PPNC2 Exam 2
Which possible dysrhythmia would a nurse anticipate testing for after noting that a client in the clinic has an irregularly irregular pulse rhythm at a rate of 88 beats/min? a. atrial fibrillation b. ventricular tachycardia c. complete heart block d. supraventricular tachycardia
a. atrial fibrillation
A patient has hypokalemia with stable cardiac function. What are the priority nursing interventions? (Select all that apply.) 1. Fall prevention interventions 2. Teaching regarding sodium restriction 3. Encouraging increased fluid intake 4. Monitoring for constipation 5. Explaining how to take daily weights
1. Fall prevention interventions 4. Monitoring for constipation
The nurse is evaluating the recent lab results for a patient. Which labs are the best indicators for malnutrition? (Select all that apply.) 1. Serum total protein 2. Potassium 3. Lipids 4. Albumin 5 Serum BUN
1. Serum total protein 5 Serum BUN
Match: 1. Lactated ringers 2. D5% in 0.45NS 3. 0.45% NaCl 4. D5W a. Hypertonic b. Isotonic c. Hypotonic
1b, 2a, 3c, 4b
Match: 1 Look alike and sound alike medications 2 Need to crush a tablet 3 Narrow Window of administration 4 Smudged name on ID band a. Right Dose b. Right Time c. Right Drug d. Right patient
1c, 2a, 3b, 4d
A nurse is administering ophthalmic ointment to a patient. Place the following steps in correct order for the administration of the ointment. 1. Clean eye, washing from inner to outer canthus. 2. Assess patient's level of consciousness and ability to follow instructions. 3. Apply thin ribbon of ointment evenly along inner edge of lower eyelid on conjunctiva. 4. Have patient close eye and rub lightly in a circular motion with a coon ball. 5. Ask patient to look at ceiling, and explain the steps to patient.
2, 1, 5, 3, 4
The nurse is performing discharge teaching for a patient with chronic obstructive pulmonary disease (COPD). What statement, made by the patient, indicates the need for further teaching? 1. "Pursed-lip breathing is like exercise for my lungs and will help me strengthen my breathing muscles." 2. "When I am sick, I should limit the amount of fluids I drink so that I don't produce excess mucus." 3. "I will ensure that I receive an influenza vaccine every year, preferably in the fall." 4. "I will look for a smoking-cessation support group in my neighborhood."
2. "When I am sick, I should limit the amount of fluids I drink so that I don't produce excess mucus."
The health care provider's order is 500 mL 0.9% NaCl intravenously over 4 hours. Which rate does the nurse program into the infusion pump? 1. 100 mL/hr 2. 125 mL/hr 3. 167 mL/hr 4. 200 mL/hr
2. 125 mL/hr
list the actions in the order the nurse will perform them when mixing a short-acting and an intermediated-acting insulin in the same syringe 1. withdraw the prescribed amount of short-acting insulin 2. put air into the short-acting insulin vial 3. put air into the intermediate-acting insulin vial 4. withdraw the prescribed amount of intermediate-acting insulin
3, 1, 2, 4
A patient is admied to the hospital with severe dyspnea and wheezing. Arterial blood gas levels on admission are pH 7.26; PaCO2, 55 mm Hg; PaO2, 68 mm Hg; and , 24. How does the nurse interpret these laboratory values? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis
3. Respiratory acidosis
Which skills can the nurse delegate to assistive personnel (AP)? (Select all that apply.) 1. Initiate oxygen therapy via nasal cannula. 2. Perform nasotracheal suctioning of a patient. 3. Educate the patient about the use of an incentive spirometer. 4. Assist with care of an established tracheostomy tube. 5. Reposition a patient with a chest tube.
4. Assist with care of an established tracheostomy tube. 5. Reposition a patient with a chest tube.
The nurse is caring for a client with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention? 1. Suction her mouth and throat. 2. Turn her on her side. 3. Put on oxygen at 2 L nasal cannula. 4. Stop feeding her.
4. Stop feeding her.
Place the steps for an ileostomy pouch change in the correct order. 1. Close the end of the pouch. 2. Measure the stoma. 3. Cut the hole in the wafer to fit around the stoma and not leave skin exposed to the effluent. 4. Press the pouch in place over the stoma. 5. Remove the old pouch. 6. Trace the correct measurement onto the back of the wafer. 7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin.
5, 8, 7, 2, 6, 3, 4, 1
according to the nursing process, which action would the nurse take after administering pain medication to a postoperative client? a. administer nonpharmacological comfort measures b. inform the healthcare provider of the nursing action c. create a care plan that addresses the client's pain level d. determine whether the pain medicine relieved the client's pain
d. determine whether the pain medicine relieved the client's pain
The nursing care for a patient with hyponatremia and fluid volume excess includes a. fluid restriction. b. administration of hypotonic IV fluids. c. administration of a cation-exchange resin. d. placement of an indwelling urinary catheter.
a. fluid restriction.
The nurse is caring for a client with pneumonia, who has severe malnutrition. The nurse should assess the patient for which of the following assessment findings? (Select all that apply.) 1. Heart disease 2. Sepsis 3. Hemorrhage 4. Skin breakdown 5. Diarrhea
2. Sepsis 3. Hemorrhage
A nurse is teaching a patient to obtain a specimen for fecal occult blood testing using fecal immunochemical testing (FIT) at home. How does the nurse instruct the patient to collect the specimen? 1. Get three fecal smears from one bowel movement. 2. Obtain one fecal smear from an early-morning bowel movement. 3. Collect one fecal smear from three separate bowel movements. 4. Get three fecal smears when you see blood in your bowel movement.
3. Collect one fecal smear from three separate bowel movements.
The nurse assesses pain and redness at a vascular access device (VAD) site. Which action is taken first? 1. Apply a warm, moist compress. 2. Aspirate the infusing fluid from the VAD. 3. Report the situation to the health care provider. 4. Discontinue the intravenous infusion.
4. Discontinue the intravenous infusion.
When performing cardiac compression on an adult, how far would the nurse depress the sternum? A. 0.75 to 1 inches B. 2 to 2.4 inches C. 0.5 to 0.75 inches D. 1 to 1.5 inches
B. 2 to 2.4 inches
When providing high quality CPR. What should be the rate of compressions delivered in a minute? A. 30 - 40 B. 60 - 70 C. 80 - 90 D. 100 - 120
D. 100 - 120
When using a chlorhexidine-impregnanted patch, how often should a central line dressing be changed? A. Every 24 hours B .Every 48 hours C. Every 3 days D. Every 7 days
D. Every 7 days Transparent dressing
A nurse discovers that a medication error occurred. What is the nurse's first response? a. Record the error in the medication record b. Notify the provider regarding course of action c. Check the patient's condition to note any possible effect of the error d. Complete an incident report explaining how the mistake was made
c. Check the patient's condition to note any possible effect of the error Always check patients first Then call the provider and then make incident report (even if nothing negative happens)
Which medication prescription requires clarification with the health care provider? a. Cefadroxil 500 mg PO bid b. Tobramycin 60 mg IM q8h c. Heparin 7500 units subcutaneously d. Diazepam 6 mg IM STAT e. Escitalopram oxalate (Lexapro) 10 mg po daily
c. Heparin 7500 units subcutaneously missing time
The typical fluid replacement for the patient with a fluid volume deficit is a. dextran. b. 0.45% saline. c. lactated Ringer's solution. d. 5% dextrose in 0.45% saline.
c. lactated Ringer's solution.
in which way would the nurse teach the parent of an 18-month-old child to install eardrops? a. by cleansing the ear canal before instilling the drops b. by applying medicated ear wicks before instilling the drops c. by pulling the pinna up and back after drop instillation to promote distribution of the drops d. by pulling the pinna down and back to straighten the auditory canal before instillation of the drops
d. by pulling the pinna down and back to straighten the auditory canal before instillation of the drops
which procedure is used to verify placement of a newly inserted central venous access device (CVAD)? a. chest x-ray b. flushing the line with heparin c. withdrawing blood to ensure patency d. chest fluoroscopy
a. chest x-ray
Which symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? (Select all that apply.) 1. Change in bowel habits 2. Blood in the stool 3. A larger-than-normal bowel movement 4. Fecal impaction 5. Muscle aches 6. Incomplete emptying of the colon 7. Food particles in the stool 8. Unexplained abdominal or back pain
1. Change in bowel habits 2. Blood in the stool 6. Incomplete emptying of the colon 8. Unexplained abdominal or back pain
A patient is receiving total parenteral nutrition (TPN). What are the primary interventions the nurse should follow to prevent a central line infection? (Select all that apply.) 1. Change the dressing using sterile technique. 2. Change TPN containers every 48 hours. 3. Change the TPN tubing every 24 hours. 4. Monitor glucose levels to watch and assess for glucose intolerance.
1. Change the dressing using sterile technique.. 3. Change the TPN tubing every 24 hours.
Which nursing actions do you take when placing a bedpan under an immobilized patient? (Select all that apply.) 1. Lift the patient's hips off the bed and slide the bedpan under the patient. 2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. 3. Adjust the head of the bed so that it is lower than the feet, and use gentle but firm pressure to push the bedpan under the patient. 4. Have the patient stand beside the bed, and then have him or her sit on the bedpan on the edge of the bed. 5. Make sure the patient has a nurse call system in reach to notify the nurse when he or she is ready to have the bedpan removed.
2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. 5. Make sure the patient has a nurse call system in reach to notify the nurse when he or she is ready to have the bedpan removed.
A client is receiving an enteral feeding at 65 mL/hr. The gastric residual volume in 4 hours was 125 mL. What is the priority nursing intervention? 1. Assess bowel sounds. 2. Raise the head of the bed to at least 45 degrees. 3. Continue the feedings; this is normal gastric residual for this feeding. 4. Hold the feeding until you talk to the primary care provider.
3. Continue the feedings; this is normal gastric residual for this feeding.
A nurse is taking a health history of a newly admied patient with a diagnosis of possible fecal impaction. Which question is the priority to ask the patient or caregiver? 1. Have you eaten more high-fiber foods lately? 2. Have you taken antibiotics recently? 3. Do you have gluten intolerance? 4. Have you experienced frequent, small liquid stools recently?
4. Have you experienced frequent, small liquid stools recently?
Place the steps of administering an intradermal injection in the correct order. 1. Inject medication slowly. 2. Note the presence of a bleb. 3. Advance needle through epidermis to 3 mm. 4. Using nondominant hand, stretch skin over site with forefinger. 5. Insert needle at a 5- to 15-degree angle into the skin until resistance is felt. 6. Cleanse site with antiseptic swab.
6, 4, 5, 3, 1, 2
If an IV ran for 7 hrs. and 30 mins.; how much volume (ml) was given if there was a 15 gtts/ml set and the flow rate was 80 ml/hr a. 600 ml/hr b. 650 ml/hr. c. 700 ml/hr. d. 750 ml/hr.
a. 600 ml/hr 7.5hr x 80ml/hr
What values are used in considering where to give an intramuscular injection? Select All That Apply. a. Age b. Blood Pressure c. Body Mass d. Volume of Medication
a. Age c. Body Mass d. Volume of Medication
What is the sequence of CPR? a. Compression, Airway, rescue breathing b. Airway, compression, rescue breathing c. Rescue breathing , airway, compression d. Defibrillate, airway, compression
a. Compression, Airway, rescue breathing
It is important for the nurse to assess for which manifestation(s) in a patient who has just undergone a total thyroidectomy (select all that apply)? a. Confusion b. Weight gain c. Depressed reflexes d. Circumoral numbness e. Positive Chvostek's sign
a. Confusion d. Circumoral numbness e. Positive Chvostek's sign
Which of the following best describes complicated grief? a. maladaptive, dysfunctional b. emotionally intense but diminish over time c. connected with a loss that is not socially supported d. experienced before a loss occurs
a. maladaptive, dysfunctional
The nurse sets the IV pump to deliver 300ml over 6.5 hrs. What ml/hr. rate would you set the pump? a. 50 ml/hr. b. 46 ml/hr. c. 36 ml/hr. d. 300 ml/hr.
b. 46 ml/hr. 300/6.5
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 if care? a. humidified oxygen is saturated with fluid b. the tracheostomy tube interferes with effective coughing c. the inner cannula of the tracheostomy tube irritates the mucosa d. the weaning process increases the amount of respiratory sections
b. the tracheostomy tube interferes with effective coughing
Which number would a nurse document as the client's fluid balance after an 8-hour shift where a client has a 6-oz (180-mL) cup of tea and 360mL of water, vomits 100mL, and the instilled intravenous (IV) fluids equaled the urinary output? a. 240mL b. 340mL c. 440mL d. 540mL
c. 440mL
a client who had been receiving palliative care for cancer has deteriorated and now needs end-of-life care. the nurse identifies that which type of care will now be removed from the treatment plan? a. chemotherapy b. repositioning c. regular oral care d. blood transfusion e. radiation therapy
a. chemotherapy d. blood transfusion e. radiation therapy
Which criteria indicates that a client on a cardiac monitor is in sinus rhythm? a. the RR intervals are relatively consistent b. one P wave precedes each QRS complex c. the ST segment is higher than the PR interval d. four to eight complexes occur in 6-second strip e. the QRS duration ranges from 0.12-0.2 sec
a. the RR intervals are relatively consistent b. one P wave precedes each QRS complex
which information would the nurse provide an older adult and caregivers regarding medication safety? SATA a. use a pill organizer b. read all medication labels c. place pills in unlabeled bottles d. review medications with pharmacist e. empty medicine cabinet every 2 years
a. use a pill organizer b. read all medication labels d. review medications with pharmacist
An accident victim is admitted into the ED with extensive injuries and significant blood loss. Plasma is hung. What purpose does this type of fluid serve? a. volume expander b. electrolyte solution c. alkalinizing solution d. acidifying solution e. nutrient solution
a. volume expander
Which possible dysrhythmia would a nurse anticipate testing for after noting that client in the clinic has an irregularly irregular pulse rhythm at a rate of 88 beats/minute? a. atrial fibrillation b. ventricular tachycardia c. complete heart block d. supraventricular tachycardia
a. atrial fibrillation
after abdominal surgery, a client's postoperative prescriptions include a nasogastric (NG) tube to lower intermittent wall suction and an antiemetic every 6 hours as needed for nausea. when the client reports feeling nauseated, which action would the nurse take first? a. check for correct placement of the NG tube b. administer the prescribed antiemetic c. assess the client's bowel sounds d. notify the primary health care provider
a. check for correct placement of the NG tube
The nurse prepares a patient for synchronized cardioversion knowing that cardioversion differs from defibrillation in that a. defibrillation delivers a lower dose of electrical energy. b. cardioversion is a treatment for atrial bradydysrhythmias. c. defibrillation is synchronized to deliver a shock during the QRS complex. d. patients should be sedated if cardioversion is done on a nonemergency basis.
d. patients should be sedated if cardioversion is done on a nonemergency basis.
Which instructions do you include when educating a person with chronic constipation? (Select all that apply.) 1. Increase fiber and fluids in the diet. 2. Use a low-volume enema daily. 3. Avoid gluten in the diet. 4. Take laxatives twice a day. 5. Exercise for 30 minutes every day. 6. Schedule time to use the toilet at the same time every day. 7. Take probiotics 5 times a week.
1. Increase fiber and fluids in the diet. 5. Exercise for 30 minutes every day. 6. Schedule time to use the toilet at the same time every day.
An older adult states that she cannot see her medication boles clearly to determine when to take her prescription. What should the nurse do? (Select all that apply.) 1. Provide a dispensing system for each day of the week. 2. Provide larger, easier-to-read labels. 3. Tell the patient what is in each container. 4. Have a family caregiver administer the medication. 5. Use teach-back to ensure that the patient knows what medication to take and when.
1. Provide a dispensing system for each day of the week. 2. Provide larger, easier-to-read labels. 5. Use teach-back to ensure that the patient knows what medication to take and when.
During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What nursing intervention should the nurse do first? 1. Stop the instillation. 2. Ask the patient to take deep breaths to decrease the pain. 3. Tell the patient to bear down as he would when having a bowel movement. 4. Continue the instillation; then administer a pain medication.
1. Stop the instillation.
The nurse is caring for a patient with an artificial airway. What are reasons to suction the patient? (Select all that apply.) 1. The patient has visible secretions in the airway. 2. There is a sawtooth pattern on the patient's EtCO2 monitor. 3. The patient has clear breath sounds. 4. It has been 3 hours since the patient was last suctioned. 5. The patient has excessive coughing.
1. The patient has visible secretions in the airway. 2. There is a sawtooth pattern on the patient's EtCO2 monitor. 5. The patient has excessive coughing.
An older-adult patient is receiving intravenous (IV) 0.9% NaCl. The nurse detects new onset of crackles in the lung bases. What is the priority action? 1. Notify a health care provider. 2. Decrease the IV flow rate. 3. Lower the head of the bed. 4. Discontinue the IV site.
2. Decrease the IV flow rate.
What should the nurse teach family caregivers when a patient has fecal incontinence because of cognitive impairment? 1. Cleanse the skin with antibacterial soap, and apply talcum powder to the buocks. 2. Initiate bowel or habit training program to promote continence. 3. Help the patient to toilet once every hour. 4. Use sanitary pads in the patient's underwear.
2. Initiate bowel or habit training program to promote continence.
The patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem does the nurse suspect? 1. A food allergy 2. Irritable bowel syndrome 3. Increased peristalsis 4. Lactose intolerance
4. Lactose intolerance
Place the following steps for discontinuing intravenous (IV) access in the correct order: 1. Perform hand hygiene and apply gloves. 2. Explain procedure to patient. 3. Remove IV site dressing and tape. 4. Use two identifiers to ensure correct patient. 5. Stop the infusion and clamp the tubing. 6. Carefully check the health care provider's order. 7. Clean the site, withdraw the catheter, and apply pressure.
6, 4, 2, 1, 5, 3, 7
What are the nurses' responsibilities and roles in providing care and support for individuals at end of life? Select All That Apply a. Disease management b. Physical Comfort c. Support well-being d. Manage pain and distressing symptoms e. Encourage curative strategies
a Disease management B Physical Comfort C Support well-being D Manage pain and distressing symptoms
What statement made by a 2-year-old patient's mother indicates that she understands how to administer her son's eardrops? a. "To straighten his ear canal, I need to pull the outside part of his ear down and back." b. "I need to straighten his ear canal before administering the medication by pulling his ear upward and outward." c. "I need to put my son in a chair and make sure that he's sitting up with his head tilted back before I give him the ear drops." d. "After I'm done giving him the ear drops. I need to make sure that my son remains sitting straight up for at least 10 minutes."
a. "To straighten his ear canal, I need to pull the outside part of his ear down and back."
An older client asks, "how do I know that the medications that I take are safe?" which response by the nurse is correct? SATA a. "ask your healthcare provider how and when you should be taking your medications" b. "stop taking a prescribed medication if you are not feeling better in a few days" c. "discard medications into the toilet that have exceeded the expiration date on the bottle" d. "check the name, dose, and instructions about administration of medications each time before leaving the pharmacy" e. "inform your health care provider of OTC medications, recreational drugs, and amount of alcohol you ingest"
a. "ask your healthcare provider how and when you should be taking your medications" d. "check the name, dose, and instructions about administration of medications each time before leaving the pharmacy" e. "inform your health care provider of OTC medications, recreational drugs, and amount of alcohol you ingest"
Which direction would be given to a patient with a prescription for a swish-and-swallow medication? a. Do not rinse your mouth after taking the medication b. Tilt your head front to back while the medicine is in your mouth c. Keep the medication away from your cheeks. Allow it to collect in the back of your throat (almost like gargling). d. Take the medication before you swallow any other medications.
a. Do not rinse your mouth after taking the medication
Which of the following landmarks are used to locate the ventrogluteal injection site? a. Greater trochanter, anterior superior iliac spine, and iliac crest b. Acromion process, humerus, and posterior superior iliac spine c. Greater trochanter, lateral femoral condyle, and the acromion process d. Greater trochanter, posterior superior iliac spine, and iliac crest
a. Greater trochanter, anterior superior iliac spine, and iliac crest
What are recommended disinfection actions to reduce the risk of Central-Line Associated Bloodstream Infections (CLABSI)? Select All That Apply (Which was originally left off the stem in class.) a. Use of a chlorhexadine- impregnanted dressing b. Clean all needleless connectors- ports- or hubs with 70% isopropyl alcohol c. Use of disinfecting caps on all hubs d. Use of hydrogen peroxide on all needleless connectors-ports- or hubs
a. Use of a chlorhexadine- impregnanted dressing b. Clean all needleless connectors- ports- or hubs with 70% isopropyl alcohol c. Use of disinfecting caps on all hubs
A patient is to have an ophthalmic ointment applied to both eyes. Which information would the nurse provide? a. Your vision may be blurry for a while after I put the ointment in your eyes b. You will need to keep your eyes wide open for 2 minutes after the ointment is applied. c. I will give you tissues to wipe the extra ointment off your face. Use one for each eye d. I will apply the ointment from the outside corner of your eye to the corner near your nose e. We will wait 5 minutes between getting the ointment in the first eye and the second.
a. Your vision may be blurry for a while after I put the ointment in your eyes c. I will give you tissues to wipe the extra ointment off your face. Use one for each eye If same medication do not have to wait 5 minutes btwn... what if different meds?
which is the most important nursing action involved in caring for a client receiving medications? a. administrating the medications b. teaching about the medications c. ensuring adherence to the medication regimen d. evaluating the client's ability to self-administer medications
a. administrating the medications
which instructions would the nurse include when teaching parents techniques to promote medication adherence in toddlers? SATA a. choose the proper dosage form b. compensate for spilled or spit-out medication by overdosing c. complete the prescribed dose d. use calibrated spoons for measuring liquid formulations e. improve palatability of the medication by mixing it with food or juice
a. choose the proper dosage form c. complete the prescribed dose d. use calibrated spoons for measuring liquid formulations e. improve palatability of the medication by mixing it with food or juice
Which finding by the nurse when assessing a client who is receiving intravenous (IV) fluids indicates need for a change in the fluid infusion rate? a. crackles in lungs b. supple skin turgor c. urine output of 480mL over 8hrs d. heart rate decrease from 126 beats/min to 96 beats/min
a. crackles in lungs
The nurse notes that the victim of an automobile crash is in need of cardiopulmonary resuscitation (CPR). Which factors would the nurse remember before performing CPR? a. emergency treatment that is provided without a client's consent b. not performed on adult clients who have already consented to a do-not-resuscitate order either verbally or in writing c. not to be performed by a primary health care provider in violation of a do-not-resuscitate order under any circumstances d. performed on appropriate clients unless a do-not-resuscitate order has been signed and made part of the client's record e. generally performed on any client who requires resuscitation in an emergency, but the client's consent is required
a. emergency treatment that is provided without a client's consent b. not performed on adult clients who have already consented to a do-not-resuscitate order either verbally or in writing d. performed on appropriate clients unless a do-not-resuscitate order has been signed and made part of the client's record
The nurse notes that the victim of an automobile crash is in need of cardiopulmonary resuscitation (CPR). Which factors would the nurse remember before performing CPR? SATA a. emergency treatment that is provided without a client's consent b. not performed on adult clients who have already consented to a do-not-resuscitate order under any circumstances c. not to be performed by a primary healthcare provider in violation of a do-not-resuscitate order under any circumstances d. performed on appropriate clients unless a do-not-resuscitate order has been signed and made part of the client's record e. generally performed on any client who requires resuscitation in an emergency, but the client's consent is required
a. emergency treatment that is provided without a client's consent b. not performed on adult clients who have already consented to a do-not-resuscitate order under any circumstances d. performed on appropriate clients unless a do-not-resuscitate order has been signed and made part of the client's record
which medication can be administered via the intramuscular route to treat anaphylaxis? a. epinephrine b. methdilazine c. phenylephrine d. mycophenolate mofetil
a. epinephrine
The lungs act as an acid-base buffer by a. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. b. increasing respiratory rate and depth when CO2 levels in the blood are low, reducing base load. c. decreasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. d. decreasing respiratory rate and depth when CO2 levels in the blood are low, increasing acid load.
a. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load.
Which intervention would the nurse perform first after finding a client with no pulse? a. initiate cardiopulmonary resuscitation (CPR) b. administer intravenous normal saline c. prepare the client for a needle thoracotomy d. obtain blood samples for further assessment
a. initiate cardiopulmonary resuscitation (CPR)
Which intervention would the nurse perform first after finding a client with no pulse? a. initiate cardiopulmonary resuscitation (CPR) b. administer intravenous normal saline c. prepare the client for a needle thoracotomy d. obtain blood samples for further assessment
a. initiate cardiopulmonary resuscitation (CPR)
Which action would the nurse perform when a client is in ventricular fibrillation? a. initiating CPR b. assessing the EKG c. using a defibrillator d. obtaining electrolytes e. adminsitering epinephrine
a. initiating CPR b. assessing the EKG c. using a defibrillator d. obtaining electrolytes e. adminsitering epinephrine
Which action would the nurse perform when a client is in ventricular fibrillation? a. initiating CPR b. assessing the EKG c. using a defibrillator d. obtaining electrolytes e. administering epinephrine
a. initiating CPR b. assessing the EKG c. using a defibrillator d. obtaining electrolytes e. administering epinephrine
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? a. inspect the catheter b. obtain an oxygen saturation level c. observe the catheter insertion site d. assess the lung sounds
a. inspect the catheter
after a subtotal gastrectomy, a client has a nasogastric (NG) tube in place for continuous low suction. three hours after surgery, the client experiences nausea and abdominal pain. the client's abdomen appears distended. which action would the nurse take? a. instill 30mL of air into the NG tube b. administer the prescribed pain medication c. inform the client that abdominal pain is common with NG tubes d. notify the health care provider immediately
a. instill 30mL of air into the NG tube
Which role would the unlicensed assistive personnel (UAP) have when caring for a client receiving intravenous (IV) therapy? a. monitoring clinical manifestations b. collecting the data to be used in the assessment of the IV site c. administering IV fluids and medications d. evaluating the client for clinical manifestations
a. monitoring clinical manifestations
which task would the nurse delegate to unlicensed assistive personnel (UAP) for a client with a nasogastric (NG) tube in place for feedings? a. oral care for the client b. skin care around the tube c. irrigation of the tube for a stable client d. monitoring for complications related to the tube
a. oral care for the client
During administration of a hypertonic IV solution, the mechanism involved in equalizing the fluid concentration between ECF and the cells is a. osmosis. b. diffusion. c. active transport. d. facilitated diffusion.
a. osmosis.
which action would the nurse take after the medication has been injected and the needle withdrawn when administering an intradermal tuberculosis skin test to a client? a. place a piece of gauze over the injection site b. scrub the site with povidone-iodine solution c. vigorously wipe the area with an alcohol wipe d. circle the area with a skin
a. place a piece of gauze over the injection site
A client with dehydration is prescribed an intravenous (IV) fluid infusion. Which health care professional would the nurse expect to be delegated this task? a. registered nurse (RN) b. licensed practical nurse (LPN) c. licensed vocational nurse (LVN) d. unlicensed assistive personnel (UAP)
a. registered nurse (RN) requires skills and assessment
Which criteria indicates that a client on a cardiac monitor is in sinus rhythm? a. the RR intervals are relatively consistent b. one P wave precedes each QRS complex c. the ST segment is higher than the PR interval d. four to eight complexes occur in a 6-second strip e. the QRS duration ranges from 0.12-0.2 seconds
a. the RR intervals are relatively consistent b. one P wave precedes each QRS complex
a healthcare provider prescribes an intermittent enteral tube feeding for a client with a nasogastric tube. place the nursing interventions in the order in which they should be implemented. a. administer the volume of feeding as per the prescription b. verify the health care provider's prescription c. flush the tube with 30 mL of water after the feeding d. elevate the head of the bed at least 30 degrees e. check the volume of residual against the parameters prescribed
b, d, e, a, c
Which comment made by a patient wearing a transdermal patch requires further investigation by the nurse? a. "I feel like a checkerboard with the patches being rotated around." b. "This patch itches and burns. I have to keep rubbing it to make it feel better" c. "I never realized I had so much hair on my chest and back until I tried to find hairless places to put on a patch." d. "These patches come loose before it is time to remove it so I have to tape around the sides to hold in place.
b. "This patch itches and burns. I have to keep rubbing it to make it feel better" Can put tape if comes loose, if burning/itching we have a problem
A client is taking NPH insulin daily q. AM. When is the client most likely to experience a hypoglycemic reaction after taking their morning dose of NPH insulin? a. 2-4 hours after administration b. 6-14 hours after administration c. 16-20 hours after administration d. 18-25 hours after administration
b. 6-14 hours after administration
In the patient with supraventricular tachycardia, which assessment indicates decreased cardiac output? a. Hypertension and dyspnea b. Chest pain and palpitations c. Abdominal distention and tachypnea d. Bounding pulses and a systolic murmur
b. Chest pain and palpitations
Which action would the nurse take as part of the procedure for administering a vaginal suppository? a. Position the patient in high fowlers b. Lubricate the applicator with a water-soluble gel c. Warm the suppository to room temperature before administration d. Instruct the patient to remain supine for 10 minutes after insertion
b. Lubricate the applicator with a water-soluble gel If warm will be a mess, more like wait for 5 mins after
Which patient teaching points should the nurse include when providing discharge instructions to a patient with a new permanent pacemaker and the caregiver? (select all that apply) a. Avoid or limit air travel. b. Take and record a daily pulse rate. c. Obtain and wear a Medic Alert ID device at all times. d. Avoid lifting arm on the side of the pacemaker above shoulder. e. Do not use a microwave oven because it interferes with pacemaker function.
b. Take and record a daily pulse rate. c. Obtain and wear a Medic Alert ID device at all times. d. Avoid lifting arm on the side of the pacemaker above shoulder.
which measure would the nurse take when administering enoxaparin subcutaneously? a. push over 2 minutes b. administer in the abdomen c. massage site after administration d. remove air pocket from prepackaged syringe before administration
b. administer in the abdomen
Which action would the nurse take when caring for a 3-month-old infant who is receiving intravenous (IV) fluids via an antecubital vein? a. monitoring for infiltration behind the infant's elbow b. applying arm boards to prevent bending at the elbows c. checking both of the infant's pupils for dilation every hour d. telling the parents why they cannot hold the infant during IV therapy
b. applying arm boards to prevent bending at the elbows
the nurse is providing care to a client who is receiving enteral feedings via nasogastric (NG) tube. which serious complication would the nurse take measures to prevent/ a. skin breakdown b. aspiration pneumonia c. retention ileus d. profuse diarrhea
b. aspiration pneumonia
which technique will the nurse employ to prevent excessive bruising when administering subcutaneous heparin? a. administer the injection via the Z-track technique b. avoid massaging the injection site after the injection c. use 2 mL of sterile normal saline to dilute the heparin d. inject the medication into the vastus lateralis muscle in the thigh
b. avoid massaging the injection site after the injection
The nurse expects the long-term treatment of a patient with hyperphosphatemia from renal failure will include a. fluid restriction. b. calcium supplements. c. magnesium supplements. d. increased intake of dairy products.
b. calcium supplements.
a client has a nasogastric feeding tube inserted, and the health care provider prescribes the feeding to be instituted immediately. which action would the nurse take first? a. instill normal saline into the tube to maintain patency b. obtain an x-ray to verify that the tube is in the stomach c. auscultate the epigastric area while instilling 30 mL of air d. withdraw stomach contents to observe color and consistency
b. obtain an x-ray to verify that the tube is in the stomach
Which clinical indicator would the nurse expect when an intravenous (IV) line has infiltrated? SATA a. heat b. pallor c. edema d. decreased flow rate e. increased blood pressure
b. pallor c. edema d. decreased flow rate
You are caring for a one year old patient and the volume of medication to be administered is 1 mL IM. Which sites are appropriate? Select All That Apply. a. deltoid b. vastus lateralis c. ventrogluteal
b. vastus lateralis c. ventrogluteal
To decrease the risk for tissue irritation, which direction would the nurse give to a patient taking a buccal medication? a. "Place every third dose under your tongue." b. "If your cheek starts to burn, swallow the medication." c. "Alternate the side of the mouth used for each dose of medication." d. "If you experience discomfort, skip a dose; if discomfort persists, notify the health care provider."
c. "Alternate the side of the mouth used for each dose of medication."
A client at the public health department just received a Mantoux TB test. Which of the following statements indicates the need for further teaching? a. "I know that some mild itching may occur and that is normal." b. "The site may swell just a bit and that is okay." c. "If it gets itchy, I can apply a dab of lotion to soothe the skin." d. "I know it is important not to scratch the injection site."
c. "If it gets itchy, I can apply a dab of lotion to soothe the skin." Don't apply ANYTHING, not hot or cold
Which patient is at greatest risk for developing hypermagnesemia? a. 83-year-old man with lung cancer and hypertension b. 65-year-old woman with hypertension taking β- adrenergic blockers c. 42-year-old woman with systemic lupus erythematosus and renal failure d. 50-year-old man with benign prostatic hyperplasia and a urinary tract infection
c. 42-year-old woman with systemic lupus erythematosus and renal failure
During a 12-hour shift, a client has 6-oz (180-mL) cup of tea and 360mL of water. The client vomits 100mL, and the instilled intravenous (IV) fluids equaled the urinary output. Which fluid balance would the nurse record for the 12-hr period? a. 240mL b. 340mL c. 440mL d. 540mL
c. 440mL
Joseph's long time partner, Charles, has died from HIV associated complications. Charles' family never acknowledged their relationship and plans on a private funeral excluding Joseph. What type of grief would you expect Joseph to experience a. Anticipatory b. Complicated c. Disenfranchised d. Uncomplicated
c. Disenfranchised Disenfranchised because maybe another partner on the side, not able to participate ; complicated hallmarks = long time)
Which type of solution should be administered via a central vascular access device? a. Isotonic solution b. Hypotonic solution c. Hypertonic solution d. Volume expander
c. Hypertonic solution
A nursing student is administering medications to a patient through a gastric tube. Which of the following actions taken by the nursing student requires the nursing instructor to intervene? a. The nursing student places all the patient's medications in different medicine cups. b. The nursing student evaluates each medication and holds the tube feeding before administering a medication that needs to be administered on an empty stomach c. The nursing student flushes the tube with 30 ml of water only before the first medication is given. d. The nursing student crushes a baby aspirin tablet and mixes it with water before administering it.
c. The nursing student flushes the tube with 30 ml of water only before the first medication is given. Determine 2 placement correct, flush before, and flush 30mL between each med, flush 30 after
The nurse should be alert for which manifestations in a patient receiving a loop diuretic? a. Restlessness and agitation b. Paresthesias and irritability c. Weak, irregular pulse and poor muscle tone d. Increased blood pressure and muscle spasms
c. Weak, irregular pulse and poor muscle tone
A patient admitted with syncope has continuous ECG monitoring. An examination of the rhythm strip reveals the following: atrial rate 74 beats/min and regular; ventricular rate 62 beats/min and irregular; P wave normal shape; PR interval lengthens progressively until a P wave is not conducted; QRS normal shape. The priority nursing intervention would be to a. give epinephrine 1 mg IV push. b. prepare for synchronized cardioversion. c. observe for symptoms of hypotension or angina. d. apply transcutaneous pacemaker pads on the patient.
c. observe for symptoms of hypotension or angina.
which information regarding palliative care as opposed to hospice care would the nurse provide during a home visit to a client with heart failure who asks about this option? a. to receive palliative care, a provider must certify that you have 6 months or less to live b. the goal of palliative care is humanize the end-of-life experience, allowing you to die with dignity c. the focus of palliative care is to enhance you and your family's quality of life despite your heart failure d. by making the choice to begin palliative care, you must no longer pursue life-extending or curative medical treatment
c. the focus of palliative care is to enhance you and your family's quality of life despite your heart failure
Important teaching for the patient scheduled for a radiofrequency catheter ablation procedure includes explaining that a. ventricular bradycardia may be induced and treated during the procedure. b. catheter will be placed in both femoral arteries to allow double-catheter use. c. the procedure will destroy areas of the conduction system that are causing rapid heart rhythms. d. general anesthetic will be given to prevent the awareness of any "sudden cardiac death" experiences.
c. the procedure will destroy areas of the conduction system that are causing rapid heart rhythms.
which finding would indicate that the prescribed enteral feedinf has been effective in a malourished client who had head and neck surgery for pharyngeal cancer? a. good skin turgor b. normal bowel sounds c. well-healed incisions d. normal appearing stools
c. well-healed incisions
which statement will the nurse include when teaching the family of a child with asthma about peak flow meters (PFMs)? a. "this device measures the peak amount of air that your child can inhale" b. "this device will improve medication delivery to the lungs when it's used with an inhaler" c. "your child should make sure to use short-acting bronchodilator before using the pFM" d. "a PFM can help you identify when asthma is getting worse even before your child has symptoms"
d. "a PFM can help you identify when asthma is getting worse even before your child has symptoms"
When providing high quality CPR. What should be the rate of compressions delivered in a minute? a. 30 - 40 b. 60 - 100 c. 80 - 90 d. 100 - 120
d. 100 - 120
which angle would an obese client be taught to self-administer an insulin injection at? a. 30-degree angle b. 60-degree angle c. 45-degree angle d. 90-degree angle
d. 90-degree angle
An infant returns to the pediatric unit with an intravenous (IV) infusion in progress after corrective surgery. Which is the priority nursing action? a. applying adequate restraints b. administering a mild sedative c. removing the nasogastric tube d. assessing the IV site for infiltration
d. assessing the IV site for infiltration
The nurse is unable to flush a central venous access device and suspects occlusion. The best nursing intervention would be to a. apply warm moist compresses to the insertion site. b. try to force 10 mL of normal saline into the device. c. place the patient on the left side with the head down. d. have the patient change positions, raise arm, and cough.
d. have the patient change positions, raise arm, and cough.
During the postoperative care of a 76-year-old patient, the nurse monitors the patient's intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because a. older adults have an impaired thirst mechanism and need reminding to drink fluids. b. water accounts for a greater percentage of body weight in the older adult than in younger adults. c. older adults are more likely than younger adults to lose extracellular fluid during surgical procedures. d. small losses of fluid are significant because body fluids account for 45% to 50% of body weight in older adults.
d. small losses of fluid are significant because body fluids account for 45% to 50% of body weight in older adults.
why is it essential for the nurse to obtain the height and weight of a severely dehydrated toddler? a. the extent of dehydration is based on these measurements b. these measurements are used as a baseline for future growth c. the management of dietary needs is based on height and weight d. the values are used to calculate fluid replacement and medication dosages
d. the values are used to calculate fluid replacement and medication dosages
Which assessment does the nurse use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) deficit? 1. Dryness of mucous membranes 2. Skin turgor 3. Fullness of neck veins when supine 4. Fullness of neck veins when upright
3. Fullness of neck veins when supine
What assessments does a nurse make before hanging an intravenous (IV) fluid that contains potassium? (Select all that apply.) 1. Urine output 2. Arterial blood gases 3. Fullness of neck veins 4. Serum potassium laboratory value in EHR 5. Level of consciousness
1. Urine output 4. Serum potassium laboratory value in EHR
The nurse is caring for a patient with pneumonia. On entering the room, the nurse finds the patient lying in bed, coughing, and unable to clear secretions. What should the nurse do first? 1. Start oxygen at 2 L/min via nasal cannula. 2. Elevate the head of the bed to 45 degrees. 3. Encourage the patient to use the incentive spirometer. 4. Notify the health care provider.
2. Elevate the head of the bed to 45 degrees.
a healthcare provider prescribes 0.2 mg of cyanocobalamin (vitamin B12) intramuscularly. a vial of the medication labeled 100 mcg = 1 mL is available. how many milliliters of solution will the nurse administer? record whole number in mL
2 mL
in which order will the nurse perform the actions associated with insulin administration? 1. wipe the top of the insulin vial with an alcohol swab 2. wash hands with soap and water 3. rotate the vial of insulin between the palms of the hands 4. withdraw the correct amount of insulin from the inverted vial 5. instill air into the vial of insulin equal to the desired dose
2, 3, 1, 5, 4
A nurse is administering a metered-dose inhaler (MDI) with a spacer to a patient with chronic obstructive pulmonary disease. Place the steps of the procedure in the correct order. 1. Insert MDI into end of spacer. 2. Perform a respiratory assessment. 3. Remove mouthpiece from MDI and spacer device. 4. Place the spacer mouthpiece into patient's mouth, and instruct patient to close lips around the mouthpiece. 5. Depress medication canister, spraying 1 puff into spacer device. 6. Shake inhaler for 2-5 seconds. 7. Instruct patient to hold breath for 10 seconds. 8. Instruct patient to breathe in slowly through mouth for 3 to 5 seconds.
2, 3, 6, 1, 4, 5, 8, 7
The nurse is administering an IV push medication to a patient who has a compatible IV fluid running through intravenous tubing. Place the following steps in the appropriate order. 1. Release tubing and inject medication within amount of time recommended by agency policy, pharmacist, or medication reference manual. Use watch to time administration. 2. Select injection port of IV tubing closest to patient. Whenever possible, injection port should accept a needleless syringe. Use IV filter if required by medication reference or agency policy. 3. After injecting medication, release tubing, withdraw syringe, and recheck fluid infusion rate. 4. Connect syringe to port of IV line. Insert needleless tip or small-gauge needle of syringe containing prepared drug through center of injection port 5. Clean injection port with antiseptic swab. Allow to dry. 6. Occlude IV line by pinching tubing just above injection port. Pull back gently on syringe plunger to aspirate blood return.
2, 5, 4, 6, 1, 3
If a nurse experiences a problem reading a provider's medication order, the most appropriate action will be to: a. Call the provider to verify the order b. Call the pharmacist to verify the order c. Consult with the charge nurse to verify the order d. Withhold the medication until the provider makes rounds
a. Call the provider to verify the order
Which nursing intervention would be the priority for the nurse preparing to administer an intravenous (IV) piggyback medication to a client who is receiving a continuous infusion of IV fluids? a. get an additional IV infusion pump for the medication b. check the compatibility of the medication and the continuous infusion of IV solution c. disconnect the continuous IV solution while administering the piggyback medication d. flush the client's venous access device to ensure patency
b. check the compatibility of the medication and the continuous infusion of IV solution
The nurse is administering intravenous (IV) fluids to a dehydrated infant. Which intervention is most important at this time? a. calculating the total caloric intake b. continuing the prescribed flow rate c. making hourly temperature assessments d. maintaining the fluid at body temperature
b. continuing the prescribed flow rate
which action would the nurse take when administering iron dextran? a. use a transdermal needle b. massage the injection site c. use the Z-track method d. apply a local anesthetic first
c. use the Z-track method
A toddler is to receive 2.5 mL of an antipyretic by mouth. Which equipment is the most appropriate for medication administration for this child? a. a medication cup b. a teaspoon c. a 10-mL syringe d. an oral-dosing syringe
d. an oral-dosing syringe
After receiving an intramuscular (IM) injection in the deltoid, a patient states, "My arm really hurts. It's burning and tingling where I got my injection." What should the nurse do next? (Select all that apply.) 1. Assess the injection site. 2. Administer an oral medication for pain. 3. Notify the patient's health care provider of assessment findings. 4. Document assessment findings and related interventions in the patient's medical record. 5. This is a normal finding, so nothing needs to be done. 6. Apply ice to the site for relief of burning pain.
1. Assess the injection site. 3. Notify the patient's health care provider of assessment findings. 4. Document assessment findings and related interventions in the patient's medical record.
Which action can a nurse delegate to assistive personnel (AP)? 1. Performing glucose monitoring every 6 hours on a patient 2. Teaching the client about the need for enteral feeding 3. Administering enteral feeding bolus after tube placement has been verified 4. Evaluating the client's tolerance of the enteral feeding
1. Performing glucose monitoring every 6 hours on a patient
Adherence to which of the following measures aims to improve safety in administration of enteral feedings? Select all that apply A. Using only Luer-Lock syringes or extension sets on enteral systems B. Use of pumps designated for tube feedings not IV fluids C. Auscultate the epigastric area while instilling air through the tube D. Instructing patients and family caregivers to seek nursing assistance before reconnecting tubing that has separated E. Clearly labeling enteral administration sets "tube feeding only" F. Elevate the HOB to 30 - 45 degrees during feedings
B. Use of pumps designated for tube feedings not IV fluids D. Instructing patients and family caregivers to seek nursing assistance before reconnecting tubing that has separated E. Clearly labeling enteral administration sets "tube feeding only" F. Elevate the HOB to 30 - 45 degrees during feedings
The nurse has just inserted an NG tube into the left naris for the purpose of initiating enteral feedings. Identify the appropriate documentation for this procedure A. 18 Fr NG tube inserted into the left naris, patient tolerated well, feeding infusing B. 18 Fr NG tube inserted as ordered, radiographic film obtained and the tip is positioned in the stomach, both nares are in good condition and intact, and feeding infusing C. 18 Fr. NG tube inserted in the left naris, patient tolerated procedure with minimal discomfort, the left naris is intact with no skin breakdown or redness noted. X-ray called and confirmed that the tip of the tube is located in the stomach. D. 18 Fr NG tube inserted for the first time by the nurse, patient tolerated the procedure well. Gastric pH was noted to be 5.0, NG tube secured to gown, and feeding infusing.
C. 18 Fr. NG tube inserted in the left naris, patient tolerated procedure with minimal discomfort, the left naris is intact with no skin breakdown or redness noted. X-ray called and confirmed that the tip of the tube is located in the stomach. know they don't have a SI obstruction bc having feeding via NG tube; note placement and French, where tip at, note pt tolerated, xray confirmation
What is the maximum volume one can inject into the deltoid muscle? a. 0.5 mL b. 1.0 mL c. 2.0 mL d. 3.0 mL
c. 2.0 mL
A client who is receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What should be the nurse's priority action? 1. Have the patient turn on the left side and perform a Valsalva maneuver. 2. Clamp the intravenous (IV) tubing to prevent more air from entering the line. 3. Have the patient take a deep breath and hold it. 4. Notify the health care provider immediately.
1. Have the patient turn on the left side and perform a Valsalva maneuver.
Which skills does the nurse teach a patient with a new colostomy before discharge from the hospital? (Select all that apply.) 1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 4. How to irrigate the colostomy 5. How to determine whether the ostomy is healing appropriately
1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 5. How to determine whether the ostomy is healing appropriately
An intravenous (IV) fluid is infusing slower than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select all that apply.) 1. Infiltration at vascular access device (VAD) site 2. Patient lying on tubing 3. Roller clamp wide open 4. Tubing kinked in bedrails 5. Circulatory overload
1. Infiltration at vascular access device (VAD) site 2. Patient lying on tubing 4. Tubing kinked in bedrails
The nurse is caring for a patient with a chest tube for treatment of a right pneumothorax. Which assessment finding necessitates immediate notification of the health care provider? 1. New, vigorous bubbling in the water seal chamber. 2. Scant amount of sanguineous drainage noted on the dressing. 3. Clear but slightly diminished breath sounds on the right side of the chest. 4. Pain score of 2 one hour after the administration of the prescribed analgesic.
1. New, vigorous bubbling in the water seal chamber.
The nurse has just witnessed her patient go into cardiac arrest. What priority interventions should the nurse perform at this time? (Select all that apply.) 1. Perform chest compressions. 2. Ask someone to bring the defibrillator to the room for immediate defibrillation. 3. Apply oxygen via nasal cannula. 4. Place the patient in the high Fowler's position. 5. Educate the family about the need for CPR.
1. Perform chest compressions. 2. Ask someone to bring the
It is important to take precautions to prevent medication errors. A nurse is administering an oral tablet to a patient. Which of the following steps is the second check for accuracy in determining the patient is receiving the right medication? 1. Logging on to automated dispensing system (ADS) or unlocking medicine drawer or cart. 2. Before going to patient's room, comparing patient's name and name of medication on label of prepared drugs with MAR. 3. Selecting correct medication from ADS, unit-dose drawer, or stock supply and comparing name of medication on label with MAR or computer printout. 4. Comparing MAR or computer printout with names of medications on medication labels and patient name at patient's bedside.
2. Before going to patient's room, comparing patient's name and name of medication on label of prepared drugs with MAR.
When delegating input and output (I&O) measurement to assistive personnel, the nurse instructs them to record what information for ice chips? 1. Two-thirds of the volume 2. One-half of the volume 3. One-quarter of the volume 4. Two times the volume
2. One-half of the volume
The nurse is performing tracheostomy care on a patient. What finding would indicate that the tracheostomy tube has become dislodged? 1. Clear breath sounds 2. Patient speaking to nurse 3. SpO2 reading of 96% 4. Respiratory rate of 18 breaths/minute
2. Patient speaking to nurse
A nurse sees an assistive personnel (AP) perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate aention by the nurse? 1. Fastening tube to the gown with new tape 2. Placing client supine while giving a bath 3. Monitoring the client's weight as ordered 4. Ambulating patient with enteral feedings still infusing
2. Placing client supine while giving a bath
Which assessment findings indicate that the patient is experiencing an acute disturbance in oxygenation and requires immediate intervention? (Select all that apply.) 1. SpO2 value of 95% 2. Retractions 3. Respiratory rate of 28 breaths per minute 4. Nasal flaring 5. Clubbing of fingers
2. Retractions 3. Respiratory rate of 28 breaths per minute 4. Nasal flaring
A patient is to receive medications through a small-bore nasogastric feeding. Which nursing actions are appropriate? (Select all that apply.) 1. Verifying tube placement after medications are given 2. Mixing all medications together to give all at once 3. Using an enteral tube syringe to administer medications 4. Flushing tube with 30 to 60 mL of water after the last dose of medication 5. Checking for gastric residual before giving the medications 6. Keeping the head of the bed elevated 30 to 60 minutes after the medications are given
3. Using an enteral tube syringe to administer medications 4. Flushing tube with 30 to 60 mL of water after the last dose of medication 5. Checking for gastric residual before giving the medications 6. Keeping the head of the bed elevated 30 to 60 minutes after the medications are given
A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health care provider and request a discontinuation of parenteral nutrition? 1. When 25% of the patient's nutritional needs are met by the tube feedings 2. When bowel sounds return 3. When the central line has been in for 10 days 4. When 75% of the patient's nutritional needs are met by the tube feedings
4. When 75% of the patient's nutritional needs are met by the tube feedings
The provider has ordered a feeding of 500 mL of formula, to be given over 12 hours via an enteral feeding pump. What rate will the nurse set on the pump? Round your answer to the nearest tenth.
41.7 ml
The nurse is preparing to perform nasotracheal suctioning on a patient. Arrange the steps in order. 1. Apply suction. 2. Assist patient to semi-Fowler's or high Fowler's position, if able. 3. Advance catheter through nares and into trachea. 4. Have patient take deep breaths. 5. Lubricate catheter with water-soluble lubricant. 6. Apply sterile gloves. 7. Perform hand hygiene. 8. Withdraw catheter.
7, 2, 6, 4, 5, 3, 1, 8
A patient has the following arterial blood gas results: pH 7.52, PaCO2 30 mm Hg, HCO3− 24 mEq/L. The nurse determines that these results indicate a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.
d. respiratory alkalosis.
What documentation is required for all IV bags that are hung for a patient? a. Date, time & your initials b. Additive sticker with date, time & initials c. Patient name and medical record number d. All of the above
d. All of the above
which response would a nurse monitor for when a client is receiving furosemide to relieve edema? SATA a. weight loss b. negative nitrogen balance c. increased urine specific gravity d. excessive loss of potassium ions e. pronounced retention of sodium ions
a. weight loss d. excessive loss of potassium ions
The nurse must take a verbal order during an emergency on the unit. Which of the following guidelines can be used for taking verbal or telephone orders? (Select all that apply). 1. Only authorized staff may receive and record verbal or telephone orders. The health care agency identifies in writing the staff who are authorized. 2. Clearly identify patient's name, room number, and diagnosis. 3. Read back all orders to health care provider. 4. Use clarification questions to avoid misunderstandings. 5. Write "VO" (verbal order) or "TO" (telephone order), including date and time, name of patient, and complete order; sign the name of the health care provider and nurse.
1. Only authorized staff may receive and record verbal or telephone orders. The health care agency identifies in writing the staff who are authorized. 2. Clearly identify patient's name, room number, and diagnosis. 3. Read back all orders to health care provider. 4. Use clarification questions to avoid misunderstandings. 5. Write "VO" (verbal order) or "TO" (telephone order), including date and time, name of patient, and complete order; sign the name of the health care provider and nurse.
An older woman is admitted to the medical unit with GI bleeding. Assessment findings that indicate fluid volume deficit include (select all that apply) a. weight loss. b. dry oral mucosa. c. full bounding pulse. d. engorged neck veins. e. decreased central venous pressure.
a. weight loss. b. dry oral mucosa. e. decrease central venous pressure.
You have Cefepime 1 Gram in 100ml N/S ordered to be given over 30 minutes. What rate should you set the pump? a. 100 ml/hr. b. 50 ml/hr. c. 150 ml/hr. d. 200 ml/hr.
d. 200 ml/hr.
Order: 500ml D5W at 100ml/hr. What drop rate per minute is needed when a 15 gtts/ml tubing is used? a. 100 gtts/min b. 50 gtts/min c. 75 gtts/min. d. 25 gtts/min
d. 25 gtts/min 100ml/60min x15drops
which information must be clearly described in the medication administration record (MAR) before administering a medication? SATA a. dosage and route b. client's full name c. time to be administered d. frequency of administration e. full name of prescribed medication
a. dosage and route b. client's full name c. time to be administered d. frequency of administration e. full name of prescribed medication
When opening an IV tubing bag, what is the first action one should take? a. Verify the drip chamber for 20 gtt drip factor b. Check the Healthcare Provider Orders c. Place a label on the line with the date d. Clamp the line with the roller clamp
d. Clamp the line with the roller clamp
Rotation sites for insulin injections should be used how frequently? a. Once a week b. Every 2 weeks c. Every 3 weeks d. Every 4 weeks
d. Every 4 weeks
Which action by the student nurse requires correction and additional education prior to administering a medication? a. The order states: Cimetidine 0.4 g PO q 6 hours. The student obtains cimetidine 400 mg tablet to administer to the patient b. The student wears gloves to apply the nitropaste patch to the client's chest c. For a 6 year old child with asthma, the student plans to use a spacer to deliver the Proventil inhaler d. The order reads: Ultram ER 300 mg PO once daily. The student plans to crush the medication to give with applesauce since the client can't swallow pills.
d. The order reads: Ultram ER 300 mg PO once daily. The student plans to crush the medication to give with applesauce since the client can't swallow pills. (ER stands for extended release)
The ECG monitor of a patient in the cardiac care unit after an MI shows ventricular bigeminy with a rate of 50 beats/min. The nurse would a. perform defibrillation. b. administer IV amiodarone. c. prepare for temporary pacemaker insertion. d. assess the patient's response to the dysrhythmia.
d. assess the patient's response to the dysrhythmia.