FinalExam2

Question 1

What type of medication administration would we instruct the client to place between the gum and cheek?

Answer 1

buccal administration

Question 2

What is important to tell the client for sublingual and buccal medication administration?

Answer 2

don’t swallow and allow to fully dissolve

Question 3

What are the types of orders?

Answer 3

written (hand or electronic), verbal, and telephone

Question 4

What would be an appropriate action if a nurse has a problem reading a providers medication order?

Answer 4

call the provider to verify the order

Question 5

What are the 5 rights of delegation?

Answer 5

task
circumstance
person
direction/communication
supervision

Question 6

True or false: Patient should breath out while using incentive spirometer.

Answer 6

False, you should breathe in, as this allows lungs to expand, preventing atelectasis

Question 7

How should patient sit during IS use?

Answer 7

upright

Question 8

Steps for using incentive spirometer (IS):
-6 steps

Answer 8

1. sit straight
2. exhale fully
3. seal mouth on mouthpiece
4. slow/steady inhale until unable
5. hold breath at least 5 secs
6. slow exhale

Question 9

For a patient receiving tube feedings when can medication be given?

Answer 9

30 mins before or after feedings

Question 10

How can infection be prevented by the nurse during suture removal?

Answer 10

clipping the shorter side and avoid pulling the knot under skin to ensure that the least amount of the suture goes under the skin as possible

Question 11

Before inserting the feeding tube, what assessments would be
appropriate to determine the patient’s risk for aspiration?

Answer 11

mental status, gag reflex, and ability to swallow

Question 12

When aspirating *continuous enteral gastric contents, how should they appear?

Answer 12

curdled enteral formula with PH of 5 or higher

Question 13

What is the purpose of capillary blood glucose?

Answer 13

determine/monitor blood glucose levels of clients at risk for hyperglycemia or
hypoglycemia

Question 14

What must be avoided when collecting the stool specimen?

Answer 14

Do not allow specimen to come in contact with water or urine

Question 15

What should be utilized to prevent other personnel from discarding urine during a 24hr urine specimen collection?

Answer 15

signage noting that a 24 hr collection is currently in place

Question 15

What action must the nurse take if a patient discards urine during a 24hr urine specimen collection?

Answer 15

restart the collection process

Question 16

What is priority for the nurse to ensure during a lumbar puncture?

Answer 16

that the patient does not move

Question 17

How often does formula in an open tube-feeding system have to be changed?

Answer 17

every 8 hrs

Question 18

How many mL in one ounce?

Answer 18

30 mL

Question 19

What PPE should be used for bacterial pneumonia?

Answer 19

surgical mask

Question 20

What type of solution should NOT be used during ostomy care?

Answer 20

NO alcohol, use warm water not hot

Question 21

What type of precautions may be used for the following:
- leukemia
-oncology
-immunocompromised
-HIV/AIDs?

Answer 21

protective/reverse isolation

Question 22

When may airborne precautions be used?

Answer 22

TB, Covid, and disseminated shingles

Question 23

What is used for airborne precautions?

Answer 23

N95 and negative pressure

Question 24

What does the BED model stand for in wound care?

Answer 24

bacteria
debridement
exudate

Question 25

What nursing interventions are needed for an evisceration?

Answer 25

sterile towels soaked in warm saline to decrease bacteria invasion and drying of the organs

Question 26

What position should a pt be in if an evisceration occurs?

Answer 26

low/semi fowlers with knees gatched

Question 27

Ostomy complication:
-can be caused by medications (antibiotics, cancer, chemo)
-moisture can contribute
-immunosuppression

Answer 27

candidiasis
use antifungal powder, promote dry environment, porous tape

Question 28

What patients may experience caput medusae?

Answer 28

this is an ostomy complication in those w/ liver disease

Question 29

What interventions can be implemented for caput medusae of the stoma?

Answer 29

Vaseline to pouch, very gentle removal/changes because they are at serious risk of bleeding

Question 30

Name that stoma complication:
-cause: malnutrition, steroids, radiation
-treated with fillers

Answer 30

mucocutaneous separation

Question 31

What is an ostomy complication that would likely occur soon after surgery if circulation of the stoma is compromised due to surgical technique or thick abdominal wall?

Answer 31

stomal necrosis

Question 32

This ostomy complication occurs due to weight gain, surgical technique, and/or weight gain.

Answer 32

retraction

Question 33

What may those with stomal stenosis require due to the impaired size of the lumen?

Answer 33

stool softeners

Question 34

What should be used for voiding if a prolapse of the stoma occurs?

Answer 34

one piece pouch system
and use cool packs + lying on back

Question 35

How long can we use peripheral IV?

Answer 35

1 week

Question 36

Which venous access device can be used for 1-4 weeks?

Answer 36

MLC (midline)

Question 37

What ratio can be used for the dilution of IV potassium (we don’t do this, this is done in pharmacy)?

Answer 37

1 mEq of potassium to 10 mL of solution

Question 38

what is the maximum IV potassium rate?

Answer 38

10 mEq/hr

Question 39

Which IV complication may present w/ resp distress, unequal breath sounds, weak pulse, inc CVP, dec BP, confusion, disorientation, LOC?

Answer 39

air embolism

Question 40

Which IV device can be used for weeks to months?

Answer 40

central line