CPCC - Midterm
Which action needs correction regarding insertion of an intravenous cannula for administration of fluids? 1. Washing hands with antibacterial soap before insertion of cannula 2. Using chlorhexidine at the selected site of insertion 3. Shaving the client's skin immediately around the insertion site 4. Applying skin protectant solutions at the site of insertion
3. Shaving the client's skin immediately around the insertion site
Which personal protective equipment will the nurse plan to wear when providing central venous access device site care? 1. Double sterile gloves and gown 2. Mask and sterile gloves 3. Hair cap and sterile gloves 4. Gown and double gloves
2. Mask and sterile gloves
When a client has sinus tachycardia, which potential causes of the dysrhythmia would the nurse consider when assessing the client? Select all that apply. One, some, or all responses may be correct. 1. Anxiety 2. Caffeine 3. Exercise 4. Anemia 5. Hypothermia
1. Anxiety 2. Caffeine 3. Exercise 4. Anemia
The nurse is suctioning a client's tracheostomy. What is the correct order of nursing actions when performing this procedure? 1. Don sterile gloves. 2. Auscultate the lungs and check the heart rate. 3. Guide the catheter into the tracheostomy tube using a sterile-gloved hand. 4. Hyperoxygenate using 100% oxygen. 5. Prepare by turning suction on to between 80 and 120 mm Hg pressure.
1. Auscultate the lungs and check the heart rate. 2. Prepare by turning suction on to between 80 and 120 mm Hg pressure. 3. Hyperoxygenate using 100% oxygen. 4. Don sterile gloves. 5. Guide the catheter into the tracheostomy tube using a sterile-gloved hand.
When assessing a client's forearm for a potential intravenous (IV) catheter insertion site, the nurse notes that the client has an excessive amount of hair. Which action would the nurse take to properly prepare the site for insertion? 1. Clip the hair. 2. Shave the area. 3. Apply a securement device. 4. Prepare the skin with a protectant solution
1. Clip the hair.
A client is admitted with cellulitis of the left leg and a temperature of 103°F (39.4°C). The primary health care provider prescribes intravenous (IV) antibiotics. Which action is the priority before administering the antibiotics? 1. Determine the client's allergies. 2. Apply a warm, moist dressing over the cellulitis. 3. Measure the amount of swelling in the client's left leg. 4. Obtain the results of the culture and sensitivity tests.
1. Determine the client's allergies.
After a laryngectomy is scheduled, which is the most important factor for the nurse to include in the preoperative teaching plan? 1. Establishing a means for communicating postoperatively 2. Demonstrating how to care for a permanent laryngeal stoma 3. Teaching how to cough to expectorate bronchial secretions effectively 4. Explaining differences between esophageal speech and transesophageal puncture
1. Establishing a means for communicating postoperatively
A client develops subcutaneous emphysema after the surgical creation of a tracheostomy. Which assessment by the nurse most readily detects this complication? 1. Palpating the neck or face 2. Evaluating the blood gases 3. Auscultating the lung fields 4. Reviewing the chest x-ray film
1. Palpating the neck or face
The nurse is caring for a client with a tracheostomy. Which action would the nurse implement when performing tracheal suctioning? 1. Preoxygenate the client before suctioning. 2. Employ gentle suctioning as the catheter is being inserted. 3. Loosen the client's secretions before suctioning by instilling saline. 4. Ensure that the cuff of the tracheostomy is inflated during suctioning.
1. Preoxygenate the client before suctioning.
When a client who has a chest tube after thoracotomy reports sharp chest pain at the chest tube and refuses to take deep breaths, which action by the nurse is best? 1. Assist the client to sit up in a chair. 2. Administer prescribed pain medications. 3. Educate about the reason for deep breathing. 4. Explain that some pain is normal with a chest tube.
2. Administer prescribed pain medications.
A client begins to have difficulty breathing 30 minutes after the insertion of a subclavian central line. Which would the nurse do first? 1. Raise the head of the bed. 2. Apply oxygen. 3. Assess breath sounds. 4. Call the primary health care provider requesting a chest x-ray
1. Raise the head of the bed.
After insertion of a central venous catheter through the left subclavian vein, a client reports chest pain and dyspnea and has decreased breath sounds on the left side. Which action would the nurse take first? 1. Administer oxygen as prescribed. 2. Activate the Rapid Response Team. 3. Give the prescribed as needed morphine sulfate. 4. Assist the client to cough and deep breathe
1. Administer oxygen as prescribed.
Which action will the nurse take to support safe oral intake after tracheostomy? 1. Include thin liquids. 2. Provide large meals. 3. Inflate the tracheostomy cuff fully. 4. Position client as upright as possible
4. Position client as upright as possible
Which action would the nurse take to determine patency of the chest tube and closed chest drainage system in a client after left lower lobectomy? 1. Milk the chest tube toward the drainage unit. 2. Check the amount of bubbling in the suction control chamber. 3. Observe for fluctuations of the fluid in the water-seal chamber. 4. Assess for extent of chest expansion in relation to breath sounds.
3. Observe for fluctuations of the fluid in the water-seal chamber.
The nurse is caring for a client who has a tracheostomy tube and is receiving mechanical ventilation. The plan of care for the tube would include which nursing intervention? 1. Verify that an inner cannula is in place. 2. Change the tracheostomy tube every week. 3. Clean the tracheostomy once a day. 4. Verify that a low-pressure cuff is in place
4. Verify that a low-pressure cuff is in place
The nurse received orders to initiate an intravenous antibiotic and obtain a blood specimen for culture and sensitivity from a client with an elevated temperature for the past 2 days. Prioritize the nurse's actions. 1. Administer the first dose of antibiotics. 2.Explain the procedure to the client. 3.Send the specimen to the laboratory. 4.Collect the specimen according to protocol.
1. Explain the procedure to the client. 2.Collect the specimen according to protocol. 3.Send the specimen to the laboratory. 4.Administer the first dose of antibiotics.
Which action is essential for the nurse to include in the plan of care for a client with atrial fibrillation? 1. Take pulse apically for a full minute. 2. Monitor blood pressure at least every 2 hours. 3. Ask client to call for assistance when ambulating. 4. Teach client to avoid taking over-the-counter aspirin.
1. Take pulse apically for a full minute.
When teaching a client with atrial fibrillation about a new prescription for warfarin, the nurse will include information about which vitamin? 1. Vitamin K 2. Vitamin D 3. Vitamin B1 4. Vitamin B12
1. Vitamin K
Which nursing action is appropriate when suctioning the secretions of a client with a tracheostomy? 1. Use a new sterile catheter with each insertion. 2. Initiate suction as the catheter is being withdrawn. 3. Insert the catheter until the cough reflex is stimulated. 4. Remove the inner cannula before inserting the suction catheter
2. Initiate suction as the catheter is being withdrawn.
The nurse instructs a client to breathe deeply to open collapsed alveoli. Which explanation could the nurse offer to explain the relationship between alveoli and improved oxygenation? 1. The alveoli need oxygen to live. 2. The alveoli have no direct effect on oxygenation. 3. Collapsed alveoli increase oxygen demand. 4. Oxygen is exchanged for carbon dioxide in the alveolar membrane.
4. Oxygen is exchanged for carbon dioxide in the alveolar membrane.
A client who had thoracic surgery is admitted to the postanesthesia care unit. The nurse notes that a chest tube is in place and is attached to a disposable plastic, water-seal drainage system. To provide appropriate care of the chest tube and drainage unit, which step would the nurse take next? 1. Ensure the security of the connections from the client to the drainage unit. 2. Empty the drainage container and measure and record the amount. 3. Verify that there is vigorous bubbling in the wet suction control compartment. 4. Check that the fluid level in the water-seal compartment increases with expiration.
1. Ensure the security of the connections from the client to the drainage unit.
Which action would the nurse take first when a client who is receiving a blood transfusion develops fever, chills, and low back pain? 1. Stop the blood transfusion and infuse saline. 2. Administer the prescribed antipyretic. 3. Obtain a prescription for an antihistamine. 4. Notify the blood bank about the symptoms
1. Stop the blood transfusion and infuse saline.
Which information would be used to determine the cause of premature atrial contractions (PACs) observed on a client's EKG? Select all that apply. One, some, or all responses may be correct. 1. Stress level 2. Tobacco use 3. Caffeine intake 4. Electrolyte levels 5. Home medications
1. Stress level 2. Tobacco use 3. Caffeine intake 4. Electrolyte levels 5. Home medications
A nurse is caring for a client with a pneumothorax who has a chest tube attached to a closed chest drainage system. If the chest tube and closed chest drainage system are effective, which type of pressure will be reestablished? 1. Neutral pressure in the pleural space 2. Negative pressure in the pleural space 3. Atmospheric pressure in the thoracic cavity 4. Intrapulmonic pressure in the thoracic cavity
2. Negative pressure in the pleural space
Which finding in a client who has had a chest tube removed would be of most concern to the nurse? 1. Poor cough effort 2. Pain at chest tube site 3. Crepitus at the chest tube site 4. Two centimeters of pink drainage on dressing
3. Crepitus at the chest tube site
A client receiving a blood transfusion reports itching and difficulty breathing. The heart rate has increased, and the blood pressure is falling. Which type of shock would the nurse suspect the client is experiencing? 1. Septic shock 2. Cardiogenic shock 3. Neurogenic shock 4. Anaphylactic shock
4. Anaphylactic shock
Which action would the nurse take to prevent complications when caring for a client with a chest tube to water seal drainage system for a pneumothorax? Select all that apply. One, some, or all responses may be correct. 1. Emptying the drainage system when full 2. Keeping the drainage system at heart level 3. Notifying the health care provider of drainage greater than 50 mL/h 4. Marking the time on the drainage unit every shift 5. Laying the drainage system on its side during transport
4. Marking the time on the drainage unit every shift
The nurse is assessing an electrocardiogram (ECG) rhythm strip. Which component of the tracing will the nurse observe to determine ventricular depolarization? 1. P wave 2. T wave 3. PR interval 4.QRS complex
4.QRS complex
A client has a peripherally inserted central catheter (PICC) in place. The client notifies the nurse that the catheter got tangled up in bedclothes and came out. Which action would the nurse take to determine the likelihood of a catheter embolus? 1. Inspect the catheter. 2. Obtain an oxygen saturation level. 3. Observe the catheter insertion site. 4. Assess the lung sounds.
1. Inspect the catheter.
Which action would the nurse take when a client reports pain and burning at a peripheral intravenous (IV) site after the nurse has flushed the saline lock with normal saline? 1. Remove the IV catheter and restart the saline lock in another site. 2. Document the findings per protocol and reassess the site in 8 hours. 3. Flush the IV catheter and saline lock again vigorously with normal saline. 4. Change the dressing and apply a new clean dressing per IV care protocol.
1. Remove the IV catheter and restart the saline lock in another site.
The nurse is suctioning a client's airway. Which nursing action will limit hypoxia? 1. Limit suctioning with catheter to 30 seconds. 2. Apply suction only after the catheter is inserted. 3. Lubricate the catheter with saline before insertion. 4. Use a sterile suction catheter for each suctioning episode
2. Apply suction only after the catheter is inserted.
Which actions will the nurse include in the plan of care for a client with a left pneumothorax who has a chest tube in place? Select all that apply. One, some, or all responses may be correct. Immobilize the left arm in a sling. 1. Immobilize the left arm in a sling. 2. Check the water-seal chamber for air bubbling. 3. Avoid use of nonsteroidal anti-inflammatory drugs. 4. Keep the client on bed rest in semi-Fowler position. 5. Observe frequently for drainage in the collection chamber. 6. Assist the client to cough and deep breathe every hour while awake.
2. Check the water-seal chamber for air bubbling. 6. Assist the client to cough and deep breathe every hour while awake.
During an 8-hour shift, a client has a 6-oz (180-mL) cup of tea and 360 mL of water. The client vomits 100 mL, and the instilled intravenous (IV) fluids equaled the urinary output. What is this client's fluid balance at the end of this 8-hour period that the nurse must document on the client's intake and output record? 1. 240 mL 2. -340 mL 3. 440 mL 4. 540 mL
3. 440 mL
A client experiences gastrointestinal (GI) bleeding, and the health care provider prescribes a blood transfusion. While receiving the blood, the client develops flank pain, chills, and fever. Which type of transfusion reaction would the nurse conclude that the client probably is experiencing? 1. Allergic 2. Pyrogenic 3. Hemolytic 4. Anaphylactic
3. Hemolytic
A client has a tracheostomy tube with a high-volume, low-pressure cuff. The nurse understands that type of cuff is designed to prevent which occurrence? 1. Any leakage of air 2. Lung infection 3. Mucosal necrosis 4. Tracheal secretions
3. Mucosal necrosis
When a client's cardiac monitor shows ventricular tachycardia, which action would the nurse take first? 1. Check for a pulse 2. Start cardiac compressions. 3. Prepare to defibrillate the client. 4. Administer oxygen via an Ambu bag
1. Check for a pulse
A client develops acute respiratory distress, and a tracheostomy is performed. Which intervention is most important for the nurse to implement when caring for this client? 1. Encouraging a fluid intake of 3 L daily 2. Suctioning via the tracheostomy every hour 3. Applying an occlusive dressing over the surgical site 4. Using cotton balls to cleanse the stoma with peroxide
1. Encouraging a fluid intake of 3 L daily
A client is admitted with multiple injuries as a result of an accident. A tracheostomy was performed. While the nurse is caring for this client, the client coughs, expelling the tracheostomy tube onto the bed. Which action would the nurse take? 1. Hold the tracheostomy open with a tracheal dilator and call for assistance. 2. Insert an obturator into the tracheostomy and gently reinsert the tracheostomy tube. 3. Pick up the tracheostomy tube from the bed and replace it until a new tube is available. 4. Obtain a new tracheostomy tube, prepare the new holder, and insert the tube using the obturator.
1. Hold the tracheostomy open with a tracheal dilator and call for assistance.
A client is hospitalized for intravenous antibiotic therapy and an incision and drainage of an abscess that developed at the site of a puncture wound. When would the nurse begin to teach the client about how to care for the wound? 1. In the preoperative period 2. Two days before discharge 3. On the first postoperative day 4. During the first dressing change
1. In the preoperative period
A client is scheduled to receive total parenteral nutrition (TPN). To administer TPN, which piece of equipment is important for the nurse to obtain? 1. Infusion pump 2. Tall intravenous (IV) pole 3. Clamp that will be taped at the bedside 4. Infusion set that delivers 60 drops/mL
1. Infusion pump
Which action would the nurse perform when a client is in ventricular fibrillation? Select all that apply. One, some, or all responses may be correct. 1. Initiating CPR 2. Assessing the EKG 3. Using a defibrillator 4. Obtaining electrolytes 5. Administering epinephrine
1. Initiating CPR 2. Assessing the EKG 3. Using a defibrillator 4. Obtaining electrolytes 5. Administering epinephrine
When caring for a client with symptomatic bradycardia caused by heart block, the nurse will anticipate the need to teach the client about which treatment option? 1. Overdrive pacing 2. Demand pacemakers 3. Cardiac resynchronization therapy 4. Implantable cardioverter-defibrillators
2. Demand pacemakers
How would the nurse position a client to practice supraglottic swallowing after tracheostomy? 1. In bed 2. Upright 3. Lying down 4. Position of comfort
2. Upright
Which actions will the nurse include when doing tracheostomy care? Select all that apply. One, some, or all responses may be correct. 1. Suction the client before starting tracheostomy care. 2. Use sterile technique when cleaning the inner cannula. 3. Use sterile cotton-tipped swabs to clean the inner cannula. 4. Don sterile gloves before removing the inner cannula. 5. Use hydrogen peroxide to clean the skin around the stoma
2. Use sterile technique when cleaning the inner cannula. 4. Don sterile gloves before removing the inner cannula.
Which action by the nurse would best facilitate communication for a client with a partial laryngectomy and tracheostomy in the immediate postoperative period? 1. Provide a means for the client to write. 2. Allow time to lip read what the client says. 3. Deflate the cuff on the tracheostomy tube to allow verbalization. 4. Remind the client that speech is possible after partial laryngectomy
1. Provide a means for the client to write.
A client with terminal bone cancer is to receive 2 mg of hydromorphone intravenously (IV) every 4 hours as needed for severe breakthrough pain. The vial contains 10 mg/mL. When the client reports severe pain, how much solution of hydromorphone would the nurse administer? Record your answer using one decimal place. Include a leading zero if applicable. _____ mL
0.2
The client with congestive heart failure is receiving furosemide 80 mg once daily. Which data collection assessment would be performed to evaluate medication effectiveness? Select all that apply. One, some, or all responses may be correct.\ 1. Daily weight 2. Intake and output 3. Monitor for edema 4. Daily pulse oximetry 5. Auscultate breath sounds
1. Daily weight 2. Intake and output 3. Monitor for edema 4. Daily pulse oximetry 5. Auscultate breath sounds
When the nurse in the coronary care unit (CCU) identifies ventricular fibrillation on a client's cardiac monitor, which intervention is the priority? 1. Defibrillate the client. 2. Notify the Rapid Response Team. 3 Administer intravenous epinephrine. 4. Initiate cardiopulmonary resuscitation.
1. Defibrillate the client.
Which actions will the nurse take when caring for a client with a chest tube in place after thoracotomy? Select all that apply. One, some, or all responses may be correct. 1. Administer prescribed analgesic medications. 2. Check around chest tube insertion site for crepitus. 3. Clamp the chest tube before the client ambulates. 4. Add fluid to the suction control chamber as needed. 5. Milk the tubing toward the collection chamber. 6. Check for air bubbling in the water-seal chamber
1. Administer prescribed analgesic medications. 2. Check around chest tube insertion site for crepitus. 4. Add fluid to the suction control chamber as needed. 6. Check for air bubbling in the water-seal chamber
In which order would the nurse complete these steps when administering a blood transfusion? 1. Obtain vital signs and history of transfusions. 2. Change main line solution to normal saline. 3. Ascertain that intravenous catheter size is 18 or 20 gauge. 4. Check primary health care provider's prescription. 5. Ascertain that intravenous catheter size is 18 or 20 gauge.
1. Check primary health care provider's prescription. 2. Obtain vital signs and history of transfusions. 3. Ascertain that intravenous catheter size is 18 or 20 gauge. 4. Change main line solution to normal saline. 5. Check client identification before hanging unit of blood.
When the nurse is assessing a client after tracheostomy placement, which finding requires immediate action by the nurse? 1. Crackling of the skin on palpation 2. Small amount of blood at the surgical site 3. Client reports the area around incision is tender 4. The client is unable to speak with a cuffed tube
1. Crackling of the skin on palpation
When caring for a client after a thoracotomy, which action would the nurse take to keep the chest tube and closed chest drainage system patent? 1. Position the drainage system below the level of the client's heart. 2. Empty the collection chamber and measure contents every 12 hours. 3. Assure that a daily chest x-ray is done to check chest tube position. 4. Keep the client on bed rest until the chest tube is discontinued.
1. Position the drainage system below the level of the client's heart.
Which action would the nurse include in the plan of care for a client who had an ischemic stroke caused by atrial fibrillation and has been placed on anticoagulation therapy to prevent further strokes from occurring? Select all that apply. One, some, or all responses may be correct. 1. Wearing a medical alert bracelet 2. Initiating bleeding precautions 3. Refraining from estrogen therapy 4. Obtaining routine prothrombin times 5. Notifying providers of anticoagulation
1. Wearing a medical alert bracelet 2. Initiating bleeding precautions 4. Obtaining routine prothrombin times 5. Notifying providers of anticoagulation
Which laboratory value would the nurse use to determine whether a client is receiving a therapeutic dose of intravenous heparin? 1. International normalized ratio (INR) is between 2 and 3 2. Prothrombin time (PT) is 2.5 times the control value 3. Activated partial thromboplastin time (APTT) is 70 seconds 4. Activated clotting time (ACT) is in the range of 70 to 120 seconds
3. Activated partial thromboplastin time (APTT) is 70 seconds
A client has a tracheostomy tube attached to a tracheostomy collar for the delivery of humidified oxygen. What is the primary reason that suctioning is included in the client's plan of care? 1. Humidified oxygen is saturated with fluid. 2. The tracheostomy tube interferes with effective coughing. 3. The inner cannula of the tracheostomy tube irritates the mucosa. 4. The weaning process increases the amount of respiratory secretions
2. The tracheostomy tube interferes with effective coughing.
When the nurse educator is observing a student performing tracheal suctioning of a client with thick secretions, which student action requires intervention? 1. Maintains a sterile field 2. Applies suction during insertion of the catheter 3. Preoxygenates with 100% oxygen for 1 minute 4. Tests suction pressure at 100 mm Hg before inserting catheter
2. Applies suction during insertion of the catheter
Which finding in a client who has home oxygen therapy with a tracheostomy collar requires immediate action by the home health nurse? 1. Condensation in the tubing 2. Oxygen flow rate 9 L/min 3. Low fluid level in the humidifier 4. Scented candle burning in the room
4. Scented candle burning in the room
The nurse is caring for a client whose mechanical ventilator settings include the use of positive end-expiratory pressure (PEEP). This treatment improves oxygenation primarily through which mechanism of action? 1. Providing more oxygen to lung tissue 2. Forcing pressure into lung tissue, which improves gas exchange 3. Opening collapsed alveoli and keeping them open 4. Opening collapsed bronchioles, which allows more oxygen to reach lung tissue
3. Opening collapsed alveoli and keeping them open
A client's intravenous cannula insertion site has become red, swollen, and warm to the touch. Purulent drainage is also noted. Which intervention would the nurse implement? 1. Temporarily slow the infusion rate to a "keep vein open" rate. 2. Elevate the extremity slightly above the level of the client's heart. 3. Frequently apply cold and warm compresses to the site. 4. Clean the site with alcohol, remove the cannula, and save for culture.
4. Clean the site with alcohol, remove the cannula, and save for culture.
Which finding best indicates that the chest tube for a client with a pneumothorax may be discontinued? 1. Clear breath sounds heard in both lungs 2. Oxygen saturation reading is higher than 90% 3. Absence of bubbling in the water-seal chamber 4. Full re-expansion of the lungs seen on chest x-ray
4. Full re-expansion of the lungs seen on chest x-ray
