funds final
Before initiating the blood transfusion, you obtain the patient's baseline vital signs, which are: heart rate 100, blood pressure 115/72, respiratory rate 18, and temperature 100.8'F. Your next action is to: A. Administer the blood transfusion as ordered. B. Hold the blood transfusion and reassess vital signs in 1 hour. C. Notify the physician before starting the transfusion. D. Administer 200 mL of the blood and then reassess the patient's vital signs.
C. Notify the physician before starting the transfusion.
A patient, who had a colostomy placed yesterday, calls on the call light to say their surgical dressing "fell off". You will re-apply what type of dressing over the stoma? A. Wet to dressing B. No dressing is needed. You will keep it open to air. C. Petroleum gauze dressing D. Telfa gauze
C. Petroleum gauze dressing
Your patient in droplet precautions has family visiting. A family member asks how far they should stand away from the patient while visiting. Your response is: A. 2 feet or more B. 3 feet or more C. Stand at the doorway D. 6 feet or more
B. 3 feet or more
You're providing diet teaching to a patient with an ileostomy. Which foods should the patient consume in very small amounts or completely avoid? A. Peanut butter, bananas, rice B. Corn, popcorn, nut and seeds C. Grape juice, bread, and pasta D. Vinegar, soft drinks, and cured meats
B. Corn, popcorn, nut and seeds
Your patient is having a transfusion reaction. You immediately stop the transfusion. Next you will: A. Notify the physician. B. Disconnect the blood tubing from the IV site and replace it with a new IV tubing set-up and keep the vein open with normal saline 0.9%. C. Collect urine sample. D. Send the blood tubing and bag to the blood bank.
B. Disconnect the blood tubing from the IV site and replace it with a new IV tubing set-up and keep the vein open with normal saline 0.9%.
A patient is about to have their chest tube removed by the physician. As the nurse assisting with the removal, which of the following actions will you perform? Select-all-that-apply: A. Educate the patient how to take a deep breath out and inhale rapidly while the tube in being removed. B. Gather supplies needed which will include a petroleum gauze dressing per physician preference. C. Place the patient in Semi-Fowler's position. D. Have the patient take a deep breath, exhale, and bear down during removal of the tube. E. Pre-medicate prior to removal as ordered by the physician. F. Place the patient is prone position after removal.
B. Gather supplies needed which will include a petroleum gauze dressing per physician preference. C. Place the patient in Semi-Fowler's position. D. Have the patient take a deep breath, exhale, and bear down during removal of the tube. E. Pre-medicate prior to removal as ordered by the physician.
A patient with Disseminated Herpes Zoster requires routine tracheostomy suction. Select the appropriate PPE you will wear: A. Surgical mask, goggles, gown B. N95 mask, face shield, gown, gloves C. N95 mask, gown, face shield D. Surgical mask, face shield, gown, gloves
B. N95 mask, face shield, gown, gloves
While helping a patient with a chest tube reposition in the bed, the chest tube becomes dislodged. What is your immediate nursing intervention? A. Stay with the patient and monitor their vital signs while another nurse notifies the physician. B. Place a sterile dressing over the site and tape it on three sides and notify the physician. C. Attempt to re-insert the tube. D. Keep the site open to air and notify the physician.
B. Place a sterile dressing over the site and tape it on three sides and notify the physician.
A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this? A. This is an expected finding. B. The lung may have re-expanded or there is a kink in the system. C. The system is broken and needs to be replaced. D. There is an air leak in the tubing.
B. The lung may have re-expanded or there is a kink in the system.
A patient is 2 days post-opt from an ileostomy placement. Which finding requires immediate nursing action? A. The stoma is excreting liquid stool. B. The patient's potassium level is 2.0 C. The stoma is bright red and moist. D. The patient reports mucoid drainage from the anus.
B. The patient's potassium level is 2.0
A patient is 8 hours post-opt from an colostomy placement. Which finding requires immediate nursing action? A. The stoma is swollen and large. B. The stoma is black. C. The stoma is not draining any stool. D. The patient states the site is tender.
B. The stoma is black.
Mr. Jay has a fecal impaction. The nurse correctly administers an oil-retention Enema by doing which of the following? A) Administering a large volume solution 500 to 1000 ml B) Mixing milk and molasses and equal parts for an enema C) Instructing the patient to retain the enema for at least 30 seconds D) Administering the enema while the patient is sitting on a toilet
C) Instructing the patient to retain the enema for at least 30 seconds
Your patient needs 1 unit of packed red blood cells. You've completed all the prep and the blood bank notifies you the patient's unit of blood is ready. You send for the blood and the transporter arrives with the unit at 1200. You know that you must start transfusing the blood within _________. A. 5 minutes B. 15 minutes C. 30 minutes D. 1 hour
C. 30 minutes
Gas exchange in the lungs occurs in the? A. Bronchioles B. Alveolar sinus C. Alveolar sacs D. Segmental Bronchi
C. Alveolar sacs
You receive a doctor's order for a patient to take Aspirin EC by mouth daily. The patient has the following medication history: diabetes type 2, peripheral vascular disease, and a permanent ileostomy. What is your next nursing action? A. Administer the medication as ordered. B. Crush the medication and mix it in applesauce. C. Hold the medication and notify the doctor the patient has an ileostomy. D. Crush the medication and mix it in pudding
C. Hold the medication and notify the doctor the patient has an ileostomy.
When inserting an indwelling urinary catheter in a male patient, the nurse cleanses the penis with an antiseptic wash. Which step should she take next? 1) Gently insert the tip of the prefilled syringe into the urethra to instill the lubricant. 2) Ask the patient to bear down as though trying to void. 3) Slowly insert the end of the catheter into the urinary meatus. 4) Insert the catheter about 7 to 9 inches (17 to 22.5 cm) or until urine flows.
1) Gently insert the tip of the prefilled syringe into the urethra to instill the lubricant.
A client has just voided 50 mL, but reports that his bladder still feels full. The nurse's next actions should include: (Select all that apply.) 1) palpating the bladder height. 2) obtaining a clean-catch urine specimen. 3) performing a bladder scan. 4) asking the patient about his recent voiding history. 5) encouraging the patient to consume cranberry juice daily. 6) inserting a straight catheter to measure residual urine.
1, 2, 4
The HCP order is 500 mL 0.9% NaCl IV over 4 hours. Which rate does a nurse program into the infusion pump? 125 mL/hr 167 mL/hr 200 mL/hr 1000 mL/hr
125 mL/hr
An IV fluid is infusing more slowly than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (SELECT ALL) a. Infiltration at vascular access device site b. Patient lying on tubing c. Roller clamp wide open d. Tubing kinked in bedrails e. Circulatory overload
a. Infiltration at vascular access device site b. Patient lying on tubing d. Tubing kinked in bedrails
A patient with a pneumothorax has a chest tube present. The water seal chamber has continuous bubbling. What intervention would you take? Notify the MD because there is a leak in the system. This is normal and expected because the patient has a pneumothorax. Increase the suction 2-5 mmHg until bubbling stops. None of the above are correct.
Notify the MD because there is a leak in the system.
a. nonblanchable redness, intact skin b. full-thickness skin loss, fat may be visible c. full thickness tissue loss, muschl and bone visible d. partial thickness skin loss or intact blister with serosanguinous fluid
a. stage 1 b. stage 3 c. stage 4 d. stage 2
The nurse must irrigate the colostomy of a patient who is unable to move independently. How should the nurse position the patient for this procedure? 1) Semi-Fowler's position 2) Left side-lying position 3) Supine, with the head of the bed lowered flat 4) Supine, with the head of bed raised to 30 degrees
2) Left side-lying position
For residents with a feeding tube, the head of bed should be positioned at: 15-30 degrees. 30-45 degrees. 45-75 degrees. 75-90 degrees.
30-45 degrees.
Select ALL the patients that would be placed in droplet precautions: A. A 5 year old patient with Chicken Pox. B. A 36 year old patient with Pertussis. C. A 25 year old patient with Scarlet Fever. D. A 56 year old patient with Tuberculosis. E. A 69 year old patient with Streptococcal Pharyngitis. F. A 89 year old patient with C. Diff.
A 36 year old patient with Pertussis. C. A 25 year old patient with Scarlet Fever. E. A 69 year old patient with Streptococcal Pharyngitis.
Which patient would benefit from a Nasogastric Tube? A stroke victim who failed their swallow evaluation A patient with Congestive Heart Failure A patient who had a left leg amputation A patient with a Platelet count of 50
A stroke victim who failed their swallow evaluation
Which of the following are included in the nursing plan of care to prevent adverse effects when caring for patients with a nasogastric tube in place for gastric decompression's? Select all that apply. A) Irrigation with Saline B) Measure the length of exposed tube C) Measure the pH of the aspirated tube contents D) Administer frequent oral hygiene
A) Irrigation with Saline B) Measure the length of exposed tube C) Measure the pH of the aspirated tube contents D) Administer frequent oral hygiene
As the nurse you know that there is a risk of a transfusion reaction during the administration of red blood cells. Which patient below it is at most RISK for a febrile (non-hemolytic) transfusion reaction? A. A 38 year old male who has received multiple blood transfusions in the past year. B. A 42 year old female who is immunocompromised. C. A 78 year old male who is B+ that just received AB+ blood during a transfusion. D. A 25 year old female who is AB+ and just received B+ blood.
A. A 38 year old male who has received multiple blood transfusions in the past year.
A patient is diagnosed with Hepatitis A and is incontinent of stool. What type of precautions would be initiated? A. Contact B. Standard C. Droplet D. Contact and Droplet
A. Contact
Your patient has a PEG tube and you are about to administer a feeding. While checking residual you obtain 95 ml of stomach contents. What would be your next nursing intervention? Hold the feeding and immediately notify the MD of the assessed amount of residual Administered the scheduled feeding Wait 30 minutes and reassess residual Skip this scheduled feeding and administer the next feeding due in 6 hours
Administered the scheduled feeding
You just inserted a Nasogastric tube. Which of the following is not a correct way to check correct placement of the tube? Administering a 100cc Water flush and assessing for patient coughing Obtaining a sample of GI contents through the tube by aspirating Following the MD order for an X-ray to confirm placement Checking pH of GI contents to be at 1 to 3.5
Administering a 100cc Water flush and assessing for patient coughing
A patient is receiving positive pressure mechanical ventilation and has a chest tube. When assessing the water seal chamber what do you expect to find? A. The water in the chamber will increase during inspiration and decrease during expiration. B. There will be continuous bubbling noted in the chamber. C. The water in the chamber will decrease during inspiration and increase during expiration. D. The water in the chamber will not move.
C. The water in the chamber will decrease during inspiration and increase during expiration.
You're providing teaching to a patient with an ileostomy on how to change their pouch drainage system. Which statement is INCORRECT about how to change a pouching system for an ostomy? Empty the pouch when it is 1/3 to 1/2 full. B. Change the pouching system every 3-5 days. C. When measuring the stoma for skin barrier placement, be sure the opening of the skin barrier is a 2/3 inch larger than the stoma. D. Keep the skin around the stoma clean and dry at all times.
C. When measuring the stoma for skin barrier placement, be sure the opening of the skin barrier is a 2/3 inch larger than the stoma.
The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action? Leaves the catheter in place and gets a new sterile catheter. Leaves the catheter in place and asks another nurse to attempt the procedure. Removes the catheter and redirects it to the urinary meatus. Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus.
Leaves the catheter in place and gets a new sterile catheter.
Which of the following is an appropriate nursing action to promote regular bowel habits? A) Encourage the patient to avoid moving his bowels until a certain time of day B) Encourage the patient to avoid excess fluid intake and too much fiber C) Avoid strenuous exercise to limit stress on the abdominal muscles and impair peristalsis D) Assisting the patient to a normal position as possible to defecate
D) Assisting the patient to a normal position as possible to defecate
As the nurse prepares to assist Mrs. P with her newly created Ileostomy, She is aware of which of the following? A) An appliance will not be required on the continual basis B) The size of the stoma stabilizes within two weeks C) Irrigation is necessary for regulation D) Fecal drainage will be liquid
D) Fecal drainage will be liquid
A patient who needs a unit of packed red blood cells is ordered by the physician to be premeditated with oral diphenhydramine and acetaminophen. You will administer these medications? A. 15 minutes before starting the transfusion B. Immediately after starting the transfusion C. Right before starting the transfusion D. 30 minutes before starting the transfusion
D. 30 minutes before starting the transfusion
A patient is receiving 1 unit of packed red blood cells. The unit of blood will be done at 1200. The patient is scheduled to have IV antibiotics at 1000. As the nurse you will: A. Stop the blood transfusion and administer the IV antibiotic, and when the antibiotic is done resume the blood transfusion. B. Administer the IV antibiotic via secondary tubing into the blood transfusion's y-tubing. C. Hold the antibiotic until the blood transfusion is done. D. Administer the IV antibiotic as scheduled in a second IV access site.
D. Administer the IV antibiotic as scheduled in a second IV access site.
*A nurse accidently gives a patient the medications that were ordered for the patient's roommate. What is the nurse's first priority?* A. Complete an occurrence report. B. Notify the health care provider. C. Inform the charge nurse of the error. D. Assess the patient for adverse effects.
D. Assess the patient for adverse effects.
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? A. Reposition the patient because the tubing is kinked. B. Continue to monitor the drainage system. C. Increase the suction to the drainage system until the bubbling stops. D. Check the drainage system for an air leak.
D. Check the drainage system for an air leak.
The patient in room 2569 calls on the call light to tell you something is wrong with his chest tube. When you arrive to the room you note that the drainage system has fallen on its side and is leaking drainage onto the floor from a crack in the system. What is your next PRIORITY? Place the patient in supine position and clamp the tubing. B. Notify the physician immediately. C. Disconnect the drainage system and get a new one. D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.
D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.
You're gathering supplies to start a blood transfusion. You will gather? A. PVC free tubing and dextrose B. Polyethylene-line tubing and 0.9% Normal Saline C. Y-tubing with in-line filter and dextrose D. Y-tubing with in-line and 0.9% Normal Saline
D. Y-tubing with in-line and 0.9% Normal Saline
Before a blood transfusion you educate the patient to immediately report which of the following signs and symptoms during the blood transfusion that could represent a transfusion reaction: A. Crackles B. high fever and hypotension C. anxiety, itching, confusion D. chills, tachycardia, flushing
D. chills, tachycardia, flushing
You're assessing a patient who is post-opt from a chest tube insertion. On assessment, you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of water in the water seal chamber when the patient breathes in and out, and bubbling in the suction control chamber. Which of the following is the most appropriate nursing intervention? A. Document your findings as normal. B. Assess for an air leak due to bubbling noted in the suction chamber. C. Notify the physician about the drainage. D. Milk the tubing to ensure patency of the tubes
Document your findings as normal.
A patient with a tracheostomy needs to be suctioned. What would you do first before suctioning the patient? Hyperoxygenate the patient before suctioning Assist the patient into Sim's position Disconnect pulse oximetry Have the patient bear down
Hyperoxygenate the patient before suctioning
Your patient has a PEG tube and you are about to administer a tube feeding using the feeding pump. You note that the last feeding tube hanging on the pole is labeled Aug 16 and today's date is Aug 18. Which nursing action is correct. Immediately discard the tubing and open a new package of tubing before proceeding with the feeding Continue to administer the feeding because the tubing is good for 4 days Change the adapter cap at the end of the tubing Notify the MD for further orders
Immediately discard the tubing and open a new package of tubing before proceeding with the feeding
During inhalation, the diaphragm contracts DOWNWARD to create NEGATIVE pressure in the chest which allows the body to inhale oxygen. True False
True
You're patient is being transported to special procedures for a PICC line placement. The patient is in droplet precautions. What are your nursing actions to ensure proper transport of the patient? A. Notify the receiving department and place a surgical mask on the patient. B. Place an N95 mask on the patient and notify the receiving department. C. Cancel transport and notify the physician for further orders. D. Notify the receiving department and place goggles, gown, and mask on the patient.
Notify the receiving department and place a surgical mask on the patient.
What is the FIRST priority in preventing transmission of infections? Wearing sterile non-latex gloves Wiping stethoscopes with alcohol Wearing gowns and goggles Performing proper hand hygiene
Performing proper hand hygiene
During the morning assessment of your patient with a chest tube, you note that there is no fluctuation in the water seal chamber. The patient does not appear to be in respiratory distress. What could have caused this ceasing of fluctuation? The lung may have re-expanded. The water in the seal chamber is inadequate. The collection chamber is full. The dry suction is turned on high.
The lung may have re-expanded.
Your patient has an endotracheal tube. You are assessing placement by listening to the lung sounds and you notice that the breath sounds and chest wall movement are absent on the left side? What is usually the cause of this? The tube may be displaced in the right main stem bronchus A pneumothorax may be developing and a STAT chest x-ray should be ordered The incorrect size tubing was used The tube is not above the carina and must be re-inserted
The tube may be displaced in the right main stem bronchus
You are assessing your patient with an endotracheal tube and note that the patient is able to make verbal sounds. What is the most likely cause? There is a leak. There is an occlusion. The tube is displaced. None of the above. This is normal
There is a leak.
Your patient has a chest tube. Your assessing the water seal chamber and you note that the water moves up as the patient inhales and then moves down when the patient exhales. What may be causing this to happen? This is normal and expected. The chest tube has a leak. The left chest tube is occluded. The water seal suction should be increased 2-5 mmHG.
This is normal and expected.
Which of the following changes in elimination would most likely occur in a client who is unable to get out of bed and is immobile? Select all that apply. Positive nitrogen balance Urinary stasis Increased risk of kidney stones Diarrhea UTIs
Urinary stasis Increased risk of kidney stones UTIs
a pediatric nurse takes a medication to a 12-year old female patient. the patient tells the nurse to take it away because she is not going to take it. what is the nurse's next action? ask the patients reason for refusal consult with the patients parents for advice take the medication away and chart the patients refusal tell the patient that her health care provider knows what is best for her
ask the patients reason for refusal
the nursing assistive personnel reports to the nurse. that a patient's catheter drainage bag has been empty for 4 hours. what is a priority nursing intervention? implement the as needed order to irrigate the catheter assess the catheter and drainage tubing for obvious occlusion notify the HCP immediately assess the vital signs and I&O record
assess the catheter and drainage tubing for obvious occlusion
after receiving an IM injection in the deltoid, a patient states "My arm really hurts. It's burning and tingling where I got my injection". What should the nurse do next. select all that apply assess the injection site administer a PO med for pain notify the patients HCP of assessment findings document assessment finding and related interventions in the patient's medical record this is a normal finding so do nothing apply ice to the site for relief of burning pain
assess the injection site notify the patients HCP of assessment findings document assessment finding and related interventions in the patient's medical record
a post-op patient with a three-way indwelling catheter and continuous bladder irrigation complains of lower abdominal pain and distention. what should be the nurse's initial intervention? increase the rate of the CBI assess the intake and output from system decrease the rate of CBI assess vital signs
assess the intake and output from system
For which of the following health problems is a patient who has a 40-year old history of smoking at risk? alcoholism, HTN obesity, diabetes stress related illnesses cardiopulmonary disease, lung cancer
cardiopulmonary disease, lung cancer
a patient is receiving total parenteral nutrition (TPN). what is the primary intervention the nurse should follow to prevent a central line infection? institue isolation precautions clean the central line port through which the TPN is infusing with antiseptic change the TPN tubing every 24 hours monitor glucose levels to watch and assess for glucose intolerance
clean the central line port through which the TPN is infusing with antiseptic
which nursing intervention decreases the risk for catheter associate UTI? cleansing the urinary meatus 3 to 4 times daily with antiseptic solution hanging the urinary drainage bag below the level of the bladder empyting the urinary drainage bag daily irrigating the urinary catheter with sterile water
cleansing the urinary meatus 3 to 4 times daily with antiseptic solution
An 86 year old woman is admitted to the unit with chills and a fever of 104. What physiological process explains why she is at risk for dyspnea? fever increases metabolic demands, requiring increased O2 need blood glucose stores are depleted and the cells do not have energy to use O2 Co2 production increases due to hyperventilation Co2 production decreases due to hypoventilation
fever increases metabolic demands, requiring increased O2 need
the nurse is caring for a patient who has decreased mobility. which intervention is a simple and cost-effective method for reducing the risks of pulmonary complication? antibiotics frequent change of position oxygen humidification chest physiotherapy
frequent change of position
A sign of severe foreign body airway obstruction is: air movement. being able to talk. coughing. grasping the throat.
grasping the throat.
a patient has newly been diagnosed with chronic lung disease. in discussing the lung disease with the nurse, which of the patient's statements would indicate a need for further education? "ill make sure that I rest between activities so I don't get SOB" "ill practice the pursed lip breathing technique to improve my exercise tolerance" if i have trouble breathing at night, ill use two or three pillows to prop up if i get SOB, ill turn up my O2 level to 6 L/min
if i get SOB, ill turn up my O2 level to 6 L/min
a patient is admitted with the diagnosis of severe left sided heart failure. what adventitious lung sounds are expected on auscultation? sonorous wheezes in the left lower lung rhonchi mid sternum crackles only in apex of lungs inspiratory crackles in lung bases
inspiratory crackles in lung bases
when assessing a patients first voided urine of the day, which finding should be reported to the health care provider? pale yellow urine slightly cloudy urine light pink urine dark amber urine
light pink urine
Which would be a contributing factor for increased risk of infection in the elderly? increased circulation limited mobility low-sodium strong immune system
limited mobility
which of the following skills can the nurse delegate to the nursing assistive personnel (NAP) select all that apply nasotracheal suctioning oropharyngeal suctioning of stable patient suctioning a new artificial airway permanent tracheostomy tube suctioning care of endotracheal tube
oropharyngeal suctioning of stable patient permanent tracheostomy tube suctioning
the nurse assess a new patient and finds the patient SOB with a RR of 32 and lying supine in bed. What is the priority nursing action? raise the HOB to 45 degrees or higher get the O2 saturation with a pulse oximeter take the BP and RR notify the HCP of SOB
raise the HOB to 45 degrees or higher
two hours after surgery, the nurse assesses a patient who had a chest tube inserted during surgery. there is 200mL of dark red drainage in the chest tube at this time. what is the appropriate action for the nurse to perform? record the amount and continue to monitor drainage notify the physician strip the chest tube starting at the chest increase the suction by 10mmHg
record the amount and continue to monitor drainage
a nursing student is administering ampicillin PO. the expiration date on the medication wrapper was yesterday. what is the appropriate action for the nursing student to take next? ask the nursing professor for advice return the medication to pharmacy and get another tablet call the health care provider after discussing this situation with the charge nurse administer the medication since medications are good for 30 days after their expiration date
return the medication to pharmacy and get another tablet
the nurse is caring for a patient with dysphagia and is feeding her pureed chicken diet when she begins to choke. what is the priority nursing intervention? suction her mouth and throat turn her on her side put on O2 at 2 L- nasal cannula stop feeding her and place on NPO
stop feeding her and place on NPO
During gas exchange, carbon dioxide is transported across the capillary membrane to be exhaled while oxygen is transported across the capillary membrane to attach to the red blood cells. True False
true
True or False: Patients with an ileostomy are at greater risk for dehydration and an electrolyte imbalance. True False
true
which of the following are measures to reduce tissue damage from shear. select all that apply use a transfer device have HOB elevated when transferring patient have HOB flat when repositioning patient raise HOB 60 degrees when patient positioned supine raise HOB 30 degrees when patient positioned supine
use a transfer device have HOB flat when repositioning patient raise HOB 30 degrees when patient positioned supine
