NMNC 4335- Midterm Exam

A client who had an appendectomy for a perforated appendix returns from surgery with a JP drain inserted in the incisional site. The purpose of the drain is to: A) promote drainage of wound exudates B) provide access for wound irrigation C) minimize development of scar tissue D) decrease postoperative discomfort

A

A healthcare provider's prescription reads 1000mL of NS to infuse over 12 hours. The drop factor is 15 drops (gtt)/1mL. The nurse prepares to set the flow rate at how many drops per minute? Record your answer to the nearest whole number. A) 21.2 gtt/min B) 21 gtt/min C) 20.8 gtt/min D) 20.9 gtt/min

B

Cefuroxime sodium, 1g in 50mL normal saline, is to be administered over 30 minutes. The drop factor is 15gtt/mL. The nurse sets the flow rate at how many drops per minute? A) 23.4 gtt/minute B) 26 gtt/minute C) 25 gtt/minute D) 21 gtt/minute

C

A health care provider's prescription reads morphine sulfate, 8mg stat. The medication ampule reads morphine sulfate, 10mg/mL. The nurse prepares how many milliliters to administer the correct dose? A) 1 mL B) 0.9 mL C) 0.76 mL D) 0.8 mL

D

Which action can the nurse take to ensure a quality blood sample when drawing blood from a patient's peripherally inserted central catheter (PICC) site? A) Discard the first 6-9 mL of blood drawn. B) Allow fluid infusions to continue to flow right up to the time of the sample. C) Flush the catheter after aspirating for blood return. D) Ensure that the patient has been resting quietly for at least 15 minutes before taking the sample.

A

Which activity is important to include in the plan of care of a patient with a peripherally inserted central catheter (PICC)? A) Use a sterile technique when changing the PICC dressing. B) Take blood pressure in the arm with the PICC line C) Change the IV tubing every 72 hours D) Use only macro-drip tubing with IV infusions through the PICC line.

A

The nurse is teaching a class on strategies of pressure injury prevention. What should be included in the information? Select all that apply. A) Pressure redistribution turn every 1-2 hour B) Encourage a diet high in protein and calories C) Keep clients clean and dry by managing incontinence D) Rub and massage the clients pressure injuries

A B C

Four complication that can arise from a peripheral IV

- Phlebitis - Infiltration - Air embolism - Extravasation - Infection - Hypervolemia

Interpret the following ABG: pH- 7.33 PCO2- 50 HCO3- 28 PaO2- 87 A) Respiratory Acidosis B) Metabolic Alkalosis C) Respiratory Alkalosis D) Metabolic Acidosis

A

Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.60 F orally. Which action should the nurse take? A) Delay hanging the blood and notify the health care provider (HCP) B) Administer an antihistamine and begin the transfusion C) Begin the transfusion as prescribed D) Administer two tablets of acetaminophen (Tylenol) and begin the transfusion

A

The nurse assists the primary health care provider with the removal of a chest tube inserted to treat a client who experienced a pneumothorax. During the procedure, the nurse instructs the client to perform which action? A) Take a deep breath and hold it B) Inhale deeply C) Breathe normally D) Breathe out forcefully

A

The nurse goes into the room of a client with a chest tube. The nurse notices that the thoracic catheter has dislodged. Which action would the nurse take next? A) Cover insertion site with petroleum gauze, apply firm pressure, notify the HCP B) Obtain an order for a chest x-ray to identify mail position of the endotracheal tube C) Reconnect the thoracic catheter to the tubing or suction using clean technique D) Administer supplemental oxygen via face mask and contact the HCP

A

The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. Approximately how long will the nurse need to stay with the client to ensure that a transfusion reaction is not occurring? A) 15 minutes B) 5 minutes C) 30 minutes D) 45 minutes

A

Which steps help to manage infection control with PICC line dressing changes? Select all that apply. A) Ensure the client and nurse wear a mask prior to the beginning the dressing change B) Don sterile gloves after removing previous dressing C) Scrub skin with chlorhexidine using sterile gauze to hold the line in place D) Use soap and water to clean skin around Statlock

A B C

When preparing to perform a 12-lead electrocardiogram on a client, which action(s) should the nurse take? Select all that apply. A) Prepare the skin before attaching electrodes B) Visualizes the chest and extremities C) Verify the client using two identifiers D) Prepare the client to experience brief pain E) Explain steps for relaxation and breathing

A B C E

How often should the IV tubing be changed on a primary IV line? A) Every 24 hours B) Every shift- 12 hours C) Every 72 hours D) Every week

C

True or False: The nurse's best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago is to notify the surgeon of the bleeding.

False

A nurse is teaching a new nurse how to remove a midline catheter. The nurse asks the new nurse what the minimum amount of time is to hold pressure on the site after the catheter is removed. Which of the following responses would indicate the new nurse understood the teaching? A) 30 seconds B) 15 seconds C) 1 minute D) 2 minutes

A

An 89-year-old client had right hip surgery a week ago. The rehab nurse assesses a purple maroon-colored blood-filled blistered area to the client's right heel. How should the nurse document her findings? A) A right heel deep tissue injury B) A stage 1 right heel pressure injury C) A stage 2 right heel pressure injury D) A stage 3 right heel pressure injury

A

Based on knowledge of areas at greatest risk for development of a pressure ulcer in a bedridden patient, the nurse identifies which position to minimize the risk? A) 30-degree side lying B) 90-degree side lying C) Sitting with the head of the bed elevated 75-degrees D) Lying supine with the bed flat at all times

A

Gentamicin sulfate, 80mg in 100mL normal saline, is to be administered over 30 minutes. The drop factor is 10 gtt/mL. The nurse sets the flow rate at how many drops per minute? Record your answer to the nearest whole number. A) 33 gtt/min B) 34 gtt/min C) 32.8 gtt/min D) 33.34 gtt/min

A

How can the nurse minimize the risk of dislodging the catheter when removing a dressing? A) Remove the transparent dressing or tape and gauze in the direction of catheter insertion. B) Apply skin protectant while the stabilization device is off C) Cleanse the insertion site quickly and gently in concentric circles. D) Lower the patient's head during the dressing change

A

You are providing care to a patient with a chest tube. On the assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the CORRECT nursing intervention for this type of finding that you would do first? A) Check the drainage system for an air leak. B) Reposition the patient because the tubing may be kinked. C) Continue to monitor the drainage system. D) Increase the suction to the drainage system until the bubbling stops.

A

Which area of the body will the client have an increased risk of developing a pressure injury? Select all that apply. A) Knees and thighs B) Wrists and hands C) Heels and ankles D) Sacrum and coccyx E) Bilateral hip bones

A C D E

Order for 500 mL of 0.45NS is to infuse over 8 hours. Calculate the flow rate A) 75mL/hr B) 63mL/hr C) 52mL/hr D) 100mL/hr

B

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next? A) Remove the IV line B) Run normal saline at a keep-vein-open rate C) Run a solution of 5% dextrose in water D) Obtain a culture of the tip of the catheter device removed from the client

B

The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which priority item? A) Skin color B) Vital signs C) Urine output D) Latest hematocrit level

B

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

B

When administering an IV piggyback medication to infuse by gravity, how can the nurse ensure that the medication will infuse properly? A) Use a secondary infusion set for the piggyback tubing B) Hang the piggyback medication higher than the primary fluid C) Attach the piggyback medication to the most proximal insertion port on the primary tubing. D) Use an infusion pump to regulate the flow of the piggyback medication

B

Why should PICC lines be changed every 7 days and prn? A) The dressing begins to irritate the skin of the client after a week B) The client is at a high risk for infection at the insertion site C) Tests have proven that no infection will begin before a week D) The nurse supervisor mandates a weekly dressing change

B

The nurse recognizes that the goal for placement of lead V6 has been met when the lead is placed in a straight line with V4 and V5 and coinciding underneath which location? A) The right axilla B) The right shoulder C) The left axilla D) The right wrist

C

Which instruction would the nurse give to nursing assistive personnel (NAP) to ensure the patient's comfort when a condom catheter is applied? A) Wear gloves when applying the condom catheter. B) Wash the penis before applying the catheter. C) Use a hair guard before applying the condom catheter. D) Clip the drainage bag to the bed.

C

Which nursing action minimizes a patient's risk for injury during removal of an indwelling urinary catheter? A) Use a 5-mL syringe to deflate the balloon B) Tugging gently on the catheter to pull the balloon through the urethra C) Checking the documentation for the volume of fluid used to inflate the balloon D) Using sterile scissors to cut the valve to deflate the balloon

C

A health care provider's prescription reads to administer an IV dose of 400,000 units of penicillin G benzathine (Bicillin). The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine (Bicillin), 300,000 units/mL. The nurse prepares how much medication to administer the correct dose? Record your answer using one decimal place. A) 1 mL B) 1.4 mL C) 1.33 mL D) 1.3 mL

D

A healthcare provider prescribes 1000mL D5W to infuse at a rate of 125mL/hr. The nurse determines it will take how many hours for 1L to infuse. A) 8.5 hrs B) 7.4 hrs C) 3 hrs D) 8 hrs

D

The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride and needs to add the medication to the IV bag. The nurse should plan to take which action immediately after injecting the potassium chloride into the port of the IV bag? A) Check the solution for yellowish discoloration B) Prime the tubing with the IV solution C) Attach the tubing to the client D) Rotate the bag gently

D

The nurse inserts an indwelling Foley catheter into the distended bladder of a postoperative client who has not voided for 8 hours. After the tubing is secured and the collection bag is hung on the bed frame, the nurse notices that 900 mL of urine has drained into the collection bag. What is the appropriate nursing action for the safety of this client? A) Raise the collection bag high enough to slow the rate of drainage. B) Check the specific gravity of the urine. C) Provide suprapubic pressure to maintain a steady flow of urine. D) Clamp the tubing for 30 minutes and then release

D

The same IV orders above (500 mL NS over 5 hours) will have how many mL left in the IV bag after 3 hours? A) 150mL B) 300mL C) 55mL/hr D) 200mL

D

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

False

Which of the following describes the function of wound dressings? Select all that apply. A) Protects surgical incision from infection B) Absorbs excess drainage C) To dry out the incision D) Creates a sterile field for the incision E) Allows for wound friction

A B D

Which of the following are primary risk factors for pressure ulcers? Select all that apply. A) Fever B) Low-protein diet C) Insomnia D) Sleeping on a waterbed E) Lengthy surgical procedures

A B E

After changing the intravenous tubing on a patient's primary infusion, the nurse notes air bubbles in the tubing. How should the nurse remove them? A) Close the clamp, stretch the tubing downward, and flick the tubing B) Inject a syringe of saline into the tubing to vent the air bubbles. C) Begin the process again D) Add more fluid to the drip chamber

A

A healthcare provider's prescription reads levothyroxine (Synthroid), 150mcg orally daily. The medication label reads Synthroid, 0.1mg/tablet. The nurse administers how many tablet(s) to the client? A) 1.5 tablets B) 1.8 tablets C) 2 tablets D) 1 tablet

A

A healthcare provider's prescription reads potassium chloride 30mEq to be added to 1000mL NS and to be administered over a 10-hour period. The label on the medication bottle reads 40mEq/20mL. The nurse prepares how many milliliters of potassium chloride to administer the correct dose of medication? A) 15 mL B) 14.3 mL C) 20 mL D) 15.5 mL

A

A nurse is preparing for a midline dressing change with a patient who is extremely diaphoretic. Which of the following dressings is most appropriate for this patient? A) A gauze dressing placed over catheter exit site B) Antibacterial ointment applied at the exit site and covered with a gauze dressing C) A transparent dressing placed over the gauze dressing at the catheter exit site D) A transparent dressing applied over catheter exit site

A

A nurse is teaching a new nurse about midline catheters. The nurse is asked about which intravenous infusions can be administered through a midline catheter. Which of the following responses would indicate the nurse needs more teaching? A) Central parental nutrition B) Fresh frozen plasma C) Long-term antibiotic therapy D) RBC's

A

A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient's pain? A) Pre-medicate the patient with a prescribed analgesic 30 minutes before the intervention. B) Thoroughly explain the procedure to the patient. C) Position the patient comfortably before the intervention. D) Use a distraction technique to divert the patient's attention during the procedure.

A

A patient is recovering from a pneumothorax and has a chest tube present. Which of the following is an appropriate finding when assessing the chest tube drainage system? A) Intermittent bubbling may be noted in the water seal chamber. B) 200 cc of drainage per hour is expected during recovery of a pneumothorax. C) The chest tube is positioned at the patient's chest level to facilitate drainage. D) All of these options are appropriate findings.

A

A primary health care provider is inserting a chest tube to treat pneumothorax. Which materials should the nurse have available to be used as the first layer of the dressing at the chest tube insertion site? A) Petrolatum jelly gauze B) Sterile 4 X 4 gauze pad C) Absorbent gauze dressing D) Gauze impregnated with povidine-iodine

A

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action? A) Obtain new IV tubing B) Scrub the spike end of the tubing with an alcohol swab C) Obtain a new IV bag D) Wipe the spike end of the tubing with Betadine

A

What is the correct order of the steps for starting an IV on a client? Place steps in appropriate order. A. Perform hand hygiene, don gloves, open the IV extension set and prime the set with sterile saline. B. Apply the tourniquet above the site chosen and clean the site. C. Open the catheter and hold it securely while inserting the catheter into the chosen vein. D. When a flash of blood is observed, insert the catheter fully into the vein, and remove the cannula. E. Attach the IV extension set and assure placement by drawing blood into the IV extension set via the saline syringe, then flush. F. Continuing to hold the catheter in place, apply a clear transparent dressing so the site is visible. G. Place initials, date, and time on the IV transparent dressing A) A, B, C, D, E, F, G B) A, B, C, D, F, E, G C) B, A, C, D, E, G, F D) G, A, B, C, D, E, F

A

What is the proper procedure when cleaning the female perineal area with iodine? A) First make sure the client is not allergic to betadine or iodine, then always clean from the meats downward (front to back) B) First make sure the client is not allergic to betadine or iodine, then always clean from the anus out C) First make sure the client is not allergic to betadine or iodine, then circle up to the meatus D) First make sure the client is not allergic to iodine, then circle out from the meatus then back

A

When changing a midline dressing, the nurse notices redness, swelling, and drainage at the catheter exit site. Which of the following actions should the nurse take next? A) Notify the practitioner B) Discontinue the catheter and start a peripheral IV line C) Flush each catheter lumen with 10 ml of normal saline followed by an antibiotic flush solution D) Swab the site with antiseptic solution, apply povidone-iodine ointment, and apply a gauze dressing

A

When drawing blood from a patient's peripherally inserted central catheter (PICC), what should the nurse do to minimize the pressure on the device during flushing? A) Use a 10-mL syringe for the flush B) Cleanse the catheter hub with an alcohol swab C) Clamp the device D) Use 3-mL syringe for the flush

A

Which nursing action demonstrates proper procedure in the collection of a wound culture specimen? A) Wear clean gloves to remove soiled dressings B) Using a circular motion to cleanse the wound before collecting the specimen. C) Sending the specimen to the lab within 30 minutes of collecting it D) Completing the lab requisition form in a timely manner after collecting the specimen

A

Which signs alert the nurse to a potential complication of an IV push? Select all that apply. A) The nurse observes clear liquid ooze from the IV insertion site B) The nurse assesses that the insertion catheter will not flush C) The client presents with labored breathing after the push D) The client says, "Stop, this is taking too long."

A B C

When choosing a site for the IV catheter, which statement(s) is/are true? Select all that apply. A) The nurse will attempt to choose a site to maximize client mobility B) The nurse and client will collaborate on choosing an appropriate site C) The client will need to have the site in an area that can be easily cared for by the client D) The nurse will choose a vein that is not visibly hard or scarred E) The vein should be visible or easily palpated above the antecubital site

A B D

A 36-year-old female, who is 29 weeks pregnant, reports she is experiencing burning when voiding. The physician orders a urinalysis. Which statement by the patient demonstrates she understands how to collect the specimen? A) "I will be sure to drink a lot of fluids to keep the urine diluted before urinating into the cup." B) "First, I will pee a small amount of urine in the toilet and then collect the rest in the cup." C) "I will cleanse back to front with the antiseptic wipe before urinating in the cup." D) "I'll hold the cup firmly against the urethra while collecting the sample."

B

A client had a central venous line placed 15 minutes ago. What priority intervention should the nurse implement next? A) Administer ordered IV fluids B) Order a stat chest x-ray C) Administer IV antibiotics ordered D) Order a stat ultrasound of the chest

B

A client has been hospitalized for 10 days in the intensive care unit on the ventilator and has been NPO. The nurse is giving the client a bath and notices skin breakdown on the sacrum exposing the dermis. When documenting in the medical record, what stage pressure injury will the nurse record? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4

B

A client is admitted to the emergency department following a fall from a horse, and the primary health care provider (PHCP) prescribes insertion of a urinary catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take with action? A) Administer parenteral pain medication before inserting the catheter B) Notify the PHCP before performing the catheterization C) Clean the meatus with soap and water before opening the catheterization kit D) Use a small-sized catheter and an anesthetic gel as a lubricant

B

A health care provider prescribes regular insulin, 8 units/hour by continuous IV infusion. The pharmacy prepares the medication and then delivers an IV bag labeled 100 units of regular insulin in 100mL normal saline. An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters per hour to deliver 8 units/hour? A) 16 mL/hour B) 8 mL/hour C) 7.4 mL/hour D) 4 mL/hour

B

A nurse is beginning a foley catheter insertion on a client with urinary retention. Which hand is sterile and what should it hold? A) Non-dominant hand, the tip of the Foley catheter with the rest coiled in hand B) Dominant hand, the tip of the Foley catheter with the rest coiled in the hand C) Dominant hand, holding the clients labia open D) Non-dominant hand, holding the clients labia open

B

Interpret the following ABG: pH- 7.27 pCO2- 34 HCO3- 15 PaO2- 90 A) Respiratory Alkalosis B) Metabolic Acidosis C) Metabolic Alkalosis D) Respiratory Acidosis

B

The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question? A) "Why do you think that you need the transfusion?" B) "Have you ever had a transfusion before?" C) "Do you know the complications and risks of a transfusion?" D) "Have you ever gone into shock for any reason in the past?"

B

The nurse is starting a client's 3rd unit of PRBCs. The client begins complaining of severe back pain, becomes apprehensive, and VS: T 100.9F, P 126, RR 28, BP 80/54. Which intervention should the nurse perform as priority? A) Slow the infusion B) Stop the infusion C) Administer Tylenol and Benadryl and continue the infusion D) Call for help

B

The nurse who is about to begin a blood transfusion knows the blood cells start to deteriorate after a certain period of time. Which item is important to check regarding the age of blood cells before the transfusion is begun? A) Blood ID number B) Expiration date C) Presence of clots D) Blood group and type

B

A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain with intravenous (IV) solution from the IV storage area to hang with the blood products at the client's bedside? A) 5% dextrose in 0.9% sodium chloride B) 5% dextrose in 0.45% sodium chlorid C) 0.9% sodium chloride D) Lactated Ringer

C

A nurse is assessing a sacral pressure injury on a client and evaluates that the wound base has yellow stringy slough noted. How should the nurse document this assessment? A) The client has a stage 3 B) The client has a stage 4 C) The client has an unstable pressure injury D) The client has a deep tissue injury

C

While changing the client's dressing, the nurse observes the wound's drainage is pale red/pinkish. What does the nurse describe the drainage as? A) Sanguineous B) Serous C) Serosanguineous D) Purulent

C

What can the nurse do to help ensure an accurate result when collecting a midstream urine sample for a patient who is menstruating? A) Notify the health care provider. B) Do nothing other than follow normal procedure, since menstruation will not affect the results. C) Postpone the specimen collection until menses has ceased. D) Make a note on the lab slip that the patient is menstruating.

D

When assessing the client that presents with a pressure injury, what description best describes an unstageable pressure injury? A) A wound that is full thickness through to the bone, muscle and tendon B) A wound that appears red, shiny, and dry with injury to the dermis C) Dark purple tissue with injury to the subcutaneous tissue D) A wound that presents with full thickness loss as well as Escher and sloughing

D