FUNDA Flashcards
- The mid-deltoid injection site is seldom used for I.M. injections because it:
A. Can accommodate only 1 ml or less of medication
B. Bruises too easily
C. Can be used only when the patient is lying down
D. Does not readily parenteral medication
A. Can accommodate only 1 ml or less of medication
ANSWER (A). The mid-deltoid injection site can accommodate only 1 ml or less of medication because of its size and location (on the deltoid muscle of the arm, close to the brachial artery and radial nerve
- The appropriate needle size for insulin injection is:
A. 18G, 1 ½” long
B. 22G, 1” long
C. 22G, 1 ½/” long
D. D25G, 5/8” long
D. D25G, 5/8” long
ANSWER (D). A 25G, 5/8” needle is the recommended size for insulin injection because insulin is administered by the subcutaneous route. An 18G, 1 ½” needle is usually used for I.M. injections in children, typically in the vastus lateralis. A 22G, 1 ½” needle is usually used for adult I.M. injections, which are typically administered in the vastus lateralis or ventrogluteal site.
- Effective skin disinfection before a surgical procedure includes which of the following methods?
A. Shaving the site on the day before surgery
B. Applying a topical antiseptic to the skin on the evening before surgery
C. Having the patient take a tub bath on the morning of surgery
D. Having the patient shower with an antiseptic soap on the evening before and the morning of surgery
D. Having the patient shower with an antiseptic soap on the evening before and the morning of surgery
ANSWER (D). Studies have shown that showering with an antiseptic soap before surgery is the most effective method of removing microorganisms from the skin. Shaving the site of the intended surgery might cause breaks in the skin, thereby increasing the risk of infection; however, if indicated, shaving, should be done immediately before surgery, not the day before.,^
- The correct method for determining the vastus lateralis site fo I.M. injection is to:
A. Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm below the iliac crest
B. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm
C. Palpate a 1” circular area anterior to the umbilicus
D. Divide the area between the greater femoral trochanter and the lateral femoral condyle into thirds, and select the middle third on the anterior of the thigh
D. Divide the area between the greater femoral trochanter and the lateral femoral condyle into thirds, and select the middle third on the anterior of the thigh
ANSWER (D). The vastus lateralis, a long, thick muscle that extends the full length of the thigh, is viewed by many clinicians as the site of choice for I.M. injections because it has relatively few major nerves and blood vessels. The middle third of the muscle is recommended as the injection site. The patient can be in a supine or sitting position for an injection into this site.
- All of the following nursing interventions are correct when using the track method of drug inejction except:
A. Prepare the injection site with alcohol
B. Use a needle that’s a least 1” long
C. Aspirate for blood before injection
D. Rub the site vigorously after the injection to promote absorption
D. Rub the site vigorously after the injection to promote absorption
ANSWER (D). The Z-track method is an I.M. injection technique in which the patient’s skin is pulled in such a way that the needle track is sealed off after the injection. This procedure seals medication deep into the muscle, thereby minimizing skin staining and irritation. Rubbing the injection site is contraindicated because it may cause the medication to extravasate into the skin.
- Jason, 3 years old, vomited. His mom stated, “He vomited 6 ounces of his formula this morning.” This statement is an example of:
A. objective data from a secondary source
B. objective data from a primary source
C. subjective data from a primary source
D. subjective data from a secondary source
A. objective data from a secondary source
ANSWER (A) objective data from a secondary source. Jason is the primary source; his mother is a secondary source. The data is objective because it can be perceived by the senses, verified by another person observing the same patient, and tested against accepted standards or norms.
- Which of the following is a primary nursing intervention necessary for all patients with a Foley Catheter in place?
A. Maintain the drainage tubing and collection bag level with the patient’s bladder
B. Irrigate the patient with 1% Neosporin solution three times a daily
C. Clamp the catheter for 1 hour every 4 hours to maintain the bladder’s elasticity
D. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity
D. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity
ANSWER (D). Maintain the drainage tubing and collection bag level with the patient’s bladder could result in reflux of urine into the kidney. Irrigating the bladder with Neosporin and clamping the catheter for 1 hour every 4 hours must be prescribed by a physician.
- When assessing a patient’s level of consciousness, which type of nursing intervention is the nurse performing?
A. Independent
B. Dependent
C. Collaborative
D. Professional
A. Independent
ANSWER (A) Independent. Independent nursing interventions involve actions that nurses initiate based on their own knowledge and skills without the direction or supervision of another member of the health care team.
- Nurse Cherry is teaching a 72 year old patient about a newly prescribed medication. What could cause a geriatric patient to have difficulty retaining knowledge about the newly prescribed medication?
A. Absence of family support
B. Decreased sensory functions
C. Patient has no interest on learning
D. Decreased plasma drug levels
B. Decreased sensory functions
ANSWER (B) Decreased sensory functions. Decreased in sensory functions could cause a geriatric patient to have difficulty retaining knowledge about the newly prescribed medications. Absence of family support and no interest on learning may affect compliance, not knowledge retention. Decreased plasma levels do not alter patient’s knowledge about the drug.
- It is the gradual decrease of the body’s temperature after death.
A. livor mortis
B. rigor mortis
C. algor mortis
D. Bubot Mortis
C. algor mortis
ANSWER (C) algor mortis. Algor mortis is the decrease of the body’s temperature after death. Livor mortis is the discoloration of the skin after death. Rigor mortis is the stiffening of the body that occurs about 2-4 hours after death.
- When performing an admission assessment on a newly admitted patient, the nurse percusses resonance. The nurse knows that resonance heard on percussion is most commonly heard over which organ?
A. thigh
B. liver
C. intestine
D. lung
D. lung
ANSWER (D) lung. Resonance is loud, low-pitched and long duration that’s heard most commonly over an air-filled tissue such as a normal lung.
- Which of the following is appropriate nursing intervention for a client who is grieving over the death of her child?
A. Tell her not to cry and it will be better.
B. Provide opportunities to the client to tell their story.
C. Encourage her to accept or to replace the lost person.
D. Discourage the client in expressing her emotions.
B. Provide opportunities to the client to tell their story.
ANSWER (B) Provide opportunities to the client to tell their story. Providing a grieving person an opportunity to tell their story allows the person to express feelings. This is therapeutic in assisting the client resolve grief.
- . A female patient who speaks a little English has emergency gallbladder surgery, during discharge preparation, which nursing action would best help this patient understand wound care instruction?
A. Asking frequently if the patient understands the instruction
B. Asking an interpreter to replay the instructions to the patient.
C. Writing out the instructions and having a family member read them to the patient
D. Demonstrating the procedure and having the patient return the demonstration
D. Demonstrating the procedure and having the patient return the demonstration
ANSWER (D) Demonstrating the procedure and having the patient return the demonstration. Demonstrating by the nurse with a return demonstration by the patient ensures that the patient can perform wound care correctly. Patients may claim to understand discharge instruction when they do not. An interpreter of a family member may communicate verbal or written instructions inaccurately.
- . During application of medication into the ear, which of the following is inappropriate nursing action?
A. In an adult, pull the pinna upward.
B. Instill the medication directly into the tympanic membrane.
C. Warm the medication at room or body temperature.
D. Press the tragus of the ear a few times to assist flow of medication into the ear canal.
B. Instill the medication directly into the tympanic membrane.
ANSWER (B) Instill the medication directly into the tympanic membrane. During the application of medication, it is inappropriate to instill the medication directly into the tympanic membrane. The right thing to do is instill the medication along the lateral wall of the auditory canal.
- A skin lesion which is fluid-filled, less than 1 cm in size is called:
A. papule
B. Vesicle
C. bulla
D. macule
B. Vesicle
ANSWER (B) vesicle. Vesicle is a circumscribed circulation containing serous fluid or blood and less than 1 cm (ex. Blister, chicken pox).
- What is the characteristic of the nursing process?
A. stagnant
B. inflexible
C. asystematic
D. goal-oriented
D. goal-oriented
ANSWER (D) goal-oriented. The nursing process is goal-oriented. It is also systematic, patient-centered, and dynamic
- Which of the following is a nursing diagnosis?
A. Hypothermia
B. Diabetes Mellitus
C. Angina
D. Chronic Renal Failure
A. Hypothermia
ANSWER (A) Hypothermia. Hyperthermia is a NANDA-approved nursing diagnosis. Diabetes Mellitus, Angina and Chronic Renal Failure are medical diagnoses.
- .A patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on the patient’s skin. The most appropriate nursing action would be to:
A. Withhold the moderation and notify the physician
B. Administer the medication and notify the physician
C. Administer the medication with an antihistamine
D. Apply corn starch soaks to the rash
A. Withhold the moderation and notify the physician
ANSWER (A). Initial sensitivity to penicillin is commonly manifested by a skin rash, even in individuals who have not been allergic to it previously,
- The most appropriate time for the nurse to obtain a sputum specimen for culture is:
A. Early in the morning
B. After the patient eats a light breakfast
C. After aerosol therapy
D. After chest physiotherapy
A. Early in the morning
ANSWER (A). Obtaining a sputum specimen early in this morning ensures an adequate supply of bacteria for culturing and decreases the risk of contamination from food or medication.
- Which of the following statements about chest X-ray is false?
A. No contraindications exist for this test
B. Before the procedure, the patient should remove all jewelry, metallic objects, and buttons above the waist
C. A signed consent is not required
D. Eating, drinking, and medications are allowed before this test
A. No contraindications exist for this test
ANSWER (A). Pregnancy or suspected pregnancy is the only contraindication for a chest X-ray. However, if a chest X-ray is necessary, the patient can wear a lead apron to protect the pelvic region from radiation. Jewelry, metallic objects, and buttons would interfere with the X-ray and thus should not be worn above the waist. A signed consent is not required because a chest X-ray is not an invasive examination. Eating, drinking and medications are allowed because the X-ray is of the chest, not the abdominal region.
- After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue, muscle cramping and muscle weakness. These symptoms probably indicate that the patient is experiencing:
A. Hypokalemia
B. Hyperkalemia
C. Anorexia
D. Dysphagia
A. Hypokalemia
ANSWER (A). Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia (an inadequate potassium level), which is a potential side effect of diuretic therapy. The physician usually orders supplemental potassium to prevent hypokalemia in patients receiving diuretics. Anorexia is another symptom of hypokalemia. Dysphagia means difficulty swallowing.
- The primary purpose of a platelet count is to evaluate the:
A. Potential for clot formation
B. Potential for bleeding
C. Presence of an antigen-antibody response
D. Presence of cardiac enzymes
A. Potential for clot formation
Answer: (A) platelet are disk shaped blood available for promoting hemostasis and assisting with blood coagulation after injury. It also is used to evaluate the patient’s potential for bleeding; however, this is not its primary purpose. The normal count ranges from 150,000 to 350,000/mm3. A count of 100,000/mm3 or less indicates a potential for bleeding; count of less than 20,000/mm3 is associated with spontaneous bleeding
- Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the patient’s medication drawer. What should the nurse in charge do?
A. Discard the syringe to avoid a medication error
B. Obtain a label for the syringe from the pharmacy
C. Use the syringe because it looks like it contains the same medication the nurse was prepared to give
D. Call the day nurse to verify the contents of the syringe
A. Discard the syringe to avoid a medication error
ANSWER (A) Discard the syringe to avoid a medication error. As a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The other options are considered unsafe because they promote error.
- Which of the following constitutes a break in sterile technique while preparing a sterile field for a dressing change?
A. Using sterile forceps, rather than sterile gloves, to handle a sterile item
B. Touching the outside wrapper of sterilized material without sterile gloves
C. Placing a sterile object on the edge of the sterile field
D. Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a sterile container
C. Placing a sterile object on the edge of the sterile field
ANSWER (C). The edges of a sterile field are considered contaminated. When sterile items are allowed to come in contact with the edges of the field, the sterile items also become contaminated.
