FUNDA 3: Skills/Procedures

A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-mL balloon inserted to relieve postoperative urinary retention. The nurse observes urine leaking from the insertion site, past the catheter. What is the nurse's first action? 1. Check the urethral catheter and drainage tubing 2. Irrigate the catheter with 30 mL sterile normal saline 3. Notify the health care provider 4. Remove and reinsert the next larger size catheter

1

A school nurse observes a 3-year-old begin to choke and turn blue while eating lunch. What should be the nurse's initial action? 1. Abdominal thrusts 2. Back blows and chest thrusts 3. Blind sweep of the child's mouth 4. Call 911 for an ambulance

1

The nurse is assessing for the presence of jugular venous distension (JVD) on a newly admitted client with a history of heart failure. Which is the best position for the nurse to place the client in when observing for JVD? 1. Head of the bed elevated to a 45-degree angle 2. Head of the bed elevated to a 60-degree angle 3. Head of the bed elevated to a 90-degree angle 4. Head of the bed flat

1

The nurse is caring for a client on a mechanical ventilator. The settings on the ventilator have just been changed, and the standing prescription is to draw arterial blood gases 30 minutes after a ventilator change. In anticipation of this blood draw, what intervention should the nurse implement? 1. Avoid suctioning the client 2. Pre-oxygenate the client 3. Raise the head of the bed 4. Reduce the amount of sedation medication

1

A blood transfusion is prescribed for a client with sickle cell exacerbation and a hemoglobin level of 6 g/dL (60 g/L). Which are appropriate actions by the registered nurse? Select all that apply. 1. Administer O negative (O-) blood to the AB positive (AB+) client 2. Delegate the fourth set of vital signs to the unlicensed assistive personnel 3. Prime line with normal saline prior to hanging the blood 4. Time the blood infusion to occur over a 6-hour period 5. Validate the client's name and room number with a licensed practical nurse

1,2,3

The nurse working in an intensive care unit receives a prescription from the primary health care provider to discontinue a triple-lumen subclavian central venous catheter. Which interventions will help prevent air embolism on removal? Select all that apply. 1. Applying an air-occlusive dressing 2. Instructing the client to bear down 3. Instructing the client to lie in a supine position 4. Pulling the line harder if there is resistance 5. Pulling the line out when the client is inhaling

1,2,3

A parent calls the clinic nurse concerned about a 5-year-old with a nosebleed. The parent says the child had a similar incident one week ago while at school. Which instructions should the nurse provide? Select all that apply. 1. Apply a cold cloth to the bridge of the nose 2. Apply continuous pressure to the nose for 10 minutes 3. Have the child lie down and turn to the left side 4. Keep the child calm and quiet 5. Take the child to the emergency department

1,2,4

Which interventions should the nurse perform when assisting the heath care provider (HCP) with removal of a client's chest tube? Select all that apply. 1. Ensure the client is given an analgesic 30-60 minutes before tube removal 2. Instruct the client to breathe in, hold it, and bear down while the tube is being removed 3. Place the client in the Trendelenburg position 4. Prepare a sterile airtight petroleum jelly gauze dressing 5. Provide the HCP with sterile suture removal equipment

1,2,4,5

The nurse is preparing to infuse 2 units of packed red blood cells (PRBCs) to a client with a gastrointestinal bleed. Which actions should the nurse take? Select all that apply. 1. Assess client's vital signs 2. Infuse both units simultaneously 3. Obtain a Y tubing set and prime with normal saline (NS) 4. Plan to remain with client during the 1st 15 minutes of transfusion 5. Set infusion pump to deliver unit over 30 to 45 minutes 6. Spike filtered intravenous (IV) tubing with dextrose 5% water (D5W)

1,3,4

While preparing to insert a peripheral intravenous (IV) line, the nurse notices scarring near the client's left axilla. The client confirms a history of left breast cancer and modified radical mastectomy. Which actions should the nurse take? Select all that apply. 1. Insert the IV line into the most distal site of the right arm 2. Place a MedicAlert bracelet on the left wrist 3. Place an appropriate precaution sign above the bed 4. Review the medical record for history of mastectomy 5. Teach the client to keep the left arm in a dependent position

1,3,4

A blizzard is predicted to hit a large city within a few hours. The home care nurse is prioritizing and revising the schedule and estimates that 3 home visits can be made before the blizzard hits. Which clients should the nurse see? Select all that apply. 1. A client who fell and hit the head but refuses to go to the emergency department 2. A client who is due for a maintenance dose of cyanocobalamin 3. A client who needs pre-filled insulin syringes 4. A client who was discharged from the hospital yesterday after heart failure treatment 5. A client with a stage 3 pressure ulcer in need of a dressing change

1,3,5

The nurse is suctioning the artificial airway of a conscious client. Which actions demonstrate correct technique? Select all that apply. 1. Apply suction for no longer than 5-10 seconds 2. Insert catheter with low, intermittent suction applied 3. Set suction higher than 130 mm Hg for thick, copious secretions 4. Wait at least 1 minute between suction passes 5. Withdraw catheter immediately if client begins coughing

1,4

is initiated with 50 units of regular insulin in 100 mL of normal saline solution at 5 units/hr. At what rate in milliliters per hour does the nurse set the IV pump? Record your answer using a whole number. Answer: (mL/hr

10

A student nurse has prepared instructions for the caregiver of an 8-month-old who weighs 16.5 lb. The health care provider (HCP) has prescribed oral amoxicillin 25 mg/kg/day in 2 divided doses for 5 days as treatment for acute otitis media. Amoxicillin for oral suspension comes packaged as 125 mg/5 mL. Which instruction by the student nurse needs an intervention by the RN? 1. "Give the medicine right before feeding your baby." 2. "Give your baby 7.5 mL of the medicine at 8 AM and 8 PM." 3. "Give your baby the medicine for the full 5 days even if the baby seems better before then." 4. "Stroke your baby's cheek gently before administering the medicine."

2

The nurse collects a sputum specimen from a client with pneumonia. Which directions should the nurse give to the client before collecting the specimen? Select all that apply. 1. "Cough deeply and expectorate into the clean specimen container." 2. "Cough deeply and expectorate into the sterile specimen container." 3. "Inhale deeply several times." 4. "Rinse your mouth with mouthwash." 5. "Rinse your mouth with water." 6. "Sit upright or on the side of the bed."

2,3,5,6

The health care provider prescribes a therapeutic heparin protocol for a client who weighs 198 lb and has a pulmonary embolus. The nurse initiates the infusion with 25,000 units of heparin in 500 mL dextrose 5% in water at 18 units/kg/hr. At what rate per hour does the nurse set the intravenous (IV) pump? Record your answer as a whole number. Answer: (mL/hr)

32

A nurse is assisting with the care of a newborn during circumcision. Which is an appropriate intervention? 1. Apply a snug-fitting diaper following the procedure 2. Anticipate the use of clean technique during the circumcision 3. Offer oral fluids during the procedure 4. Wrap the newborn's upper body in a blanket restraint for the circumcision

4

An experienced nurse precepts a graduate nurse in the intensive care unit while caring for a client with a right subclavian triple-lumen central venous catheter (CVC). Which statement by the graduate nurse indicates understanding of the CVC? 1. "All 3 lumens come together, so all drugs infused through the CVC must be compatible." 2. "It is used to provide enteral nutrition to the client who cannot eat." 3. "Sterile gloves must be worn when administering drugs through the CVC." 4. "The lumen hub should be cleaned thoroughly with antiseptic prior to drug administration."

4

The nurse helps the health care provider perform a thoracentesis at the bedside. In which of the following positions does the nurse place the client to facilitate needle insertion and promote comfort? 1. Fetal position, lying on unaffected side with knees draw to the abdomen and hands clasped around them 2. Lying on the affected side with head of the bed elevated to 30-45 degrees 3. Prone with head turned to the affected side and arms over the head, supported by a pillow 4. Upright leaning forward over the bedside table, with arms supported on pillows

4

The nurse inserts a small-bore nasogastric (NG) tube and prepares to initiate enteral feedings for a hospitalized client with laryngeal cancer. Which action should the nurse take first? 1. Crush and administer medications 2. Dilute enteral formula as prescribed 3. Flush the tube with 30 mL of water 4. Verify tube placement with an x-ray

4

The nurse working in an extended care facility transcribes a prescription from the health care provider for a single daily dose of 150 mg of ranitidine; this is to be taken orally at bedtime for treatment of gastroesophageal reflux disease. Of the following prescriptions, which one is transcribed correctly? 1. Ranitidine 150 mcg daily by mouth 2. Ranitidine 150 mg per os qhs 3. Ranitidine 150 mcg po qd nightly 4. Ranitidine 150 mg PO at bedtime

4

The nurse is beginning intravenous (IV) resuscitation therapy for a client weighing 85 kg (187 lb) with visible second- and third-degree burns covering 40% of his body. Using the Parkland Formula, enter the amount of fluid in liters needed during the first 8 hours of IV fluid resuscitation. Record your answer using 1 decimal place. Answer: (liters)

6.8

A client with heart failure is prescribed a continuous intravenous (IV) infusion of dobutamine at 10 micrograms per kilogram per minute. He weighs 70 kilograms. The concentration of dobutamine is 250 milligrams in 500 milliliters dextrose 5% and water (D5W). For how many milliliters per hour should the nurse program the IV pump? Record your answer as a whole number Answer: (milliliters)

84

A client with hypokalemia is prescribed intravenous (IV) potassium chloride (KCL) to infuse at 10 mEq/hr. The pharmacy sends 20 mEq in 250 mL D5W. To deliver the prescribed dose, the nurse sets the infusion pump at how many milliliters per hour? Record your answer using a whole number. Answer: (mL/hr)

125

The nurse is caring for a client who is having a thoracentesis. Following the procedure, the nurse monitors for complications. The initial postprocedure monitoring plan should include what? Select all that apply. 1. Level of alertness 2. Lung sounds 3. Oxygen saturation 4. Respiratory pattern 5. Temperature 6. Urine output

1,2,3,4

The nurse is administering cleansing enemas to a client the night before bowel surgery. During instillation of the enema, the client reports cramping and pain. What action should the nurse take? 1. Have the client take slow, deep breaths 2. Stop infusing the solution for 30 seconds, then resume at a slower rate 3. Tell the client that the process will not take much longer 4. Withdraw the tube approximately 2 cm and continue the infusion

2

The nurse caring for a client with a single-lumen jugular central venous catheter (CVC) plans to administer 3 mL of an intravenous (IV) push medication through the CVC. Which size syringe is best for the nurse to choose when preparing the medication? 1. 1 mL 2. 3 mL 3. 10 mL 4. 30 mL

3

The nurse notes muffled heart tones in a client with a pericardial effusion. How would the nurse assess for a pulsus paradoxus? 1. Check for variation in amplitude of QRS complexes on the electrocardiogram strip 2. Compare apical and radial pulses for any deficit 3. Measure the difference between Korotkoff sounds auscultated during expiration and throughout the respiratory cycle 4. Multiply diastolic blood pressure (DBP) by 2, add systolic blood pressure (SBP), and divide the result by 3; [(DBP x 2) + (SBP)]/3

3

The nurse is to administer an albuterol nebulizer treatment to a client with acute bronchospasm. The prescribed dosage is 5 mg every 4 hours. The available solution is albuterol inhaled, 2.5 mg/3 mL (0.083%). How many mL does the nurse administer with each dose? Record your answer as a whole number. Answer: (mL)

6

Funda: Skills/Procedures #13 - Drag and Drop http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4348626

c

Funda: Skills/Procedures #2 - Drag and Drop http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4348625

c

Funda: Skills/Procedures #69 - Hotspot http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4338069

c

Funda: Skills/Procedures #76 - Drag and Drop http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4348632

c

Funda: Skills/Procedures #87 - Drag and Drop http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4348633

c

Funda: Skills/Procedures #88 - Drag and Drop http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4348634

c

Funda: Skills/Procedures #92 - Drag and Drop http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4348635

c

Funda: Skills/Procedures #10 - Drag and Drop http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4338153

c

Immediately after delivery, an 8 lb 9 oz client requires naloxone hydrochloride due to respiratory depression. The health care provider prescribes naloxone 0.01 mg/kg to be given intramuscularly stat. Naloxone 0.04 mg/mL is available. How many milliliters will the nurse administer? Record your answer using two decimal places. Answer: (mL)

0.97

A hospitalized client is scheduled for a percutaneous kidney biopsy at 10 AM. At 8 AM, the nurse reviews the client's vital signs and most current serum laboratory results. Which finding is most important to report to the health care provider (HCP)? 1. Blood pressure of 180/100 mm Hg 2. Creatinine of 2 mg/dL (176.8 µmol/L) 3. Hemoglobin of 9.8 g/dL (98 g/L) 4. Platelet count of 120,000/mm3 (120 x 109/L)

1

A nurse working at the department of health tuberculosis clinic assesses a client's tuberculin skin test (TST) response. Which response does the nurse identify as a positive reaction? 1. 5-millimeter (mm) raised, hard area in an HIV-infected client 2. 7-mm warm, red area in an organ transplant client 3. 10-mm red wheal in an injection drug client 4. 12-mm raised, hard area in a healthy client with no risk factors

1

The charge nurse observes a new staff nurse collecting a urine sample for urinalysis and culture as pictured. What is the charge nurse's best action? Click on the exhibit button for additional information. Exhibit: https://drive.google.com/open?id=0B40rfZ_HhbqwWEE1ZDVGLUZ2dkE 1. Advise the staff nurse to discard the collected urine specimen and record the output 2. Advise the staff nurse to use a sterile specimen cup rather than a graduated container for collection 3. Explain to the staff nurse that midstream clean catch or straight catheterization is required 4. Remind the staff nurse that the specimen should be kept cool until it is sent to the laboratory

1

The nurse inserts a urinary catheter into a female client who has not voided for 6 hours. No urine is returned. What action should the nurse take next? 1. Leave the catheter in place and insert a new catheter higher up in the perineal area 2. Leave the catheter in place for 30 minutes and then recheck 3. Notify the prescribing health care provider that there is an obstruction 4. Remove the catheter and reinsert it at a position higher than the initial insertion

1

The nurse is assessing a client's peripheral pulses. The nurse palpates the top portion of the client's foot. The right pulse is easily palpable, and the left pulse is diminished but still palpable. How should the nurse document these findings? 1. Bilateral dorsalis pedis (DP) pulses palpable. Right DP 2+, left DP 1+. 2. Bilateral DP pulses palpable. Right DP 3+, left DP 2+. 3. Bilateral popliteal pulses palpable. Right foot > left foot. 4. Bilateral posterior tibial (PT) pulses palpable. Right PT 2+, left PT 1+.

1

The nurse is assessing urine dipstick results in a client with right flank area pain for the past 24 hours. According to the dipstick results, what is the nurse's best action? Click on the exhibit button for additional information. Exhibit: https://drive.google.com/open?id=0B40rfZ_HhbqwNlo4dy1UTDBZOG8 1. Ask the client about any recent illnesses 2. Consult the diabetes educator 3. Notify the health care provider (HCP) immediately 4. Repeat the test to verify the findings

1

The nurse is assisting a client who has a bedside needle liver biopsy scheduled. Which are the essential actions? Select all that apply. 1. Assess for rising pulse and respirations afterward 2. Check PT/INR and PTT values before the procedure 3. Ensure that the client's blood is typed and crossmatched 4. Have the client void to ensure an empty bladder 5. Position the client flat or on the left side after the procedure

1,2,3

The nurse prepares to insert an indwelling urinary catheter in a client who is disoriented to time, place, and person and cannot follow directions or commands. Which intervention is most important when inserting the urinary catheter? 1. Ensure the client understands the procedure prior to implementation 2. Maintain a sterile field and keep the urinary catheter sterile 3. Place the catheter supply kit between the client's legs in the center of the bed 4. Throw swabs used to clean the perineum directly into the biohazard bin

2

A client receives intermittent bolus enteral feedings through a nasogastric (NG) tube. Which are appropriate nursing actions prior to starting the feeding? Select all that apply. 1. Discard the aspirated residual volume in a biohazard container 2. Flush tube before the feeding 3. Place client in the Semi-Fowler's position 4. Start the feeding after obtaining a gastric residual volume <250 mL 5. Start the feeding when the residual volume has a pH of 6

2,3,4

The health care provider (HCP) orders a magnetic resonance cholangiopancreatography (MRCP) for a client. Which statements by the client would require the nurse to contact the HCP? Select all that apply. 1. "I am allergic to iodine and shellfish." 2. "I ate lunch 2 hours ago." 3. "I had my last period 6 weeks ago." 4. "I have a metal rod in my leg." 5. "I smoked a cigarette about an hour ago."

3,4

The nurse prepares equipment for insertion of a large-bore nasogastric (NG) tube for a hospitalized client. Which actions should the nurse take to measure and mark the tube? Select all that apply. 1. Fold tube in half and mark at the halfway point 2. Extend tape measure from naris to stomach 3. Measure from tip of nose to earlobe to xiphoid process 4. Place a small piece of tape at the point of measurement 5. Use rubber clamp after measuring to mark the point of measurement

3,4

The nurse is assisting with procedural moderate sedation (conscious sedation) at a client's bedside. The unlicensed assistive personnel (UAP) comes to the door and indicates that the client in the next room needs the nurse right now. How should the nurse respond? 1. Ask the UAP to go back and ask the client what the current needs are 2. Ask the UAP to stay and take over while the nurse goes to check on the client in the next room 3. Tell the UAP to inform the client in the next room that the nurse will be there shortly 4. Tell the UAP to tell the charge nurse about the needs of the client in the next room

4

The nurse is drawing a blood specimen from the client's right basilic vein. The client cries out and reports a shooting, severe "pins and needles" sensation in the arm. The nurse should take what action next? 1. Apply ice locally 2. Apply lidocaine/prilocaine cream 3. Reassure the client 4. Withdraw the needle

4

The nurse performs nasogastric (NG) tube insertion using a large-bore NG tube on a hospitalized client with a gastrointestinal bleed. During insertion, after the tube passes the nasopharynx, the client begins to cough and gag. Which action should the nurse take first? 1. Ask the client to take several small sips of water 2. Continue to slowly advance the tube until placement is reached 3. Gently remove the tube and reinsert in the other naris if possible 4. Pull back on the tube slightly and then pause to give the client time to breathe

4

The nurse reinforces the physical therapist's teaching regarding the use of a cane when caring for a client with osteoarthritis of the left knee. Which client statement indicates the need for further teaching? 1. "I will hold the cane in my right hand." 2. "I will move my left leg forward after moving the cane." 3. "I will place the cane several inches in front of and to the side of my right foot." 4. "My cane should equal the distance from my waist to the floor."

4

The occupational health nurse administers an intradermal tuberculin skin test (TST) to a health care worker (HCW). The site must be assessed for a reaction afterward. The nurse instructs the HCW to return in how many hours? 1. 12 hours 2. 24 hours 3. 36 hours 4. 72 hours

4

A client diagnosed with hypertension has been prescribed a clonidine patch. Which instructions should the nurse include? Select all that apply. 1. Apply patch to the upper arm or chest 2. Fold used patches in half with sticky sides together before discarding 3. Remove patch if dizziness occurs when getting up 4. Rotate sites each time a new patch is applied 5. Shave hair before applying patch

1,2,4

A 2-year-old is admitted to the emergency department for anaphylactic reaction to a bee sting. The nurse teaches the parent about emergency use of epinephrine injection. Which statement indicates that the parent understands the instruction? Select all that apply. 1. "I will keep an epinephrine injection in close proximity to my child at all times." 2. "I will give the injection if my child has trouble breathing after a bee sting." 3. "I will give the injection in the upper arm." 4. "The injection can be given through clothing." 5. "If I give the injection, I'll still take my child to the emergency room."

1,2,4,5

The nurse is inserting an indwelling (Foley) urinary catheter into a male client. After inserting the catheter about 6 in (15.2 cm), the nurse notes drops of urine in the tubing. What action should the nurse take next? 1. Further insert the catheter 1-2 in (2.5-5.1 cm) 2. Have the client hold his breath 3. Immediately inflate the 5 mL balloon 4. Secure the tubing to the client's leg

1

The nurse observes a student nurse administer a tuberculin skin test using the intradermal route. The nurse intervenes when the student performs which action? 1. Advances tip of needle through epidermis until the bevel is no longer visible under the skin 2. Chooses a 1 mL tuberculin syringe with a 27-gauge 1/4 inch needle; dons clean gloves 3. Injects medication slowly while raising a small wheal (bleb) on the skin 4. Inserts needle at a 10-degree angle almost parallel to skin with the bevel up

1

The nurse prepares a client for scheduled surgery. Which actions are the nurse's legal responsibility with regard to informed consent? Select all that apply. 1. Acting as a witness that the client signed the consent form voluntarily 2. Documenting in the medical record the date and time the signature was obtained 3. Educating the client if there is a misunderstanding about the procedure 4. Explaining to the client the right to refuse surgery 5. Verifying that the client is competent to provide informed consent

1,2,5

The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions? Select all that apply. 1. Do not leave a tourniquet on more than 1 minute while looking for a vein 2. Draw the specimen while the skin is still wet with the alcohol prep 3. If pulsating red blood is noted, withdraw the needle and apply pressure for 5 minutes 4. Use a highly visible vein on the ventral side of the client's wrist 5. Vigorously shake the specimen tube to mix obtained blood with anticoagulant solution

1,3

The nurse auscultates rhonchi in a client with a tracheostomy tube and performs endotracheal suctioning to clear the secretions. Which nursing interventions are most appropriate to limit the risks associated with suctioning? Select all that apply. 1. Apply suction only while withdrawing catheter 2. Instill sterile normal saline to loosen secretions 3. Limit aspiration time to 10 seconds with each suction pass 4. Maintain sterile technique throughout suctioning procedure 5. Pre-oxygenate with 100% oxygen

1,3,4,5

The nurse plans to administer 9:00 AM medications via the nasogastric (NG) route to a client with an NG tube. The nurse contacts the primary health care provider (PHCP) to clarify which prescriptions that are contraindicated using this route? Select all that apply. 1. Enteric-coated ibuprofen 200-mg tablet 2. Extra-strength acetaminophen 500-mg tablet 3. Metoprolol extended-release 50-mg tablet 4. Sulfamethoxazole double-strength 800-mg tablet 5. Tamsulosin 0.4-mg slow-release capsule

1,3,5

The nurse is assigned to care for 5 clients using assistance from an experienced unlicensed assistive personnel (UAP). Which tasks should the nurse assign to the UAP? Select all that apply. 1. Emptying a urinary drainage bag and recording output 2. Emptying and recharging a Hemovac drain 3. Escorting a disgruntled visitor off the unit 4. Providing perineal care around the Foley catheter with soap and water 5. Reapplying sequential compression devices

1,4,5

A client is receiving a continual IV infusion of D5W and intermittent peritoneal dialysis with a 4-hour dwell time. Calculate the total net intake for the 0700-1500 shift in milliliters. Record your answer using a whole number. Click on the exhibit button for additional information. Exhibit: https://drive.google.com/open?id=0B40rfZ_HhbqwVnFhbEpZVVB1am8 Answer: (mL)

1810

A 2-year-old at an outpatient clinic stops breathing and does not have a pulse. CPR is initiated. When the automated external defibrillator (AED) arrives, the nurse notes that it has only adult AED pads. What is the appropriate action at this time? 1. Continue CPR without using the automated external defibrillator (AED) until paramedics arrive 2. Place one AED pad on the chest and the other on the back 3. Place one AED pad on the upper right chest and the other on the lower left side 4. Place one AED pad on the upper right chest and dispose of the other

2

A client with a dislocated shoulder is prescribed a shoulder sling. The nurse applies the sling and evaluates the fit before discharge from the emergency room. Which assessment finding indicates an incorrect fit? 1. The elbow is flexed at 90 degrees 2. The hand is held slightly below elbow level 3. The sling ends in the middle of the palm with fingers visible 4. The sling supports the wrist

2

The 70-year-old client with type 2 diabetes and hypertension is scheduled for ureteral stent removal in 2 hours. The preoperative protocol ECG is done in the inpatient unit, and results indicate a "possibly acute" ST segment elevation. What action is most important for the nurse to take? 1. Document the test results on the preoperative checklist 2. Notify the health care provider about the test results 3. Place the printed ECG in the front of the chart 4. Report the results to the surgical nurse to tell the surgeon

2

The nurse is assigned to care for a hospitalized confused client with an indwelling urinary catheter. On entering the client's room, the nurse notes the client pulling at the catheter and grimacing in pain. Blood is trickling from the client's meatus and the urine in the drainage bag is pink. Which action should the nurse take first? 1. Collect a urine specimen and send to the lab 2. Deflate the balloon on the urinary catheter 3. Remove the catheter by gently pulling from the urethra 4. Use a sterile 4x4 pad to absorb the blood around the meatus

2

The nurse observes a client self-administering nasal fluticasone. Which observation would require the nurse to intervene and provide further teaching? 1. A sitting position is assumed as the head is bowed slightly forward 2. The client points the spray tip toward the nasal septum during instillation 3. The nasal spray tip is inserted into the nostril as the other nostril is occluded 4. While administering the medication, the client inhales deeply through the nose

2

The nurse observes a student nurse administer ear drops to an elderly client to help loosen cerumen. The nurse intervenes when the student performs which action? 1. Instills ear drops at room temperature 2. Instills ear drops with dropper by occluding the ear canal 3. Places a cotton ball loosely in outermost auditory canal after the instillation 4. Pulls pinna up and back and instills drops

2

The nurse plans to start an IV line to infuse 2 units of packed red blood cells for a stable 42-year-old client with a gastrointestinal bleed. Which IV catheter size is best? 1. 14-gauge 2. 18-gauge 3. 20-gauge 4. 22-gauge

2

A nurse is preparing to perform postmortem care on a client who recently died from metastatic cancer. No family members were present at the time of death. What interventions can be delegated to experienced unlicensed assistive personnel? Select all that apply. 1. Notifying the family of the client's death 2. Placing dentures in the client's mouth 3. Positioning a pillow beneath the client's head 4. Transporting the client to the morgue 5. Washing the client's body

2,3,4,5

A nurse is teaching a parent of an infant about administration of an oral medication. What should be included in the teaching? Select all that apply. 1. Add the medication to the formula bottle before feeding 2. Ask the pharmacy to flavor the medication 3. Hold the infant in a semi-reclining position during administration 4. Use a universal dropper for medication 5. Use the nipple of a bottle to administer the medication

2,3,5

Which steps should the nurse take to decompress the stomach for a client with abdominal distension and vomiting after insertion of a large-bore nasogastric (NG) tube? Select all that apply. 1. Connect the blue pigtail air vent to suction 2. Flush the tubing with water regularly 3. Leave the blue pigtail air vent open to air 4. Plug the blue pigtail lumen to prevent leakage 5. Use an adaptor to connect main NG lumen to suction tubing

2,3,5

The nurse initiates a norepinephrine infusion through a client's only IV access into a large peripheral vein. The client reports severe pain at the IV site shortly after the infusion is started. The nurse observes blanching along the vein pathway. Which interventions are appropriate for the nurse to perform? Select all that apply. 1. Administer morphine IV PRN for pain after flushing line with saline 2. Elevate the extremity above the level of the heart 3. Establish new IV access proximal to the affected site 4. Notify the health care provider 5. Prepare to administer the drug phentolamine 6. Stop the infusion and disconnect IV tubing

2,4,5,6

The health care provider orders 2 mEq/kg (2 mmol/kg) of 8.4% sodium bicarbonate IV to be administered over the next 4 hours. The client weighs 150 lb and the pharmacy supplies the following IV solution: 8.4% sodium bicarbonate in 1000 mL D5W with 150 mEq (150 mmol) sodium bicarbonate. At what rate should the nurse set the infusion pump? Record your answer using a whole number. Answer: (mL/hr)

227

The nurse assesses a client during the dwell time of a peritoneal dialysis cycle. Which assessment would require immediate intervention? 1. Blood pressure of 168/88 mm Hg and pulse of 72/min 2. Client experiencing intermittent nausea 3. Crackles present in the left and right lung bases 4. Presence of 1+ pitting edema in ankles and feet bilaterally

3

The nurse is feeding a confused client via a small-bore nasoenteric tube. The nurse observes the client pulling at the tube and then notices an increase in external tube length from the original exit mark. After immediately stopping the feeding, which action is appropriate for the nurse to take next? 1. Advance the tube to the original exit mark, check gastric aspirate pH, and resume feeding 2. Contact the health care provider to request a prescription for hand mitts 3. Contact the health care provider to request an x-ray to verify tube placement 4. Reinsert the guide wire and advance the tube to its original exit mark

3

A client has a subclavian vein central venous access device (CVAD). The nurse attempts to flush the catheter with 0.9% normal saline solution using a 10-mL syringe, but meets resistance, is unable to aspirate blood, and suspects an occlusion. What is the nurse's next most appropriate action? 1. Flush and lock with heparinized saline flush 2. Flush with 0.9% normal saline using a 5-mL syringe 3. Notify the health care provider (HCP) 4. Reposition the client

4

A client postoperative from a transurethral prostatectomy has a triple-lumen Foley catheter and is receiving continuous bladder irrigation of sterile normal saline solution at 175 mL/hr. The nurse empties the urine drainage bag for a total of 2300 mL at the end of the 8-hour shift. How many milliliters does the nurse document as the total amount of urine output for the shift? Record your answer as a whole number. Answer: (mL)

900

Funda: Skills/Procedures # - Drag and Drop http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4348631

c

Funda: Skills/Procedures #102 - Drag and Drop http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4348636

c

Funda: Skills/Procedures #103 - Drag and Drop http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4348637

c

Funda: Skills/Procedures #110 - Drag and Drop http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4348638

c

Funda: Skills/Procedures #21 - Drag and Drop http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4348627

c

Funda: Skills/Procedures #31 - Drag and Drop http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4348628

c

Funda: Skills/Procedures #35 - Hotspot http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4338068

c

Funda: Skills/Procedures #43 - Drag and Drop http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4348629

c

Funda: Skills/Procedures #52 - Drag and Drop http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4348630

c

Funda: Skills/Procedures #99 - Hotspot http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4338152

c

Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test? Select all that apply. 1. Avoid the arm on the affected side after a mastectomy 2. Do not make further attempts to draw blood if unsuccessful on first 2 attempts 3. If necessary to use an arm with IV infusing, draw proximal to infusion point 4. Insert the needle bevel up at a 15-degree angle to the skin 5. Obtain a finger capillary specimen from the middle of the finger pad

1,2,4

The nurse is caring for a client with a deep vein thrombosis. The client is prescribed a continuous IV heparin infusion of a standard concentration: heparin 25,000 units in 500 mL D5W. After receiving heparin for 6 hours at the prescribed rate of 1300 units/hr, the client's partial thromboplastin time (PTT) is 44 seconds. The nurse must adjust the infusion rate according to the heparin drip protocol, shown in the exhibit. According to the protocol, at what rate in milliliters per hour should the nurse set the IV infusion pump? Record your answer using a whole number. Click on the exhibit button for additional information. EXHIBIT: https://drive.google.com/open?id=0B40rfZ_HhbqwWG82REc0eENBeTA Answer: (mL/hr)

28

A child on the playground is experiencing an anaphylactic reaction. The school nurse arrives with an EpiPen. The weather is cold and the child is wearing several layers of clothing. How should the nurse proceed with the EpiPen? 1. Inject into the upper arm where the sleeve can be pulled up 2. Inject into the most accessible vein 3. Inject through the clothing into thigh and hold in place for 10 seconds 4. Take the child inside, remove excess clothing, and inject into the thigh

3

A client with end-stage renal disease, oxygen-dependent chronic obstructive pulmonary disease (COPD), and a Do Not Resuscitate (DNR) code status is admitted to the medical floor for COPD exacerbation. The nurse walks into the room and finds that the client is not breathing. What should the nurse do first? 1. Activate the code system 2. Call the health care provider (HCP) stat 3. Check the apical pulse 4. Check the blood pressure

3

An experienced nurse precepts a graduate nurse caring for a hospitalized client who has a prescription for a transfusion of packed red blood cells (RBCs) to be hung over 3 hours. Which statement by the graduate nurse indicates the correct rationale for asking the client to void prior to starting the transfusion? 1. "A drop in blood pressure is expected during the transfusion and getting up to void may cause a fall." 2. "Bedrest is required; therefore, voiding will prevent intermittent catheterization during the procedure." 3. "If a transfusion reaction occurs, it will be important to collect a fresh urine specimen to check for hemolyzed RBCs." 4. "The urine is collected and analyzed prior to starting the transfusion to assess the client's baseline results."

3

The orthopedic health care provider instructs a client with a fractured right femur, who has been non-weight bearing for the past 5 weeks, to progress to full weight bearing on the right leg. Which advanced crutch gait that most closely resembles normal walking should the office nurse teach the client? 1. 2-point gait 2. 3-point gait 3. 4-point gait 4. 5-point gait

3

Which client finding is most important for the nurse to follow up? 1. Client with distinct liver edge even with right costal margin 2. Client with pyelonephritis who has costovertebral angle tenderness 3. Client with rash that has purplish blotches that do not blanch 4. Client with spinal injury whose toes point downward with the Babinski test

3

The charge nurse is instructing a new graduate nurse on performing postmortem care. Which client situations might cause the nurse to delay or not perform postmortem care? Select all that apply. 1. Client died following a prolonged illness 2. Client's family was not present when death occurred 3. Client's religious background requires special ceremonial treatment of the body 4. Death occurred in the emergency department following a suicide attempt 5. Family requests a priest to perform last rites

3,4,5

The nurse is interviewing a non-English-speaking client. Which best practices will the nurse use when working with a professional medical interpreter for clients of limited English proficiency? Select all that apply. 1. Address the interpreter directly 2. Ask the client's adult child to translate 3. Hold a pre-conference with the interpreter 4. Identify any gender or age preferences 5. Speak in short sentences

3,4,5

The nurse is to administer prescribed heparin 70 units/kg IV bolus before initiating the continuous infusion per institution protocol. Heparin 1,000 units/mL is available. The client weighs 108 lb. How many milliliters of heparin bolus should the nurse administer? Record your answer using one decimal place. Answer: (mL)

3.4

An IV infusion of norepinephrine at 8 mcg per minute is prescribed for a client in a shock state. The concentration of norepinephrine is 4 mg in 250 mL dextrose 5% and water (D5W). For how many mL per hour should the nurse program the IV pump? Record your answer using a whole number. Answer: (mL/hr)

30

A health care provider (HCP) prescribes cefuroxime 30 mg/kg/day PO divided in equal doses every 12 hours for a child with a urinary tract infection. The child weighs 32 lb. Based on the cefuroxime label, how many milliliters would the nurse administer per dose? Record your answer using one decimal place. Click the exhibit button for additional information. EXHIBIT: https://drive.google.com/open?id=0B40rfZ_HhbqwdTdjWExIaUZyME0 Answer: (mL)

4.4

The nurse is preparing to administer an antibiotic to a child with a severe respiratory infection. The prescription reads: 7.5 mg/kg every 24 hours divided into 2 doses, to be given by mouth in liquid form. Recommended dosage is 250-500 mg every 24 hours. The client weighs 78 lb. The pharmacy has supplied the drug in 125 mg/5 mL. How many mL should the client receive for each dose? Record your answer using one decimal place. Answer: (mL)

5.3

A client started a 24-hour urine collection test at 6:00 AM. The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 mL at 10:00 AM by mistake but adding all specimens to the collection container before and after that time. What action should the nurse take? 1. Add 250 mL to the total output after the 24-hour urine collection is complete tomorrow morning 2. Discard urine and container, and restart the 24-hour urine collection tomorrow morning 3. Discard urine and container, have client void, add urine to new container, and then restart test 4. Relabel the same collection container, and change the start time from 6:00 AM to 10:00 AM

2

A new graduate nurse is administering enoxaparin to a client. Which action indicates the need for further orientation by the registered nurse preceptor? 1. Discourages the client from rubbing the injection site 2. Ejects air bubble that is in the syringe prior to administration 3. Inserts needle and injects medication at a 90-degree angle 4. Selects an injection site on the left lateral side of the abdomen

2

A nurse in a pediatric clinic is preparing to administer ear drops to a 5-year-old. Which is an appropriate action by the nurse? 1. Have the child sit upright with the chin tilted down 2. Pull the pinna upward and back 3. Remove the medication from the refrigerator just before use 4. Touch the dropper to the entrance of the ear canal

2

The nurse assists a student nurse with the administration of heparin via the subcutaneous route. Which of these steps indicate that the student nurse understands the correct procedure? Select all that apply. 1. Aspirates before injecting medication 2. Cleanses site with alcohol, and gently pinches 1 inch of skin to make a fold 3. Inserts a 3/8 inch 25-29 gauge needle into skin fold at a 90-degree angle and injects drug 4. Massages injection site gently to improve drug absorption 5. Selects a site 2 inches (5 cm) from umbilicus and above iliac crest 6. Waits 5-10 seconds before withdrawing needle and then releases skin fold

2,3,5,6

The nurse plans to start an intravenous (IV) line on a female client hospitalized with pneumonia. The nurse reviews the electronic medical record for relevant information and learns that the client is right-handed and has a history of a left-sided mastectomy with lymph node removal. Which site is best for the nurse to select for the client's IV line? 1. Basilic vein of the left forearm 2. Cephalic vein in the right antecubital space 3. Median vein of the right forearm 4. Radial vein of the left wrist

3

The nurse receives report on 4 clients. Which client should the nurse assess first? 1. Client with end-stage renal disease receiving hemodialysis who reports fever with chills and nausea 2. Client taking ibuprofen for ankylosing spondylitis who reports black-colored stools 3. Client with altered mental status who is not following commands starts vomiting 4. Client with acute diverticulitis receiving antibiotics who reports increasing abdominal pain

3

The nurse teaches a client with newly diagnosed Sjögren's syndrome how to self-administer ophthalmic lubricating ointment medication. Which statement that the client makes indicates the need for further teaching? 1. "After applying the ointment, I'll tightly close my eyes and rub the lid for 2-3 minutes." 2. "I'll squeeze a thin strip of ointment on my lower eyelid, from the inner to the outer edge." 3. "I'll tilt my head back, pull my lower lid down, and look upward when administering the ointment." 4. "I'll use my ointment at bedtime and my eye drops during the day."

1