N250L Week 6 Quiz
A nurse in the diabetic clinic is assessing blood glucose levels in patients ranging from infants to the elderly. Which techniques would best ensure that the nurse obtains an adequate amount of blood for testing any of these patients? (Select all that apply.) Hold the area to be punctured in a dependent position. Squeeze the area to be punctured. Warm the area to be punctured. Gently hit the area to be punctured
Hold the area to be punctured in a dependent position. (Having the puncture site in dependent position increases blood flow to the area. Warming the area to be punctured promotes vasodilation, which facilitates bleeding. Squeezing and gently hitting the area are not appropriate actions.) Warm the area to be punctured. Having the puncture site in dependent position increases blood flow to the area. (Warming the area to be punctured promotes vasodilation, which facilitates bleeding. Squeezing and gently hitting the area are not appropriate actions.)
a urine specimen for culture and sensitivity is being collected from a male patient. Which steps would be used to obtain an accurate specimen? (SATA) 1. . Check 2 pt. identifiers 2. Help patient to perform pericare before the sterile part of the procedure 3. Wipe head of the penis back and fort 3 times with each swab 4. collect 10 to 20 mL for the sample 5. have patient initially void into a bedpan or clean container 6. have patient hold penis above the sterile specimen cup without touching the container
1, 2, 5, 6 Rationale: Two identifiers are required to ensure correct patient. Pericare before collection of specimen reduces the number of organisms. The head of the penis is cleaned with a circular motion. A 90- to 120-mL amount of urine is collected. Having patient initially void flushes microorganisms that normally accumulate in the urethra. Holding the penis above the cup prevents touching, thus contaminat- ing the container.
the nurse is preparing to obtain a throat culture on a 22-year-old demale. Which steps would facilitate obtaining an accurate specimen? 1. Placing patient in a sitting position or with head elevated at a 45 degree angle 2. having patient lean forward 3. insterting swab without toughing lip, teeth, tough, or cheeks 4. swabbing the tonsillar area 5. swabbing the uvula 6. having patient blwo her nose
1, 3, 4 Rationale: The head of the bed elevated to 45 degrees and the patient leaning back against the bed allow for easy access to oral struc- tures. Careful insertion of swab without touching lips, teeth, tongue, or cheeks prevents contamination with organisms of the oral cavity. Swabbing the tonsillar area is correct, but not the uvula. Having her blow her nose is not indicated for a throat culture but is recommended when obtaining a nasal culture.
Which of the following are necessary to prepare the patient for postural drainage? (Select all that apply.) a. Encourage fluid intake of 1500 to 2000 mL. b. Explain the procedure and positioning techniques. c. Schedule treatment 1 to 2 hours after meals. d. Coordinate treatments with other respiratory or medical therapies.
a. Encourage fluid intake of 1500 to 2000 mL. b. Explain the procedure and positioning techniques. c. Schedule treatment 1 to 2 hours after meals. d. Coordinate treatments with other respiratory or medical therapies. Coordinating therapy around a patient's meals and activities reduces the risks for aspiration, conflict with other therapies, and fatigue. In addition, adequate fluid intake helps to liquefy secretions so the patient can easily clear them. As always, informing patients of any therapy promotes cooperation and decreases anxiety.
cardiac monitoring via telemetry has begun, and the telemetry technicaian keep calling to report artifact on the patient's electrocardiogram (ECG) rhythm,. How would you trouble shoot this artifact problem? 1 moving electrodes to different locations on the chest 2. wiping electrode skin areas with alcohol]3. preparing skin by washing with soap and water and drying with a washcloth 4. not changin electrodes for 2 days 5. inspecting electrodes for secure placement
1, 3, 4, 5 Rationale: Coordinating therapy around meals and activi- ties reduces the risk for aspiration, conflict with other therapies, or fatigue. In addition, adequate fluid intake may help to liquefy secretions so the patient can easily clear the secretions. As always, informing patients of any therapy helps promote cooperation and decreases anxiety. Selection of lung regions for CPT is made on the basis of patient assessment.
Place the following steps for collecting a sterile urine specimen for a culure and sensitivity from a Luer-Lok Cather port in the correct order 1. Attach the Luer-Lok port 2. Clamp drainage tube with clamp or rubber band for 15 minutes 3. Clearn catherter entry port and wait for disinfectant to dry 4. Unclamp catherter and allow urine to flow into drainage bag 5. apirate 3 mL of urine into syringe attached to Luer-Lok
2, 3, 1, 5, 4 Rationale: Clamping tube for 15 minutes allows for the collection of fresh sterile urine. Cleansing port prevents entry of microorganisms into catheter and contamination of specimen. Use of Luer-Lok syringe prevents injury by needlestick. Collection of proper volume is needed to perform the test. Unclamping catheter allows drainage of urine to prevent stasis of urine in bladder.
Mr. Thomas is scheduled for chest physiotherapy. Place in correct order the following steps. 1. Obtain vital signs and pulse oximetry. 2. Place patient in proper position to drain selected lung segment. 3. Maintain position for 10 to 15 minutes.4. Perform chest physiotherapy maneuvers. 5. Perform respiratory assessment. 6. Provide rest period between positions.
5, 1, 2, 3, 4, 6 Complete respiratory assessment reveals the lung segments requiring postural drainage. Baseline vital signs and pulse oximetry reading provide information regarding patient tolerance of the procedure. Proper positioning and drainage techniques are needed to clear selected lung segments and airways. It is important to have the patient in the correct position before therapy is begun. Providing rest periods helps the patient tolerate the complete procedure.
A postoperative patient is suspected of having a wound infection. Which method would be most appropriate for the nurse to use when obtaining an anaerobic culture? Touching the wound edges with the swab from the culture tube Aspirating the drainage using a 21-gauge needle attached to a syringe Using the culture swab, then crushing the attached medium ampule Aspirating the drainage using the sterile tip of a 10-mL syringe
Aspirating the drainage using the sterile tip of a 10-mL syringe For an anaerobic culture, the specimen must be placed in a special medium container. No needle is used in the wound area to obtain the specimen; the standard culture swab with the attached medium ampule is also not used.
A patient is receiving chest physiotherapy in the home setting. The home health nurse observes the session and notes that the patient is not tolerating the procedure well. Which of the following is the best choice for modifying care? a.Reduce treatments by 2 per day. b. Suggest using an Acapella device. c. let the patient select when treatment is given. d. Administer a bronchodilator therapy.
B. Suggest using an Acapella device. An Acapella device in conjunction with CPT maneuvers provides airway vibration and assists in clearing the airways. Reducing treatment sessions at all is not acceptable because the patient needs the therapy. The nurse may shorten the session if the patient is able to clear the airway with a shorter session. Administering a bronchodilator requires an order from the health care provider; this would take some time, and the nurse can institute other therapies. Letting the patient select when to have CPT therapy may not be appropriate in that these therapies may have to be scheduled at specific time periods.
indiactions for a 12-lead electrogardiocragm (ECG) include: (SATA) 1. suspected acute coronary syndromes, including myocardial infarction 2. evaluation of implanted defibrillators and pacemakers 3. Disorders of the cardiac rhythm 4. evaluation of syncope 5. evaluation of metabolic disorders 6. effects and side effects of pharmacotherapy
Correct order: 5, 1, 2, 3, 4, 6 5. evaluation of metabolic disorders 1. suspected acute coronary syndromes, including myocardial infarction 2. evaluation of implanted defibrillators and pacemakers 3. Disorders of the cardiac rhythm 4. evaluation of syncope 6. effects and side effects of pharmacotherapy Rationale: Respiratory assessment deter- mines the lung segments requiring PD. Baseline vital signs and oxim- eter provide information regarding patient tolerance of the procedure. Proper positioning and drainage techniques are needed to clear selected lung segments and airways. It is important to have the patient in the correct position before initiating therapy. Providing rest periods helps the patient tolerate the complete procedure.
A patient with suspected sepsis is to have blood cultures obtained but is currently receiving antibiotics. What is the most appropriate nursing action? Call the physician for further clarification of the order. Stop the scheduled antibiotics until the specimens are drawn. Notify the laboratory which antibiotics the patient is receiving. Scrub the venipuncture site for 2 minutes for a sterile specimen.
Notify the laboratory which antibiotics the patient is receiving. Because antibiotics may interrupt growth of the organism in the laboratory, the nurse must notify the laboratory regarding the antibiotics the patient is currently receiving. It is always best to initiate blood cultures before a patient begins antibiotic therapy, but the patient may develop an infection against which the ordered antibiotic is not effective. The antibiotics should not be stopped.
A patient is to be placed on a ventilator. Which nursing action has been found to be most effective in reducing the risk for ventilator-associated pneumonia? Performing mouth care at least 4 times a day Repositioning the patient every 2 to 3 hours Assessing lung sounds every shift Performing range-of-motion exercises 3 times a day
Performing mouth care at least 4 times a day Studies have shown that frequent mouth care decreases the incidence of ventilator-associated pneumonia. The other procedures are important to do, but they do not affect the incidence of ventilator-associated pneumonia.
A patient needs to expectorate a sputum specimen. The nurse's teaching has been effective if the patient is seen doing which activity as part of the procedure? Brushing his teeth with toothpaste before producing the specimen Rinsing his mouth with mouthwash before producing the specimen Providing the specimen immediately after awakening before eating Taking a few sips of water to loosen respiratory secretions
Providing the specimen immediately after awakening before eating The ideal time to collect sputum is early morning because bronchial secretions tend to accumulate during the night. The sputum specimen will be most concentrated and free of food particles if obtained before breakfast. Toothpaste and mouthwashes decrease the viability of microorganisms and therefore should not be used.
An unconscious elderly patient with poor circulation has to have an arterial blood gas drawn. Which nursing diagnosis would be given priority during and after the procedure? Ineffective airway clearance Impaired gas exchange Risk for injury Deficient knowledge regarding arterial blood gases
Risk for injury The site used is of great importance because the patient has poor circulation. Injury could occur if the wrong site was used, or if the technique was inappropriately done. The radial area is often used because a strong pulse is usually palpable. The patient is unconscious, so knowledge deficit would not be an appropriate nursing diagnosis, and the focus of the question is on the procedure, not on the underlying problem for which the procedure is needed.
A patient with pulmonary edema had BiPAP started 30 minutes ago. The nurse should inform the patient that he will undergo which diagnostic test shortly? a. Arterial blood gas b. Chest x-ray c. Pulmonary function test d. Pulse oximetry reading
a. Arterial blood gas When a patient is placed on noninvasive positive-pressure ventilation (BiPAP), it is necessary to evaluate the oxygenation and ventilation status of the patient. Although an arterial blood gas is an invasive procedure, it is important to know the patient's oxygen and carbon dioxide levels. Chest x-ray will provide information on fluid overload, and a pulmonary function test is inappropriate when a patient is acutely ill. A pulse oximetry reading would yield information on oxygenation.
Which of the following CPT maneuvers can be delegated? (Select all that apply.) a. Postural drainage b. Acapella device c. Vibration d. Shaking
a. Postural drainage b. Acapella device c. Vibration d. Shaking All of these maneuvers may be delegated to assistive personnel. However, the nurse is responsible for performing respiratory assessment, reviewing the chest x-ray when appropriate, and determining that the patient is stable for the procedure.
The low-pressure alarm has sounded on a patient's ventilator. The nurse should check for which of the following situations? a. The ventilator circuit has a leak. b. The patient coughed during the inspiratory cycle. c. The airway needs suctioning. d. The patient is biting on the endotracheal tube.
a. The ventilator circuit has a leak. The two most common causes for the low-pressure alarm sounding (indicating a sudden drop in pressure) are a leak in the ventilate circuit or the patient tube becoming disconnected from the ventilator. Patient coughing or biting on the ET tube may cause the high-pressure alarm to sound. Secretions building up in the airway may cause a decrease in the pressure but not a sudden drop. Suctioning is the correct way to address that situation when identified.
The nurse is assessing a patient who is experiencing respiratory distress. which findings would best indicate the need ofr supplemental oxygen therapy? (SATA) A. shortness of breath B. PsO2 58 mmHg C. SpO2 89% D. Dimished breath shounds in all lobes E. Cyanosis of ral mucosa membranes
b, c, e Rationale: Oxygen is administered to treat hypoxemia as evidenced by an SpO2 less than 90% or a PaO2 less than 60 mm Hg. Cyanosis around oral mucous membranes can indicate hypoxemia. Shortness of breath and diminished breath sounds are not indicators for patient need of oxygen unless accompanied by the other findings.
The nurse is caring for a patient recieving BiPAP ventilation via face mask for treatment of respiratory distress. Which interventions can be delegated to nursing assistant personal? A. Educating the patient and family about the use of BiPAP B. Repositioning patin in bed or chair C. Titrating patient's FiO2 D. Adjusting mask if it becomes displaced E. Recording patient's SpO2 level F. Assessming patient's respiratory status
b, d, e Rationale: NAPs cannot perform a complete respiratory assessment; they can measure respirations in stable patients. NAPs cannot educate patients and families. These tasks and skills fall under the nurse's scope of practice and should be performed by the nurse. Oxygen is a medication and should not be titrated or adjusted by unlicensed personnel. This also falls under the nurse's scope of practice. The NAP is allowed to reposition patients, help adjust oxygen-delivery devices if they are uncomfortable or not properly placed, and record the patient's SpO2 level in the health record.
The nurse is teaching the patient how to use the peak flowmeter. The nurse asks the patient to demonstrate the procedure. Place the steps of using a peak flowmeter in the correct order a. Having patient take deep breath and hold it b. place marker of meter at bottom of scale c. have patient place mouthpiece in his or her mouth d. have patient blow out as hard and fast as possible e. have patient stand up, if able f. record the value
b, e, a, c, d, f b. place marker of meter at bottom of scale e. have patient stand up, if able a. Having patient take deep breath and hold it c. have patient place mouthpiece in his or her mouth d. have patient blow out as hard and fast as possible f. record the value Rationale: Organized teaching for a peak flowmeter. Refer to Procedural Guideline 23.1 for correct order of steps.
Before discharge, the nurse designs a patient teaching plan to help the patient and family correctly perform chest physiotherapy. Why is this teaching an important aspect of patient safety? a. Reduces readmission to a health care facility. b. Decreases the amount of medical equipment needed in the home care setting. c. Because patients and families need to know changes or effects associated with chest PT and when to notify the health care provider. d. Decreases anxiety of the family caregiver.
c. Because patients and families need to know changes or effects associated with chest PT and when to notify the health care provider. The patient and the caregiver need to know and recognize changes in the patient's respiratory or physiological status to determine the effectiveness of therapy and to know when they should inform the health care provider of the need for additional therapy.
Use of noninvasive positive-pressure ventilation (CPAP or BiPAP) has the potential to cause carbon dioxide retention in selected patients. Patients with which of the following underlying diagnoses are at greatest risk for carbon dioxide retention? a. Heart failure b. Pulmonary fibrosis c. Chronic obstructive pulmonary disease d. Pulmonary edema
c. Chronic obstructive pulmonary disease Patients diagnosed with COPD who have ventilatory failure are at risk to retain carbon dioxide. Patients with heart failure, pulmonary fibrosis, or pulmonary edema are at greatest risk for oxygen failure.
The nurse is providing discharge instructions to a patient regarding the use of their peak flowmeter. Which statement by the patient indicates the need for further education? a. "I should measure my peak flow at the same time every day." b. "I should measure my peak flow during asthma symptoms." c. "I should measure my peak flow after taking my asthma medication." d. "I should measure my peak flow at various times during the day."
d. "I should measure my peak flow at various times during the day." Health care providers usually recommend that patients measure and record their peak expiratory flow rate during the following times: same time every day (values are lowest in the morning and typically highest between noon and 5 pm), before taking asthma medicines, during asthma symptoms or an asthma attack, after taking medicine for an asthma attack.