4335 Midterm

Which actions would the nurse take when obtaining a sputum culture from a client with a diagnosis of pneumonia? Select all that apply.

Have the client brush his teeth before expectoration Instruct the client outtake deep breaths before coughing Obtain the specimen early in the morning Explain the procedure to the client

The nurse is planning to teach a client with chronic obstructive pulmonary disease how to cough effectively. Which instruction should be included?

Take a deep abdominal breath, bend forward, and cough three or four times on exhalation

The nurse assists the primary health care provider with the removal of a chest tube inserted to treat a client who experienced a pneumothorax. During the procedure, the nurse instructs the client to perform which action?

Take a deep breath and hold it

A health care provider prescribes 1000mL D5W to infuse at a rate of 125mL/hr. The nurse determines that it will take how many hours for 1L to infuse?

8 hours`

The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question?

"Have you ever had a transfusion before?"

The nurse is caring for a client receiving an albuterol/ipratropium nebulized breathing treatment. Which report from the client should the nurse note as an expected side effect of this combination medication?

"I feel like my heart is racing."

A nurse instructs a client with allergic rhinitis about the correct technique for using an intranasal inhaler. Which statement indicates that the client understands the instructions?

"I should hold one nostril closed while I insert the spray into the other nostril."

A healthcare provider prescribes heparin sodium, 1300 units/hour by continuous IV infusion. The pharmacy prepares the medication and delivers an IV bag labeled heprain sodium 20,000 units/250mL D5W. An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters per hour to deliver 1300 units/hour? Record the answer to the nearest whole number.

16 mL/hour

A health care provider's prescription reads morphine sulfate, 8mg stat. The medication ampule reads morphine sulfate, 10mg/mL. The nurse prepares how many milliliters to administer the correct dose?

0.8 mL

A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain with intravenous (IV) solution from the IV storage area to hang with the blood products at the client's bedside?

0.9% sodium chloride

The Nasal Cannula delivers how many liters per minute?

1-6 Liters per minute

A health care provider's prescription reads to administer an IV dose of 400,000 units of penicillin G benzathine (Bicillin). The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine (Bicillin), 300,000 units/mL. The nurse prepares how much medication to administer the correct dose? Record your answer using one decimal place.

1.3 mL

Which respiratory rate is classified as bradypnea for an adult?

15 breaths per minute

The nurse is instructing a client with chronic obstructive pulmonary disease (COPD) how to do pursed-lip breathing. In which order from first to last should the nurse explain the steps to the client? All options must be used. 1. "Breathe in normally through your nose for two counts (while counting to yourself, one, two)." 2. "Relax your neck and shoulder muscles." 3. "Pucker your lips as if you were going to whistle." 4. "Breathe out slowly through pursed lips for four counts (while counting to yourself, one, two, three, four)."

2, 1, 3, 4

A health care provider's prescription reads 1000mL of NS to infuse over 12 hours. The drop factor is 15 drops (gtt)/1mL. The nurse prepares to set the flow rate at how many drops per minute? Record your answer to the nearest whole number.

21

Which respiratory rate is classified as tachypnea?

23 breaths per minute

Cefuroxime sodium, 1g in 50mL normal saline, is to be administered over 30 minutes. The drop factor is 15gtt/mL. The nurse sets the flow rate at how many drops per minute?

25 gtt/minute

Based on knowledge of areas at greatest risk for development of a pressure ulcer in a bedridden patient, the nurse identifies which position to minimize the risk?

30-degree side lying

A patient recovering from surgery in the postoperative area suddenly becomes confused, pulse ox reading shows a drop from 98% to 90% on room air. What is the most appropriate intervention?

Apply nasal cannula

What is the nurse's initial action when preparing to change a patient's colostomy pouching system?

Applying clean gloves

Case Study: Abdominal Pain: J.M. is a 32-year-old female who comes to prompt care in acute distress with complaints of abdominal pain. J.M. says the pain began a few days ago and has steadily increased. She states she now feels pain in the 'sides of my back.' J.M. is also nauseated. J.M. is appears restless and keeps moving from back to side to reduce her discomfort. Vital signs are as follows: BP 156/78, apical pulse 106, temperature 100.2 Fahrenheit, Oxygen saturation 98% on room air. She is awake, alert, and orientated X 4. Lungs are clear to auscultation, heart sounds are normal, abdomen is non distended with + bowel sounds in all 4 quadrants. No rebound tenderness. J.M. is voiding small amounts of orange-red urine. Which physical assessment findings are of most concern to you as you perform a 'focused' assessment? Choose all the apply.

Assess abdominal pain Assess vital signs Assess flank pain

Following nasal surgery, what should the nurse do first?

Assess respiratory status

A client with newly diagnosed chronic obstructive disease is to be discharged home with oxygen per nasal prongs. Which teaching points should the nurse include in this client's discharge plan? Select all that apply. Scroll down to review all 6 answer choices.

Avoid areas where people are smoking cigarettes or cigars Place gauze between the ears and oxygen tubing to prevent skin irritation

A client is admitted to the hospital with a diagnosis of right lower lob pneumonia. The nurse ausculates the affected lung area, expecting to note which type of breath sounds?

Bronchial

A nurse is teaching a new nurse about midline catheters. The nurse is asked about which intravenous infusions can be administered through a midline catheter. Which of the following responses would indicate the nurse needs more teaching?

Central parental nutrition

You are providing care to a patient with a chest tube. On assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the CORRECT nursing intervention for this type of finding that you would do first?

Check the drainage system for an air leak.

Which nursing action minimizes a patient's risk for injury during removal of an indwelling urinary catheter?

Checking the documentation for the volume of fluid used to inflate the balloon

After changing the intravenous tubing on a patient's primary infusion, the nurse notes air bubbles in the tubing. How should the nurse remove them?

Close the clamp, stretch the tubing downward, and flick the tubing

Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.60 F orally. Which action should the nurse take?

Delay hanging the blood and notify the healthcare provider (HCP)

J. M's urinalysis shows severe hematuria, and her CBC reveals an elevated WBC count. The HCP has diagnosed J.M. as having Pyelonephritis. The HCP prescribes Ciprofloxacin 500 mg tid for 7 days. J.M. asks the RN how can she avoid getting a UTI so that she does not have this problem again? Upon discharge, what will you include in the teaching plan? Select all that apply

Drink 8-10 glasses of water per day When you have a bowel movement, wipe from front to back Be sure and urinate, before and after sexual intercourse

Which term is used to document the presence of difficulty breathing noted in the provision of client care?

Dyspnea

The nurse who is about to begin a blood transfusion knows the blood cells start to deteriorate after a certain period of time. Which item is important to check regarding the age of blood cells before the transfusion is begun?

Expiration date

Chest tubes are used to drain fluid, blood, or air from the pleural space within the lung in order to re-expand a collapsed lung and restore the normal positive pressure in the pleural space. T/F

False

Nasal cannulas are the least common type of low-flow oxygen delivery system. T/F

False

The nurse's best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago is to notify the surgeon of the bleeding. T/F

False

The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client's intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which complication has occurred?

Infiltration

A patient is recovering from a pneumothorax and has a chest tube present. Which of the following is an appropriate finding when assessing the chest tube drainage system?

Intermittent bubbling may be noted in the water seal chamber.

What can the nurse do to help ensure an accurate result when collecting a midstream urine sample for a patient who is menstruating?

Make a note on the lab slip that the patient in menstruating.

Low-flow devices

Nasal Cannulas, face masks, and NRB (non-rebreather) masks

A client is admitted to the emergency department following a fall from a horse, and the primary health care provider (PHCP) prescribes insertion of a urinary catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take with action?

Notify the PHCP before performing the catheterization

Respiration

Oxygen and carbon dioxide exchange in the lungs. Controlled by the pulmonary and cardiovascular systems.

Moderate-flow devices

Partial non-rebreather (PRB) masks

A primary health care provider is inserting a chest tube to treat pneumothorax. Which materials should the nurse have available to be used as the first layer of the dressing at the chest tube insertion site?

Petrolatum jelly gauze

List 4 complications that can arise from a peripheral IV

Phlebitis Infiltration Air embolism Extravasation Infection Hypervolemia

When pouching a patient's colostomy, which action reduces the patient's risk for injury?

Protecting the skin from irritation caused by fecal drainage

How can the nurse minimize the risk of dislodging the catheter when removing a dressing?

Remove the transparent dressing or tape and gauze in the direction of catheter insertion.

The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride and needs to add the medication to the IV bag. The nurse should plan to take which action immediately after injecting the potassium chloride into the port of the IV bag?

Rotate the bag gently

Ventilation

The movement of air in and out of the lungs. Controlled by the neurologic and musculoskeletal systems.

A standard surgical mask is used as part of droplet precautions to protect the nurse from acquiring the client's infection. T/F

True

Noninvasive ventilation delivers ventilatory support without an artificial airway (endotracheal or tracheostomy tube) to patients who can breathe spontaneously. T/F

True

When suctioning the tracheostomy tube 3 days following insertion, what should the nurse do?

Use a sterile catheter each time the client is suctioned

Which activity is important to include in the plan of care of a patient with a peripherally inserted central catheter (PICC)?

Use a sterile technique when changing the PICC dressing

Which of the following oxygen deliver devices is the most precise oxygen delivery device?

Venturi mask

Which nursing action demonstrates proper procedure in the collection of a wound culture specimen?

Wear clean gloves to remove soiled dressings

Which skin preparation would be best to apply around the client's colostomy?

adhesive skin barrier

For a client with asthma, the healthcare provider (HCP) prescribes albuterol, two puffs twice a day via MDI, and beclomethasone, two puffs twice a day via MDI. The nurse should instruct the client to administer:

albuterol first and follow with beclomethasone two times a day

The nurse observes a client using a metered-dose-inhaler (MDI) to aid in management of asthma. Which actions indicate that the client needs further instruction? SATA.

holds the breath for 3 seconds after inhaling with the MDI inspires rapidly when dispensing the medication from the MDI cleans the inhaler and canister in soapy water before using again in rapid succession

A client who had an appendectomy for a perforated appendix returns from surgery with a JP drain inserted in the incisional site. The purpose of the drain is to:

promote drainage of wound exudates

Which is an expected outcome of pursed-lip breathing for clients with emphysema?

to promote carbon dioxide elimination

Guaifenesin 300 mg four times a day has been prescribed as an expectorant. The dosage strength of the liquid is 200 mg/5mL. How many milliliters should the nurse administer for each dose?

7.5 mL

A health care provider prescribes regular insulin, 8 units/hour by continuous IV infusion. The pharmacy prepares the medication and then delivers an IV bag labeled 100 units of regular insulin in 100mL normal saline. An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters per hour to deliver 8 units/hour?

8 mL/hour

A 36-year-old female, who is 29 weeks pregnant, reports she is experiencing burning when voiding. The physician orders a urinalysis. Which statement by the patient demonstrates she understands how to collect the specimen?

"First, I will pee a small amount of urine in the toilet and then collect the rest in the cup."

The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. Approximately how long will the nurse need to stay with the client to ensure that a transfusion reaction is not occurring?

15 minutes

A healthcare provider's prescription reads potassium chloride 30mEq to be added to 1000mL NS and to be administered over a 10-hour period. The label on the medication bottle reads 40mEq/20mL. The nurse prepares how many milliliters of potassium chloride to administer the correct dose of medication?

15mL

A nurse is teaching a new nurse how to remove a midline catheter. The nurse asks the new nurse what the minimum amount of time is to hold pressure on the site after the catheter is removed. Which of the following responses would indicate the new nurse understood the teaching?

30 seconds

A nurse is preparing for a midline dressing change with a patient who is extremely diaphoretic. Which of the following dressings is most appropriate for this patient?

A gauze dressing placed over catheter exit site

Case Study: Abdominal Pain: J.M. is a 32-year-old female who comes to prompt care in acute distress with complaints of abdominal pain. J.M. says the pain began a few days ago and has steadily increased. She states she now feels pain in the 'sides of my back.' J.M. is also nauseated. J.M. is appears restless and keeps moving from back to side to reduce her discomfort. Vital signs are as follows: BP 156/78, apical pulse 106, temperature 100.2 Fahrenheit, Oxygen saturation 98% on room air. She is awake, alert, and orientated X 4. Lungs are clear to auscultation, heart sounds are normal, abdomen is non distended with + bowel sounds in all 4 quadrants. No rebound tenderness. J.M. is voiding small amounts of orange-red urine. Based on the results of the subjective and physical assessment findings, what lab studies do you think may be ordered for J.M.? Answer all that apply.

CBC Urinalysis Urine culture ("clean catch")

The nurse inserts an indwelling Foley catheter into the distended bladder of a postoperative client who has not voided for 8 hours. After the tubing is secured and the collection bag is hung on the bed frame, the nurse notices that 900 mL of urine has drained into the collection bag. What is the appropriate nursing action for the safety of this client?

Clamp the tubing for 30 minutes and then release

When changing a midline dressing, the nurse notices redness, swelling, and drainage at the catheter exit site. Which of the following actions should the nurse take next?

Notify the practitioner

Which action can the nurse take to ensure a quality blood sample when drawing blood from a patient's peripherally inserted central catheter (PICC) site?

Discard the first 6-9 mL of blood drawn

To prevent exhaled carbon dioxide accumulation within a face mask, the flow rate must be set at 2 L/ min - 5 L/min. T/F

False

Which of the following are primary risk factors for pressure ulcers? SATA

Fever Low-protein diet Lengthy surgical procedures

The nurse is caring for a client who has been placed on droplet precautions. Which protective gear is required to take care of this client? Select all that apply.

Glasses Gown Gloves Surgical mask

When administering an IV piggyback medication to infuse by gravity, how can the nurse ensure that the medication will infuse properly?

Hang the piggyback medication higher than the primary fluid

The nurse team leader is making rounds and observes the client who had a tracheostomy tube inserted 2 days ago. The nursing policy manual recommends use of the gauze pad. The nurse should:

make sure the gauze pad is dry and the client is in a comfortable position

Case Study: Abdominal Pain: J.M. is a 32-year-old female who comes to prompt care in acute distress with complaints of abdominal pain. J.M. says the pain began a few days ago and has steadily increased. She states she now feels pain in the 'sides of my back.' J.M. is also nauseated. J.M. is appears restless and keeps moving from back to side to reduce her discomfort. Vital signs are as follows: BP 156/78, apical pulse 106, temperature 100.2 Fahrenheit, Oxygen saturation 98% on room air. She is awake, alert, and orientated X 4. Lungs are clear to auscultation, heart sounds are normal, abdomen is non distended with + bowel sounds in all 4 quadrants. No rebound tenderness. J.M. is voiding small amounts of orange-red urine. What assessment questions would be most appropriate for J.M. ? Choose all that apply.

Is it painful when you urinate? Has there been a change in characteristics of urination, such as diminished or excessive?

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action?

Obtain new IV tubing

A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient's pain?

Pre-medicate the patient with a prescribed analgesic 30 minutes before the intervention.

Case Study: Abdominal Pain: J.M. is a 32-year-old female who comes to prompt care in acute distress with complaints of abdominal pain. J.M. says the pain began a few days ago and has steadily increased. She states she now feels pain in the 'sides of my back.' J.M. is also nauseated. J.M. is appears restless and keeps moving from back to side to reduce her discomfort. Vital signs are as follows: BP 156/78, apical pulse 106, temperature 100.2 Fahrenheit, Oxygen saturation 98% on room air. She is awake, alert, and orientated X 4. Lungs are clear to auscultation, heart sounds are normal, abdomen is non distended with + bowel sounds in all 4 quadrants. No rebound tenderness. J.M. is voiding small amounts of orange-red urine. What are the possible causes of J.M.'s abdominal pain, nausea, and urine color? Select all that apply

Renal Calculi Pyelonephritis Urinary tract infection

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next?

Run normal saline at a keep-vein-open rate

The nurse has a prescription to give a client salmeterol, 2 puffs, and beclomethasone dipropionate, 2 puffs, by metered-dose inhaler. The nurse should administer the medication using which procedure?

Salmeterol first and then the beclomethasone

The nurse assesses the client's stoma during the initial postoperative period. What observation should the nurse report to the healthcare provider (HCP) immediately?

The stoma is dark red to purple

Simple face masks are used in patients who require short-term, higher oxygen concentration, such as FiO2 35% to 60%. T/F

True

The NRB non-breather mask delivers 10-15 Liters per minute and is used for medical emergencies. T/F

True

High-flow devices

Venturi mask, HFNCs

The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which priority item?

Vital signs

A healthcare provider's prescription reads levothyroxine (Synthroid), 150mcg orally daily. The medication label reads Synthroid, 0.1mg/tablet. The nurse administers how many tablet(s) to the client?

1.5 tablets

The nurse is suctioning a client who had a laryngectomy. What is the maximum amount of time the nurse should suction the client?

10 seconds

Gentamicin sulfate, 80mg in 100mL normal saline, is to be administered over 30 minutes. The drop factor is 10gtt/mL. The nurse sets the flow rate at how many drops per minute? Record your answer to the nearest whole number.

33 gtt/minute

When drawing blood from a patient's peripherally inserted central catheter (PICC), what should the nurse do to minimize the pressure on the device during flushing?

Use a 10-mL syringe for the flush

Which instruction would the nurse give to nursing assistive personnel (NAP) to ensure the patient's comfort when a condom catheter is applied?

Use a hair guard before applying the condom catheter