a bit uncomfortable, and a sensation of cold may be felt in the throat, but pain, nausea, and vomiting is not normally involved

A nurse is irrigating a client's nasogastric tube. Place the following steps in the correct order. Use all options.

1)Check placement of the nasogastric tube. 2)Draw up 30 mL of irrigation solution into a syringe. 3)Clamp the nasogastric tube near the connection site. 4)Hold the syringe upright, and gently insert the irrigant. 5)Hold the end of the nasogastric tube over an emesis basin. 6)Inject air into the blue air vent. Rationale:Checking placement before the instillation of fluid is necessary to prevent accidental instillation into the respiratory tract if the tube has become dislodged. Drawing up the specified amount of solution into a syringe ensures delivery of the proper amount of irrigant through the tube. Clamping prevents leakage of gastric fluid. Gentle insertion of saline solution (or gravity insertion) is less traumatic to gastric mucosa. Return flow may be collected in an irrigating tray or other available container and measured. This amount needs to be subtracted from the irrigant to record the true nasogastric drainage. Following irrigation, the blue air vent is injected with air to keep it clear.

A nurse is flushing a client's central venous access device (CVAD). Arrange the following steps in the correct order. Use all options.

1)Cleanse the end cap with an antimicrobial swab. 2)Insert a saline flush syringe into the cap on the extension tubing. 3)Pull back on the syringe to aspirate catheter for positive blood return. 4)Instill the solution over 1 minute and then remove the syringe. 5)Insert the heparin syringe, instill the solution, and remove the device. 6)Reclamp the lumen. Rationale:Cleaning the cap reduces the risk for contamination. Positive blood return confirms patency before administration of medications and solutions. Flushing maintains patency of the IV line. Action of positive pressure end cap is maintained with the removal of the syringe before the clamp is engaged. CVADs should be 'locked' with a heparin solution (10 U/mL) after each intermittent use to prevent clotting. Clamping prevents air from entering the CVAD.

The nurse is preparing to backprime by gravity. Place in order, from first to last, the actions the nurse will perform. Use all options.

1)Close the roller clamp on the tubing. 2)Spike the new bag. 3)Hang the spiked bag on the IV pole. 4)Compress the drip chamber and allow it to fill about halfway full. 5)Connect the secondary bag to the primary bag at the appropriate port. Rationale: When preparing to backprime a secondary tubing by gravity, the nurse should first close the roller clamp on the tubing to prevent any accidental loss of medication, then spike the new bag and hang it on the IV pole. Then the nurse should compress the drip chamber and allow the drip chamber to become about half full. The nurse should then open the roller clamp carefully and prime the rest of the tubing, close the clamp again, connect the tubing to the appropriate port, and then unclamp the roller clamp and begin the infusion at the prescribed rate.

The nurse is preparing to assess a client's abdomen. Place the following steps of the assessment in the correct order. Use all options.

1)Inspection 2)Auscultation 3)Percussion 4)Palpation Rationale:The order of the techniques for the abdominal assessment differs from that for the other systems. This is the preferred approach because performing palpation and percussion before auscultation may alter the sounds heard on auscultation.

The nurse is preparing to insert a nasogastric (NG) tube into an adult client. Place the following steps in the correct order. Use all options.

1)Place the client in high Fowler's position. 2)Measure the intended length to insert the NG tube. 3)Lubricate the tube tip with water-soluble lubricant. 4)Direct the tube upward and backward along the floor of the nose. 5)Instruct the client to place the chin onto the chest. 6)Advance the tube while the client swallows. Rationale:An upright position is more natural for swallowing and protects against bronchial intubation aspiration, if the client should vomit. Therefore, the high Fowler's position is recommended for the client. Measurement ensures that the tube will be long enough to enter the client's stomach. Lubrication reduces friction and facilitates passage of the tube into stomach. Following the normal contour of the nasal passage while inserting the tube reduces irritation and the likelihood of mucosal injury. Bringing the head forward helps close the trachea and open the esophagus. Swallowing helps advance the tube, causes the epiglottis to cover the opening of the trachea, and helps to eliminate gagging and coughing.

The nurse is caring for a Jackson-Pratt drain. Place in order, from first to last, the actions the nurse will perform. Use all options.

1)Place the graduated collection container under the drain outlet. 2)Remove the cap from the bulb. 3)Empty the bulb's contents into the collection chamber. 4)Wipe the outlet of the bulb with a sterile gauze pad. 5)Fully compress the bulb. 6)Replace the cap on the bulb. Rationale:When caring for a Jackson—Pratt drain, the nurse should first place the graduated collection container under the drain outlet, then remove the cap from the bulb, and then empty the bulb's contents into the collection chamber, being careful not to contaminate the outlet. Once empty, the nurse should wipe the outlet of the bulb with a sterile gauze pad, fully compress the bulb, and finally, replace the cap on the bulb

The nurse is preparing to administer an intermittent feeding to a client who has a nasogastric feeding tube. Place the following steps in the correct order. Use all options

1)Position the client with the head of bed elevated 30 to 45° degrees. 2)Verify correct tube placement. 3)Aspirate all gastric contents. 4)Verify that residual volume is less than 200 mL. 5)Flush the tube with 30 mL of water. 6)Administer the feeding. Rationale:Elevating the head of the bed 30 to 45° degrees minimizes the possibility of aspiration into the trachea. Verifying correct tube placement ensures that the formula is being delivered to the stomach appropriately. The nurse should aspirate all gastric contents with the syringe and measure to check for gastric residual, the amount of feeding remaining in the stomach from the previous feeding. This is done to identify delayed gastric emptying. High gastric residual volumes (200 to 250 mL or greater) can be associated with high risk for aspiration and aspiration-related pneumonia, so feedings should be held if residual volumes exceed 200 mL on two successive assessments. Flushing the tube prevents occlusion.

The nurse is administering an intermittent tube feeding using a gravity set-up and open feeding bag system. At what level should the nurse place the feeding bag on the pole? 12 in (30 cm) above the stomach. 24 in (60 cm) above the stomach. 12 in (30 cm) below the stomach. At stomach level.

12 in (30 cm) above the stomach. Rationale:The nurse would hang the feeding bag 12 in (30 cm) above the stomach. Proper feeding bag height reduces the risk of formula being introduced too quickly.

The nurse has finished aspirating the gastric contents before administering a prefilled, continuous tube feeding. At this point in the procedure, how much sterile water would the nurse use to flush the tube? 30 mL 10 mL 20 mL 40 mL

30 mL Rationale:Following aspiration of the gastric contents, the nurse would use 30 mL of sterile water to flush the tube. Water rinses the feeding from the tube and keeps it patent.

When irrigating a nasogastric (NG) tube, how many mL of irrigating solution would the nurse usually instill into the tube unless another amount is prescribed? 25 mL 15 mL 30 mL 20 mL

30 mL Rationale:Normally the nurse would instill 30 mL of irrigating solution or the specific amount prescribed into the NG tube. Irrigation clears the tube of any debris or formula and helps to keep it patent.

The nurse is providing a continuous tube feeding for a client. At what angle should the head of the bed be set during the feeding? 30 to 45 degrees. 15 to 20 degrees. 90 degrees. 20 to 25 degrees.

30 to 45 degrees. Rationale:During the administration of a continuous tube feeding, the head of the bed should be elevated at 30 to 45 degrees. This position minimizes possibility of aspiration into the trachea. Clients considered high risk for aspiration should be assisted to at least a 45-degree position.

The nurse is administering medications to a client via a gastric tube. After administering the last dose of medication, how much water should the nurse flush through the gastric tube? 65 to 75 mL 30 to 60 mL 15 to 25 mL 5 to 15 mL

30 to 60 mL Rationale:When administering medications via a gastric tube, the nurse would flush the tube with 30 to 60 mL of water to maintain tube patency. A 5- to 10-mL water flush would be used between medications when the nurse is administering more than one medication at a time. A 15- to 25-mL or a 65- to 75-mL water flush would be inaccurate amounts for the task.

After injecting the medication into the injection port of a volume control administration set, what would the nurse do with the volume control chamber to mix the medications? Invert it. Inject air into it. No action is needed. Agitate it gently.

Agitate it gently. Rationale: The nurse would rotate or gently agitate the volume control chamber to ensure that the medication is evenly mixed with the solution. Air would not be injected into the chamber.

The nurse is educating a family of a client with a gastric tube about administering medications. What would be appropriate to include? Select all that apply. Delayed-response tablets cannot be ground. Sterile water must be used in the gastrointestinal system. Tablets must be ground to a fine powder. Enteric-coated tablets cannot be ground. All ground powder must be mixed with tap water.

All ground powder must be mixed with tap water., Tablets must be ground to a fine powder., Enteric-coated tablets cannot be ground., Delayed-response tablets cannot be ground. Rationale:Tablets must be ground into a fine powder and mixed with tap water. Enteric-coated and delayed-response tablets cannot be ground; if a medication has enteric coating or a delayed response, it was intended not to have an immediate response, so crushing the medication would not produce the delayed effect. Sterile water is not necessary when administering medications through the gastric tube.

What will the nurse place at the bedside of a client receiving epidural analgesia? Ampule of 0.4 mg epinephrine Bottle of sterile saline An extra chest drainage system Ampule of 0.4 mg naloxone

Ampule of 0.4 mg naloxone Rationale:At the bedside of a client receiving epidural analgesia, the nurse should ensure that an ampule of 0.4 mg naloxone and a syringe are present. This medication reverses the respiratory depressing effects of opioids when needed and should be readily available. Epidural analgesia does not usually affect the neurotransmitter epinephrine and, therefore, is not needed at the bedside. A chest drainage system and a bottle of sterile saline would be at the bedside of a client with a chest tube but is not indicated for epidural analgesia.

A client tells the nurse that the heartburn she is experiencing is worse when she eats spicy foods. What would the spicy food be considered? An aggravating factor. An alleviating factor. Associated phenomenon. A physiologic response

An aggravating factor. Rationale:An aggravating factor makes the pain occur or increase in intensity. Alleviating factors make the pain go away or lessen. Associated phenomena are factors that consistently relate to the pain. Physiologic responses are physical signs related to the pain, such as a change in vital signs.

Which client would be at highest risk for experiencing fluid overload as a complication of IV therapy? A teenager receiving an IV infusion for dehydration. An infant receiving an IV infusion for bronchitis. An adult injured in a car accident receiving medication via an IV infusion. An older adult client receiving an IV infusion for pneumonia.

An older adult client receiving an IV infusion for pneumonia. Rationale:Although any client receiving IV therapy could develop fluid overload, older adult clients are more at risk for fluid overload due to the possible decrease in cardiac and/or renal functions

A nurse is caring for a client who is about to undergo orthopedic surgery. The client will be receiving epidural analgesia prior to the surgery for pain management. The nurse should understand that who is responsible for inserting the catheter into the client's epidural space? Anesthesiologist Nurse Nursing assistant Orthopedic surgeon

Anesthesiologist Rationale:The anesthesiologist or radiologist usually inserts the catheter in the mid-lumbar region into the epidural space that exists between the walls of the vertebral canal and the dura mater or outermost connective tissue membrane surrounding the spinal cord.

While removing a client's peripherally inserted central catheter (PICC), part of the catheter breaks off. What action is the nurse's priority? Have the client perform the Valsalva maneuver. Measure the catheter and compare it with the length listed in the chart. Apply a tourniquet to the client's upper arm. Apply pressure to the site with sterile gauze until hemostasis is achieved.

Apply a tourniquet to the client's upper arm. Rationale:In the event that a portion of the catheter breaks off during removal of a PICC, the nurse should immediately apply a tourniquet to the upper arm, close to the axilla, to prevent advancement of the piece of catheter into the right atrium. The other actions should be performed during a routine PICC removal. Use of the Valsalva maneuver by the client during expiration reduces the risk for air embolism. Measurement and inspection of the PICC following removal ensures that the entire catheter was removed. Application of adequate pressure with sterile gauze following PICC removal prevents hematoma formation.

How would the nurse care for the access site after removing the needle from the implanted port of a central venous access device (CVAD)? Apply steady pressure to the site with an antimicrobial wipe. Allow the site to air dry before applying a transparent dressing. Apply a sterile bandage after wiping the site with an alcohol wipe. Apply gentle pressure to the site with a gauze square.

Apply gentle pressure to the site with a gauze square. Rationale:The nurse would apply gentle pressure with gauze on the insertion site and apply a commercial adhesive bandage over the port if any oozing occurs. Otherwise, a dressing is not necessary. Using an antimicrobial wipe to apply pressure is not recommended, because it may cause burning. Gentle pressure controls bleeding. The site should not be allowed to air dry

A nurse is caring for a client with a gastrostomy tube and observes that a large amount of drainage is leaking from the tube. On inspection the nurse finds a great deal of slack in the tube. Which action should the nurse take next? Notify the health care provider. Gently rotate the external bumper 90 degrees. Apply gentle pressure to the tube while pressing the external bumper closer to the skin. Apply a skin barrier to the insertion site

Apply gentle pressure to the tube while pressing the external bumper closer to the skin. Rationale:If there is a large amount of slack between the internal guard and the external bumper, drainage can leak out of the site. In this case, the nurse should apply gentle pressure to tube while pressing the external bumper closer to the skin. Although the nurse should gently rotate the external bumper 90 degrees at least once a day, this action would not address the leaking of the tube. Skin barrier should be applied to protect the skin from irritation by the tube; however, this action would not address the leaking, either. There is no need to notify the health care provider regarding this issue.

The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client? Apply petroleum-based ointment and sterile occlusive dressing. Instruct client to remain flat for 30 minutes. Apply pressure to insertion site for at least 3 minutes. Ask client to perform Valsalva maneuver.

Apply pressure to insertion site for at least 3 minutes. Rationale:The nurse recognizes the client prescribed warfarin is at risk for bleeding and individualizes care by applying pressure to the insertion site for longer than the minimum recommended 1 minute. The remaining interventions are appropriate for all clients when discontinuing a PICC line; they do not individualize care for the client prescribed warfarin.

The nurse has just confirmed proper placement of a nasogastric tube. Which action should the nurse take next? Measure the length of the exposed tube. Secure the tube to the client's nose using tape. Apply skin barrier to the tip and end of the nose. Lubricate the lips generously.

Apply skin barrier to the tip and end of the nose. Rationale:Skin barrier improves adhesion and protects the skin. Applying the skin barrier should occur before taping the tube to the client's nose, measuring the length of exposed tube, or lubricating the lips.

A client rates pain on a numeric pain scale at a "5" out of 10. What type of pain is this client experiencing? Severe Moderate Debilitating Mild

Moderate Rationale:On a numeric rating scale, no pain is rated as 0, mild pain is rated as 1 to 3, moderate pain is 4 to 6, severe pain is 7 to 9, and a 10 is pain as bad as it gets.

When removing the old dressing from the site of a Penrose drain, the nurse notes that some of the dressing material has stuck to the client's skin. What action should the nurse take next? Gently pull the dressing material off the client's skin and observe for irritation. Apply sterile saline to loosen the dressing material from the skin. Use an alcohol based adhesive remover to aid in removal of the dressing. Administer an analgesic to the client and warn the client this may be a little painful.

Apply sterile saline to loosen the dressing material from the skin. Rationale:The nurse should apply sterile saline to loosen the dressing material from the skin. If any part of the dressing sticks to the underlying skin, the nurse should use small amounts of sterile saline to help loosen and remove it. Sterile saline moistens the dressing for easier removal and minimizes damage and pain. Gently pulling the dressing off without the saline will likely be painful and may cause irritation to the site. An alcohol based adhesive remover is to remove tape or other adhesive materials

The nurse is preparing to administer metoprolol 25 mg by intravenous bolus through an infusion of 0.9 % sodium chloride at 100 mL/hr. What are appropriate assessments prior to administering the medication? Select all that apply. Client's knowledge of the medication Compatibility of the prescribed medication and 0.9% sodium chloride Client's IV site for complications Appropriateness of the drug for the client Client's vital signs Client's neurologic status

Appropriateness of the drug for the client, Compatibility of the prescribed medication and 0.9% sodium chloride, Client's vital signs, Client's IV site for complications, Client's knowledge of the medication Rationale: It is important for the nurse to know the therapeutic effect of the medication to determine appropriateness for the client. Compatibility of the medication will prevent complications. A patent IV site is necessary for effective absorption of the medication. Metoprolol will affect vital signs, so it will be important to assess before administration. Assessing the client's knowledge will help identify teaching opportunities prior to administration. A neurologic assessment is appropriate but is not related to the administration of metoprolol intravenously.

The nurse is providing care for several clients on a busy floor. The nurse receives a prescription to administer a transfusion of packed red blood cells for a client with decreased hemoglobin. Which action should the nurse take before entering the client's room to begin the transfusion? Review the client's most recent vital signs. Arrange for another nurse to monitor the nurse's other assigned clients. Verify the client's name and date of birth with another nurse. Prime the blood administration set with dextrose 5% normal saline solution.

Arrange for another nurse to monitor the nurse's other assigned clients. Rationale:Before administering a blood transfusion, the nurse should arrange for another nurse to monitor the nurse's other assigned clients for at least 15 minutes, because the nurse will need to remain with the client receiving the transfusion during this time to monitor for transfusion reaction. Verifying the client's name and date of birth with another nurse is important to avoid error and should happen at the bedside in the presence of the client medical record, client identification band, and the label of the blood product, not prior to entering the room. It is important for the nurse to obtain the client's vital signs immediately prior to starting the transfusion to obtain a baseline. Reviewing a prior assessment is not adequate. Changes in vital signs may indicate a transfusion reaction. The nurse will prime the blood administration set with normal saline solution only to prevent clumping of red blood cells and hemolysis.

When completing a routine assessment of a client's peripherally inserted central catheter (PICC), the nurse finds no redness, swelling or drainage at the insertion site. The transparent dressing is dry and intact and adheres to the skin around all edges. What is the most appropriate intervention at this time? Document the assessment findings. Flush the catheter using a sterile prefilled normal saline flush. Ask the client about any pain or discomfort at the insertion site. Change the transparent dressing using sterile technique.

Ask the client about any pain or discomfort at the insertion site. Rationale:Assessing for pain and discomfort is part of a routine assessment of the PICC, as these may indicate infection or infiltration. The assessment should be complete before documenting. The dressing is intact and assessment findings do not warrant a dressing change at this time. Flushing the PICC is not part of the routine assessment.

The nurse is flushing the implanted port of a client's central venous access device (CVAD) and meets resistance. The nurse verifies that the clamp is open, pushes down on the needle, and, after attempting another flush, meets continued resistance. What should the nurse do next? Flush the port with heparin. Notify the health care provider. Change the access needle. Ask the client to perform a Valsalva maneuver

Ask the client to perform a Valsalva maneuver. Rationale: If resistance is met when flushing a client's implanted port, the nurse should first verify the clamp is open, push down on the needle, and attempt to flush again. If continued resistance is met, the nurse should ask the client to perform a Valsalva maneuver, change positions, or place the affected arm over the head. The access needle would not be changed until other remedies have been attempted. Flushing the port with heparin may prevent a port from clotting but will not resolve a clot. The health care provider should be notified after all remedies have been attempted; the health care provider may give a prescription for a clot-dissolving agent.

Which would be most appropriate for the nurse to do when removing a nasogastric (NG) tube? Ask the client to take a deep breath and pull out the tube quickly and carefully. Ask the client to turn the head to the side with the chin tilted up when pulling out tube. Ask the client to take short shallow breaths and pull out the tube slowly and carefully. Ask the client to take a deep breath and pull out the tube slowly and carefully.

Ask the client to take a deep breath and pull out the tube quickly and carefully. Rationale:When pulling out an NG tube, the nurse should ask the client to take a deep breath on the count of three and pull it out quickly and carefully. The client holds his or her breath to prevent accidental aspiration of gastric secretions in the tube. Careful removal minimizes trauma and discomfort for the client.

The student nurse is preparing a medication for administration by IV bolus and has selected a 10 milliliter 0.9% sodium chloride prefilled flush syringe for reconstituting the medication. What will the nursing instructor do next? Ask the student to review the prescribed use of 0.9% sodium chloride prefilled flush syringes Assist the student in performing the third check for medication administration Instruct the student to clean the top of the vial with alcohol prior to injecting 0.9% sodium chloride Ask the student to prepare a label for the medication syringe

Ask the student to review the prescribed use of 0.9% sodium chloride prefilled flush syringes Rationale:The nursing instructor should ask the student to review the prescribed use of prefilled 0.9% sodium chloride flush syringes. Prefilled 0.9% sodium chloride flush syringes have not been approved for reconstitution or dilution of medication. If reconstitution is needed, the nurse should use 0.9% sodium chloride labeled for reconstitution of medications. Cleaning the top of the vial with alcohol, preparing a medication label and performing the third check are all steps that will be completed prior to administration of the medication, but the first thing that the nursing instructor needs to address is the inappropriate use of the prefilled syringe.

When accessing the implanted port of a central venous access device (CVAD), what action should the nurse take to ensure the port is patent? Aspirate a few milliliters of blood into the extension tubing to check for blood return. Aspirate a few milliliters of blood into the syringe to check for blood return. Open the clamp on the extension tubing and instill 3 to 5 mL of air. Open the clamp on the extension tubing and flush with 3 to 5 mL of saline.

Aspirate a few milliliters of blood into the extension tubing to check for blood return. Rational: The nurse should check the patency of the implanted port of the CVAD by pulling back on the syringe plunger to aspirate for blood return. Positive blood return indicates that the port is patent. The nurse should aspirate only a few milliliters of blood and should not allow blood to enter the syringe. Flushing the port with 3 to 5 mL of saline checks that the needle is placed correctly. Air should not be used to flush the port as this can cause air embolism.

The nurse is injecting medication into the port of a drug-infusion lock. Which action would the nurse take to ensure that the catheter is in the vein? Inspect the port for evidence of collected fluid. Instill saline to check for swelling around the site. Aspirate gently for a blood return. Ask the client if he is experiencing any pain at the site.

Aspirate gently for a blood return. Rationale: The nurse would aspirate gently for a blood return, which indicates that the catheter of the drug-infusion lock is in the vein. Saline is then used to flush the lock. Asking the client about pain may provide clues to potential problems but would not verify the catheter's location in the vein. Inspecting the port provides no information about the catheter's location.

A nurse enters a client's room to perform a tube feeding. Which nursing action should be performed first? Pour a premeasured amount of tube feeding formula into the nasogastric tube. Check gastric residual. Flush the nasogastric tube with the ordered amount of water. Aspirate stomach contents and check pH.

Aspirate stomach contents and check pH. Rationale:Nasogastric tube placement should be checked before flushing, giving medications, or feeding. After placement has been ensured, the gastric residual should be checked, the nasogastric tube should be flushed as ordered, and the tube feeding administered.

The nurse notes an unexpected decrease in the amount of drainage in a client's T-tube drain. What action should the nurse take next? Document the decrease in drainage. Increase the suction to the drain. Assess for any kinks in the tubing. Change the dressing surrounding the drain.

Assess for any kinks in the tubing. Rationale:The nurse should check the drain tubing for any kinks, because kinked tubing could block any drainage. The nurse should ensure there is not a reason for the decrease in drainage before just documenting it. This type of drain does not have suction. Changing the dressing will not address any kink in the tubing.

A client has been receiving an IV piggyback medication via gravity. On assessment the nurse notes that the infusion has not completed but is no longer dripping in the drip chamber. What action should the nurse perform first? Hang the IV piggyback medication higher on the IV pole. Using a sterile syringe, flush the site with 10 mL of sterile saline. Assess the client's IV site for infiltration or other complication. Obtain a sterile syringe and attempt to get a blood return from the site.

Assess the client's IV site for infiltration or other complication. Rationale: When an IV infusion is not dripping or infusing, the nurse should first assess the client's IV site to ensure there are no complications. After ensuring the IV site is safe to continue using, the nurse may try troubleshooting such as flushing it with sterile saline or hanging the IV bag a little higher and see if it will begin infusing. A blood return does not ensure that the IV is not infiltrated and should not be the nurse's first action.

The nurse irrigates the client's colostomy. The client reports nausea and cramping. What action does the nurse take? Assess the temperature of the irrigation water. Ensure that the normal saline is flowing smoothly. Discontinue the irrigation process for the day. Administer antinausea medications immediately.

Assess the temperature of the irrigation water. Rationale:Nausea and abdominal cramping can occur if the water temperature is too cool. Lukewarm water is used. Normal saline is not used in a colostomy irrigation, but the flow of fluid, unless very fast, should not induce cramping. If an irrigation is due to be completed, then discontinuing for the day is not done for a bit of cramping. The nurse does need to administer medications immediately. The first step is to assess the water temperature and the nurse's actions during the irrigation process.

The nurse is caring for a client with a Jackson-Pratt drain. Which intervention by the nurse is priority before beginning the dressing change? Checking the client's latest laboratory values Assessing the client's need to void Assessing the need for analgesia Gathering the needed supplies

Assessing the need for analgesia Rationale:Although all noted interventions may be indicated, assessing the need for analgesia is priority. The nurse should administer appropriate prescribed analgesic and then allow enough time for the analgesic to achieve its effectiveness before beginning the procedure

The nurse, assessing a client's pain, asks the client if there are any other factors that consistently relate to the pain. What characteristic of the pain is the nurse assessing with this question? Associated phenomena. Aggravating factors. Chronology. Alleviating factors

Associated phenomena. Rationale:When assessing the associated phenomena of a client's pain, the nurse would ask if there are any factors consistently related to the pain. Chronology refers to how the pain develops and progresses. Aggravating factors are factors that make the pain occur or increase in intensity. Alleviating factors are factors that make the pain go away or lessen.

How often will the nurse empty a Jackson-Pratt drain? Select all that apply. At least every shift When the drain is one-half to two-thirds full Once every 24 hours At least every 4 hours Only when the drain is full

At least every 4 hours, When the drain is one-half to two-thirds full Rationale:The nurse should empty the Jackson-Pratt drain when the drain is one-half to two-thirds full and at least every 4 hours. The nurse should not wait until the drain is full, because this could interfere with the proper functioning of the drain. Once per shift or once per day is not often enough to catch any early indications of a complication.

The nurse is administering a medication to a client by piggyback IV infusion. Which accurately describes a step in this procedure? After assessing the IV site, close the clamp on the long, primary infusion tubing. After assessing the IV site, open the clamp on the short, secondary infusion tubing. Attach the infusion tubing spike into the port of the medication container. Using clean technique, remove the cap on the tubing spike and port of medication container.

Attach the infusion tubing spike into the port of the medication container. Rationale: The nurse administering an IV medication via piggyback infusion would assess the IV site, close the clamp on the short, secondary infusion tubing, use aseptic technique to remove the cap on the tubing spike and the port of the medication container, and attach the infusion tubing to the medication container by inserting the tubing spike into the port of the medication container.

A nurse must assess the bowel sounds of a client who is having abdominal pain. Which type of assessment should the nurse perform? Palpation Inspection Percussion Auscultation

Auscultation Rationale:Auscultation is the act of listening with a stethoscope to sounds produced within the body. This technique is used to assess blood pressure and heart, lung, and bowel sounds. Percussion is the act of striking one object against another to produce sound. The fingertips are used to tap the body tissues to produce vibrations and sound waves. The characteristics of the sounds produced are used to assess the location, shape, size, and density of tissues. Abnormal sounds suggest alteration of tissues, such as an emphysematous lung or the presence of a mass, such as an abdominal tumor. Palpation uses the sense of touch. The hands and fingers are sensitive tools and can assess skin temperature, turgor, texture, and moisture, as well as vibrations within the body (such as those caused by the heart) and shape or structures within the body. Inspection is the process of performing deliberate, purposeful observations in a systematic manner. The nurse closely observes visually but also uses hearing and smell to gather data throughout the assessment

The acute care nurse is assessing a newly admitted client's abdomen. Which finding would indicate the need to contact the health care provider? Auscultation of bowel sounds every 30 seconds Umbilicus centrally located Auscultation of gurgles and clicks Auscultation of a bruit

Auscultation of a bruit Rationale:A bruit may be heard in the presence of stenosis (narrowing) or occlusion of an artery. Bruits may also be caused by abnormal dilation of a vessel. The other findings are normal.

The acute care nurse is preparing to care for an 86-year-old client who just returned to the unit after surgery to repair a fractured hip. The client has severe dementia. Which pain management strategy would be most appropriate for this client? Authorized agent-controlled analgesia (AACA) Patient-controlled analgesia (PCA) As needed (PRN) administration of intramuscular analgesic medications As needed (PRN) administration of oral analgesic medications

Authorized agent-controlled analgesia (AACA) Rationale:AACA can be implemented to provide prompt, safe, and effective pain relief for the client who, because of cognitive or physical limitations, is unable to self-administer analgesics using a PCA pump. This strategy is most appropriate in this case because the client will likely have severe pain and will be unable to self-administer analgesics. PRN administration of oral analgesic medications is inappropriate. Oral analgesics are typically not effective for postoperative pain immediately after repair of a hip fracture and the client likely lacks the cognitive ability to ask for pain medication. Intramuscular administration (IM) of analgesics is the least desirable route of administration. IM administration may cause additional pain and the client likely lacks the cognitive ability to ask for pain medication.

The nurse is caring for a client who had a percutaneous endoscopic gastrostomy tube inserted earlier in the day. The sutures are still in place. Which interventions should the nurse plan to perform? Select all that apply. Place a dressing between the skin and external bumper. Administer prescribed analgesics, as needed. Gently rotate the external bumper 90 degrees once during the shift. Measure the length of exposed tube and compare it with the length documented after insertion. Avoid placing tension on the feeding tube. Gently clean around the insertion site using a cotton-tipped applicator dipped in sterile saline.

Avoid placing tension on the feeding tube., Gently clean around the insertion site using a cotton-tipped applicator dipped in sterile saline., Administer prescribed analgesics, as needed., Measure the length of exposed tube and compare it with the length documented after insertion. Rationale:Feeding tubes can be uncomfortable, especially the first few days after insertion. Analgesic medication may permit the client to tolerate the insertion site care more easily. Cleansing the new site with sterile saline solution helps prevent infection. Measuring the tube assures that the tube has not migrated. Avoiding placing tension on the tube helps prevent skin breakdown. Rotating the external bumper 90 degrees should be done after sutures have been removed. A dressing should be used only if drainage is present; otherwise, it should be left open to the air.

When assessing a client, the nurse may identify which physiologic response to pain? Moving away from the painful stimuli. Moaning and crying. Muscle tension and rigidity. Protecting the painful area.

Muscle tension and rigidity. Rationale:Physiologic responses to pain are involuntary responses, such as increased blood pressure, and muscle tension and rigidity. The other examples are behavioral or voluntary responses.

The nurse prepares the sterile tray for indwelling catheter insertion while wearing sterile gloves. The nurse then pulls the client's blankets away from the pelvis to begin catheter insertion. What action should the nurse take next? Position the catheter kit closer to the client. Dispose of the catheter kit and begin again. Change into a new pair of sterile gloves. Begin cleansing the meatus with antiseptic.

Change into a new pair of sterile gloves. Rationale:The client must be prepared prior to preparing the catheter kit. The nurse must wear sterile gloves while preparing the sterile tray, because it involves opening sterile supplies. If the nurse then touches a non-sterile surface, like the client's blankets, the sterile gloves must be changed prior to continuing the procedure. The nurse does not need to reposition the kit at this time. The nurse is no longer sterile and cannot proceed with cleaning the client with sterile solution. Only the nurse's gloves are contaminated; the nurse does not need to dispose of the kit.

The nurse is flushing the implanted port of a client's central venous access device (CVAD) and meets resistance. What should the nurse do next? Ask the client to perform a Valsalva maneuver and place the client's arm below the heart. Change the position of the client and lower the head of the bed. Notify the health care provider immediately. Check that the clamp is open, gently push down on needle, and attempt to flush again.

Check that the clamp is open, gently push down on needle, and attempt to flush again. Rational: The nurse should first check the clamp to ensure that it is open, and then gently push down on the needle and attempt to flush again. If this does not work, the nurse could ask the client to perform a Valsalva maneuver, change the position, or place the affected arm over the head. The nurse could also lower or raise the head of the bed. If the port still does not flush, the needle should be removed and a new needle inserted. If the port does not flush this time, the health care provider should be notified.

The nurse is preparing to administer medication to a client using a piggyback IV infusion. The client is receiving a continuous IV infusion of dextrose 5% and water (D5W). Which would be most important for the nurse to do before administering the medication? Readjust the flow rate of the continuous infusion. Ask the pharmacy about the medication's adverse effects. Put on sterile gloves to set up the piggyback infusion. Check the compatibility of the medication with the IV solution.

Check the compatibility of the medication with the IV solution. Rationale: When administering a piggyback IV medication, it is imperative that the nurse check to make sure that the prescribed medication is compatible with the continuous infusion to prevent the risk of injury. There is no need to readjust the flow rate of the continuous infusion. Rather the nurse would ensure that the piggyback medication is infusing at the correct rate. The nurse should be knowledgeable about the medication to be administered and any potential adverse effects. The nurse would typically consult a drug reference. If additional information is needed, the nurse could check with the pharmacy. Clean, disposable gloves, not sterile gloves, are used.

After hanging an antibiotic via secondary tubing, the nurse notes that the antibiotic is not infusing. What actions will the nurse take to troubleshoot this problem? Select all that apply. Assist the client to a supine position. Assess the IV insertion site. Check for any kinks in the tubing. Ensure the roller clamp is open. Check the connections and ensure they are secure.

Check the connections and ensure they are secure., Ensure the roller clamp is open., Check for any kinks in the tubing., Assess the IV insertion site. Rationale: To troubleshoot when an IV is not infusing, the nurse should check the tubing for any kinks that may be impeding flow, ensure the client is not lying on the tubing, check any connections to ensure they are secure, ensure the roller clamp is in open position, and assess the IV insertion site for any complications. The client's position will not affect the infusion.

The nurse is required to give a prescribed medication via a gastric tube. The medication is available in tablet form. What should the nurse do first? Check the drug administration guide to see if the medication can be crushed. Split the tablet into two halves for administration. Mix the crushed tablet with a small amount of normal saline. Use the tablet "as is," making sure to flush the tube after administration.

Check the drug administration guide to see if the medication can be crushed. Rationale:When giving medications via a gastric tube, the medication should be in liquid form to prevent the tube from clogging. The nurse would first check the drug reference guide to see if the tablet can be crushed. If it can, the nurse would then crush the tablet and mix it with 15 to 30 mL of water or the recommended liquid. Splitting the tablet in half or using it "as is" would be inappropriate because the tablet would still be in solid form.

The nurse is preparing to administer medications to a client with a gastric tube. What is the best way to determine which medications can be crushed? Check the drug guide. Call the manufacturer. Ask another nurse. Call the health care provider

Check the drug guide. Rationale:Certain solid dosage medications can be crushed and combined with liquid, but the nurse must check the drug guide first before administering to a client with a gastric tube. Calling the health care provider is unnecessary because the prescription has already been given. Asking another nurse or calling the manufacturer of the medication can provide this information, but these methods are not as accurate as checking the drug guide.

The client with a gastric tube is prescribed a delayed-release tablet. Which are appropriate actions for the nurse? Select all that apply. Call the health care provider for prescription. Crush the timed-release medication. Check the drug guide. Split the medication. Hold the medication

Check the drug guide., Call the health care provider for prescription., Hold the medication. Rationale:If a medication has a delayed-release response, it cannot be crushed or split. The medication is intended to have a delayed response and crushing it would not produce this effect; it would have an immediate effect instead. Holding the medication and calling the health care provider for additional prescription are also appropriate actions, as well as checking the drug guide to verify if the medication can be crushed or split.

A client has a peripheral access IV infusion running via an electronic infusion device. While monitoring the infusion, the nurse notices that the electronic infusion device is not running. What should the nurse do? Check the IV connector to ensure the clamp is closed. Lower the height of the pole. Check the electronic device for proper functioning. Attempt to flush the IV with 5 to 10 mL saline in a syringe.

Check the electronic device for proper functioning. Rationale:If the electronic infusion is not running, the nurse would check the electronic device for proper functioning, make sure the flow clamp is open and that the drip chamber is approximately half full, and check the IV site for problems with the catheter. If the IV is free flowing, the nurse would raise the height of the IV pole. The nurse could also attempt to flush the IV with 1 to 3 mL of saline in a syringe.

The nurse is monitoring an IV site for a client who reports that the needle feels "funny." What should the nurse do first? Reassure the client that this is a normal feeling associated with an IV infusion. Check the integrity of the IV system, IV solution and tubing, and flow rate. Remove the catheter and apply a gauze dressing. Discontinue the IV infusion and notify the health care provider.

Check the integrity of the IV system, IV solution and tubing, and flow rate. Rationale:The nurse would first check the integrity of the IV system, IV solution and tubing, and validate the correct drip rate. Next, the nurse would assess the venous access for redness, edema, warmth, coolness, pallor, and pain. If any of these are present, the nurse would discontinue the IV, initiate a new venous access in a different site, and notify the health care provider.

Following completion of a piggyback infusion by gravity, what extra step must the nurse perform with the gravity setup after replacing the primary IV fluid container to the original height? Check the client's ID band and ask about any allergies. Rehang the piggyback tubing on the IV pole to finish the infusion. Check the primary infusion rate and adjust as needed. Readjust the flow rate of the piggyback infusion.

Check the primary infusion rate and adjust as needed. Rationale: After replacing the primary IV fluid container to its original height, the nurse should check the primary infusion rate and adjust as needed to the prescribed flow rate. The piggyback tubing should be disposed of according to facility policy or detached from the primary tubing and recapped using sterile technique for future use. There would be no need to readjust the flow rate of the piggyback infusion or to rehang the piggyback to finish the infusion as it has completed. Checking the client's ID band and asking about allergies should be done before any medications are given, administered, or hung.

The nurse is administering an intermittent tube feeding using a gravity set-up and open feeding bag system. After checking tube placement, which action would the nurse take next? Check the residual (the amount of feeding left in the stomach from the last feeding). Attach the feeding set-up to the feeding tube. Open the roller clamp and run formula through tubing to purge the air. Flush the tube with sterile water for irrigation.

Check the residual (the amount of feeding left in the stomach from the last feeding). Rationale:After checking for tube placement, the nurse would check for the residual and then flush the tube with 30 mL of sterile water. If the residual amount does not exceed agency policy or the limit indicated in the medical record, then the nurse would proceed with the feeding.

After setting up a piggyback IV infusion of antibiotics for a client, the nurse notices that the solution is not infusing. Which should the nurse do first? Adjust the roller clamp. Adjust the infusion rate if necessary. Notify the health care provider. Check the tubing for kinks and pressure points.

Check the tubing for kinks and pressure points. Rationale: The nurse would first check the tubing for kinks, blockages, and pressure points. The nurse would then adjust the roller clamp and the infusion rate, if necessary. The health care provider would not be notified in this situation.

The nurse is following the protocol for irrigating a client's nasogastric (NG) tube. Before attaching the syringe to irrigate the tube, which action would be most important for the nurse to do? Clear the air vent. Have the client lie flat. Clamp the tube. Check tube placement.

Check tube placement. Rationale:The nurse needs to check tube placement before instilling any solution into the NG tube to prevent possible aspiration. The tube is clamped intermittently throughout the procedure to prevent air from entering the system. However, if the tube was clamped for irrigating, the tube could not be irrigated. There is no need to clear the air vent. The client should be in an upright position to discourage aspiration if any reflux or vomiting should occur.

After accessing the implanted port of a client's central venous access device (CVAD), what action does the nurse take to prevent air embolism? Clamp the extension tubing Start the intravenous infusion Flush the extension tubing with normal saline Flush the extension tubing with heparin

Clamp the extension tubing Rationale: The nurse removes the syringe and clamps the extension tubing to prevent air from entering the CVAD, which may cause an air embolism. The tubing is flushed with normal saline prior to this step. Flushing the line with heparin helps to prevent clotting and ensures patency of the line. A heparin flush is not used if an IV fluid infusion is running; however, starting the infusion will not prevent an air embolism.

The health care provider prescribes digital removal of stool for a client with liver cirrhosis. The nurse notes that the client is on precautions for a low platelet count. What action does the nurse take? Discuss the situation with the client and family. Administer a large dose of stool softener orally. Document that the procedure cannot be performed. Clarify the request with the health care provider.

Clarify the request with the health care provider. Rationale: The nurse clarifies this request with the health care provider. The provider may determine that the removal of stool represents more benefit than risk to the client. The nurse does not discuss this with the client and family currently. The provider might initially prescribe stool softeners and laxatives to cause the stool to more easily removed, but this cannot always take the place of manual stool manipulation. The nurse would not document that the procedure cannot be performed. The nurse takes a professional course of action by collaborating with the health care provider to ensure good care for the client with thrombocytopenia

After mixing medication with the solution in the volume control chamber, what would be the nurse's next step? Clean the injection port on the primary IV infusion tubing closest to the client with an antimicrobial swab. Use an alcohol swab to clean the injection port on the primary IV infusion tubing furthest away from the client. Insert the tubing into the administration chamber. Connect the tubing to the injection port.

Clean the injection port on the primary IV infusion tubing closest to the client with an antimicrobial swab. Rationale: After mixing the medication with the solution in a volume control chamber, the nurse would use an antimicrobial swab to clean the injection port on the primary IV infusion tubing closest to the client. This deters the entry of microorganisms into the chamber.

The emergency room nurse is caring for a client reporting severe right lower quadrant pain that had started as milder pain near the umbilicus. Vital signs include a fever of 38.6°C (101.5°F), pulse 92 bpm, respirations 24 breath/min, and blood pressure 136/80 mm Hg. What should the nurse do next? Select all that apply. Keep the client NPO Administer a tap water enema Give an antiemetic Cleanse the abdomen with chlorhexidine Begin an OR checklist

Cleanse the abdomen with chlorhexidine, Keep the client NPO, Begin an OR checklist Rationale:The nurse would suspect acute appendicitis due to the pain location and vital signs. Thus, the client wound need to remain NPO and be immediately prepared for surgery, which includes applying the chlorhexidine cleanser to the abdomen and beginning an OR checklist. There is no need for a tap water enema or an antiemetic, because nausea or constipation are not mentioned in the assessment findings.

A client is receiving an intermittent piggyback IV infusion of medication. Once the solution in the piggyback container is infused, what is the nurse's next step? Close the clamp on the primary infusion tubing and piggyback set and remove both sets. Close the clamp on the piggyback tubing and leave it on the pole. Close the clamp on the primary infusion tubing and dispose of following facility policy. Unclamp the tubing on the primary infusion set and remove the piggyback set.

Close the clamp on the primary infusion tubing and dispose of following facility policy. Rationale: Once the solution in a piggyback container is infused, the nurse should close the clamp on the piggyback tubing and follow facility policy regarding the disposal of the equipment. The nurse should then replace the primary IV fluid container to the original height, if it had been lowered for the piggyback infusion.

When preparing to backprime by gravity, what will the nurse do first? Close the roller clamp on the tubing. Spike the new bag. Fill the drip chamber halfway full. Hang the spiked bag on the IV pole.

Close the roller clamp on the tubing. Rationale: To prevent accidental waste of the medication in the bag, the nurse should first close the roller clamp on the tubing. Once the clamp is closed, it is then safe to spike the new bag, hang it on the IV pole, and squeeze the drip chamber to fill it halfway. By keeping the roller clamp closed until the drip chamber is half full, the nurse prevents air from getting into the tubing. Once the drip chamber is half full, the nurse opens the roller clamp and allows the fluid to prime the remainder of the tubing.

The nurse returns to a client's room after the infusion of IV pain medication via a volume control administration set has been completed. Which sequence would the nurse now perform? Recheck the flow rate of the primary infusion, close the roller clamp, turn off the pump, remove the volume control device and recap it. Close the roller clamp, turn off the pump, remove the volume control device, recap it, and recheck the flow rate of the primary infusion. Open the roller clamp, remove the volume control device, and recheck the flow rate of the primary infusion. Remove the volume control device, recap it, close the roller clamp, and recheck the flow rate of the primary infusion.

Close the roller clamp, turn off the pump, remove the volume control device, recap it, and recheck the flow rate of the primary infusion. Rationale: When removing the equipment following an infusion via a volume control administration set, the nurse would close the roller clamp, turn off the pump, remove the volume control device, recap it, and recheck the flow rate of the primary infusion. The roller clamp is closed to prevent IV leakage. The flow rate of the primary infusion is rechecked at the end in case it was disturbed during removal of the equipment.

The nurse is preparing to administer an intermittent feeding to a client who has a feeding tube. The nurse is unable to aspirate gastric contents and realizes that the tube is clogged. Which action is correct? Insert a stylet until resistance is felt, and then gently rotate the stylet until resistance decreases. Mix meat tenderizer with 30 mL of warm water, instill the mixture into the feeding tube, wait 15 minutes, and then flush vigorously. Connect a syringe filled with warm water to the feeding tube and flush it out using gentle pressure. Advance the tube no more than 4 in (10 cm), auscultate for bowel sounds, and then attempt to aspirate again.

Connect a syringe filled with warm water to the feeding tube and flush it out using gentle pressure. Rationale:Most obstructions are caused by coagulation of formula. The nurse should try using warm water and gentle pressure to remove the clog. Carbonated sodas, such as Coca-Cola, and meat tenderizers have not been shown effective in removing clogs in feeding tubes. Never use a stylet to unclog tubes. Advancing the tube is not needed, as this will not address the clog.

The nurse has completed irrigation of a nasogastric tube connected to suction. Which step would the nurse perform following the injection of irrigation solution into a client's nasogastric tube? Check the placement of the tube by aspirating gastric contents. Inject 30 mL of sterile water into the tube. Connect the unclamped NG tube back to the suction unit. Aspirate half the used amount of irrigation solution back into the syringe

Connect the unclamped NG tube back to the suction unit. Rationale:Following the administration of the irrigation solution into a client's NG tube, the nurse would either connect the NG tube back to the suction unit and unclamp it to withdraw fluid, or aspirate an equal amount of fluid back into the syringe. Alternatively, the nurse can hold the end of the NG tube over an irrigation tray or emesis basin and observe for the return flow of NG drainage.

The nurse is preparing to administer medications to a client with a gastric tube. What equipment will the nurse gather to administer medications to the client? Select all that apply. Waterproof pad Irrigation set Pill cutter Gloves Tap water

Gloves, Waterproof pad, Tap water, Irrigation set Rationale:To administer medications the equipment needed includes gloves, waterproof pad, irrigation set, and tap water. A pill cutter is not needed to administer medications to a client with a gastric tube.

The nurse is preparing to reuse an intermittent administration set for administering a medication intravenous piggyback. The label on the tubing indicates that it was hung 12 hours ago. What action should the nurse take next? Complete an incident report about the old tubing. Continue with preparing to hang the medication. Obtain a new intermittent administration set. Report the finding to the unit charge nurse

Continue with preparing to hang the medication. Rationale: The nurse should continue with preparing to hang the medication. Intermittent administration sets can be used for 24 hours. Intermittent administration sets disconnected after use should be replaced every 24 hours to prevent complications, especially infections. Because the tubing label indicates it is still well within the 24-hour time frame there is no need for the nurse to obtain a new set, complete an incident report, or to report this to the charge nurse.

The nurse is attaching a label to a client's volume control administration set. Which client information should be printed on the label? Medication dosage. Client emergency contact. Medication expiration date. Client insurance carrier.

Medication dosage. Rationale: The volume control device label would include the client's name, identification number, medication name, medication dose, name and volume of the solution for dilution, and the date and time of administration.

The nurse is assessing a cancer client's pain. The client is unable to point to a specific area of pain; rather, the client moves a hand over the abdomen to indicate the pain. What type of pain is this client experiencing? Diffuse Dull Sharp Shifting

Diffuse Rationale:Diffuse pain covers a large area and cannot be localized. Sharp pain is sticking and intense. Dull pain is not as acute as sharp pain, and shifting pain moves from one area to another.

Digital removal of stool is considered a last resort after other unsuccessful methods of bowel evacuation have been performed. Which is the correct rationale for this statement? The procedure often causes rebound diarrhea and electrolyte loss. Most clients will not consent to have digital removal of stool. Digital removal of stool may cause parasympathetic stimulation. Nurses find the procedure distasteful and difficult to perform

Digital removal of stool may cause parasympathetic stimulation. Rationale:Digital removal of stool may stimulate a vagal response, which increases parasympathetic stimulation, and thus should be avoided. Whether the nurse finds the procedure distasteful or difficult is not a valid rationale for not performing it. It is not true that most clients will not consent to have digital removal of stool. Administering more than three cleansing enemas, not digital removal of stool, may result in fluid and electrolyte imbalances

While receiving a medication IV piggyback, the client reports discomfort at the IV site. Upon assessment, the site is cool to the touch and slightly swollen. What is the best action by the nurse? Monitor the site closely for any signs of complications. Apply a cool moist compress for 20 minutes. Slow the rate of infusion until client reports relief. Discontinue the IV site and restart IV in a new location.

Discontinue the IV site and restart IV in a new location. Rationale: The assessment reveals the IV has infiltrated. The nurse should stop the IV fluid and remove the IV from the extremity, then restart the IV in a different location. Applying a cool moist compress or slowing the rate will not address the problem of the IV fluid going into the surrounding tissue instead of the vein. Monitoring the site is not appropriate, because there is already a complication present that requires action by the nurse.

The nurse is assuming care for a client who is receiving an infusion of packed red blood cells (PRBCs). The PRBCs were hung 4 hours ago, and 100 mL is left to infuse. Which action is most appropriate? Discontinue the infusion and record the volume left in the blood bag. Fully open the roller clamp on the infusion set and infuse the remaining PRBCs as rapidly as possible. Continue to infuse the PRBCs until they are completely infused. Insert a larger gauge IV catheter and transfer the infusion to the new insertion site.

Discontinue the infusion and record the volume left in the blood bag. Rationale:Transfusions must be completed within 4 hours due to the potential for bacterial growth in a blood product at room temperature.

The health care provider has written a prescription for a client's nasogastric (NG) tube to be removed. Which would the nurse do first? Discontinue the suction. Remove the tube from the client gown. Separate the NG tube from the suction tubing. Take off the adhesive tape from the client's nose.

Discontinue the suction. Rationale:The prescription in which the nurse performs the above steps for removing an NG tube are as follows: discontinue the suction, remove the tube from the client gown, take off the adhesive tape from client's nose, and separate the NG tube from the suction tubing.

The nurse is caring for a client who has a Penrose drain. On assessment, the nurse notes that there is a safety pin on the drain just outside the wound incision area. What action should the nurse take related to this finding? Notify the health care provider of the finding at the incision site. Obtain a wound culture to test for possible infection. Remove the safety pin and clean with an antiseptic preparation. Document the presence and location of the safety pin.

Document the presence and location of the safety pin. Rationale:The nurse should document the presence and location of the safety pin, because this is an expected finding. Many times, the surgeon will use a large safety pin inserted into the Penrose drain just outside of the wound to hold the drain in place and prevent it from slipping into the wound. Because this is an expected finding, the other options would not be correct actions to take.

In what position would the nurse hold the syringe when instilling irrigation solution into the nasogastric (NG) tube? Upward at a 30-degree angle. Upward at a 90-degree angle. Downward at a 30-degree angle. Downward at a 90-degree angle.

Downward at a 90-degree angle. Rationale:After drawing up the irrigation in the syringe, the nurse would hold the syringe upright (90-degree angle) and downward. This allows for a natural flow of the irrigation solution into the NG tube.

The nurse needs to place gauze from a wrapped item into the sterile field. Which action does the nurse take? Remove the gauze from the package with one sterile hand. Drop the item from 6 in (15 cm) above the sterile field. Lay the item in an open package on the 1-in (2.5-cm) border. Extend the sterile field by laying the open package beside it.

Drop the item from 6 in (15 cm) above the sterile field. Rationale: Dropping the item from roughly 6 in (15 cm) above the surface prevents contamination of the field or dropping the item too close to the 1-in (2.5-cm), nonsterile border. Removing the gauze with one sterile hand risks contamination of that hand. It does not extend the sterile field to lay an unsterile package to the outside of the 1-in (2.5-cm) border.

The nurse is flushing a client's peripherally inserted central catheter (PICC) to maintain patency, because it is being used intermittently. After flushing with normal saline, which action should the nurse perform next? Attempt a blood return. Flush the line with heparin. Document the procedure. Restart the infusion.

Flush the line with heparin. Rationale:After flushing the PICC with saline, the nurse should flush the line with heparin to maintain patency. Because the PICC is being used intermittently, the infusion is not restarted. The nurse attempts a blood return prior to flushing the PICC. Documentation should occur following the procedure.

Before administering an IV medication through a drug-infusion lock, the nurse fails to get a blood return upon aspiration. Which is a sign that infiltration has occurred at the site? Bruising Edema Fever Chills

Edema Rationale: When assessing a drug-infusion lock IV site, the nurse looks for the following signs of infiltration: edema, swelling, pain, coolness, or fluid leaking from the site. Fever and chills is a sign of infection. Bruising may be present but does not indicate that infiltration has occurred.

When administering a continuous tube feeding using a feeding pump and closed tube feeding system, the nurse plans to check for residual at which frequency? Every 2 to 4 hours. Every 1 to 2 hours. Every 4 to 6 hours. Every 6 to 8 hours.

Every 4 to 6 hours. Rationale:When administering a continuous tube feeding, the nurse would check for residual every 4 to 6 hours.

A nurse is caring for a client recovering from abdominal surgery who is experiencing paralytic ileus. The client has a nasogastric tube connected to suction. How often should the nurse irrigate this tube? Every 1 to 2 hours Every 8 to 10 hours Every 4 to 8 hours Nasogastric tubes should not be irrigated.

Every 4 to 8 hours Rationale:The tube must be kept free from obstruction or clogging and is usually irrigated every 4 to 8 hours.

The nurse is assessing a client following the administration of an antibiotic via the client's drug-infusion lock. How often would the nurse check the drug-infusion lock site? Every four hours. Every six hours. Every eight hours. Every two hours

Every eight hours. Rationale: To ensure patency of the system, the nurse would check the medication lock site at least every eight hours or according to facility policy.

The nurse is caring for a client receiving patient-controlled analgesia. How often would the nurse assess the client? Every two hours. Every six hours. Every shift. Every four hours

Every four hours. Rationale:The nurse would assess a client receiving patient-controlled analgesia at least every four hours, or more often, as needed. The nurse would monitor the client's vital signs at least every four hours.

A nurse learns that a client will be receiving analgesia via a patient-controlled transdermal system (PCTS). Which opioid analgesic can be administered through iontophoresis via PCTS? Fentanyl Oxycodone Codeine Morphine

Fentanyl Rationale:The device is preprogrammed to deliver a fixed 40-µg dose of fentanyl when the client pushes the device button.

The nurse is attaching the infusion tubing to the medication container when administering a piggyback IV infusion of medication. What motion would the nurse use when inserting the tubing spike into the port? Firm pushing and twisting motion. Gentle pushing motion. Gentle twisting motion. Firm pulling and twisting motion.

Firm pushing and twisting motion. Rationale: When administering a piggyback infusion, the nurse would attach the infusion tubing to the medication container by inserting the tubing spike into the port with a firm pushing and twisting motion, taking care to avoid contaminating either end.

The nurse is administering an intermittent tube feeding to a client via gravity using an open feeding bag system. What step would the nurse perform when the feeding bag is empty? Remove the bag and tubing and discard. Assess the abdomen for bowel sounds. Flush the feeding bag with 30 mL water. Aspirate the gastric contents.

Flush the feeding bag with 30 mL water. Rationale:When the feeding bag is empty, the nurse would flush the feeding bag with 30 mL water to flush out the bag itself and the feeding tube at the same time. The nurse would then clamp the tubing when the water is instilled.

The nurse meets resistance when irrigating a nasogastric tube. What action does the nurse take? Attach the tubing to suction. Instruct the client to cough deeply. Flush with a small amount of air. Attempt to irrigate more forcefully.

Flush with a small amount of air. Rationale:Flushing the tube with air will push the end of the tube away from the gastric wall, enabling flushing. Attaching the tubing to suction will not help this client. It is never wise to flush any tubing after meeting resistance; troubleshooting the tubing or catheter is done when resistance is met. Though coughing increases intrathoracic pressure, it will not likely dislodge the nasogastric tube to allow for irrigation and proper suction, if needed.

A nurse is caring for a client with a central venous access device (CVAD) whose implanted port will not be used for a long period of time. What action will the nurse take to maintain patency of the port? Flush with heparin solution Place a sterile dressing over the port Apply firm pressure after deaccessing the port Flush with normal saline solution

Flush with heparin solution Rationale:Implanted ports should be "locked" with a heparin solution (100 U/mL) before removal of an access needle and/or for periodic access and flushing to prevent clotting and maintain patency. Flushing with a saline solution is done to remove substances from the well of the port. Gentle pressure should be applied after removing the needle to prevent bleeding and a small adhesive bandage may be applied if oozing continues. Otherwise a dressing is not necessary.

Which action is important for the nurse to take prior to deaccessing the implanted port of a central venous access device (CVAD) to remove all substances from the port? Scrubbing the needleless connector with an antimicrobial swab Flushing the port with heparin solution Clamping the extension tubing Flushing the port with normal saline

Flushing the port with normal saline Rationale:Prior to deaccessing the implanted port, the nurse would flush the port with normal saline solution to remove all substances from the port because it may be inactive for a period of time. Flushing the port with heparin solution helps prevent clotting and maintains patency. Scrubbing the needleless connector with an antimicrobial swab reduces infection. Clamping the extension tubing reduces air embolism.

After emptying the drainage from a Jackson-Pratt drain, how will the nurse re-establish suction to the drain? Reapply the cap and fully compress the bulb. Turn the suction back on at the wall unit. This type of drain does not use suction. Fully compress the bulb and reapply the cap.

Fully compress the bulb and reapply the cap. Rationale:To re-establish suction after emptying a Jackson-Pratt drain, the nurse should fully compress the bulb and then reapply the cap. Applying the cap before compressing the bulb will not allow the air to escape and, therefore, no suction can be applied. Wall suction is not used with the Jackson-Pratt drain.

Following the removal of a nasogastric NG tube, the nurse should monitor the client for which possible adverse reaction? Elevated blood pressure. Gastric distention. Decreased fluid output. Fluid and electrolyte imbalance.

Gastric distention. Rationale:Following the removal of an NG tube, the nurse would monitor for gastric distention and nausea and vomiting. If the client's abdomen is showing signs of distention, the nurse should notify the health care provider who may prescribe the nurse to replace the NG tube.

When a nurse meets resistance while irrigating a nasogastric tube, the nurse should assess the client for which sign/symptom? Vital signs. Gastric fullness. Respiratory rate. Cyanosis.

Gastric fullness. Rationale:Following resistance upon tube irrigation, the nurse would assess the client for nausea, vomiting, gastric fullness, and stomach distention. If the client is showing these signs, the health care provider should be notified.

The nurse removes the medication syringe from the port and inserts the syringe of normal saline into the port. Why should the nurse gently flush with the saline? Gently flushing ensures that fluid is not pushed too quickly into the injection site. Gentle flushing ensures that saline is not forced out of the tubing and wasted. Gently flushing ensures that the medicine remaining in the extension tubing is not administered faster than the rest of the medication. Gentle flushing ensures that the IV is administered safely.

Gently flushing ensures that the medicine remaining in the extension tubing is not administered faster than the rest of the medication. Rationale: The nurse would push the syringe plunger slowly so that the medicine remaining in the extension tubing is not administered faster than the rest of the medication. IV medications must be infused at their specific recommended rate, otherwise complications could occur.

The nurse, assessing a client for pain, looks for behavioral responses to the pain. Which is an example of a behavioral response? Anxiety Depression Grimacing Fear

Grimacing Rationale:Facial grimaces are a behavioral response to pain. Anxiety, fear, and depression are affective responses to pain.

An older adult woman has been in the hospital for more than 1 week. While assessing her intravenous catheter port, the nurse finds a staph infection, which has developed in the past day or so. This infection is an example of which type of infection? Health care-associated infection Sexually transmitted infection Droplet infection Respiratory infection

Health care-associated infection Rationale:This infection is best described as a health care-associated infection. A health care-associated infection is an infection not present on admission to health care agency and that has been acquired during the course of treatment for other conditions. The other terms listed do not apply to this infection.

A nurse is assessing a client who has recently had bowel surgery and will be receiving a nasogastric tube. Which finding would most likely contraindicate placement of a nasogastric (NG) tube by the nurse in this client? Abdominal distention Bleeding in the gastrointestinal tract History of facial fractures One nare being less patent than the other

History of facial fractures Rationale:Clients with facial fractures or facial surgeries present a higher risk for misplacement of the tube into the brain. Many institutions require a health care provider to place NG tubes in these clients, which would contraindicate the nurse placing the tube. The nurse should assess the patency of the client's nares by asking the client to occlude one nostril and breathe normally through the other. However, the nurse does this to select the nostril through which air passes more easily, not because one nare being less patent than the other is a contraindication for NG tube placement by the nurse. Abdominal distention does not contraindicate NG tube placement. Monitoring bleeding in the gastrointestinal (GI) tract is one of the indications for NG tube placement, so bleeding in the GI tract is not a contraindication.

The nurse, removing a nasogastric (NG) tube from a client, flushes the NG tube prior to removing it. Which would be most appropriate for the nurse to do? Flush the tube with 50 to 75 mL sterile water. Flush the tube with irrigation solution. Instill 30 to 50 mL of air to clear the tube. Instill 15 to 30 mL of air to clear the tube

Instill 30 to 50 mL of air to clear the tube. Rationale:When flushing the NG tube prior to removal, the nurse would either flush the tube with 10 mL of water or normal saline solution or instill 30 to 50 mL of air to clear the tube. The nurse would also check the facility's policy.

The nurse is caring for a client receiving IV medication. Which would be the appropriate action when the piggyback infusion does not infuse? Make sure the piggyback infusion bag is lower than the primary infusion bag. Make sure the connections are tight and the clamps are closed. If the IV is in the wrist or antecubital fossa, make sure the elbow or wrist is bent. If the IV is in the arm, make sure the arm is not raised above heart level.

If the IV is in the arm, make sure the arm is not raised above heart level. Rationale: If the piggyback IV infusion does not infuse, the nurse would make sure the connections are tight and the clamps are open and make sure the piggyback infusion bag is higher than the primary infusion bag. If the IV is in the wrist or antecubital fossa, the nurse would make sure the elbow or wrist is not bent for too long. If the IV is in the arm, the nurse would make sure that the arm is not raised above heart level.

The nurse is administering an IV medication to a client via a volume control administration set. When would the nurse regulate the calculated rate? After attaching the label to the volume control device. Immediately after agitating the volume control chamber to mix the medications. Immediately after inserting the tubing into the injection port. Immediately after opening the roller clamp on the volume control device tubing.

Immediately after opening the roller clamp on the volume control device tubing. Rationale: The order in which the nurse would perform the above actions is: (1) agitate the volume control chamber to mix the medications, (2) insert the tubing into the injection port, (3) open the roller clamp on the volume control device tubing, (4) regulate the calculated drip rate, and (5) attach the label to the volume control device.

Which nursing interventions may be used for a client with a fecal impaction prior to digital removal of stool? Select all that apply. Administer oil and cleansing enemas. Include 30 grams of fiber in the diet. Ensure adequate hydration. Increase level of activity. Adjust medications to reduce the chance of constipation.

Include 30 grams of fiber in the diet., Adjust medications to reduce the chance of constipation., Administer oil and cleansing enemas., Ensure adequate hydration. Rationale:Before digital removal of feces is considered, dietary interventions, adequate fluids, and medication adjustment should be included in the client's plan of care. If a client with a fecal impaction cannot expel the fecal mass voluntarily and oil and cleansing enemas fail to break up the mass, the impaction may need to be removed manually. Increasing the level of activity might have prevented constipation and impaction, but it will not relieve the client with an impaction.

The nurse is preparing to irrigate the client's nasogastric (NG) tube. Which statement accurately describes the proper method of injecting irrigation solution into an NG tube? Inject half the solution, wait five minutes and inject the other half. Inject the solution quickly and forcefully. Inject the solution intermittently at three-minute intervals. Inject the solution slowly with gentle force.

Inject the solution slowly with gentle force. Rationale:When irrigating a nasogastric tube, the nurse should inject the solution slowly with gentle force, unless policy dictates that a gravity flow be used. Slowly injected solution clears the tube of secretions, feeding, or debris.

The nurse cares for a client with a gastric tube in place. Which actions does the nurse perform? Select all that apply. Set the pump to deliver total parenteral nutrition (TPN) continuously at a low rate. Insert a large syringe to decompress the stomach when the client reports nausea. Administer one can of nutritional formula every 4 hours as prescribed. Deliver a dose of regular insulin through the tube with each meal time feeding. Give liquid stool softener and crushed pain medication through the tube as needed.

Insert a large syringe to decompress the stomach when the client reports nausea., Administer one can of nutritional formula every 4 hours as prescribed., Give liquid stool softener and crushed pain medication through the tube as needed. Rationale:The gastric tube is used to remove stomach or intestinal secretions (decompression), deliver formula feedings to meet nutritional needs, and deliver liquid, powder, or crushed medications. The gastric tube is not used to deliver subcutaneous injections or intravenous fluids. The nurse is correct to use a syringe to decompress the stomach for reports of nausea; this action can prevent vomiting. The nurse administers liquid and crushable medications through the tube in addition to any enteral feeding prescribed. Regular insulin cannot be administered orally or gastrically; it is only subcutaneous and intravenous. Parenteral nutrition is intravenously delivered through an infusion pump into a central IV access.

The nurse is caring for a client who has an implanted port central venous access device (CVAD) and needs to have an intravenous (IV) solution infused. The nurse has appropriately prepared the solution, the infusion set, and the port site. Just before inserting the access needle, the nurse notes that it is bent at an angle. Which action is correct? Obtain a new access needle and report the flawed needle to the facility's risk manager. Insert the needle through the skin into the center of the infusion port and begin the infusion. Insert the needle through the skin close to the edge of the port, and then use the rigid port side to brace the needle while straightening it. Using sterile forceps, gently straighten the needle, and then insert it into the center of the infusion port.

Insert the needle through the skin into the center of the infusion port and begin the infusion. Rationale: Implanted port CVADs are accessed with a specially-designed, angled needle; the nurse should not attempt to straighten it or replace it.

When irrigating a nasogastric tube, the nurse does not get a return after instilling irrigation solution and reconnecting the tube back to the suction unit. What would be the nurse's next step in this situation? Instill 20 mL of water into the tube and aspirate again. Instill 20 mL of air into the tube and aspirate again. Instill 30 mL of irrigation solution into the tube and aspirate again. Check the placement of the tube and repeat the procedure.

Instill 20 mL of air into the tube and aspirate again. Rationale:If the nurse does not get a return after instilling the irrigation solution and reconnecting the tube back to the suction unit, he or she should instill 10 to 20 mL of air into the tube to clear it and aspirate again.

The nurse is preparing to remove stool digitally for a client who is constipated. Which steps are included in this process? Select all that apply. Put on sterile gloves. Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. Generously lubricate index finger of dominant hand with water-soluble lubricant. Instruct client to bear down, if possible, while extracting feces to ease in removal. Insert gloved finger gently into anal canal, pointing toward the umbilicus.

Instruct client to bear down, if possible, while extracting feces to ease in removal., Generously lubricate index finger of dominant hand with water-soluble lubricant., Gently work the finger around and into the hardened mass to break it up and then remove pieces of it., Insert gloved finger gently into anal canal, pointing toward the umbilicus. Rationale:Steps in the process of digitally removing stool include: generously lubricating index finger of dominant hand with water-soluble lubricant, inserting gloved finger gently into anal canal, pointing toward the umbilicus, gently working the finger around and into the hardened mass to break it up and then remove pieces of it and instructing client to bear down, if possible, while extracting feces to ease in removal. It is not necessary to put on sterile gloves, because this is not a sterile procedure. Clean gloves are sufficient for this procedure, so use of sterile gloves is not indicated.

When assessing a client's pain, what characteristic of pain does the nurse assess using a pain rating scale? Location Quality Intensity Duration

Intensity Rationale:For clients who can self-report about their pain, the nurse uses a pain rating scale to assess the intensity of the pain. The intensity is the degree (amount) of pain experienced.

The nurse is caring for a client who just returned from the postanesthesia care unit and rates current pain as "9 out of 10." Which prescribed medications would provide the fastest relief from pain? Intravenous morphine sulfate Intramuscular ketorolac tromethamine Oral acetaminophen and oxycodone Oral acetaminophen with codeine

Intravenous morphine sulfate Rationale: Intravenous morphine sulfate would provide the fastest relief from pain because the intravenous route provides the most rapid onset. The other medications listed are either oral or intramuscular, and thus not as fast-acting.

The nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) pump. The nurse notes that the client's respiratory rate is 10 breaths per minute. The client is somnolent, with minimal response to physical stimulation. The nurse should prepare to administer which medication? Intravenous naloxone Nebulized albuterol Intravenous flumazenil Oral modafinil

Intravenous naloxone Rationale:The client is experiencing respiratory depression as a result of the morphine and thus should be given naloxone, which reverses the effects of opioid analgesics. Flumazenil is administered to reverse the effects of benzodiazepines. Modafinil enhances wakefulness but is not appropriate for this clinical situation. Also, oral medications should not be given to a client who is somnolent. Albuterol is a bronchodilator and not appropriate for this clinical situation

What are the advantages of using an IV pump to backprime secondary tubing? Select all that apply. It ensures the medication will infuse without any complications. It allows for easy priming when re-using a secondary tubing set. It ensures medication is not lost during priming of the tubing. It eliminates reliance on gravity to determine which bag flows. It keeps the system closed therefore less chance of contamination.

It allows for easy priming when re-using a secondary tubing set., It keeps the system closed therefore less chance of contamination., It ensures medication is not lost during priming of the tubing., It eliminates reliance on gravity to determine which bag flows. Rationale: The advantages of using an IV pump to backprime secondary tubing include: helping to ensure that medication is not lost or accidentally wasted during the priming process; it is a closed system, so it decreases the risk of contamination during the process; it allows for easy priming when re-using secondary tubing; and it eliminates the reliance on gravity to determine which bag will flow. It does not ensure the medication will infuse without complications as the tubing could still get kinked or there could be a problem with the IV site.

The nurse is caring for a client with a gastrostomy tube and notes a patchy, red rash at the insertion site. Which action would be most appropriate to address this concern? Apply a skin barrier to the insertion site. Notify the health care provider for a prescription to apply an antifungal powder. Apply gentle pressure to the tube while pressing the external bumper closer to the skin.

Notify the health care provider for a prescription to apply an antifungal powder. Rationale:If the skin has a patchy, red rash, the cause could be candidiasis (yeast). The nurse should notify the health care provider for a prescription to apply an antifungal powder. Applying gentle pressure to the tube while pressing the external bumper closer to the skin is performed when there is slack between the external bumper and the internal guard, resulting in leaking from the tube. An antibiotic would not be indicated for treating candidiasis. A skin barrier should be applied to protect the skin from irritation by the tube; however, this action would not address candidiasis, either.

Inspection of a client's peripheral venous access site reveals signs of phlebitis. Which action by the nurse would be most appropriate? Discontinue the IV and start it at another site. If phlebitis worsens, notify the health care provider. Keep the IV in place until the solution has been infused, and then discontinue it and notify the health care provider. Notify the health care provider, discontinue the IV, and start it at another site. Keep the IV in place, notify the health care provider, and start treatment for phlebitis.

Notify the health care provider, discontinue the IV, and start it at another site. Rationale:When the nurse suspects phlebitis due to the findings of redness, swelling, and heat, the health care provider should be notified. The IV will need to be discontinued and restarted at another site. The health care provider should be notified immediately, not just if the phlebitis worsens.

The nurse is not successful in attempting to irrigate a nasogastric tube. The nurse repositions the client and tries to flush the tube with air and water multiple times without success. What action does the nurse take next? Replace the nasogastric tube. Notify the health care provider. Remove the nasogastric tube. Document implemented interventions.

Notify the health care provider. Rationale:If the nasogastric tube is not working properly after correct nursing interventions are attempted, the health care provider is notified to discuss possible complications and further interventions. The nurse may end up removing and replacing the nasogastric tube, but this is not the next action. Documentation occurs after notifying the provider and includes all actions and outcomes of those actions.

The nurse is preparing to initiate an infusion of packed red blood cells (PRBCs). While observing the information on the blood bag, it is essential to verify which information with another nurse? Select all that apply. Number on the client's identification band Client's room number Name on the client's identification band Patency of the client's venous access device Client's vital signs

Number on the client's identification band, Name on the client's identification band Rationale:Two nurses must compare and validate the following information with the medical record, client identification band, and the blood product label: medical prescription for transfusion of blood product, informed consent, client identification number, client name, blood group and type, and expiration date. The client's vital signs and room number and the patency of the venous access device are not required to be validated by two nurses.

When monitoring the peripheral access IV sites of various clients receiving IV therapy, the nurse would assess closely for which finding as the most common complication related to IV therapy? Thrombus Sepsis Phlebitis Infection

Phlebitis Rationale:The most common complication related to IV therapy is phlebitis. Chemical irritation or mechanical trauma can cause injury to the vein and lead to phlebitis. Infection, thrombus, and sepsis manifest as redness, pus, warmth, induration, and pain similar to phlebitis and may be caused by poor aseptic technique.

The nurse is assessing a client's pain and asks the client, "What words would you use to describe your pain?" What characteristic of pain is the nurse assessing with this question? Duration Location Quality Intensity

Quality Rationale:The nurse assesses the quality of pain by asking the client to describe it. The location of pain is assessed by asking the client where the pain is being experienced. Duration refers to how long the client has been experiencing the pain. The pain intensity is assessed with a pain rating scale.

Which are basic principles of surgical asepsis? Select all that apply. Never turn the back on a sterile field. Hold sterile objects at hip level or above. Only a sterile object can touch another sterile object. Consider the outer 1-inch (2.5 centimeters) edge of a sterile field to be contaminated. Avoid talking, coughing, sneezing, or reaching over a sterile field. Forceps soaked in disinfectant can be used to add items to a sterile field.

Only a sterile object can touch another sterile object., Never turn the back on a sterile field., Avoid talking, coughing, sneezing, or reaching over a sterile field., Consider the outer 1-inch (2.5 centimeters) edge of a sterile field to be contaminated. Rationale:Never walk away from or turn the back on a sterile field. This prevents possible contamination while the field is out of the worker's view. Consider the outer 1-inch (2.5 centimeters) edge of a sterile field to be contaminated. Only a sterile object can touch another sterile object. Unsterile touching sterile means contamination has occurred. Avoid talking, coughing, sneezing, or reaching over a sterile field or object. This helps to prevent contamination by droplets from the nose and the mouth or by particles dropping from the worker's arm. Hold sterile objects above waist level. This will ensure keeping the object within sight and preventing accidental contamination. Use dry, sterile forceps when necessary. Forceps soaked in disinfectant are not considered sterile.

The nurse performs hand hygiene and identifies and assesses a client prior to administering an IV antibiotic via a volume control administration set. Which would the nurse do next? Fill the chamber with the prescribed amount of solution to dilute the medication. Open the clamp between the IV solution and the volume control administration set. Close the clamp between the IV solution and the client's IV insertion site. Clean the medication injection port of the volume control set with an alcohol swab.

Open the clamp between the IV solution and the volume control administration set. Rationale: The order in which the nurse would perform these actions is (1) open the clamp between the IV solution and the volume control administration set, (2) fill the chamber with the prescribed amount of solution to dilute the medication, (3) close the clamp between the IV solution and the volume control administration set, and (4) clean the medication injection port of the volume control set with an alcohol swab.

A nurse learns that a client will be receiving patient-controlled analgesia (PCA). The nurse understands that PCA may be delivered in which forms? Select all that apply. Oral analgesic agents Epidural opioid analgesic agents Perineural opioid analgesic agents Intravenous opioid analgesic agents Ophthalmic instillation of opioid analgesic agents Subcutaneous opioid analgesic agents

Oral analgesic agents, Intravenous opioid analgesic agents, Subcutaneous opioid analgesic agents, Epidural opioid analgesic agents, Perineural opioid analgesic agents Rationale:PCA can be used with oral analgesic agents as well as with infusions of opioid analgesic agents by intravenous, subcutaneous, epidural, and perineural routes. PCA is not delivered by ophthalmic instillation (eye drops) of opioid analgesic agents

While assessing the IV site of a client who has had abdominal surgery, the nurse suspects infiltration. Which finding would help support the nurse's suspicions? Redness Heat Pallor Edema

Pallor Rationale:The nurse inspects the site for swelling, leakage, and coolness or pallor, which may indicate infiltration. When this happens, the catheter may become dislodged from the vein, and IV solution may flow into subcutaneous tissue. Heat, redness, and slight edema may indicate sepsis, phlebitis, or thrombus.

The nurse is monitoring a client who had a nasogastric (NG) tube placed postoperatively after abdominal surgery. Which criterion would the nurse use to determine that the tube could be removed? Stable vital signs. Absent bowel sounds. Loss of appetite. Passage of flatus.

Passage of flatus. Rationale:The criteria used to determine that an NG tube can be removed are: return of appetite, return of bowel sounds, and passage of flatus. All of these signs represent a return to normalcy of the gastrointestinal system. Stable vital signs are preferable, but this is not one of the major criteria for tube removal.

A nurse is assisting a surgeon who will be placing a hollow, open-ended rubber tube in a client with an abscess to drain the wound. This drain will be placed such that one end will be in the abscess and the other will pass through an opening in the skin known as a stab wound. The nurse recognizes that which type of drain is needed? T-tube drain Jackson—Pratt drain Hemovac drain Penrose drain

Penrose drain Rationale:A Penrose drain is a hollow, open-ended rubber tube. It allows fluid to drain via capillary action into absorbent dressings. Penrose drains are commonly used after a surgical procedure or for drainage of an abscess. After a surgical procedure, the surgeon places one end of the drain in or near the area to be drained. The other end passes through the skin, directly through the incision or through a separate opening referred to as a stab wound. A biliary drain, or T-tube, is sometimes placed in the common bile duct after removal of the gallbladder (cholecystectomy) or a portion of the bile duct (choledochostomy). The tube drains bile while the surgical site is healing. A Jackson-Pratt (J-P) or grenade drain collects wound drainage in a bulblike device that is compressed to create gentle suction. It consists of perforated tubing connected to a portable vacuum unit. A Hemovac drain is placed into a vascular cavity where blood drainage is expected after surgery, such as with abdominal and orthopedic surgery. The drain consists of perforated tubing connected to a portable vacuum unit.

The nurse prepares for a sterile procedure. What action does the nurse perform first? Perform hand hygiene with alcohol-based handrub. Place all the necessary supplies in the room. Identify the client the procedure is prescribed for. Put on personal protective equipment, if required.

Perform hand hygiene with alcohol-based handrub. Rationale: Hand hygiene is done prior to donning any personal protective equipment, before entering the room, and before interacting directly with the client, such as checking the name on the armband.

The nurse performs gastrostomy site care and notes drainage. What action does the nurse take? Administer an antibiotic ointment to the site. Place a drain sponge under the external bumper. Notify the health care provider. Clean the site with hydrogen peroxide

Place a drain sponge under the external bumper. Rationale:When the nurse notes drainage, a precut sponge or gauze is placed around the tube for comfort and to prevent irritation. Drainage is a normal finding. The health care provider is notified if the drainage has an odor, appears infected, or looks like the feeding solution being administered. Gastrostomy sites are no longer cleansed with hydrogen peroxide as this disrupts healing. Antibiotic ointments have not been found to be useful and are not used.

A nurse is preparing to access the implanted port of a client's central venous access device (CVAD). The nurse asks the client to turn the head away from the access site, but the client is unable to do so. What is the next action by the nurse? Place a mask on the client. Urge the client not to cough. Ask the client to hold the breath. Tell the client to look away.

Place a mask on the client. Rationale: Turning the head away from the access site helps to deter the spread of microorganisms. If a client is unable to turn the head away from the site, the nurse should place a mask on the client to help deter the spread of microorganisms. Masks may also be necessary based on facility policy. Asking the client to hold the breath, look away, or avoid coughing would not be effective in preventing the spread of microorganisms.

A nurse is caring for a client who just underwent thoracic surgery and who will be receiving epidural analgesia. The nurse understands that epidural analgesia can be administered in which ways? Select all that apply. Intermittent bolus dose Postoperatively Continuous infusion pump Patient-controlled analgesia pump Patient-controlled transdermal system One-time bolus dose

Postoperatively, Continuous infusion pump, One-time bolus dose, Patient-controlled analgesia pump, Intermittent bolus dose Rationale:The epidural analgesia can be administered as a bolus dose (either one time or intermittently), via a continuous infusion pump, or by a patient-controlled epidural analgesia pump. Epidural analgesia is being used more commonly to provide pain relief during the immediate postoperative phase. The transdermal system uses a different route than the epidural route.

The nurse uses a small amount of sterile solution from a large, multiuse bottle to moisten gauze in a sterile field. What technique does the nurse use? Pour the liquid into the palm of a sterilely gloved hand for use. Pour the liquid into a sterile container within the sterile field. Pour the liquid onto gauze on the sterile field until the gauze is moist. Pour the liquid into the cap of the bottle and dip the gauze as needed.

Pour the liquid into a sterile container within the sterile field. Rationale: The liquid from a large container is poured into a sterile container present within the sterile field. The gauze is placed in this container if needed or moistened as desired for use. If gauze is laying on the field and the field become moist, it may be considered contaminated.

The nurse has begun inserting the nasogastric (NG) tube when the client coughs. After assessing that the client can speak without difficulty, what does the nurse do next? Assess the client's respiratory status. Insert the tube into the other nostril. Notify the health care provider. Proceed with nasogastric tube placement

Proceed with nasogastric tube placement. Rationale:The nurse first ensures that any coughing is related to the gag reflex rather than accidental placement of the NG tube into the airway. When the client breathes and speaks adequately, placement may continue. The nurse has performed the necessary respiratory assessment by ensuring the client can speak well. There is no reason to begin again with the other nostril or to notify the health care provider.

A nurse has just inserted a nasogastric tube in a client. Which method is most reliable for verifying the correct placement of the tube? Confirmation that pH of the aspirate is less than 5.5 Off-white fluid aspirated Green fluid with particles aspirated Radiographic confirmation of position

Radiographic confirmation of position Rationale:Radiographic (x-ray) examination is the only reliable method to determine accurate tube placement. In the absence of an x-ray, pH testing is predicative of correct placement. Although visualization of aspirated contents can help confirm correct placement of the tube, this method is not as reliable as an x-ray.

The nurse is using a large syringe to administer an intermittent feeding to a client who has a nasogastric feeding tube. Which method should the nurse use to increase the flow rate of the formula? Raise the height of the syringe. Ask the client to bear down while the formula is infusing. Using the plunger of the syringe, steadily infuse the formula over the desired period of time. Attach the syringe to a syringe pump and set the infusion rate to 250 mL/hr.

Raise the height of the syringe. Rationale:Syringe feedings are infused via gravity. Raising the syringe will increase the rate of infusion. Syringe pumps are used for IV infusions rather than gastric feeding. Feeding through a syringe should be done by gravity, not by positive pressure using the plunger. The client bearing down will likely have little effect on the rate of infusion.

The nurse is unable to flush the implanted port of a client's central venous access device (CVAD), despite repeated efforts at repositioning the client. Which action by the nurse is most appropriate? Place the client's arm below the level of the heart and attempt to flush the port. Re-access the port with a new needle, according to facility policy. Contact the health care provider for further prescription. Increase pressure used, gradually, while flushing until the problem resolves.

Re-access the port with a new needle, according to facility policy. Rationale: If resistance is met when flushing the client's implanted port and the nurse has attempted all remedies including changing client position, the nurse should re-access the port with a new needle and attempt to flush again, according to facility policy. After the port has been re-accessed and the nurse is still unable to flush the port, the nurse should contact the health care provider for a further prescription. Placing the client's arm below the level of the heart will not remedy the problem. Increasing pressure or "forcing" the flush may result in damage to the port and should not be attempted.

The nurse is responding to a client's call light. The client states, "I was getting out of bed and caught my IV on the siderail. I think I may have pulled it out." The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which action is most appropriate? Apply a new dressing and observe for signs of infection over the next several hours. Remove the IV catheter and reinsert another in a different location. Decontaminate the visible portion of the catheter, and then gently reinsert. Verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of catheter open to air.

Remove the IV catheter and reinsert another in a different location. Rationale:An IV catheter should not be reinserted. Whether the IV is salvageable depends on how much of the catheter remains in the vein. Because this catheter has been almost completely pulled out of the insertion site, it should be discarded and a new one inserted at a different location. It is not acceptable simply to apply a new dressing and leave the catheter sticking out of the site.

The nurse is monitoring a client receiving an IV infusion to replace fluids lost during surgery and notices air bubbles in the tubing above the roller clamp. Which action would be most appropriate? Make sure the flow clamp is open and that the drip chamber is approximately half full. Change the IV solution administration set immediately. Remove the bubbles by closing the roller clamp, stretching the tubing downward and tapping the tubing with a finger. Disconnect the tubing from the client to purge the air from the tubing.

Remove the bubbles by closing the roller clamp, stretching the tubing downward and tapping the tubing with a finger. Rationale:If the bubbles are above the roller clamp, the nurse can easily remove them by closing the roller clamp, stretching the tubing downward, and tapping the tubing with a finger so the bubbles rise to the drip chamber. Ensuring that the flow clamp is open and that the drip chamber is half full helps to promote fluid flow. It would not be necessary to change the administration set to troubleshoot this problem. Disconnecting the tubing from the client would be inappropriate and disrupt the integrity of the sterile IV administration system.

The nurse is irrigating a nasogastric (NG) tube connected to suction for a client undergoing gastric decompression and meets resistance after attaching the irrigation syringe to the NG tube. Which would be most appropriate for the nurse to do first? Use 50 mL air instead of irrigation solution. Reposition the client and try again. Notify the health care provider. Use 20 mL sterile saline instead of irrigation solution.

Reposition the client and try again. Rationale:The nurse who meets resistance when irrigating a nasogastric tube connected to suction should reposition the client first and try again because sometimes the tube can get pushed up against the stomach wall. Repositioning the client can help to remedy this situation. If repositioning fails, the nurse can use 20 mL air instead of irrigation solution to reposition the end of the tube

The nurse is about to begin a focused abdominal assessment on a client that is scheduled for surgery tomorrow. What primary nursing action should be done prior to the physical assessment? Request that the client try to empty the bladder. Remove the client's blankets so abdomen can be assessed. Auscultate the for bowel sounds at the ileocecal valve. Place the client in a protective lateral Sims' position

Request that the client try to empty the bladder. Rationale:The nurse should ask the client to empty the bladder prior to assessment to avoid discomfort or pressure during the physical examination. Auscultating for bowel sounds is part of the actual physical assessment. The ileocecal valve is the area where bowel sounds are most often heard. The client should be placed in a supine position for physical assessment of the abdomen, lateral Sims is used for enema insertion. A drape or blanket should not be removed, but be used to cover all parts not being assessed to provide as much privacy as possible

The nurse is caring for a client receiving patient-controlled analgesia (PCA). The nurse knows to assess the client's sedation score for what reason? To make sure the infusion site is not jeopardized by client sedation. The client must be sedated to control the PCA button and relieve pain. The client must be able to tell the nurse when the PCA stops working. Respiratory depression can occur with the use of opioid analgesics.

Respiratory depression can occur with the use of opioid analgesics. Rationale:The nurse would assess the sedation score of a client because clinically significant respiratory depression can occur with the use of opioid analgesics. If the client is too sedated, he/she will not be able to control the PCA. The nurse would also assess the client to determine if the PCA is not working. Continued assessment of the infusion site is necessary for the early detection of problems

The nurse is caring for a client during the first 12 hours of receiving epidural analgesia and assesses the client every hour. Along with vital signs, which best describes the priority of the hourly assessment? Respiratory status, oxygen saturation, pain, and sedation level Heart rate, capillary refill, bowel sounds and pedal pulses Gastrointestinal status, bowel movements, and urine output Temperature, pedal pulses, and assessment of cranial nerves

Respiratory status, oxygen saturation, pain, and sedation level Rationale:Respiratory status, oxygen saturation, pain and sedation level are the best description of the priority of the hourly assessments for this client. The priority concern for this client is the risk of respiratory depression because of the use of analgesia; therefore, the priority assessments during the first 12 hours of epidural therapy include assessing the client's vital signs, respiratory status, pain status, sedation level, oxygen saturation at least once per hour during the first 12 hours of therapy. If there are no complications after 12 hours, the assessments should continue every 2 hours and then decrease per facility policy. Airway, breathing, and circulation are the top priorities in the care of any client, and in this client, breathing is a concern because of the risk of respiratory depression from the epidural analgesia. Although important, the other options do not best describe the priority assessments because the main concern, the risk of respiratory depression, is not the focus of the other options.

The nurse is administering an IV analgesic to a client through a drug-infusion lock. Which would be important for the nurse to obtain when gathering equipment for this procedure? Infusion pump. Saline. Long length of tubing. Sterile water.

Saline. Rationale: The drug-infusion lock consists of a needle or catheter connected to a short length of tubing, capped with a sealed injection port. The device is kept patent by flushing with saline (not sterile water) on a routine basis, and before and after an infusion. An infusion pump is not used with this device.

What is the best way for the nurse to ensure there is not any tension on the tubing when caring for a client with a Jackson-Pratt drain? Tape the drain to the dressing material securely below the level of the wound. Allowed the Jackson—Pratt drain to hang freely to avoid any kinks in the tubing. Secure the drain to the client's gown with a safety pin below the level of the wound. Apply an abdominal binder over the entire wound and drain to support the site.

Secure the drain to the client's gown with a safety pin below the level of the wound. Rationale:To ensure there is not any tension on the tubing of a Jackson-Pratt drain, the nurse should secure the drain to the client's gown with a safety pin below the level of the wound. Taping the drain or applying an abdominal binder will keep the bulb compressed and hinder the suction action of the drain. The drain should not be allowed to hang freely because this causes tension on the drain site.

Following insertion of a nasogastric tube, the nurse needs to stabilize the tubing for the client. Which action is appropriate for the nurse to take? Tape the tubing to the client's sleeve below shoulder level. Secure the tubing with a safety pin to the client's gown at shoulder level. Attach the tubing to the bed linens with a rubber band and safety pin. Allow the tubing to hang freely to allow for freedom of movement.

Secure the tubing with a safety pin to the client's gown at shoulder level. Rationale:The nurse would secure the tube to the client's gown at the sleeve by using a safety pin, and perhaps a rubber band, ensuring that the air vent is above the level of the stomach. Securing the tube prevents tension and tugging on the tube. Securing the tube in any other place and in any other manner or failure to secure the tube at all can allow the tube to be accidentally removed, possibly requiring reinsertion.

A nurse has just received a client's laboratory results and is reviewing them. Which finding should the nurse recognize as an indication of malnutrition or malabsorption? Hemoglobin (Hgb) 11.3 g/dL (113 g/L) Hematocrit (Hct) 56% (0.56) Serum albumin 2.8 g/dL (28 g/L) Creatinine 1.9 mg/dL (168 μmol/L)

Serum albumin 2.8 g/dL (28 g/L) Rationale:Normal serum albumin is 3.3 to 5 g/dL (33 to 50 g/L). Decreased albumin indicates malnutrition or malabsorption. Decreased Hgb indicates anemia. Increased creatinine indicates dehydration. Increased Hct indicates dehydration.

While assessing a client receiving peripheral IV therapy as part of the treatment plan for hypovolemia, the nurse suspects that the client is experiencing fluid overload based on which finding? Deceased blood pressure. Change in the level of consciousness. Pounding headache. Shortness of breath.

Shortness of breath. Rationale:Fluid overload is caused when too large a volume of fluid infuses into the circulatory system. This complication manifests as engorged neck veins, shortness of breath and abnormal breath sounds (suggesting respiratory failure), increased blood pressure, and difficulty breathing. A pounding headache is a sign of speed shock and the change in level of consciousness is related to the existence of an air embolus.

The nurse is caring for a client with a gastrointestinal bleed who has a nasogastric (NG) tube. After administering the medications via the NG tube, what would the nurse do next? Reestablish nasogastric tube to low-intermittent wall suction. Flush with 30 mL hot water after the last medication. Shut off nasogastric tube for 30 minutes. Flush with 5 mL cold water after each medication.

Shut off nasogastric tube for 30 minutes. Rationale:The nasogastric tube should be shut off for 30 minutes to enhance medication absorption and then reestablish decompression. The nasogastric tube should be reestablished to suction per the health care provider's prescription. The nasogastric tube should be flushed with 5 to 10 mL warm water after each medication, and 30 to 60 mL warm water after the last dose of medication.

Which should the nurse advise the client to do following successful administration of a tube feeding? Sit up for 1.5 to 2 hours. Lay flat for 30 to 60 minutes. Ambulate for 20 minutes if not contraindicated. Sit up for 1 hour.

Sit up for 1 hour. Rationale:After administering a tube feeding, the nurse should have the client sit up for at least 30 minutes to one hour to minimize risk for backflow or aspiration if any reflux or vomiting should occur.

The nurse is administering a prescribed antibiotic to a client via a piggyback IV infusion. After hanging the piggyback solution container on the IV pole and labeling it, what would the nurse do next? Squeeze the drip chamber of the tubing and release. Open the clamp and prime the tubing. Clean the access port above the roller clamp on the primary IV tubing. Close the clamp and place a needleless connector on the end of the tubing.

Squeeze the drip chamber of the tubing and release. Rationale: The correct order for these procedure steps is (1) squeeze the drip chamber of the tubing and release, (2) open the clamp and prime the tubing, (3) close the clamp and place a needleless connector on end of the tubing, and (4) use an antimicrobial swab to clean the access port or stopcock above the roller clamp on the primary IV tubing.

The nurse is administering an IV medication to a client through a drug-infusion lock. What action would the nurse perform immediately after cleaning the access port of the drug-infusion lock with an antimicrobial swab? Stabilize the port with the non-dominant hand and insert the syringe of normal saline into the access port. Insert the syringe with medication into the port and gently inject medication, using a watch to verify administration rate. Release the clamp on the extension tubing of the medication lock and insert the syringe of normal saline into the access port. Stabilize the port with the dominant hand and insert the syringe of normal saline into the access port.

Stabilize the port with the non-dominant hand and insert the syringe of normal saline into the access port. Rationale: After cleaning the access port of a drug-infusion lock, the nurse would stabilize the port with the non-dominant hand and insert the syringe of normal saline into the access port. The nurse would then release the clamp on the extension tubing of the medication lock and insert the syringe of normal saline into the access port, aspirate gently, and check for blood return. Lastly, the nurse would flush the drug-infusion lock with normal saline, insert the syringe with medication into the port, and inject the medication.

The nurse is administering a medication by intravenous bolus through an intravenous infusion and notices a cloudy, white substance forming in the IV tubing. What is the next action by the nurse? Decrease the administration rate. Stop administering the medication. Flush the intravenous line with 0.9% sodium chloride. Assess the IV site for infiltration.

Stop administering the medication. Rationale: A cloudy, white substance in the tubing indicates incompatibility of the medication and the intravenous solution. To avoid complications, the nurse should stop administering the medication and clamp the IV at the site nearest to the client. The IV tubing should be changed, and compatibility should be confirmed by checking resources such as online database or pharmacy. The nurse should assess the IV site prior to administering medications. Decreasing the administration rate will not solve the incompatibility. Flushing the intravenous line when there is an incompatibility puts the client at risk for injury related to embolism.

The nurse is administering a medication through a medication infusion lock and observes that the client is experiencing pain. Which should the nurse do to stop the pain for the client? Stop the administration of medication, assess the site, and flush the medication lock. Restart the medication administration at a slower rate. Flush the site. Continue administration, but at a slower rate

Stop the administration of medication, assess the site, and flush the medication lock. Rationale: If the nurse observes pain, stop administering the medication, assess the site, and reflush the medication lock. As long as there are no signs of inflammation or infiltration, restart the medication administration at a slower rate, which should stop the pain.

The nurse is administering a medication by intravenous bolus when the client reports pain and burning at the IV site. What is the next action by the nurse? Stop the infusion and assess for signs of infiltration. Encourage the client to take deep breaths during the administration to minimize pain. Flush the site with normal saline to verify patency of the IV site. Place a warm pack on the IV site and continue to administer the medication.

Stop the infusion and assess for signs of infiltration. Rationale:Signs of adverse reaction necessitate stopping the administration of the medication and further assessment. Continuing with the administration of the medication may lead to complications at the IV site. Patency of the IV site may be verified with a saline flush, but after stopping the infusion of the medication. Pain at the IV site requires an assessment of the IV site, encouraging the client to take deep breaths to minimize pain is inappropriate.

When assessing a client receiving patient-controlled analgesia (PCA), the nurse assigns the client a sedation score of 4. What is the appropriate action by the nurse? Increase the medication dosage. Reduce the medication dosage programmed in the PCA device and monitor the client. Document the score and continue with client care. Stop the medication infusion immediately and notify the health care provider

Stop the medication infusion immediately and notify the health care provider. Rationale:For a client who is somnolent with a sedation score of 4, the nurse would stop the medication infusion immediately and notify the health care provider. The nurse would prepare to administer oxygen and a narcotic antagonist such as naloxone.

A nurse aspirates a small amount of fluid from a client's nasogastric tube. The nurse determines that the tube is in the intestines based on the aspirate being which color? Straw-colored Tan Off-white Green

Straw-colored Rationale:Gastric fluid can be green with particles, off-white, or brown if old blood is present. Intestinal aspirate tends to look clear or straw-colored to a deep golden yellow color. Also, intestinal aspirate may be greenish brown if stained with bile. Respiratory or tracheobronchial fluid is usually off-white to tan and may be tinged with mucus.

Which includes practices used to render and keep objects and areas free from microorganisms? Hand hygiene Clean technique Medical asepsis Surgical asepsis

Surgical asepsis Rationale:This statement describes surgical asepsis, or sterile technique. Medical asepsis, or clean technique, involves procedures and practices that reduce the number and transfer of pathogens. Hand hygiene is a type of medical asepsis specific to the hands and includes hand washing and use of alcohol-based handrubs.

A nurse is caring for a client who will be undergoing removal of the gall bladder. Which type of drain should the nurse expect the surgeon to place in the client's common bile duct to drain bile while the surgical site is healing? Hemovac drain Penrose drain Jackson—Pratt drain T-tube drain

T-tube drain Rationale:A biliary drain, or T-tube, is sometimes placed in the common bile duct after removal of the gallbladder (cholecystectomy) or a portion of the bile duct (choledochostomy). The tube drains bile while the surgical site is healing. A Penrose drain is a hollow, open-ended rubber tube. It allows fluid to drain via capillary action into absorbent dressings. Penrose drains are commonly used after a surgical procedure or for drainage of an abscess. After a surgical procedure, the surgeon places one end of the drain in or near the area to be drained. The other end passes through the skin, directly through the incision or through a separate opening referred to as a stab wound. A Jackson-Pratt (J-P) or grenade drain collects wound drainage in a bulblike device that is compressed to create gentle suction. It consists of perforated tubing connected to a portable vacuum unit. A Hemovac drain is placed into a vascular cavity where blood drainage is expected after surgery, such as with abdominal and orthopedic surgery. The drain consists of perforated tubing connected to a portable vacuum unit.

Which should be documented by the nurse? The specific items that the nurse transferred into a sterile field. The fact that the nurse washed her hands before a procedure. The fact that the nurse donned gloves two different times during a procedure. The fact that sterile technique was used for a given procedure.

The fact that sterile technique was used for a given procedure. Rationale: The fact that sterile technique was used for a given procedure should be documented, but the other items listed do not need to be documented, as they are standard procedure.

The nurse prepares for a sterile dressing change on one end of the table by opening a sterile field and dropping the supplies onto it. The nurse needs to gather additional supplies remaining on the other side of the table. What action does the nurse take? Reach toward the other end of the table and pick up the supplies. Prepare a second sterile field to cover the entire table surface. Take a few steps around the table to pick up the additional supplies. Discard the current sterile field and supplies and begin again.

Take a few steps around the table to pick up the additional supplies. Rationale:The nurse can step around the edge of the table, without turning his or her back on the sterile field, to gather the remaining supplies. Reaching across the current sterile field would be a reason to discard all the supplies and the field due to contamination. The table does not need to be completely covered with sterile drapes.

After inserting a nasogastric tube, what should the nurse do to ensure that the tube is properly placed in the client? Test the pH of aspirated content. Ask about stomach distention and fullness. Obtain an abdominal ultrasound. Observe for immediate drainage from the tube.

Test the pH of aspirated content. Rationale:Current research demonstrates that the use of pH is predictive of correct placement of a nasogastric tube. The pH of gastric contents is acidic (less than 5.5). If the client is taking an acid-inhibiting agent, the range may be 4.0 to 6.0. The pH of intestinal fluid is 7.0 or higher, indicating the tube is beyond the stomach. The pH of respiratory fluid is 6.0 or higher. An x-ray can also be used to check placement of the tube, as well as aspirating the gastric contents and checking them for color and consistency. A feeling of fullness will not confirm tube placement. An ultrasound is not used for confirmation of tube placement.

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

The NG tube is in the client's airway. Rationale:The tube is in the airway if the client shows signs of distress and cannot speak or hum. Excessive coughing and gagging may occur if the tube has curled in the back of throat. A vasovagal reaction is typically manifested by lightheadedness and fainting, not by gasping and an inability to vocalize. There is no indication that the client is forcefully resisting the procedure.

Which finding best indicates to the nurse that the client has a therapeutic outcome from a blood transfusion?

The client has a steady gait while ambulating to void. Rationale:The expected outcome is best indicated by evidence of a stabilized cardiac output and fluid balance. This is observed through a lack of dizziness and steady gait and increased urine output. An increased blood pressure is a positive indicator; however, a blood pressure of 90/48 mm Hg is lower than desired. The client's positive color can indicate improved peripheral perfusion, or the client may be flushing as an effect of the transfusion. The absence of adverse effects, though desired, is not the best indicator of a therapeutic outcome.

The nurse has taught a client how to irrigate the client's colostomy. Which outcomes does the nurse anticipate when the client performs this procedure correctly? Select all that apply. The client performs hand hygiene following irrigation of the colostomy. The client's stoma and surrounding skin remain free from irritation. The client expels soft, formed stool. The client voices concern over looking at the colostomy. The client demonstrates the ability to irrigate the colostomy.

The client's stoma and surrounding skin remain free from irritation., The client performs hand hygiene following irrigation of the colostomy., The client expels soft, formed stool., The client demonstrates the ability to irrigate the colostomy. Rationale:After a client irrigates the colostomy successfully, the nurse anticipates the client will be able to expel soft, formed stool and can demonstrate the ability to irrigate the colostomy correctly and confidently. In addition, the client's stoma and surrounding skin should remain free from irritation. Hand hygiene should be performed after irrigating the colostomy. If the client voices concern over looking at the colostomy, then the client may not be ready to irrigate it. This is an unexpected response. The nurse would need to take time to discuss the client's feelings about the colostomy and the change in body image prior to teaching irrigation.

What are the expected outcomes when caring for a T-tube drain? Select all that apply. The client is able to get out of bed without assistance. Care is accomplished without causing trauma to the wound. Care is accomplished without contaminating the wound. The drain will remain patent. The client does not experience pain or discomfort.

The drain will remain patent., The client does not experience pain or discomfort., Care is accomplished without contaminating the wound., Care is accomplished without causing trauma to the wound. Rationale:The expected outcomes when caring for a T-tube drain are that the drain will remain patent, the wound is not contaminated during care, no trauma is caused to the wound and that the client did not experience pain or discomfort. Increasing the ability of the client to get out of bed without assistance is not an expected outcome related to care of a T-tube drain

The nurse is directed to administer to the client an IV heart medication using a volume control administration set. Which accurately describes this process? A needle is connected to a short amount of tubing capped with a sealed injection port to inject medications. The medication is diluted in a small amount of solution in a cylindrical chamber that is attached to the IV line. Medication is mixed in a vial, which is connected to a smaller IV solution container. The medication is diluted in a large amount of IV solution and added to the IV line.

The medication is diluted in a small amount of solution in a cylindrical chamber that is attached to the IV line. Rationale: A volume control administration set is a method of administering IV medications, which are diluted in a small amount of solution in a volume control set, a cylindrical chamber that is added to the IV line. A needle connected to tubing capped with a sealed injection port is known as a drug infusion lock.

The charge nurse is observing a new nurse care for a client who is receiving a continuous feeding through a nasogastric feeding tube. Which action by the new nurse would require intervention by the charge nurse? The new nurse places the client in the left lateral recumbent position. The new nurse asks the client whether nausea or abdominal pain is present. The new nurse changes gloves before preparing the feeding bag. The new nurse interrupts the feeding every 4 hours and aspirates gastric contents.

The new nurse places the client in the left lateral recumbent position. Rationale:The client's head should be elevated 30 to 45 degrees. All of the other actions are correct and would not require intervention by the charge nurse.

The nurse assists a new nurse to add items to a sterile field. Which action by the new nurse requires further instruction? The nurse drops the item from the wrapper into the side of the sterile field. The nurse keeps hands and wrists on the outside of the wrapped sterile item. The nurse grasps the remaining flap of the wrapper and pulls back toward wrist. The nurse holds wrapped item in dominant hand to open, opening top flap away from body.

The nurse drops the item from the wrapper into the side of the sterile field. Rationale: The outer edges of the sterile field are considered nonsterile. Dropping items into the outer edges of the field causes those items to be considered contaminated. Items are dropped toward the center of the field from approximately six inches above the surface of the field. The nurse opens the package outward over the hands, maintaining the sterility of the item inside the package. Items are typically held in the non-dominant hand while the dominant hand pulls the package open.

The nurse determines that the sterile field has been contaminated when which action occurs? The nurse turns his or her back to the field. A sterile object falls within the 1-in (2.5-cm) border of the field. The field is above waist level. The nurse reaches around the sterile field.

The nurse turns his or her back to the field. Rationale:A sterile field becomes compromised if the nurse turns away from it, if it drops below waist level, if an object falls onto or outside of the 1-in (2.5-cm) border of the field, or if the nurse reaches over the sterile field.

The nurse squeezes the drip chamber on the tubing, releases it, then watches it fill to the line before opening the clamp and priming the tubing. Why is the tubing primed? To mix the medication with the IV fluid. To make sure the medication goes all the way to the tip. To check that the entire system is working properly. To make sure the tube is clear of air.

To make sure the tube is clear of air. Rationale: Priming the tubing ensures that no air enters the client.

The nurse is caring for a client receiving patient-controlled analgesia (PCA) on hospice care. The nurse understands which as the purpose of the PCA pump's lockout interval? To disconnect the PCA device if the client attempts to self-administer more than 10 doses of medication. To prevent the medication syringe from being removed from the PCA device during administration. To ensure that doses of medication are administered only at predetermined times. To prevent reactivation of the PCA pump and administration of another dose during the specified period of time.

To prevent reactivation of the PCA pump and administration of another dose during the specified period of time. Rationale:A lockout interval is programmed into the PCA unit to prevent reactivation of the pump and administration of another dose during that period of time. The pump mechanism can also be programmed to deliver only a specified amount of analgesic within a given time interval. These safeguards limit the risk for overmedication and allow the client to evaluate the effect of the previous dose. The lockout interval does not disconnect the device. The client pushes a button to activate the PCA device to deliver a small preset bolus dose of the analgesic when pain occurs, not at predetermined times. A PCA pump's locked safety system, not lockout interval, prohibits tampering with the device.

The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply. Type of IV solution Client's reaction to the procedure Rate of the IV solution Manufacturer of the IV catheter Gauge and length of the IV catheter Location of the IV catheter access

Type of IV solution, Client's reaction to the procedure, Gauge and length of the IV catheter, Location of the IV catheter access, Rate of the IV solution Rationale:The nurse should document the location where the IV access was placed, as well as the size of the IV catheter or needle, the type of IV solution, the rate of the IV infusion, and the use of a securing or stabilization device. Additionally, document the condition of the site. Record the client's reaction to the procedure and pertinent client teaching, such as asking the client to alert the nurse if the client experiences any pain from the IV or notices any swelling at the site. Document the IV fluid solution on the intake and output record.

The nurse is caring for a client's wound that has a Jackson-Pratt drain in place. What would be the nurse's next step after emptying the chamber's contents into the graduated collection container? Put on clean gloves. Replace the cap on the chamber. Use a gauze pad to clean the outlet. Fully compress the chamber.

Use a gauze pad to clean the outlet. Rationale:The order in which the nurse would perform the steps to care for a Jackson-Pratt drain is (1) empty the chamber's contents completely into the container, (2) use the gauze pad to clean the outlet, (3) fully compress the chamber, and (4) replace the cap. Clean gloves would be put on prior to emptying the chamber.

The nurse is preparing to administer a medication by intravenous bolus through a continuous infusion via an infusion pump. What is an appropriate action at this time? Use the injection port on the infusion set closest to the client. Don sterile gloves after cleansing the injection port. Add the medication to the IV solution bag for administration by the infusion pump. Continue the infusion after checking compatibilities of the medication.

Use the injection port on the infusion set closest to the client. Rationale: Using the injection port closest to the client minimizes dilution of the medication. The infusion pump should be paused to prevent infusion of fluid and pump occlusion alarms. Adding the medication to the IV bag would cause dilution of the medication. Clean gloves would be used during the administration of medication; sterile gloves are not required.

The nurse has just completed programming of a patient-controlled analgesia (PCA) pump using prescribed parameters. Which action should the nurse take next? Document implementation of the PCA on the client's chart. Check the pump's electrical cords for cracks, splits, or fraying. Verify the settings with another nurse. Attach the PCA pump tubing to the client's intravenous access device.

Verify the settings with another nurse. Rationale:The next action should be to verify the settings with another nurse. This action helps prevent errors. Settings should be verified before documentation. Settings should be verified before attaching the device to the client. Checking the pump's electrical cords for cracks, splits, or fraying should be performed before programming is initiated.

The nurse is teaching a student nurse the advantages of using a volume control administration set to administer IV medications. What is the primary advantage of using this device? When fluid volume is a concern, it limits how much fluid can be infused at one time. It reduces the risk of accidental contamination with microorganisms. It is easier to administer than other IV routes. It prevents accidental needlestick injuries.

When fluid volume is a concern, it limits how much fluid can be infused at one time. Rationale: The main advantage of using a volume control set is that it limits how much fluid can be infused at one time, for clients for whom fluid volume is a concern. The possibility of contamination and needlestick injuries is the same with all methods.

The nurse is preparing an IV antibiotic medication to administer to a client through a drug-infusion lock. When would the nurse perform the "third check" of the label? When reaching for the container. After administering the medication to the client. When prepared before giving it to the client. After retrieval from the drawer.

When prepared before giving it to the client. Rationale: The "Three Checks" denotes that the label on the medication package or container should be checked three times during medication preparation and administration. The nurse would read the label when reaching for the container or unit-dose package, after retrieval from the drawer and compared with the MAR, and when all the medications for one client have been prepared, before giving them to the client; the third check may be done at the bedside, depending on facility policy.

The nurse, who is monitoring the IV site of a client receiving peripheral venous fluid therapy, checks for bleeding at the site. The nurse understands that bleeding at an IV site is most likely to occur at which time? When the IV is infusing. When the IV solution is changed. When the IV is discontinued. When the IV is initiated.

When the IV is discontinued. Rationale:Bleeding at an IV site may be caused by anticoagulant medication and is most likely to occur when the IV is discontinued.

A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse? Notify the health care provider of the client's response. Stop the transfusion and infuse normal saline using a new administration set. Check the client's vital signs. Stop the transfusion and infuse normal saline using the blood tubing.

Which finding best indicates to the nurse that the client has a therapeutic outcome from a blood transfusion? The client has a steady gait while ambulating to void. The client's blood pressure increases to 90/48 mm Hg. The client's face exhibits a normal skin tone and color. The client is free of chills, fever, and shortness of breath

The medical-surgical nurse is caring for a client admitted with gastroenteritis. Which assessment finding would indicate that the nurse should contact the health care provider? Dull sounds percussed in right upper quadrant at midclavicular line Whooshing sound at the top of the abdomen near the aorta Loud, gurgling sounds in all four quadrants of the client's abdomen Diffuse abdominal tenderness upon palpation of the abdomen

Whooshing sound at the top of the abdomen near the aorta Rationale:Whooshing sound at the top of the abdomen near the aorta may indicate an aneurysm or arterial stenosis and needs further assessment by the health care provider. Loud, gurgling in all four quadrants is normal with the expected increased motility of gastroenteritis and is called Borborygmi. The liver spans for about 6 to 12 cm and would be percussed as dull sounds at the right midclavicular line. Diffuse abdominal tenderness on palpation and cramping is common with gastroenteritis.

How would the nurse secure a Jackson-Pratt drain after emptying it? With a safety pin, secure the drain to the client's gown below the wound. With tape, secure the drain to the client's gown above the wound. With a safety pin, secure the drain to the client's gown above the wound. With a safety pin, secure the drain to the side of the bedding.

With a safety pin, secure the drain to the client's gown below the wound. Rationale:After performing drain care, the nurse would secure the Jackson-Pratt drain to the client's gown below the wound with a safety pin, making sure there is no tension on the tubing.

The nurse is assessing the insertion site of a client's peripherally inserted central catheter (PICC). What is a normal finding? a sterile bandage covering the site gauze pad covering the site a transparent dressing covering the site tape covering the site

a transparent dressing covering the site Rationale:A PICC is held in place with a transparent dressing. The nurse should assess whether the dressing is intact and adheres to the skin around all the edges. Tape, gauze, or a sterile bandage covering the site should all be unexpected findings. If a gauze pad is used as a dressing on a PICC, it must be changed within 48 hours.

Which procedures can be delegated to an unlicensed assistive personnel (UAP)? Select all that apply. digital removal of stool administration of a small-volume enema administration of a large-volume enema application of a fecal incontinence device administration of enemas until clear

administration of enemas until clear, administration of a large-volume enema, application of a fecal incontinence device, administration of a small-volume enema Rationale:The nurse may delegate the administration of small-volume and large-volume enemas to UAPs, as well as the administration of enemas until clear. Application of a fecal incontinence device may also be delegated to UAPs. Digital removal of stool is not delegated to unlicensed assistive personnel (UAP). Depending on the state's nurse practice act and the organization's policies and procedures, the digital removal of stool may be delegated to licensed practical/vocational nurses (LPN/LVNs)

The nurse is assessing a client's peripherally inserted central catheter (PICC) insertion site. The nurse measures the length of the catheter that extends out from the insertion site to: assess whether the catheter is ready to be removed. determine if the catheter is still patent. assess if the catheter has migrated inward or moved outward. record the catheter size for when it needs to be replaced.

assess if the catheter has migrated inward or moved outward. Rationale:The nurse measures the length of the catheter extending out from the insertion site to compare it to the documented length at time of insertion. This assesses whether the catheter has migrated inward or moved outward. The measurement should not be used to determine the size of the replacement tubing, to ensure patency, or to determine time for catheter removal. Flushing will assist in determining patency. Removal and replacement are dependent on the individual client treatment plan.

The nurse is completing the abdominal portion of an admission assessment for a client admitted with asthmatic bronchitis who is otherwise healthy. What would the nurse expect to document? Select all that apply. soft, tinkling sounds in the right lower quadrant" nothing heard after auscultating for 2 minutes in all four quadrants bowel sounds occurred every 5 to 34 seconds blowing, swooshing sounds at the ileac region loud, continuous gurgling sounds in all four quadrants

bowel sounds occurred every 5 to 34 seconds, soft, tinkling sounds in the right lower quadrant" Rationale:Because the client is healthy otherwise, documentation should include abdominal findings that are within normal limit. Normoactive bowel sounds occur every 5 to 34 seconds and are soft, tinkling sounds. Hyperactive bowel sounds tend to be gurgling, continuous, and louder. Although a healthy person can have these sounds, they are not considered normal bowel sounds. Blowing, swooshing sounds at the ileac region would be documented as a bruit. Bowel sounds are considered absent after auscultating for 2 minutes in each quadrant with no sounds heard, and the client's clinical picture should be considered.

The nurse is accessing the implanted port of a client's central venous access device (CVAD) to administer medications. After holding the port stable, the nurse should insert the needle into which location? right side of the port left side of the port top of the port center of the port

center of the port Rationale: The nurse should visualize the center of the port and insert the needle through the skin into the port septum, located in the center of the port, until the needle hits the back of the port. To function properly, the needle must be in the middle of the port and inserted to the back wall of the port.

When administering a medication by intravenous bolus, what is the best way for the nurse to determine the rate of administration? reviewing the facility policy regarding intravenous infusion checking a drug resource for the recommend administration rate asking the charge nurse for the recommended rate for administration verifying in the medication administration record the rate at which the last dose was administered

checking a drug resource for the recommend administration rate Rationale:Because different medications have different recommended rates, it is best to check a drug resource such as a drug reference book, pharmacy, or an online database for a recommended administration rate. Relying on the advice of others in this situation may prove inaccurate. Relying on the rate at which it was last administered may be inaccurate. Most facility policies will not address the rate at which specific medication should be administered.

When administering an intravenous medication by piggyback, which action by the nurse will best prevent precipitate from forming in the IV tubing? clamping the primary intravenous tubing to prevent backflow ensuring there are no incompatibilities between the medication and the IV fluid stopping the infusion if any cloudiness is noted in the infusion tubing asking the client about any allergies before administering the medication

ensuring there are no incompatibilities between the medication and the IV fluid Rationale: To prevent precipitate, the nurse must ensure that there are no incompatibilities between the medication and the IV fluids. It is important to ask the client about any allergies to prevent an allergic reaction, but this does not prevent precipitate. If cloudiness is seen in the tubing, the infusion should be stopped, but cloudiness in the tubing would indicate that precipitate has already formed. Clamping the primary IV tubing will help prevent backflow to the primary fluid, but it will not prevent precipitate if the fluid and medication are not compatible.

The nurse irrigates a client's nasogastric tube with 20 mL of air. The nurse assesses for which outcome? obtaining gastric secretion residual reducing the intensity of nausea flushing the nasogastric tube easily auscultating normal bowel sounds

flushing the nasogastric tube easily Rationale:When the nurse irrigates the nasogastric tube with air, the primary anticipated outcome is to be able to flush the tube easily. The client with a nasogastric tube is not expected to have normoactive bowel sounds. The nurse may obtain gastric secretions for pH, but this is not the goal of irrigating the tube. Irrigation does not reduce nausea, although placing the tube to suction should reduce nausea.

The nurse has difficulty irrigating a nasogastric tube. The nursing interventions are successful, and the nurse irrigates the tube. Which finding indicates to the nurse that the client tolerated the procedure well? gastric gurgling nausea vomiting abdominal distention

gastric gurgling Rationale:Gastric gurgling is a normal finding, particularly after the nurse has flushed with air and water. Abdominal distention, nausea, and vomiting are indications that the client did not tolerate the irrigating procedure and may require additional interventions such as nausea medication.

What is the best way for the nurse to clean the wound site in a client with a Penrose drain? in a circular motion beginning at the outer edge of the wound and moving in toward the pin site in a wedge pattern from pin site to outer edge of wound and repeat in an up-and-down pattern beginning on left side of pin and then to right side in a circular motion beginning at the pin site and moving outward toward the edge of the wound

in a circular motion beginning at the pin site and moving outward toward the edge of the wound Rationale:The best way is to clean the site using a circular motion beginning at the pin site and moving outwards. The nurse should begin at the drain insertion site and slowly move in a circular motion toward the outside or periphery of the drain site. This helps to ensure that cleaning is done from the cleanest area of the wound site or drain site to least clean areas and does not contaminate the wound. Using a wedge pattern or an up-and-down pattern is more likely to cause contamination of the wound as the nurse cleans from the cleanest area, out to the least clean and then returns to most clean areas to repeat the procedure possibly bringing bacteria or other contaminants to the wound area. Using a circular motion beginning at the outer edge of the wound would be cleaning from the most contaminated area into the least contaminated area putting the client at increased risk of infection.

Assessing the insertion site of a client's peripherally inserted central catheter (PICC), the nurse notes redness, swelling, and odor at the site. Which complication does the nurse suspect? infection rash speed shock Infiltration

infection Rationale:Redness, swelling, odor, drainage, and discomfort signify an infection at the insertion site. Swelling, pallor, coldness, or pain around the site are symptoms of infiltration. A rash would appear as red, itching bumps. Speed shock is the body's reaction to a substance injected into the circulatory system too rapidly; it manifests as a pounding headache, rapid pulse rate, apprehension, chills, back pains, and dyspnea

Which action by the unlicensed assistive personnel (UAP) would require the nurse to intervene? reporting amount of stool output emptying a client's colostomy bag irrigating a client's colostomy assisting a client who changes own ostomy bag

irrigating a client's colostomy Rationale:Colostomy irrigation is not delegated to the UAP due to the invasive nature of the procedure. However, the UAP may empty a client's colostomy bag and report intake and output, including colostomy output. If a client is able to change one's own colostomy bag, the UAP may assist the client by gathering supplies and helping him or her clean up after the bag has been changed.

Which documentation does the nurse complete after inserting a client's nasogastric (NG) tube? number of attempts to pass the tubing through the nostril measurement of the exposed tube client's vital signs and bowel sounds amount of time it took to complete the procedure

measurement of the exposed tube Rationale:The nurse would document the size and type of NG tube that was inserted, the nare used for insertion, the measurement of the exposed tube, the characteristics of the drainage in the tube, and the client's reaction to the procedure. It is not relevant to know how long the NG insertion took or how difficult it was, unless there was trauma. Placing an NG tube is procedure that is not expected to alter the client's vital signs, and it will not immediately alter the client's bowel sounds.

The nurse is caring for a client receiving an antibiotic via a peripherally inserted central catheter (PICC). What two solutions should the nurse use to flush the line and keep it patent? heparin and sterile water normal saline and heparin sterile saline and sterile water sterile water and normal saline

normal saline and heparin Rationale:When a PICC is being used intermittently, the nurse should flush the PICC after each use with normal saline and heparin to maintain patency. Sterile water is not used for flushing a PICC line. Heparin maintains patency.

A nurse is administering blood products to a client via an implanted port central venous access device (CVAD). What technique should the nurse use to locate the site of the port? Auscultation Observation Percussion palpation

palpation Rationale: The nurse should put on clean gloves and palpate the location of the port. Because the port is implanted, observation alone should not locate the site. Percussion and auscultation would not be effective, because there are no associated sounds that should enable the nurse to locate the port.

The nurse is deaccessing the implanted port of a client's central venous access device (CVAD). After removing the dressing and tape from the needle, what action would the nurse perform next? Unclamp the extension tubing and flush with 10 mL heparin. Unclamp the extension tubing and flush with a minimum of 5 mL normal saline. Clean the end cap on the extension tubing and insert the heparin-filled syringe. Clean the end cap on the extension tubing and insert the saline-filled syringe.

removing, carefully, all the tape securing the needle in place Rationale: When deaccessing an implanted port, the nurse would put on clean gloves, stabilize the port with the nondominant hand, and then gently pull back the transparent dressing, beginning with the edges and proceeding around the edge of the dressing, carefully removing all the tape securing the needle in place

The nurse is deaccessing the implanted port of a client's central venous access device (CVAD) following chemotherapy. Which action would be appropriate? removing the sterile dressing with a quick pulling motion stabilizing the port with the dominant hand removing, carefully, all the tape securing the needle in place putting on sterile gloves

removing, carefully, all the tape securing the needle in place Rationale:When deaccessing an implanted port, the nurse would put on clean gloves, stabilize the port with the nondominant hand, and then gently pull back the transparent dressing, beginning with the edges and proceeding around the edge of the dressing, carefully removing all the tape securing the needle in place.

The nurse is administering a piggyback IV infusion of medication via gravity. What should the nurse use to regulate the flow of the gravity infusion at the prescribed delivery rate? stopcock tubing spike roller clamp access port

roller clamp Rationale: When using a gravity infusion, the nurse should use the roller clamp on the primary infusion tubing to regulate the flow at the prescribed delivery rate. The nurse should connect the piggyback setup to the access port or stopcock and use the tubing spike to attach the infusion tubing to the medication container.

The nurse is administering an IV medication to a client through a drug-infusion lock and meets resistance when injecting the medication. Why would the nurse not use force to finish the injection? It may cause infection to the site. It may cause a blood clot to break off and lodge elsewhere in the body. It may cause speed shock to occur. It may lead to fluid overload from excess fluid being used.

t may cause a blood clot to break off and lodge elsewhere in the body. Rationale: The nurse would not force an injection in a drug-infusion lock because a clot could break off and cause blockage in another part of the body. The syringe should not be reinserted. Infection is caused by microorganisms entering the site. Speed shock occurs due to IV overload.

After measuring from the client's nostril to the ear lobe, how does the nurse continue to measure the length of the nasogastric (NG) tube to be inserted for a client? to the tenth intercostal space to the abdominal umbilicus to the mammary line to the xiphoid process

to the xiphoid process Rationale:The nurse measures the distance to insert the NG tube by placing the tip of the tube at client's nostril and extending to the tip of the ear lobe and then to the tip of the xiphoid process. This measurement ensures that the tube will be long enough to enter the client's stomach without needless coiling. Measuring to the mammary line is too short by about 1 in (2.5 cm) and to the tenth intercostal space or the umbilicus is too long.

After putting on gloves, the nurse lubricates the nasogastric (NG) tube prior to insertion into the client's nares. Which lubricant is appropriate to use? normal saline solution sterile water petroleum jelly water-soluble lubricant

water-soluble lubricant Rationale:The nurse would lubricate the tip of the tube with water-soluble lubricant. Lubrication reduces friction and facilitates passage of the tube into the stomach. Water-soluble lubricant will not cause pneumonia if the tube accidentally enters the lungs. Saline and water are not considered lubricants. Jelly-based lubricants can be dangerous, particularly if aspirated.

The nurse is preparing to administer medications to a client with a gastric tube. What information should the nurse check before administering any medication through the gastric tube? Select all that apply. client's allergies residual of stomach contents if medication should be given on full or empty stomach whether tube feedings should be held placement of tube

whether tube feedings should be held, client's allergies, if medication should be given on full or empty stomach Rationale: Before any medications should be administered the nurse should check for allergies, if the medication(s) should be administered on a full or empty stomach, and whether tube feeding should be held. Residual and placement of tube should be initiated immediately before administering medications