NF Final SponselA

10 CC Syringe: Secondary Tubing Primary Tubing IV Sites used for Infants Syringe used to irrigate Central Venous Catheter

Syringe used to irrigate Central Venous Catheter

Which syringe can be used to administer episodic insulin injections? (Select all that apply.) 3 mL syringe Insulin syringe 1 mL syringe Tuberculin syringe

insulin syringe

Fluids that have the same osmolality as body fluids are used most often to replace extracellular volume and are known as _______________ fluids. isotonic hypotonic normal hypertonic

isotonic

The nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take? gg. Dissolve each medication in 5 L of sterile water hh. Draw up medications together in the syringe ii. Push the syringe plunger gently when feeling resistance jj. Flush the tube with 15 mL of sterile water

jj. Flush the tube with 15 mL of sterile water *dissolve meds in 30 mL*

A nurse in a provider's office is collecting information from an older adult who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which adverse effects? e. Constipation f. Gastric ulcers g. Respiratory depression h. Liver damage

liver damage

The nurse is preparing to administer an intermittent tube feeding by NG tube. The GRV is 250 mL. What should the nurse do next? Hold the feeding for one hour. Discard the aspirate and administer the feeding. Return aspirated contents to the stomach. Call the physician.

Return aspirated contents to the stomach.

The ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs. Ventilation Perfusion Diffusion

Perfusion

What condition is indicated when a patient with a chest tube experiences sharp, stabbing chest pain without precipitating factors? Myocardial infarction Pneumonitis Spontaneous pneumothorax Tube displacement

Spontaneous pneumothorax

A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? u. Abdominal binder v. Montgomery straps w. Hypoallergenic tape x. Plastic tape

Montgomery straps **less restrictive. These are adhesive strips applied to skin on either side of surgical wound. The stips have holes for using gauze to tie dressing securely. When dressing is changed, ties are released, the dressing replaced, and ties secured again w/o removing adhesive strips*

The nurse is preparing to administer a unit of blood to a patient using blood tubing. On the blood product side of the Y tubing, she will hang blood. What will she hang on the other side of the Y tubing? 0.45% Normal Saline 0.5% Dextrose and 0.9%Normal Saline 5% Dextrose Normal Saline

Normal Saline

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation? a. Urine has unusual odor b. Urine specific gravity is 1.035 c. Bladder scan shows 525 mL of urine d. Urine is positive for ketones

c. Bladder scan shows 525 mL of urine

A nurse is administering 1 L of sodium chloride to a client who is postop and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? a. Increase in hematocrit b. Increase in respiratory rate c. Decrease in heart rate d. Decrease in capillary refill time

c. Decrease in heart rate

A nurse is caring for a client with a terminal illness. Which of the following findings indicates that the client's death is imminent? a. Urinary retention b. Cold extremities c. Hypertension d. Tachycardia

cold extremities

Your patient has a new order for oxygen and has already voiced their dislike of anything covering their face. Which oxygen delivery system would be the best choice for this patient? nasal cannula face mask face tent non-rebreather mask

nasal cannula

The nurse is preparing to administer an immunization to an adult. The preferred site for administration of immunizations in this age group is the: The ventrogluteal The dorsogluteal The vastus lateralis The deltoid

The deltoid

T/F Hyperventilate patient before suctioning the tracheotomy.

True

T/F The tubing of a chest tube must be long enough to allow a patient to move but not so long that the dependent loops hang down the side of the bed.

True

Prevention of Medication Errors includes all except which action? Use workarounds to increase efficiency and reduce steps in the process. Preparation of medication for only one patient at a time. Minimize distractions during medication administration. Stay up to date on latest medication administration practices.

Use workarounds to increase efficiency and reduce steps in the process.

An appropriate technique for administration of a parenteral medication is observed when the nurse: Uses strict aseptic technique Slowly inserts the needle through the patient's tissue Injects medication as rapidly as possible Tightly holds the inside surface of the syringe plunger

Uses strict aseptic technique

Anti-neoplastic (chemo) and Total Parenteral Nutrition (TPN): Phlebitis Vesicant Central Venous Line Infiltration

Vesicant

Rapid acting insulin duration of action expected: 2-4 hours 3-6 hours 12-18 hours 24 hours

2-4 hours

Long acting insulin duration of action expected: 2-4 hours 3-6 hours 12-18 hours 24 hours

24 hours

Short acting insulin duration of action expected: 2-4 hours 3-6 hours 12-18 hours 24 hours

3-6 hours

Which of the following should be in the nurses documentation regarding airway suctioning? -Vital signs -Client's response to procedure -Secretions -All of the answers are correct

-All of the answers are correct

The nurse is educating the patient about the use of the incentive spirometer before surgery. What is the correct rate of use? 10 times every 6 hours 2 times daily 5 times every 4 hours 10 times every hour while awake

10 times every hour while awake

The patient is scheduled to receive a blood transfusion. Consent has been signed and a type and cross completed in the last 72 hours. The patient blood type is AB -, what type of blood can this patient receive? AB-, A-, B-, O- Only O Only B Only A

AB-, A-, B-, O- ~~ AB- *can receive* AB-, A-, B-, O- ~~~ AB- *can give* to AB+ or AB- ~~AB+ *can receive* everyone ~~~AB+ *can give* to AB+

What may be injected (administered) through the blue (pig tail) air vent of a Salem sump tube? Medications only Air only Feeding solution only Water only

Air only

A nurse is admitting a client who has varicella. Which of the following types of transmission precautions should the nurse initiate? A. Airborne B. Droplet C. Contact D. Protective environment

Airborne

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? a. Insert the suction catheter while the client is swallowing b. Apply intermittent suction when withdrawing the catheter c. Place the catheter in a location that is clean and dry for later use d.Hold the suction catheter with her clean, nondominate hand

Apply intermittent suction when withdrawing the catheter *Correct answer rationale: *this prevents injury to mucosa. Suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise** *insert suction catheter while client is inhaling to prevent inserting catheter into esophagus*

A patient is donating his own blood for an upcoming surgery. What is the name of the type of blood he will receive? Allogenic Autologous Anemic Agglutinate

Autologous

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? A. Use a resuscitation bag with 80% oxygen prior to the procedure B. Select a suction catheter that is half the size of the lumen C. Place end of the suction catheter in water-soluble lubricant D. Adjust the wall suction apparatus to a pressure of 170 mm Hg

B. Select a suction catheter that is half the size of the lumen

What is the evidence based way to verify NG tube placement after initial placement? By x-ray By CT scan By insufflation of air into the tube while auscultating the abdomen By measuring the pH of tube aspirate

By x-ray

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take? A. Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube B. Position the client on his right side C. Insert tip of tubing 8 cm (3.1 in) D. Hold enema container 61 cm (24 in) above rectum

C. Insert tip of tubing 8 cm (3.1 in) *insert 7-10 cm (3-4 in)*

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect? A. Neck vein distention B. Urine specific gravity of 1.010 C. Rapid heart rate D. BP 144/82 mm Hg

C. Rapid heart rate

a nurse is teaching clients in an outpatient facility about the use of insulin to treat type 1 diabetes mellitus. For which of the following types of insulin should the nurse tell the clients to expect a peak effect 1 to 5 hr after administration? a.insulin glargine b.NPH insulin C.Regular insulin D.insulin lispro

C.Regular insulin -insulin glargine, a long‑acting insulin, does not have a peak effect time, but is fairly stable in effect after metabolized. -NPH insulin has a peak effect around 6 to 14 hr following administration. -insulin lispro has a peak effect around 30 min to 2.5 hr following administration

A patient with a Salem sump tube is being cared for by a new graduate nurse. Which action by the new nurse is correct? Checking pH of the gastric aspirate. Irrigating the blue "pigtail". Checking placement by air bolus prior to flushing the tube. Setting the suction above 120 mmHg for continuous suction.

Checking pH of the gastric aspirate.

When a person living with diabetes encounters a hypoglycemic episode, which of the following is the best way to treat it? Drink water Drink juice Administer additional insulin Exercise

Drink juice

When do you need a speech pathologist?

Dysphagia

T/F The stylet inside a nasoenteral tube should be removed immediately after insertion to prevent injury.

False

T/F Yellow is a normal color for gastric aspirate.

False

T/F You do not need to wear gloves to check placement and flush a nasogastric tube.

False

Which of the following conditions can be complications of diabetes? (Select all that apply.) Heart disease Stroke Gingivitis Kidney Disease

Heart disease Stroke Gingivitis Kidney Disease

A blood test that gives the healthcare provider an average of the blood sugar levels over the last 3 months is called Blood insulin level Hematocrit Blood Glucose Hemoglobin A1C

Hemoglobin A1C

A patient with basilar skull and facial fracture following a motor vehicle accident requires a feeding tube. Which is the best route for tube insertion? (Select all that apply) Jejunostomy tube Nasoenteral tube Orogastric tube Nasogastric tube

Jejunostomy tube Orogastric tube *Nasoenteral and NG are incorrect b/c pt has facial trauma*

The nurse is caring for a patient who needs a blood transfusion. The patient has been tested and has the O+ blood type. The nurse know this means that which antigen is present on the surface of the red blood cell? Neither types A nor B antigens are present The type A antigen is present Both types A and B antigens are present The type B antigen is present

Neither types A nor B antigens are present

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? a. Maintain suction while removing NG tube b. Instill 100 mL of air into NG tube before removal c. Pinch the NG tube while removing tube d. Instruct the client to breathe in and out during the removal of the NG tube

Pinch the NG tube while removing tube *Instill only 50 mL of air to decrease risk for aspiration* *client should take deep breaths*

The nurse is administering blood. What should the nurse do to detect a blood transfusion reaction? Remain with the patient during the first 15 minutes. Transfuse blood at 50 gtt/min. Monitor vital signs every hour. Transfuse the blood at 10 mL/hr..

Remain with the patient during the first 15 minutes.

T/F Prior to removing a nasogastric tube, the patient should be instructed to hold their breath.

True

A nurse is concerned about the type of blood that a patient is to receive. A patient with an O blood type may safely receive which type of blood? Type B blood Type A blood Type O blood Type AB blood

Type O blood

When a patient experiences a transfusion reaction, what are the 2 cardinal symptoms? chest pain and wheezing Arrythmias and flushed skin distended neck veins and cough elevated temperature and heart rate

elevated temperature and heart rate

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? oo. Position the client w/ HOB elevated to 30 degrees prior to insertion of NG tube pp. Remove the NG tube if the client begins to gag or choke qq. Apply suction to the NG tube prior to insertion rr. Have client take sips of water to promote insertion of the NG tube into the esophagus

rr. Have client take sips of water to promote insertion of the NG tube into the esophagus

A nurse is caring for a client with an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? ss. Rinse the feeding bag with water between feedings tt. Tell the client to keep the HOB elevated at least 30 degrees uu. Make sure the enteral formula is at room temperature vv. Wipe the top of the formula can with alcohol

tt. Tell the client to keep the HOB elevated at least 30 degrees

What is a way to administer insulin that can result in better control of blood glucose levels for most diabetics? -One injection of long acting insulin each day. -Insulin pump -Multiple episodic injections throughout the day to mimic the natural functioning of the pancreas. -A combination of an insulin pump and episodic injections throughout the day.

-Insulin pump

The hospitalized diabetic patient is given an injection of intermediate acting insulin at 1200. When should the patient and the nurse be alert for a hypoglycemic episode? 1600 - 2400 1400 - 1500 There is no time more likely than another. 1300

1600 - 2400 --The most likely time for a hypoglycemic episode is when the insulin is at peak action. Intermediate insulin peaks *4 -12* hours after injection so this is the most likely time for a hypoglycemic episode.

a nurse is caring for a client in an outpatient facility who has been taking acarbose for type 2 diabetes mellitus. Which of the following laboratory tests should the nurse plan to monitor? a. WBC b.serum potassium C.Platelet count D.liver function tests

D. liver function tests *acarbose can cause liver toxicity when taken long‑term. liver function tests should be monitored periodically while the client takes this medication* -WBC: infection is not an adverse effect of acarbose. -acarbose does not affect potassium levels. -acarbose does not affect the platelet levels.

Which of the following can affect blood glucose levels? (Select all that apply.) Exercise Stress Insulin production Food intake

Exercise Stress Insulin production Food intake

How should the nurse measure the approximate distance to advance an nasogastric tube? From the tip of the nose to the ear to the umbilicus. From the tip of the nose to the xyphoid process From the tip of the nose to the ear to the xyphoid process. From the tip of the nose to the ear to the middle of the sternum

From the tip of the nose to the ear to the xyphoid process.

This is your first ever day of clinical. Your patient's primary nurse asks you to flush the patient's Salem sump tube. There is a bottle of sterile normal saline at the bedside dated, timed, and initialed 36 hours ago. What should you do?

Politely decline

When administering episodic insulin injections, which site is an acceptable site to use? Deltoid Ventrogluteal Dorsogluteal Posterior aspect of the upper arm

Posterior aspect of the upper arm

A nurse in the ED is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? a. Warm, dry skin b. Increased urinary output c. Tachycardia d. Bradypnea

Tachycardia *d/t in circulating blood vol that occurs w/ internal bleeding, the O2 carrying capacity of blood is reduced. The body attempts to relieve hypoxia by increasing HR and CO along w/ increasing respiratory rate*

Which of the following might cause the pH of NG tube aspirate to be higher than expected? (Select all that apply.) The NG tube has migrated into a lung. The NG tube is in the normally functioning stomach. The NG tube is in the small intestine. Patient is taking a gastric acid inhibitor medication.

The NG tube has migrated into a lung. The NG tube is in the small intestine. Patient is taking a gastric acid inhibitor medication. *low pH = acid* *high pH = base*

The patient is scheduled to receive 1 unit of packed RBC's. She has small, fragile veins and a 22-gauge IV catheter in her right forearm. What should the nurse do? Use the IV catheter that is in place. Cancel the blood transfusion. Transfuse the blood over 6 hours. Insert an 18-gauge IV catheter in the antecubital fossa.

Use the IV catheter that is in place.

The process of moving gases into and out of the lung. Ventilation Perfusion Diffusion

Ventilation

What primary "intervention" should a nurse who is preparing a blood transfusion perform? Have the patient void or empty the urine drainage container. Set up Y tubing. Verify blood product and the patient. Obtain 0.9% Normal saline

Verify blood product and the patient.

A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following findings should the nurse expect? a. Albumin level of 3 g/dL b. HDL level of 90 mg/dL c. Norton scale score of 18 d. Braden scale score of 20

a. Albumin level of 3 g/dL *3.5 g/dL and lower indicates protein deficiency, placing client at risk for poor wound healing*

The nurse knows that the primary function of the alveoli is: regulate tidal volume store oxygen carry out gas exchange produce hemoglobin

carry out gas exchange

A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention? q. Holding a community clinic to administer influenza immunizations r. Screening groups of older adults in nursing care facilities for early influenza manifestations s. Educating parents of young children about dangers of influenza t. Finding rehabilitation programs for older adults who have complications from influenza

r. Screening groups of older adults in nursing care facilities for early influenza manifestations

a nurse is providing teaching for a client who has a new prescription for metformin. Which of the following adverse effects of metformin should the nurse instruct the client to report to the provider? a.somnolence b.Constipation C.Fluid retention D.Weight gain

somnolence *can indicate lactic acidosis, which is manifested by extreme drowsiness, hyperventilation, and muscle pain. it is a rare but very serious adverse effect caused by metformin and should be reported to the provider.* -Diarrhea is an adverse effect of metformin. -Fluid retention is not an adverse effect caused by metformin. -anorexia and weight loss are adverse effects of metformin

A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity ADLs. Which of the following activities should the nurse recommend to the client? a. Sweeping the floor b. Shoveling snow c. Cleaning windows d. Washing dishes

washing dishes

A nurse is caring for a client who has TB. Which of the following actions should the nurse take? (SATA) ww. Place the client in a room with negative-pressure airflow xx. Wear gloves when assisting the client with oral care yy. Limit each visitor to 2 hour increments zz. Wear a surgical mask when providing client care aaa. Use antimicrobial sanitizer for hand hygiene

ww. Place the client in a room with negative-pressure airflow xx. Wear gloves when assisting the client with oral care aaa. Use antimicrobial sanitizer for hand hygiene

What is the primary role of the nurse include during chest tube removal? -Prepares an occlusive dressing -Provide education, support and assessment of the patient -Performs clipping of the sutures -Removes chest tube firmly and quickly

-Provide education, support and assessment of the patient

The nurse completed suctioning a patient's airway. Which action should the nurse take first? -Reposition the patient and assist with oral hygiene using sterile gloves -Remove the face shield and save for future suctioning -Reduce the suction level to medium -Return oxygen to previous level

-Return oxygen to previous level

What is the expected amount of drainage for an adult patient with a mediastinal chest tube? -A minimum of 1000 mL/hr during the first 24-hour period -Up to 100 mL/hr during the immediate postoperative period (hour) -200 mL/hr during the first 24-hour period -Less than 10 mL/hr during the immediate postoperative period

-Up to 100 mL/hr during the immediate postoperative period (hour)

A nurse is caring for a client who has a prescription for 5 units of regular insult and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. 1. Inject 10 units of air for NPH 2. Inject 5 units of air for regular insulin 3. Withdraw 5 units of regular insulin 4. Withdraw 10 units of NPH insulin

1. Inject 10 units of air for NPH 2. Inject 5 units of air for regular insulin 3. Withdraw 5 units of regular insulin 4. Withdraw 10 units of NPH insulin

Intermediate acting insulin duration of action expected: 2-4 hours 3-6 hours 12-18 hours 24 hours

12-18 hours

A nurse is reviewing lab values for a client who has positive Chvostek's sign. Which of the following lab findings should the nurse expect? a. Decreased calcium b. Decreased potassium c. Increased potassium d. Increased calcium

Decreased calcium *calcium is necessary for nerve condution and muscle contractions. The nurse should tap facial nerve in front of ear. If facial muscle twitching followows this stimulus, it is a positive Chvostek's sign*

Mr. G has had multiple blood transfusions for his lymphoma. He received a transfusion one week ago and today presents with fever of 101.4, chills, nausea and is reporting dark urine. What type of reaction is Mr. G having? Hematochromatosis Transfusion related acute lung injury (TRALI) Acute immune hemolytic reaction Delayed hemolytic reaction

Delayed hemolytic reaction

Exchange of respiratory gases in the alveoli and capillaries Perfusion Ventilation Diffusion

Diffusion

Which of the following are complications of nasogastric suctioning? (Select all that apply.) Dry sore throat Irritation or erosion of skin around naris Gastric decompression Pulmonary aspiration

Dry sore throat Irritation or erosion of skin around naris Pulmonary aspiration

How should the patient be positioned for NG tube placement? Supine Semi-Fowler's Left Sims High Fowler's

High Fowler's

Which of the following dietary habits indicates that the patient living with diabetes needs more teaching regarding dietary control of their chronic disease? Large intake of high calorie snack foods Eating lots of vegetables and fruits. Choosing lean meats like cuts of beef and pork that end in "loin." Choosing whole grain foods over processed grain products

Large intake of high calorie snack foods

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? a. "when descending stairs, I will first shift my weight to my right leg" b. "I should place my crutches 12 inches in front and to the side of each foot" c. "as I sit down, I will hold one crutch in each hand" d. "I will make sure the shoulder rests are snug against my armpits"

a. "when descending stairs, I will first shift my weight to my right leg"

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? a. Is your pain constant or intermittent? b. What would you rate your pain on a scale 0 to 10? c. Does the pain radiate? d. Is your pain sharp or dull?

d. Is your pain sharp or dull? *Constant or intermittent = onset/duration* *Rate on pain scale = intensity* *Does it radiate? = pain pattern*

A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? fff. Auscultate lung sounds ggg. Measure urine output hhh. Monitor BP readings iii. Monitor serum electrolyte levels

fff. Auscultate lung sounds

nurse is caring for a client whose receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? i. Hemolytic j. Febrile k. Circulatory overload l. Sepsis

hemolytic **Hemolytic rxn: client's blood is incompatible w/ donor's blood. Chills, low back pain, hypotension, and tachycardia **Febrile rxn: client's blood is sensitive to WBCs and platelets in donor's blood. Fever, chills, headache, and flushing **Circulatory overload rxn: when blood is administered too quickly for client's circulatory system to handle. Dyspnea, cough, headache, hypertension **Sepsis: when blood is contaminated w/ bacteria. High fever, vomiting, diarrhea

The nurse is caring for a patient with a history of COPD. The nurse knows that the best location to assess for hypoxia is the: oral mucosa earlobe wrist lower extremities

oral mucosa *He will likely exhibit cyanosis around oral mucosa*

A nurse is obtaining the BP in a lower extremity. Which actions should the nurse take? m. Auscultate BP at dorsalis pedis artery n. Measure BP w/ client sitting on side of bed o. Place cuff 7.6 cm (3 in) above popliteal artery p. Place bladder of cuff over posterior aspect thigh

p. Place bladder of cuff over posterior aspect thigh

Intramuscular injections are administered into the deltoid muscle correctly when the nurse: Identifies the site at 3 fingerwidths below the acromium process Selects a 25-gauge needle Uses a 2-inch needle Injects at a 45-degree angle

Identifies the site at 3 fingerwidths below the acromium process

Identify the Central Venous Line Access Devices (CVAD): Select All that apply: Port-a-cath (implanted port) Peripherally Inserted Central Catheter (PICC) Non-tunneled catheter Tunneled catheter

Port-a-cath (implanted port) Peripherally Inserted Central Catheter (PICC) Non-tunneled catheter Tunneled catheter

How to assess a recent fall: *S* symptoms *P* previous fall *L* location of fall *A* activity at time of fall *T* time of fall *T* trauma after fall

How to assess a recent fall: *S* symptoms *P* previous fall *L* location of fall *A* activity at time of fall *T* time of fall *T* trauma after fall

The nurse is caring for a patient who has a dressing over a surgical wound created the night before. The dressing has never been changed. The physician has written an order for the dressing to be changed at 0600 the next morning. What should the nurse do first? -Administer an analgesic 30 minutes after a dressing change. -Administer an analgesic 30-45 minutes before a dressing change. -Culture the wound if wound exudate is present. -change the dressing so she can assess the wound.

-Administer an analgesic 30-45 minutes before a dressing change.

When should a nurse consider culturing a wound? -when the patient is afebrile -When the exudate is not present -when the tissue is clean and dry -when the surrounding area shows inflammation

-when the surrounding area shows inflammation

The nurse administering a medication by the parenteral route knows that it is important to follow careful aseptic guidelines as he/she prepares the injection, solution, skin and self in order to prevent: The injection from hurting the patient too much. Shift to shift communication errors. A sterile abscess at the injection site. An infection.

An infection.

The nurse needs to document on a patient with a colostomy: Identify documentation criteria that would pertain to a colostomy: Select all that apply: Appearance of stoma Bowel sounds Amount, appearance of stool Appearance of skin around stoma

Appearance of stoma Amount, appearance of stool Appearance of skin around stoma

People with A blood have anti-______ antibodies; people with type B blood have anti-________ bodies. A. A; B B. B; A C. AB; B; A D. O

B; A

Possible complications from enema administration may include: Select All that Apply Bowel perforation Fluid overload F/E imbalance Abdominal pain, bloating

Bowel perforation Fluid overload F/E imbalance Abdominal pain, bloating

CATSPRRR Compatibility Allergies Tubing Correct Site Pump Safety Rate Release Clamp Return and Inspect

CATSPRRR Compatibility Allergies Tubing Correct Site Pump Safety Rate Release Clamp Return and Inspect

Place in Superior Vena Cava:

Central Venous Line

Enemas until clear: Fleets Cleansing Tap Water Normal Saline

Cleansing

After insertion of the needle into a patient's tissue, a nurse aspirates and notices a very small amount of blood return. What should the nurse do? Discontinue the procedure and repeat the entire preparation of the medication Discontinue the procedure and notify the nurse in charge Continue with the injection Remove and change the needle, and then readminister the medication

Discontinue the procedure and repeat the entire preparation of the medication

Stimulants: Metamucil Colace Lactulose Dulcolax, Senokot

Dulcolax, Senokot

With dehydration will you see an increase or decrease in the specific gravity lab value? -Increase -Decrease

Increase

Swelling at the end of IV catheter, erythema, pain: Phlebitis Infiltration Vesicant Swelling

Infiltration

What instructions should the nurse give to the family member who is to administer a subcutaneous Lovenox injection for a patient? Insert the needle at a 45-degree angle if 2 inches of tissue can be pinched. Injections should be given in the anterior or posterior abdominal wall at least 2 inches from the umbilicus Massage the site after the injection. Rotate injection sites around the umbilicus visualizing the face of the clock.

Injections should be given in the anterior or posterior abdominal wall at least 2 inches from the umbilicus

Osmotics: Metamucil Colace Lactulose Emolient

Lactulose

Muslims and Hindus believe use of the _______ hand is dirty and the __________ hand is clean.

Left; right

Bulk Forming: Colace Metamucil Lactulose Dulcolax, Senokot

Metamucil

The nurse classifies a pressure ulcer according to the type of tissue in the wound bed. What does it indicate if the wound bed has granulation in it? Movement toward healing The presence of significant infection Colonization by bacteria Wound needs debridement

Movement toward healing

NG Tube and Administering Medications Info: - Crush/dissolve meds - use *30 mL* of *warm water* to deliver meds through tube (client must be in *high* fowler's position* - Flush w/ *30 mL* of water after

NG Tube and Administering Medications Info: - Crush/dissolve meds - use *30 mL* of *warm water* to deliver meds through tube (client must be in *high* fowler's position* - Flush w/ *30 mL* of water after

A person w/o the D antigen is Rh ___________ Positive Negative Neutral

Negative

Safest enema, no fluid absorption

Normal Saline

_________ blood have both A and B antibodies and can receive only type O blood. A. A B. AB C. O D. B

O ~~O+ *can receive* O+ and O- ~~~O+ *can give* to O+, A+, B+, AB+ ~~O- *can receive* O- ~~~O- *can give* to everyone

Inflammation of vein with erythema and pain: Infiltration Phlebitis Vesicant

Phlebitis

A person w/ the D antigen is Rh ________ Positive Negative Neutral

Positive

The nurse administers the intramuscular medication of iron by the Z-track method. Why was the medication administered by this method? Reduces discomfort from the needle Prevents leakage of medication into subcutaneous tissue and irritating sensitive tissue. Ensures the medication is deposited into the correct tissue. Provides faster absorption of the medication

Prevents leakage of medication into subcutaneous tissue and irritating sensitive tissue.

Change every 96 hours: Secondary Tubing Primary Tubing IV Sites used for Infants Syringe used to irrigate Central Venous Catheter

Primary Tubing

What does the nurse do to administer an intramuscular injection via the Z-track method? Does not aspirate back on the syringe Immediately removes the needle after injecting the medication Pulls the skin tissue laterally 1 to 1½ inches Releases the skin before removing the needle from the site

Pulls the skin tissue laterally 1 to 1½ inches

A patient has asked for a pain medication to relieve the discomfort from her abdominal incision. She has experienced nausea and vomiting since this morning after several bites of her soft diet breakfast. She last received a dose of her ordered oral analgesic 4 hours ago about one hour before breakfast. The medication, hydrocodone 10 mg PO, is ordered every 4h prn. Which of the following rights of drug administration will most likely be a concern for the nurse caring for this patient? Right Route Right Dose Right Patient Right Time

Right Route *pt has nausea et vomiting... oral dose will do her no good*

When suctioning a tracheotomy, do you suction side to side or just suction straight back?

SIDE TO SIDE

Change every 24 hours: Secondary Tubing Primary Tubing IV Sites used for Infants Syringe used to irrigate Central Venous Catheter

Secondary Tubing

What's the best position to place a pt for an enema?

Sims

Which answer does not apply to a physician's order for IV therapy? Infusion rate What size of IV catheter to use Medication or additives type of solution Amount of IV fluid

What size of IV catheter to use

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? bbb. Check the client for injuries ccc. Move hazardous objects away from the client ddd. Notify the provider eee. Ask the client to describe how she felt prior to the fall

bbb. Check the client for injuries

Oral medications come in many forms. Choose the oral forms from the list below. A. Capsules B. Tablet C. Suppository D. Elixir

A. Capsules B. Tablet D. Elixir

In advancing the NG tube, which technique provides the safest outcome? A. Rotate tube if resistance is felt B. Advance the tube in between swallows C. Start w/ the pt's head flexed D. Check the tube placement by instilling air and auscultating over the stomach

A. Rotate tube if resistance is felt

________ blood has neither antibody and can receive all blood types: A. A+ B. B- C. AB+ D. O-

AB+ --AB+ can receive All blood types --AB- can receive AB-, A-, B-, O-

What is the chain of infection?

Agent Reservoir Exit portal Transmission Entry portal Host *ARE-TEH*

Rh type ________ is widely prevalent and is most likely to elicit an immune response A B C D

D

Moist Heat Effects: *positive* reduces skin dryness, penetrates deep, lessens fluid loss *negative* macerates skin, cools rapidly, great burn risk (Turn flash card for Dry heat effects)

Dry Heat Effects: *positive* less likely to burn skin, no maceration, stays hot longer *negative* increases loss of body fluid, no deep penetration, dries skin

Mineral Oil: Emolient Dulcolax, Senokot Colace Lactulose

Emolient

The patient is to receive low-molecular-weight heparin by injection. Where on the patient's anatomy should the nurse prepare to inject this medication? Ventrogluteal Abdomen Scapular region Vastus lateralis

abdomen

A ___________________ is a noninvasive alternative for management of male urinary incontinence. Because it is noninvasive, the risk for UTI is decreased. The device fits over the penis and connects to a small collection bag that attaches to the leg with a strap, or to a standard urinary collection bag that hangs on the bed frame below the level of the bladder.

condom catheter

With dehydration the patient may exhibit the which of the following signs? (Select all that apply) increased skin temperature anuria decreased pulse rate dry conjunctivae

dry conjunctivae ' increased skin temperature anuria

Lines used to administer antibiotics, total parenteral nutrition (TPN), or lipids should be changed:

every 24 hours

How often should you change the ostomy pouch?

every 3-7 days unless leaking

What should a diabetic inspect daily?

feet

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? kk. The top of the can is parallel to the clients waist ll. When walking, the client moves the cane 46 cm (18 in) forward mm. The client holds the cane on the stronger side of her body nn. The client moves her stronger limb forward with the cane

mm. The client holds the cane on the stronger side of her body

What should the pH be when the NG tube is placed?

pH 5.0 or less

The nurse is caring for a patient who is bleeding. To control bleeding, she would apply a _______ dressing.

pressure

Dysphagia diet

pureed *double check this*

Which notations are not safe to use in medication administration process? q1d .5, 2.0 cc 0.5, 2 mL

q1d .5, 2.0 cc

Any person, animal, plant, soil or substance in which an infectious agent normally lives and multiplies.

resivoir

If SpO2 drops below 90% while suctioning, what should you do?

resupply supplemental O2

-----NG Info:----- *Large Bore* - gastric decompression or removal of secretions *Fine/small* - medication or enteral feedings ------Single / Double Lumen NG:----- *Single Lumen* - administer feedings and medications; suction can cause compression of stomach, tearing, and erosion of lining *Double Lumen* - Gastric decompression, feedings, adminsiter meds, can be used with suctioning, most common

-----NG Info:----- *Large Bore* - gastric decompression or removal of secretions *Fine/small* - medication or enteral feedings ------Single / Double Lumen NG:----- *Single Lumen* - administer feedings and medications; suction can cause compression of stomach, tearing, and erosion of lining *Double Lumen* - Gastric decompression, feedings, adminsiter meds, can be used with suctioning, most common

Which situation noticed during evaluation would determine that the staples or sutures should remain in place? -the patient is anxious about their removal. -the wound edges are separated. -A cosmetically aesthetic result would not be achieved. -No drainage or erythema is present.

-the wound edges are separated.

What are the anatomical landmarks for the ventrogluteal injection site? Greater trochanter and iliac crest Posterior superior iliac spine and iliac crest Greater trochanter and knee Acromion process, scapula, and axilla

Greater trochanter and iliac crest

While assessing the patient's IV infusion, the nurse notes that it is infusing more slowly than it should be. What should the nurse do first? Observe for fluid overload. Discontinue the IV. Increase the rate of infusion. Check the position of the IV fluid and extremity.

Check the position of the IV fluid and extremity.

Which antiseptic does Infusion Nurse Society (INS) suggest for IV insertions?

Chlorhexidine

Stool softeners: Metamucil Colace Lactulose Emolient

Colace

a nurse is providing teaching to a client who has a prescription for pramlintide for type 1 diabetes mellitus. Which of the following should the nurse include in the teaching? (select all that apply.) a."take oral medications 1 hr before injection." b."use upper arms as preferred injection sites." C."Mix pramlintide with breakfast dose of insulin." D."inject pramlintide just before a meal." e."Discard open vials after 28 days."

D."inject pramlintide just before a meal." e."Discard open vials after 28 days." *Pramlintide can cause hypoglycemia, especially when the client also takes insulin, so it is important to eat a meal after injecting this medication* *unused medication in the open pramlintide vial should be discarded after 28 days* -Pramlintide delays oral medication absorption, so oral medications should be taken 1 to 2 hr after pramlintide injection -the thigh or abdomen, rather than the upper arms, are preferred sites for pramlintide injection. -Pramlintide should not be mixed in a syringe with any type of insulin.

When should the RN review the patient's medication list with the patient? During admission. Before transfer. At discharge During admission, before transfer, at discharge, and when new medications are ordered.

During admission, before transfer, at discharge, and when new medications are ordered.

What are the first signs that a person is having a transfusion reaction?

Elevated temperature Elevated heart rate

Cold Therapy: - Reduces recovery time post op, provides pain relief, reduces muscle spasm, decreases nerve conduction velocity, decreases inflammation et edema, decreases hematoma formation, local anesthetic effect, coolness decreases itching, improves neuro outcomes in TBI/post cardiac arrest (Turn flash card for Heat Therapy)

Heat Therapy: -Prevents hypothermia during surgery, stimulates circulation (vasodilation), used to debride wounds and apply meds, relaxes muscles, provides pain relief

How to clean the eye: Wash Inner eye to out canthus (soak crusted lids for 2-3 minutes w/ warm, damp cloth prior to)

How to clean the eye: Wash Inner eye to out canthus (soak crusted lids for 2-3 minutes w/ warm, damp cloth prior to)

What is the best intervention the nurse should take once they recognizes that the patient has phlebitis at his IV site? Place a moist warm compress over the site. Elevate the affected extremity. Reduce the IV flow rate. Adjust the additive in the current IV.

Place a moist warm compress over the site. *this decreases swelling and pain*

IV therapy should not be initiated in the following areas: (Select all that apply). Side of patient where they are experiencing paralysis Area affected with wound Side of previous CVA Side of previous mastectomy

Side of patient where they are experiencing paralysis Area affected with wound Side of previous CVA Side of previous mastectomy

Which syringe should the nurse select for an injection of 0.45 mL of medication to a pediatric patient? Insulin syringe Low-dose insulin syringe Tuberculin syringe 3-mL syringe

Tuberculin syringe

A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (SATA) a. Check the cord routinely for frays or tearing b. Keep the unit at least 4 feet away from a gas stove c. Consider purchasing a generator for power backup d. Observe for signs of hypoxia e. Use synthetic clothing and bedding

a. Check the cord routinely for frays or tearing c. Consider purchasing a generator for power backup d. Observe for signs of hypoxia *should be at least 10 ft from gas stove* *use cotton clothing*

When do you flush a saline lock?

before and after med administration

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? cc. Gently shake the container of medication prior to administration dd. Transfer the medication to a medicine cup ee. Place the client in a semi-Fowler's position prior to medication administration ff. Verify the dosage by measuring the liquid before administering it

cc. Gently shake the container of medication prior to administration

The nurse has a responsibility to ensure that every IM injection is given safely. Which of the following is not a complication from IM injections? Hyperventilation Hematoma Abscess formation Sciatic nerve injury

hyperventilation

deficiency in the amount of oxygen reaching the tissues. Hypoxia Hypoventilation Infiltration Resivoir

hypoxia

A nurse is preparing to anchor w/ tape the catheter tube for a male who has a newly inserted indwelling urinary catheter. At which of the following locations should the nurse tape the catheter? a. Lateral thigh b. Lower abdomen c. Mid-abdominal region d. Medial thigh

lower abdomen

Intravenous pumps that have built-in software programmed from health care pharmacy databases with unit-specific profiles are known as ______________.

smart pumps

Colostomy effluent expected would be: ureterostomy ileal conduit soft or formed stool liquid thick

soft or formed stool

The risk for catheter-associated urinary tract infection can be reduced by using ___________ when inserting the catheter.

sterile technique

T/F A little bubbling in a chest tube is okay. A lot means there is a leak!

true

T/F The 1" border is not sterile; if tables are draped, only the surface is sterile.

true

When evaluating a patient, the nurse observes an unexpected outcome of treatment when the surrounding skin of an ulcer becomes macerated. The nurse should: -use dressings with increased moiture absorption -obtain a wound culture -monitor the patient for systemic signs and symptoms -apply pressure-reducing devices.

use dressings with increased moiture absorption

When removing a fecal impaction a decrease in heart rate (pulse) or dysrhythmias can occur due to the stimulation of the:

vagus nerve

Start blood transfusion slowly, about _______ mL/hr, no more than 150 mL/hr

75

What is the correct volume of warmed solution for adult enemas?

750-1000 mL

9 Rights to Medication: Right Patient Right Drug Right Dose Right Route Right Effects Right Time Right to Refusal Right Documentation Right Education

9 Rights to Medication: Right Patient Right Drug Right Dose Right Route Right Effects Right Time Right to Refusal Right Documentation Right Education

The nurse caring for a patient receiving IV fluids knows that the current recommendation for changing the tubing on a continuously running IV is:

96 hours

The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the nurse realizes that physical activity: (Select all that apply.) improves joint motion. increases social activity enhances mental stimulation decreases circulation.

improves joint motion. increases social activity enhances mental stimulation

The patient with a nasogastric (NG) tube in place may experience skin breakdown: behind the ears in the nose on the tongue around the lips

in the nose

The nurse is caring for a patient who has a peripheral IV. While performing her routine assessment, she notes that the insertion site is pale, cool, and edematous. The patient indicates that the site is also painful to the touch. The nurse recognizes these symptoms as revealing a possible _______________. infiltration normal functioning IV site. extravasation phlebitis

infiltration

when I.V. fluid or medications leak into the surrounding tissue

infiltration

The nurse notes that urine does not flow after a female patient is catheterized. The nurse believes that the catheter has been kinked due to the patient lying on it. Which action should the nurse take? -Deflate the balloon and then reinsert it. -Irrigate the catheter with saline. -Assess that the tubing is not leaking and re-position the patient. -Insert a new catheter.

-Assess that the tubing is not leaking and re-position the patient.

With fluid volume overload the patient may exhibit which of the following signs? (Select all that apply). -Bounding pulse rate -vomiting, diarrhea, abdominal cramping -Flat neck veins -Periorbital edema

-Bounding pulse rate -vomiting, diarrhea, abdominal cramping -Periorbital edema

What should a nurse try first when attempting to promote urination? -Encourage fluids -Restricting fluid intake to 1000 mL/day -Administering medication before bed to stimulate voiding -Having the patient lie down

-Encourage fluids

A nurse needs to order a serum trough level to be drawn on a patient. When should he or she schedule the blood draw to be obtained? -2 hours after the medication is given -Right before the next dose of the drug is due. -Midpoint between the times the drug doses are given. -When the serum level is scheduled to plateau, usually early in the morning.

-Right before the next dose of the drug is due.

When administering regular insulin injections, which way should the diabetic patient rotate injections sites? -Rotate between all sites on one side of the body before moving to the other side of the body. -Rotate within one major site before moving on to another general site. -There is no need to rotate sites. -Rotate between major sites, not returning to a major site until they have used all the other major sites.

-Rotate within one major site before moving on to another general site.

What should the nurse do when removing intermittent sutures? -Snip the suture as close to the skin as possible. -Snip both sides of the suture before removing. -Snip the suture as close to the knot as possible. -Pull up the knot to apply as much tension as possible.

-Snip the suture as close to the skin as possible.

onstipation interventions include which of the following: Select All that Apply -Walking 20 minutes three times a week -Maintain adequate fluid intake -Increase fiber intake -Administer daily enemas

-Walking 20 minutes three times a week -Maintain adequate fluid intake -Increase fiber intake

A patient using nasal cannula has gurgling on inspiration. The nurse notes a productive cough but the inability to clear secretions from the mouth. Which action should the nurse take first to prepare for oropharyngeal suctioning? -Insert the suction device to the back of the throat -Connect tubing to a standard suction catheter -Wash hands and apply clean gloves -Remove the patient's nasal cannula

-Wash hands and apply clean gloves

The nurse is removing a Foley catheter where 10 mL of fluid was inserted into the balloon when the RN placed the foley before surgery. How much fluid should you expect to remove when deflating the balloon?

10 mL

What is the usual time limit for sending a urine specimen to the lab before needing it to be refrigerated?

15 min

A medication order is for 0.5 g PO every 12 hours. The medication is available in 250 mg tablets. How many tablets should the nurse administer?

2 tablets

When inserting a urinary catheter into a female patient, how far should the nurse initially insert the catheter?

2-3 inches

What is the appropriate size of rectal tube for adult enemas?

22-30 Fr

The average adult urinary output is ________________mL per 24 hours. (Give a range: example 5-10mL)

2200 to 2700 mL

When preparing an adult pt for an enema, the nurse understands that the tube or nozzle should be inserted how far? A. 2-3 inches B. 3-4 inches C. 4-5 inches D. 5-6 inches

3-4 inches

What is the minimum amount of expected urinary output in one hour?

30 mL/hr

Blood can be given through a warmer, but it should never be warmed over _______ degrees Celsius

37

Never allow blood to infuse more than ______ hours

4

Mediastinal chest tubes should have no more than __________ mL of drainage in the first 24 hours.

500

Cold Application: *P* protection *R* rest *I* ice *C* compression *E* elevation

Cold Application: *P* protection *R* rest *I* ice *C* compression *E* elevation

Common places on the chest and abdomen you'll see a chest tube inserted: *Apical and Anterior *Low and posterior or lateral *Mediastinal and Just below sternum

Common places on the chest and abdomen you'll see a chest tube inserted: *Apical and Anterior *Low and posterior or lateral *Mediastinal and Just below sternum

IV Infiltration from vesicant: Vesicant Infiltration Extravasation Phlebitis

Extravasation

The nurse is caring for a patient receiving intravenous therapy. The nurse should report which of the following to the primary care provider? Initiation of IV fluids Small infiltration Completion of each liter of fluid Extravasation

Extravasation

T/F According to Evidence Based Practice, you should always aspirate the catheter balloon before placement.

FALSE

T/F You can let the pt drink water w/ NG tube in place.

FALSE -ice chips in moderation are okay

T/F If the patient has a cast on his left leg and is using a cane, he/she should hold the cane in their left hand?

False

Hypertonic Enema: Safest w/ no fluid absorption Fleets Tap Water Hypotonic

Fleets

What should the nurse NOT do upon noting that the patient's IV site is pale, cool, and edematous? Stop the infusion. Flush the IV site. Elevate the extremity. Start a new IV.

Flush the IV site.

Order of removing PPE:

GLOVES EYEWEAR GOWN MASK

Order of donning PPE:

GOWN MASK EYEWEAR GLOVES

Lungs remove carbon dioxide faster than it is produced: Hypoxia Hypoventilation Hyperventilation Resivoir

Hyperventilation

Alveolar ventilation is inadequate to meet the body's oxygen demand or to eliminate sufficient carbon dioxide: Hypoxia Hypoventilation Hyperventilation Resivoir

Hypoventilation

Which task cannot be given to the nursing assistant personnel/ CNA? (Select all that apply). IV dressing change Repositioning the patient with an IV in place Hitting the silence alarm button on electronic infusion device Changing IV solution

IV dressing change Hitting the silence alarm button on electronic infusion device Changing IV solution

Scalp and feet: Secondary Tubing Primary Tubing IV Sites used for Infants Syringe used to irrigate Central Venous Catheter

IV sites used for infants

The nurse knows that which of the following factors contribute to the development of pressure ulcers? SELECT ALL THAT APPLY Poor nutrition Moisture and ammonia Uncontrolled pain Immobility Friction and shear

Poor nutrition Moisture and ammonia Immobility Friction and shear

The charge nurse is observing a new nurse administering an IM medication. Which action by the nurse indicates need for corrective instruction on injection technique? Use of the z track for IM injections expected to be irritating Selection of the ventrogluteal site for the injection. Selection of the dorsogluteal injection site for the injection. Use of clean gloves to administer the injection

Selection of the dorsogluteal injection site for the injection.

Hypotonic Enema: Cleansing Fleets Tap Water Normal Saline

Tap water

The nurse is preparing to administer an intramuscular medication. In determining what size needle and syringe to use to administer the medication, the nurse is not concerned with which of the following? The body size of the patient The viscosity of the medication The quantity of medication Whether or not the syringe has a safety needle

Whether or not the syringe has a safety needle

The patient is admitted with an open pressure ulcer with necrotic tissue around the base of the wound. How would the nurse classify this ulcer? Wound that cannot be staged Stage II pressure ulcer Stage III pressure ulcer Stage IV pressure ulcer

Wound that cannot be staged

A nurse is preparing to insert an IV into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection? a. Thread IV catheter so that the hub rests at insertion site b. Shaving excess hair from around insertion site c. Cleanse site w/ hydrogen peroxide before IV catheter insertion d. Palpate the site carefully just before inserting IV catheter

a. Thread IV catheter so that the hub rests at insertion site

A nurse is preparing to assist w/ ambulation of an older adult client who was on bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall? a. Use gait belt during ambulation b. Ensure client is wearing socks before ambulating c. Instruct client to sit on edge of bed for 15 seconds before ambulating d. Walk 2 feet behind client during ambulation

a. Use gait belt during ambulation *wear nonskid shoes or slippers* *dangle feet for 60 seconds*

A nurse is planning to administer pain medication to a client who has pain following abdominal surgery. Which of the following actions should the nurse take first? a. Use pain scale to determine client's pain level b. Discuss adverse effects of pain medication w/ the client c. Obtain client's vital signs d. Check client's allergies

a. Use pain scale to determine client's pain level

Per agency policy, what items do you place at the bedside for a chest tube? A. 2 Rubber tipped hemostats/chest tube B. Occlusive dressing C. All the above

all the above

a nurse is providing teaching to a client who has type 2 diabetes mellitus and is starting repaglinide. Which of the following statements by the client indicates understanding of the administration of this medication? a."i'll take this medicine with my meals." b."i'll take this medicine 30 minutes before i eat." C."i'll take this medicine just before i go to bed." D."i'll take this medicine as soon as i wake up in the morning."

b."i'll take this medicine 30 minutes before i eat." *causes a rapid, short‑lived release of insulin. the client should take this medication within 30 min before each meal so that insulin is available when food is digested* -should not be taken with a meal. -should not be taken just before bedtime. -Repaglinide is not taken upon awakening in the morning

Cyanosis

blue discoloration

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take? a. Auscultate for bowel sounds after each feeding b. Ensure formula is cold before administering c. Elevate client's HOB 45 degrees before feeding d. Flush tubing w/ 15 mL of water after the enteral feeding

c. Elevate client's HOB 45 degrees before feeding *auscultate BEFORE each feeding to ensure peristalsis* *flush w/ at LEAST 30 mL BEFORE and AFTER*

A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene? a. The client is receiving formula at room temperature b. The feedings infuse at a slow, continuous drip over 8 hr each night c. The family member washes out the feeding bag w/ warm water once every 24 hours d. The family member flushes the tubing w/ water before and after giving medications

c. The family member washes out the feeding bag w/ warm water once every 24 hours

What should the nurse do to decrease the potential for infection related to IV therapy? -After cleansing the skin, dab it dry with a sterile gauze pad. -Use the clean technique for dressing changes. -Change the IV tubing every 12 hours. -Palpate the insertion site daily through the intact dressing.

-Palpate the insertion site daily through the intact dressing.

A patient with pneumonia is receiving supplemental oxygen. Which assessment finding(s) by the nurse should be reported as an early indication of hypoxia? increased blood pressure increased level of conciousness cyanosis around lips and oral mucosa anxiety and restlessness

anxiety and restlessness *Cyanosis is not an early indication*

The nurse assigns nursing assistive personnel (NAP) to care for several patients with continuous IV infusions. Which of the following can NAP assist with? -Confirming the correct IV drip rate -Informing the nurse if they notice anything abnormal -Assessing the patient for response to IV therapy -Changing empty IV solution containers

-Informing the nurse if they notice anything abnormal

To administer an injection intradermally, the nurse should: -Expect a small amount of bleeding after injection -Use a tuberculin or small syringe with a 1-inch needle -Inject no more than 1 mL of solution -Insert the needle at a 5- to 15-degree angle

-Insert the needle at a 5- to 15-degree angle

What is an appropriate technique for the nurse to implement when changing the dressing at a peripheral IV site? -Wear sterile gloves to remove the old dressing. -Cleanse with an antiseptic solution in a circular manner toward the insertion site. -Keep one finger over the IV catheter until the tape is replaced. -Tape the connection between the IV catheter port and the tubing.

-Keep one finger over the IV catheter until the tape is replaced.

Which activities related to urinary elimination may be delegated to a nursing assistant? -Reporting to the physician the patient is having blood in their urine. -Inserting a Foley Catheter -Obtaining a midstream urine specimen -Documentation of an assessment of foley catheter care.

-Obtaining a midstream urine specimen

The nurse is caring for a patient who has experienced hypovolemia secondary to acute vomiting and diarrhea. The nurse anticipates what type of intravenous fluid to be ordered by the health care provider? -Hypotonic or isotonic solutions -Hypertonic or isotonic solutions -Whole blood -Hypertonic solutions only

-Hypotonic or isotonic solutions

The nurse answers the patient's call light to find the patient agitated and stating that she "felt something pop." the nurse finds that the patient's abdominal surgical wound has eviscerated. What should the nurse do? -Cover the wound with a moist saline dressing. -Cover the wound with a dry sterile dressing. -Notify the surgeon when he makes rounds. -Try to reinsert the abdominal contents.

-Cover the wound with a moist saline dressing.

The nurse is preparing to give a medication by IV bolus. When assessing the patient's IV insertion site, the nurse notes that it is warm, reddened, and tender. What action should the nurse take first? -Inject a local anesthetic to relieve the tenderness. -Discontinue the IV infusion. -Slow the infusion rate and slowly inject the medication. -Apply warm compresses over the insertion site.

-Discontinue the IV infusion.

What should the nurse do to reestablish the vacuum of the Hemovac system after emptying? -Pin the drainage tubing to the patient's gown. -Place a safety pin on the part of the drain outside the body. -Place the evacuator on a flat surface with open outlet facing upward and press downward until the bottom and top are in contact. -Replace the cap immediate after emptying.

-Place the evacuator on a flat surface with open outlet facing upward and press downward until the bottom and top are in contact.

A patient has medication ordered to be given by IV bolus. The nurse recognizes which advantage of this type of administration? -Medications are given over a longer time frame. -Small volumes are used, so fluid overload can be avoided. -Medications given by IV bolus are less irritating to the veins. -There is a slower onset of medication effects.

-Small volumes are used, so fluid overload can be avoided.

Once an artificial airway is placed, what is the first action to identify proper placement? -rise and fall of the abdomen. -patient is cyanotic and breath sounds are only heard on the right lung. -listening at the trachea for breath sounds. -auscultation of both lungs and the rise and fall of chest.

-auscultation of both lungs and the rise and fall of chest.

The nurse is changing a surgical dressing and is cleansing the wound. She knows that: -she should start at the center of suture line and clean away from suture line -she should start at one end of the incision line and swab the entire length. -she should work in a circular motion around the incision line -the incidion lines should be cleansed last.

-she should start at the center of suture line and clean away from suture line

The nurse is caring for four patients during a shift. Which of the following patients is at greatest risk for developing a pressure ulcer? -The patient who is bedridden, but who turns himself randomly -The patient whose braden Scale score is 18 -the patient whose Braden Scale score is 8 -The paitent who can ambulate to the bathroom independently

-the patient whose Braden Scale score is 8 *The lower the number the higher the risk!*

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nontracheal suctioning for the client? a. Insert suction catheter while client is swallowing b. Apply intermittent suction when withdrawing the catheter c. Place the catheter in a location that is clean and dry for later use d. Hold the suction catheter with her clean, nondominant hand

b. Apply intermittent suction when withdrawing the catheter

A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention? a. Teaching clients to perform self-exams of breasts and testicles b. Educating clients about recommended immunization schedule for adults c. Teaching clients w/ type I diabetes about care of the feet d. Recommending that clients over age 50 have fecal occult blood tests annually

b. Educating clients about recommended immunization schedule for adults

A nurse is initiating a protective environment for a client who has had an allogenic stem cell transplant. Which of the following precautions should the nurse plan for this client? a. Make sure the client's room has at least6 air exchanges per hour b. Make sure the client wears a mask when outside her room if there is construction in the area c. Place client in a private room w/ negative-pressure airflow d. Wear an N95 respirator when giving client direct care

b. Make sure the client wears a mask when outside her room if there is construction in the area

A nurse is planning care for a client who has a single lumen NG tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (SATA) a. Set suction machine at 120 m HG b. Provide oral hygiene frequently c. Measure amount of drainage from NG tube every shift d. Secure NG tube to client's gown e. Apply petroleum jelly to client's nares

b. Provide oral hygiene frequently c. Measure amount of drainage from NG tube every shift d. Secure NG tube to client's gown

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? a. Remove the outer cannula cautiously for routine cleaning b. Use tracheostomy covers when outdoors c. Use sterile technique when performing tracheostomy care at home d. Cleanse irritated skin with full-strength hydrogen peroxide

b. Use tracheostomy covers when outdoors *the outer cannula stabilizes the airway; therefore, the client should never remove it for cleaning*

Janice knows that it is important to immediately start Mrs. B on a bowel medication regimen to prevent fecal impaction. Unresolved fecal impaction can result in

intestinal obstruction

While the nurse is administering an enema, the pt complains of some cramping. Which action should the nurse take next? A. DC the procedure completely B. Increase the ht of the solution C. Slow the rate of infusion D. Have the pt roll into a supine position

slow the rate of infusion