Skills Exam 1

Question 1

While receiving a medication IV piggyback, the client reports discomfort at the IV site. Upon assessment, the site is cool to the touch and slightly swollen. What is the best action by the nurse?

Answer 1

Discontinue the IV site and restart IV in a new location.
Rationale:The assessment reveals the IV has infiltrated. The nurse should stop the IV fluid and remove the IV from the extremity, then restart the IV in a different location. Applying a cool moist compress or slowing the rate will not address the problem of the IV fluid going into the surrounding tissue instead of the vein. Monitoring the site is not appropriate, because there is already a complication present that requires action by the nurse.

Question 2

The nurse is administering a prescribed antibiotic to a client via a piggyback IV infusion. After hanging the piggyback solution container on the IV pole and labeling it, what would the nurse do next?

Answer 2

Squeeze the drip chamber of the tubing and release.
Rationale:The correct order for these procedure steps is (1) squeeze the drip chamber of the tubing and release, (2) open the clamp and prime the tubing, (3) close the clamp and place a needleless connector on end of the tubing, and (4) use an antimicrobial swab to clean the access port or stopcock above the roller clamp on the primary IV tubing.

Question 3

A client is receiving an intermittent piggyback IV infusion of medication. Once the solution in the piggyback container is infused, what is the nurse’s next step?

Answer 3

Close the clamp on the primary infusion tubing and dispose of following facility policy.

Rationale:Once the solution in a piggyback container is infused, the nurse should close the clamp on the piggyback tubing and follow facility policy regarding the disposal of the equipment. The nurse should then replace the primary IV fluid container to the original height, if it had been lowered for the piggyback infusion.

Question 4

The nurse is directed to administer to the client an IV heart medication using a volume control administration set. Which accurately describes this process?

Answer 4

The medication is diluted in a small amount of solution in a cylindrical chamber that is attached to the IV line.
Rationale:A volume control administration set is a method of administering IV medications, which are diluted in a small amount of solution in a volume control set, a cylindrical chamber that is added to the IV line. A needle connected to tubing capped with a sealed injection port is known as a drug infusion lock.

Question 5

The nurse is preparing to reuse an intermittent administration set for administering a medication intravenous piggyback. The label on the tubing indicates that it was hung 12 hours ago. What action should the nurse take next?

Answer 5

Continue with preparing to hang the medication.
Rationale:The nurse should continue with preparing to hang the medication. Intermittent administration sets can be used for 24 hours. Intermittent administration sets disconnected after use should be replaced every 24 hours to prevent complications, especially infections. Because the tubing label indicates it is still well within the 24-hour time frame there is no need for the nurse to obtain a new set, complete an incident report, or to report this to the charge nurse.

Question 6

The nurse is administering a piggyback IV infusion of medication via gravity. What should the nurse use to regulate the flow of the gravity infusion at the prescribed delivery rate?

Answer 6

roller clamp
Rationale:When using a gravity infusion, the nurse should use the roller clamp on the primary infusion tubing to regulate the flow at the prescribed delivery rate. The nurse should connect the piggyback setup to the access port or stopcock and use the tubing spike to attach the infusion tubing to the medication container.

Question 7

When preparing to backprime by gravity, what will the nurse do first?

Answer 7

Close the roller clamp on the tubing.
Rationale:To prevent accidental waste of the medication in the bag, the nurse should first close the roller clamp on the tubing. Once the clamp is closed, it is then safe to spike the new bag, hang it on the IV pole, and squeeze the drip chamber to fill it halfway. By keeping the roller clamp closed until the drip chamber is half full, the nurse prevents air from getting into the tubing. Once the drip chamber is half full, the nurse opens the roller clamp and allows the fluid to prime the remainder of the tubing.

Question 8

After injecting the medication into the injection port of a volume control administration set, what would the nurse do with the volume control chamber to mix the medications?

Answer 8

Agitate it gently.
Rationale:The nurse would rotate or gently agitate the volume control chamber to ensure that the medication is evenly mixed with the solution. Air would not be injected into the chamber.

Question 9

Following completion of a piggyback infusion by gravity, what extra step must the nurse perform with the gravity setup after replacing the primary IV fluid container to the original height?

Answer 9

Check the primary infusion rate and adjust as needed.
Rationale:After replacing the primary IV fluid container to its original height, the nurse should check the primary infusion rate and adjust as needed to the prescribed flow rate. The piggyback tubing should be disposed of according to facility policy or detached from the primary tubing and recapped using sterile technique for future use. There would be no need to readjust the flow rate of the piggyback infusion or to rehang the piggyback to finish the infusion as it has completed. Checking the client’s ID band and asking about allergies should be done before any medications are given, administered, or hung.

Question 10

The nurse is administering an IV medication to a client via a volume control administration set. When would the nurse regulate the calculated rate?

Answer 10

Immediately after opening the roller clamp on the volume control device tubing.
Rationale:The order in which the nurse would perform the above actions is: (1) agitate the volume control chamber to mix the medications, (2) insert the tubing into the injection port, (3) open the roller clamp on the volume control device tubing, (4) regulate the calculated drip rate, and (5) attach the label to the volume control device.

Question 11

The nurse performs hand hygiene and identifies and assesses a client prior to administering an IV antibiotic via a volume control administration set. Which would the nurse do next?

Answer 11

Open the clamp between the IV solution and the volume control administration set.
Rationale:The order in which the nurse would perform these actions is (1) open the clamp between the IV solution and the volume control administration set, (2) fill the chamber with the prescribed amount of solution to dilute the medication, (3) close the clamp between the IV solution and the volume control administration set, and (4) clean the medication injection port of the volume control set with an alcohol swab.

Question 12

The nurse is caring for a client receiving IV medication. Which would be the appropriate action when the piggyback infusion does not infuse?

Answer 12

If the IV is in the arm, make sure the arm is not raised above heart level.
Rationale:If the piggyback IV infusion does not infuse, the nurse would make sure the connections are tight and the clamps are open and make sure the piggyback infusion bag is higher than the primary infusion bag. If the IV is in the wrist or antecubital fossa, the nurse would make sure the elbow or wrist is not bent for too long. If the IV is in the arm, the nurse would make sure that the arm is not raised above heart level.

Question 13

The nurse is preparing to administer medication to a client using a piggyback IV infusion. The client is receiving a continuous IV infusion of dextrose 5% and water (D5W). Which would be most important for the nurse to do before administering the medication?

Answer 13

Check the compatibility of the medication with the IV solution.
Rationale:When administering a piggyback IV medication, it is imperative that the nurse check to make sure that the prescribed medication is compatible with the continuous infusion to prevent the risk of injury. There is no need to readjust the flow rate of the continuous infusion. Rather the nurse would ensure that the piggyback medication is infusing at the correct rate. The nurse should be knowledgeable about the medication to be administered and any potential adverse effects. The nurse would typically consult a drug reference. If additional information is needed, the nurse could check with the pharmacy. Clean, disposable gloves, not sterile gloves, are used.

Question 14

After mixing medication with the solution in the volume control chamber, what would be the nurse’s next step?

Answer 14

Clean the injection port on the primary IV infusion tubing closest to the client with an antimicrobial swab.
Rationale:After mixing the medication with the solution in a volume control chamber, the nurse would use an antimicrobial swab to clean the injection port on the primary IV infusion tubing closest to the client. This deters the entry of microorganisms into the chamber.

Question 15

After hanging an antibiotic via secondary tubing, the nurse notes that the antibiotic is not infusing. What actions will the nurse take to troubleshoot this problem? Select all that apply.

Answer 15

Assess the IV insertion site., Ensure the roller clamp is open., Check the connections and ensure they are secure., Check for any kinks in the tubing.
Rationale:To troubleshoot when an IV is not infusing, the nurse should check the tubing for any kinks that may be impeding flow, ensure the client is not lying on the tubing, check any connections to ensure they are secure, ensure the roller clamp is in open position, and assess the IV insertion site for any complications. The client’s position will not affect the infusion.

Question 16

The nurse is attaching a label to a client’s volume control administration set. Which client information should be printed on the label?

Answer 16

Medication dosage.
Rationale:The volume control device label would include the client’s name, identification number, medication name, medication dose, name and volume of the solution for dilution, and the date and time of administration.

Question 17

After setting up a piggyback IV infusion of antibiotics for a client, the nurse notices that the solution is not infusing. Which should the nurse do first?

Answer 17

Check the tubing for kinks and pressure points.
Rationale:The nurse would first check the tubing for kinks, blockages, and pressure points. The nurse would then adjust the roller clamp and the infusion rate, if necessary. The health care provider would not be notified in this situation.

Question 18

The nurse is teaching a student nurse the advantages of using a volume control administration set to administer IV medications. What is the primary advantage of using this device?

Answer 18

When fluid volume is a concern, it limits how much fluid can be infused at one time.
Rationale:The main advantage of using a volume control set is that it limits how much fluid can be infused at one time, for clients for whom fluid volume is a concern. The possibility of contamination and needlestick injuries is the same with all methods.

Question 19

The nurse squeezes the drip chamber on the tubing, releases it, then watches it fill to the line before opening the clamp and priming the tubing. Why is the tubing primed?

Answer 19

To make sure the tube is clear of air.

Rationale:Priming the tubing ensures that no air enters the client.

Question 20

The nurse is preparing to backprime by gravity. Place in order, from first to last, the actions the nurse will perform. Use all options.

Answer 20

Your Response:
1)Close the roller clamp on the tubing.
2)Spike the new bag.
3)Hang the spiked bag on the IV pole.
4)Compress the drip chamber and allow it to fill about halfway full.
5)Connect the secondary bag to the primary bag at the appropriate port.
Rationale:When preparing to backprime a secondary tubing by gravity, the nurse should first close the roller clamp on the tubing to prevent any accidental loss of medication, then spike the new bag and hang it on the IV pole. Then the nurse should compress the drip chamber and allow the drip chamber to become about half full. The nurse should then open the roller clamp carefully and prime the rest of the tubing, close the clamp again, connect the tubing to the appropriate port, and then unclamp the roller clamp and begin the infusion at the prescribed rate.

Question 21

A client has been receiving an IV piggyback medication via gravity. On assessment the nurse notes that the infusion has not completed but is no longer dripping in the drip chamber. What action should the nurse perform first?

Answer 21

Assess the client’s IV site for infiltration or other complication.
Rationale:When an IV infusion is not dripping or infusing, the nurse should first assess the client’s IV site to ensure there are no complications. After ensuring the IV site is safe to continue using, the nurse may try troubleshooting such as flushing it with sterile saline or hanging the IV bag a little higher and see if it will begin infusing. A blood return does not ensure that the IV is not infiltrated and should not be the nurse’s first action.

Question 22

The nurse returns to a client’s room after the infusion of IV pain medication via a volume control administration set has been completed. Which sequence would the nurse now perform?

Answer 22

Close the roller clamp, turn off the pump, remove the volume control device, recap it, and recheck the flow rate of the primary infusion.
Rationale:When removing the equipment following an infusion via a volume control administration set, the nurse would close the roller clamp, turn off the pump, remove the volume control device, recap it, and recheck the flow rate of the primary infusion. The roller clamp is closed to prevent IV leakage. The flow rate of the primary infusion is rechecked at the end in case it was disturbed during removal of the equipment.

Question 23

The nurse is attaching the infusion tubing to the medication container when administering a piggyback IV infusion of medication. What motion would the nurse use when inserting the tubing spike into the port?

Answer 23

Your Response:Firm pushing and twisting motion.
Rationale:When administering a piggyback infusion, the nurse would attach the infusion tubing to the medication container by inserting the tubing spike into the port with a firm pushing and twisting motion, taking care to avoid contaminating either end.

Question 24

When administering an intravenous medication by piggyback, which action by the nurse will best prevent precipitate from forming in the IV tubing?

Answer 24

ensuring there are no incompatibilities between the medication and the IV fluid
Rationale:To prevent precipitate, the nurse must ensure that there are no incompatibilities between the medication and the IV fluids. It is important to ask the client about any allergies to prevent an allergic reaction, but this does not prevent precipitate. If cloudiness is seen in the tubing, the infusion should be stopped, but cloudiness in the tubing would indicate that precipitate has already formed. Clamping the primary IV tubing will help prevent backflow to the primary fluid, but it will not prevent precipitate if the fluid and medication are not compatible.

Question 25

When administering an IV antibiotic to a client, where would the nurse hang the piggyback container?

Answer 25

On the IV pole, higher than the primary IV solution container.
Rationale:The nurse would hang the piggyback container on the same IV pole, positioning it higher than the primary IV solution according to manufacturer’s recommendations. The position of containers influences the flow of IV fluid into the primary setup.

Question 26

What are the advantages of using an IV pump to backprime secondary tubing? Select all that apply.

Answer 26

It keeps the system closed therefore less chance of contamination., It allows for easy priming when re-using a secondary tubing set., It ensures medication is not lost during priming of the tubing., It eliminates reliance on gravity to determine which bag flows.
Rationale:The advantages of using an IV pump to backprime secondary tubing include: helping to ensure that medication is not lost or accidentally wasted during the priming process; it is a closed system, so it decreases the risk of contamination during the process; it allows for easy priming when re-using secondary tubing; and it eliminates the reliance on gravity to determine which bag will flow. It does not ensure the medication will infuse without complications as the tubing could still get kinked or there could be a problem with the IV site

Question 27

The nurse is administering a medication to a client by piggyback IV infusion. Which accurately describes a step in this procedure?

Answer 27

Attach the infusion tubing spike into the port of the medication container.
Rationale:The nurse administering an IV medication via piggyback infusion would assess the IV site, close the clamp on the short, secondary infusion tubing, use aseptic technique to remove the cap on the tubing spike and the port of the medication container, and attach the infusion tubing to the medication container by inserting the tubing spike into the port of the medication container.

Question 28

The nurse has just compared the label on the piggyback medication with the medication administration record (MAR), using the Rights of Medication Administration for a section check. What is the next step in the process?

Answer 28

Calculate the drip rate for the prescribed infusion time.
Rationale:The correct procedure is to (1) check the medication prescription against the original prescription and check for allergies; (2) use the drug guide to check that the prescription dose is safe, the administration rate is correct, and that the client has no contraindications; (3) choose the correct medication piggyback set from the client’s medication drawer and check the expiration date; (4) compare the label on the piggyback medication with the MAR; (5) calculate the drip rate.

Question 29

Inspection of a client’s peripheral venous access site reveals signs of phlebitis. Which action by the nurse would be most appropriate?

Answer 29

Notify the health care provider, discontinue the IV, and start it at another site.
Rationale:When the nurse suspects phlebitis due to the findings of redness, swelling, and heat, the health care provider should be notified. The IV will need to be discontinued and restarted at another site. The health care provider should be notified immediately, not just if the phlebitis worsens.

Question 30

A client has a peripheral access IV infusion running via an electronic infusion device. While monitoring the infusion, the nurse notices that the electronic infusion device is not running. What should the nurse do?

Answer 30

Check the electronic device for proper functioning.
Rationale:If the electronic infusion is not running, the nurse would check the electronic device for proper functioning, make sure the flow clamp is open and that the drip chamber is approximately half full, and check the IV site for problems with the catheter. If the IV is free flowing, the nurse would raise the height of the IV pole. The nurse could also attempt to flush the IV with 1 to 3 mL of saline in a syringe.

Question 31

The nurse is monitoring an IV site for a client who reports that the needle feels “funny.” What should the nurse do first?

Answer 31

Check the integrity of the IV system, IV solution and tubing, and flow rate.
Rationale:The nurse would first check the integrity of the IV system, IV solution and tubing, and validate the correct drip rate. Next, the nurse would assess the venous access for redness, edema, warmth, coolness, pallor, and pain. If any of these are present, the nurse would discontinue the IV, initiate a new venous access in a different site, and notify the health care provider.

Question 32

While assessing the IV site of a client who has had abdominal surgery, the nurse suspects infiltration. Which finding would help support the nurse’s suspicions?

Answer 32

Pallor
Rationale:The nurse inspects the site for swelling, leakage, and coolness or pallor, which may indicate infiltration. When this happens, the catheter may become dislodged from the vein, and IV solution may flow into subcutaneous tissue. Heat, redness, and slight edema may indicate sepsis, phlebitis, or thrombus.

Question 33

The nurse is responding to a client’s call light. The client states, “I was getting out of bed and caught my IV on the siderail. I think I may have pulled it out.” The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which action is most appropriate?

Answer 33

Remove the IV catheter and reinsert another in a different location.
Rationale:An IV catheter should not be reinserted. Whether the IV is salvageable depends on how much of the catheter remains in the vein. Because this catheter has been almost completely pulled out of the insertion site, it should be discarded and a new one inserted at a different location. It is not acceptable simply to apply a new dressing and leave the catheter sticking out of the site.

Question 34

A nurse would perform additional monitoring of the IV site and infusion according to facility policy for which client?

Answer 34

A client who is receiving IV medications.
Rationale:The nurse should monitor the IV infusion every hour or per agency policy, but more additional monitoring is necessary if the client is receiving IV medications. This promotes the safe administration of IV fluids and medications.

Question 35

The nurse, who is monitoring the IV site of a client receiving peripheral venous fluid therapy, checks for bleeding at the site. The nurse understands that bleeding at an IV site is most likely to occur at which time?

Answer 35

When the IV is discontinued.
Rationale:Bleeding at an IV site may be caused by anticoagulant medication and is most likely to occur when the IV is discontinued.

Question 36

The nurse knows that monitoring the infusion rate and IV site is a nursing responsibility. When does the nurse routinely monitor client IVs?

Answer 36

Beginning of the work shift.
Rationale:The nurse is responsible for monitoring the infusion rate and the IV site. This is routinely done as part of the initial client assessment and at the beginning of a work shift. In addition, IV sites would be checked at specific intervals and each time an IV medication is given, per the institution’s policies.

Question 37

Which client would be at highest risk for experiencing fluid overload as a complication of IV therapy?

Answer 37

An older adult client receiving an IV infusion for pneumonia.
Rationale:Although any client receiving IV therapy could develop fluid overload, older adult clients are more at risk for fluid overload due to the possible decrease in cardiac and/or renal functions.

Question 38

The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply.

Answer 38

Location of the IV catheter access, Client’s reaction to the procedure, Rate of the IV solution, Type of IV solution, Gauge and length of the IV catheter
Rationale:The nurse should document the location where the IV access was placed, as well as the size of the IV catheter or needle, the type of IV solution, the rate of the IV infusion, and the use of a securing or stabilization device. Additionally, document the condition of the site. Record the client’s reaction to the procedure and pertinent client teaching, such as asking the client to alert the nurse if the client experiences any pain from the IV or notices any swelling at the site. Document the IV fluid solution on the intake and output record.

Question 39

The nurse is monitoring a client receiving an IV infusion to replace fluids lost during surgery and notices air bubbles in the tubing above the roller clamp. Which action would be most appropriate?

Answer 39

Remove the bubbles by closing the roller clamp, stretching the tubing downward and tapping the tubing with a finger.
Rationale:If the bubbles are above the roller clamp, the nurse can easily remove them by closing the roller clamp, stretching the tubing downward, and tapping the tubing with a finger so the bubbles rise to the drip chamber. Ensuring that the flow clamp is open and that the drip chamber is half full helps to promote fluid flow. It would not be necessary to change the administration set to troubleshoot this problem. Disconnecting the tubing from the client would be inappropriate and disrupt the integrity of the sterile IV administration system.

Question 40

While assessing a client receiving peripheral IV therapy as part of the treatment plan for hypovolemia, the nurse suspects that the client is experiencing fluid overload based on which finding?

Answer 40

Shortness of breath.
Rationale:Fluid overload is caused when too large a volume of fluid infuses into the circulatory system. This complication manifests as engorged neck veins, shortness of breath and abnormal breath sounds (suggesting respiratory failure), increased blood pressure, and difficulty breathing. A pounding headache is a sign of speed shock and the change in level of consciousness is related to the existence of an air embolus.

Question 41

When monitoring the peripheral access IV sites of various clients receiving IV therapy, the nurse would assess closely for which finding as the most common complication related to IV therapy?

Answer 41

Phlebitis
Rationale:The most common complication related to IV therapy is phlebitis. Chemical irritation or mechanical trauma can cause injury to the vein and lead to phlebitis. Infection, thrombus, and sepsis manifest as redness, pus, warmth, induration, and pain similar to phlebitis and may be caused by poor aseptic technique.

Question 42

While removing gloves after performing client care, what action does the nurse take?

Answer 42

Ensure the skin of the hands does not touch the outside surface of the glove.
Rationale:The glove surface is contaminated, and one of the goals of wearing gloves is decreasing contamination between client and nurse. The nurse does not touch the outer surface of the glove with bare skin. Using hand sanitizer on the glove is a needless and unhelpful step. The gloves and sterile field remnants can be disposed of separately. Optimally, the gloves need to be folded into each other for disposal to decrease contamination risk.

Question 43

The nurse is preparing to put on sterile gloves. When putting on the first glove, how does the nurse grasp the folded cuff?

Answer 43

Thumb and forefinger
Rationale:When putting on sterile gloves, the nurse grasps the folded cuff of the first glove with the thumb and forefinger of the opposite hand. The other grasping positions are awkward and not attempted.

Question 44

The nurse is performing a sterile dressing change. What action would require the nurse to put on a new pair of gloves?

Answer 44

The nurse touches the client’s skin with one hand.
Rationale:The nurse would need to put on a new pair of gloves if the ones being worn became contaminated, such as by touching the client’s skin with one of the gloves. Picking up a sterile dressing from the field, keeping both hands above waist level, or touching one glove to the other glove would not cause contamination and thus not necessitate putting on a new pair of gloves.

Question 45

When removing soiled gloves, which should the nurse do first?

Answer 45

Grasp the outside of one glove with the opposite gloved hand.
Rationale:When removing soiled gloves, the nurse would grasp the outside of one glove with the opposite gloved hand and peel it off, turning the glove inside out as it is pulled. The removed glove is held in the remaining gloved hand. The nurse would then slide the fingers of the ungloved hand under the remaining glove at the wrist and peel off the glove over the first glove, containing one glove inside the other.

Question 46

The nurse has prepared a sterile field with the necessary sterile supplies. The nurse begins to perform the care and realizes that an item is missing. What action would be appropriate?

Answer 46

Call someone to bring in the necessary item to the client’s room.
Rationale:So as not to disrupt the prepared sterile field, when the nurse notices that an item is missing, the most appropriate action would be to call someone to bring the necessary item to the client’s room. If the nurse leaves the room at any time to obtain an item, the sterile field is no longer considered sterile and an entirely new sterile field would need to be set up. Skipping the part of care that requires the missing item would be inappropriate.

Question 47

The nurse opens the package of sterile gloves using the interior side folds, and the package will not open fully for the nurse to reach the gloves. What action does the nurse take?

Answer 47

Open the top and bottom folds completely.
Rationale:When the inside folds of the glove package will not open correctly, the nurse might not have fully opened the top and bottom folds of the package. When this occurs, the package keeps closing back in on itself, making it difficult to put the sterile gloves on correctly. Therefore, opening the bottom and top fold completely allows the interior side folds to open as needed. Sliding the gloves out of the package leads to the gloves contacting the edge of the sterile package, which is not considered sterile—just like any sterile field edge. Reaching under the package is not a useful action, and there is no reason to obtain new gloves yet.

Question 48

What action does the nurse perform to remove gloves after performing a sterile procedure?

Answer 48

Invert the glove as it is removed.
Rationale:Inverting the glove as it is removed is correct. This action decreases contamination risk during removal. Pulling the gloves off from the fingertips is a less clean manner in which to dispose of the gloves and can lead to contamination to the nurse. Gloves are not laid into the sterile field, but directly disposed of. The nurse disposes of the gloves together, not one at a time.

Question 49

When removing soiled gloves, which action should the nurse take?

Answer 49

Using the gloved dominant hand, grasp the glove of the non-dominant hand near the cuff on the outside.
Rationale:When removing soiled gloves, the nurse would use the gloved dominant hand to grasp the opposite (non-dominant) glove near the cuff end on the outside and remove it by pulling it off while inverting it so that the contaminated area remains on the inside. The nurse would then slide the fingers of the now ungloved hand between the remaining glove and the wrist, pulling it off while inverting it, to keep the contaminated area on the inside and secure the first glove inside the second.

Question 50

What action should the nurse take when changing a sterile dressing on a central venous access device?

Answer 50

Cleanse the central venous access device site while wearing sterile gloves.
Rationale:The nurse performs site care after applying sterile gloves, including cleansing the site with an antiseptic. Sterile gloves are not needed to remove the existing dressing, and, if used, the gloves must be discarded prior to completing site care and the dressing change. The nurse does not need to leave the bed in the lowest position while at the bedside. The sterile supplies are placed to the side of the nurse so that the nurse does not have to reach across the sterile field to perform care.

Question 51

The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate?

Answer 51

Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole.
Rationale:It is appropriate to adjust the gloves as long as the nurse only touches sterile surface to sterile surface. Leaving the thumb and finger in the thumb hole or only using the correctly gloved hand to perform the sterile procedure would not be appropriate, nor would donning a second pair of gloves, in this case.

Question 52

The nurse has put on one sterile glove and is preparing to put on the other. What is the next step in donning the second glove?

Answer 52

Slide the gloved fingers under the cuff of the second glove.
Rationale:After putting on the first glove, the nurse would slide the fingers of the gloved hand under the cuff of the second glove, thereby maintaining sterility, and insert the hand into the glove. When putting on the first glove, the nurse would use the thumb and index finger to grasp its cuff. Holding the second glove in the palm of the gloved hand would be inappropriate. Using the fingers to grasp the edges of the cuff of the second hand could cause contamination of the first gloved hand.

Question 53

The nurse puts on sterile gloves in preparation for a sterile central line dressing change. The nurse realizes that the bed is too low to complete the procedure adequately. What action does the nurse take?

Answer 53

Ask someone to raise the bed.
Rationale:The nurse can ask someone else to raise the bed. This may be the client or anyone in the room capable of assisting. Other than this, the nurse would need to call someone to come in and raise the bed or change the gloves for new sterile gloves. Once the nurse uses any part of the sterile glove to touch a non-sterile surface, that glove is no longer sterile. It makes no difference if the nurse removes the sterile gloves; once they are removed they cannot be reused safely. Placing clean gloves over the sterile gloves destroys the sterility.

Question 54

The nursing instructor observes the nursing student removing sterile gloves. Which action indicates the need for further teaching?

Answer 54

The student pulls the gloves off starting with the fingertips prior to removal.
Rationale:Grabbing the outside surface of the non-dominant glove with the glove on the dominant hand ensures the gloves are removed smoothly without contaminating the room, surfaces, or the nurse’s hands. The nurse ensures that the dirty side of the glove does not touch the skin and that any contaminants are contained to the glove’s outer surface. The other actions are correct. The student does use one gloved hand to grab the outside surface of the other, reaches under the glove on one hand to peel the glove off the other hand, and rolls gloves into each other during removal for disposal in the waste can.

Question 55

While performing a sterile dressing change, the nurse inadvertently contaminates the right-hand glove. Which action by the nurse would be most appropriate?

Answer 55

Replace the current gloves with a new set of sterile gloves.
Rationale:If gloves become contaminated at any time, the nurse should remove the gloves and put on a new pair of sterile gloves. Using only the left hand, applying a new pair of gloves over the current pair, or covering the contaminated glove with a non-sterile one would be inappropriate.

Question 56

When putting on the second sterile glove, the nurse places the gloved thumb at which location?

Answer 56

Outward away from the gloved hand
Rationale:When putting on the second sterile glove, the nurse holds the gloved thumb outward away from the rest of the gloved hand. The remaining gloved four fingers are placed inside the cuff of the second glove to apply it to the ungloved hand. The other grasping positions are awkward and not attempted

Question 57

Which statement best explains the rationale for bringing an extra pair of sterile gloves into an adult client’s room before preparing for a sterile procedure?

Answer 57

If the first pair is contaminated and needs to be replaced, the nurse does not need to leave the room for a new pair.
Rationale:It is a good idea to bring an extra pair of gloves when gathering supplies, according to facility policy. That way, if the first pair is contaminated in some way and needs to be replaced, the nurse will not have to leave the procedure to get a new pair. None of the other answers is as good of a rationale for bringing an extra pair of gloves into a procedure.

Question 58

While donning sterile gloves for a client’s dressing change, the nurse rips the cuff while pulling it over a wristwatch. What is the appropriate nursing action?

Answer 58

Obtain a new pair of sterile gloves.
Rationale:The nurse must change gloves. The ripped glove is not sterile, nor is the wrist which should be covered by the cuff. The intact glove may also be contaminated because the fingers were in the cuff as it ripped.

Question 59

The nurse is putting on sterile gloves. Which principle would be important to keep in mind?

Answer 59

The hands should remain above waist level at all times.
Rationale:When putting on sterile gloves, the nurse must ensure that the hands remain above waist level at all times. The inner package should be placed on the surface with the cuff side toward the body. The inner aspect of the cuff is used to put on the glove for the dominant hand, while the gloved fingers are slid under the cuff of the second glove to apply it. The cuffs are adjusted once both gloves are on.

Question 60

The nurse gathers supplies, including an extra pair of sterile gloves, for a sterile dressing change on a client’s large abdominal wound. The nurse uses the extra gloves for what purpose?

Answer 60

To use if the first pair of sterile gloves gets contaminated
Rationale:The nurse brings in extra sterile gloves in case the first pair is contaminated by touching a non-sterile surface. It is always better to plan that this might occur. The existing dressing is removed with clean gloves and is considered dirty. Any drainage should be on the dressing when it is removed. Handled according to the nurse’s discretion but drainage does not usually indicate the nurse needs to change gloves. The gloves can be left for the next dressing change, but this is not the purpose of bringing them into the room.

Question 61

The nurse prepares for a sterile procedure. What action does the nurse perform first?

Answer 61

Perform hand hygiene with alcohol-based handrub.
Rationale:Hand hygiene is done prior to donning any personal protective equipment, before entering the room, and before interacting directly with the client, such as checking the name on the armband.

Question 62

The nurse assists a new nurse to add items to a sterile field. Which action by the new nurse requires further instruction?

Answer 62

The nurse drops the item from the wrapper into the side of the sterile field.
Rationale:The outer edges of the sterile field are considered nonsterile. Dropping items into the outer edges of the field causes those items to be considered contaminated. Items are dropped toward the center of the field from approximately six inches above the surface of the field. The nurse opens the package outward over the hands, maintaining the sterility of the item inside the package. Items are typically held in the non-dominant hand while the dominant hand pulls the package open.

Question 63

Regarding sterile technique- Which should be documented by the nurse?

Answer 63

The fact that sterile technique was used for a given procedure.
Rationale:The fact that sterile technique was used for a given procedure should be documented, but the other items listed do not need to be documented, as they are standard procedure.

Question 64

The nurse needs to place gauze from a wrapped item into the sterile field. Which action does the nurse take?

Answer 64

Dropping the item from roughly 6 in (15 cm) above the surface prevents contamination of the field or dropping the item too close to the 1-in (2.5-cm), nonsterile border. Removing the gauze with one sterile hand risks contamination of that hand. It does not extend the sterile field to lay an unsterile package to the outside of the 1-in (2.5-cm) border.

Question 65

The nurse uses a small amount of sterile solution from a large, multiuse bottle to moisten gauze in a sterile field. What technique does the nurse use?

Answer 65

Pour the liquid into a sterile container within the sterile field.
Rationale:The liquid from a large container is poured into a sterile container present within the sterile field. The gauze is placed in this container if needed or moistened as desired for use. If gauze is laying on the field and the field become moist, it may be considered contaminated.

Question 66

The nurse prepares for insertion of an indwelling urinary catheter for a female client. Prior to catheter insertion, what should the nurse do? Select all that apply.

Answer 66

Question the client about any allergies to latex or iodine., Assess the client’s degree of physical limitations., Confirm the medical prescription for indwelling catheter insertion.
Rationale:The nurse should confirm the medical prescription for indwelling catheter insertion prior to the procedure. By assessing the client’s degree of physical limitations, the nurse can determine how much the client can help during the procedure and what other assistance may be needed. The client does not need to drink water prior to the procedure as this will not change anything with the procedure or its outcomes. The client should be questioned about any allergies to latex or iodine and changes should be made to the procedure based on any client allergies. The client should not void prior to the procedure and this could, in fact, affect the presence of urinary return when assessing proper catheter placement.

Question 67

The nurse is inserting an indwelling urinary catheter for a female client. The client moves her leg accidently, contaminating supplies. What is the correct action by the nurse?

Answer 67

Stop the procedure, obtain new supplies, and restart procedure.
Rationale:The supplies are contaminated and, therefore, new supplies should be obtained before the procedure is restarted. Recleansing the perineal area only does not address the contaminated supplies. The client may need help to position legs, but the procedure will still need to be started with new supplies. Replacing sterile gloves only does not address the contaminated supplies.

Question 68

A nurse is caring for a female client with an indwelling urinary catheter. While performing client assessment, the nurse notes urine leaking around the catheter. What is the correct response by the nurse?

Answer 68

Remove the current catheter and reinsert a new one.
Rationale:The catheter should not be pushed upward as this could cause damage to the urethra. The balloon should not be refilled with water as this could cause damage to the urethra and the integrity of the balloon may be damaged. Repositioning the client would not adequately fix the problem. The best course of action is to remove the current catheter and insert a new one, using sterile technique.

Question 69

The nurse is caring for a female client with an indwelling urinary catheter. Upon entering the room, the nurse notices that the client has placed the catheter bag next to her in bed. The client’s bladder is distended, and she reports of bladder pain. What is the correct action by the nurse?

Answer 69

Place the catheter bag lower than the client and assess for the flow of urine.
Rationale:Urine may not be flowing from the catheter to the bag, causing bladder distention. The bag should be placed lower than the client and the nurse should assess for the flow of urine. Administering a PRN dose of pain medication may be prescribed but will not address bladder distention due to poor urine flow into the catheter bag. Raising the head of the bed could cause more bladder pressure and will not alleviate the problem. The bag should be lowered first before the catheter is replaced.

Question 70

The nurse is caring for a female client with an indwelling urinary catheter. The nurse notes that the catheter is not draining. What is the first action by the nurse?

Answer 70

Check the catheter tubing for kinks or twisting.
Rationale:The catheter should first be checked for kinks or twisting that may be causing it not to drain. The catheter should not be pushed upward as this could cause damage to the urethra. The balloon should not be refilled with water as this could cause damage to the urethra and the integrity of the balloon may be damaged. The catheter may need to be replaced if kinks or twisting are not evident.

Question 71

The nurse is placing an indwelling urinary catheter for a female client. Once urine drains into the catheter tubing, what should the nurse do next?

Answer 71

Advance the catheter an additional 2 to 3 in (5 to 7.5 cm).
Rationale:Advancing the catheter an additional 2 to 3 in (5 to 7.5 cm) ensures placement in the bladder and facilitates balloon inflation without damaging the urethra. The nurse should not stop advancing the catheter immediately when urine is noted in the catheter tubing or retract the catheter to ensure placement in the bladder and facilitate balloon inflation without damaging the urethra. The catheter would not need to be rotated unless resistance is met.

Question 72

The nurse is caring for a female client with an indwelling urinary catheter. The client reports sudden pain and urethral spasm. What is the best action by the nurse?

Answer 72

Deflate the balloon, remove the catheter, and replace.
Rationale:Sudden pain and urethral spasm can indicate that the catheter balloon may be lodged in the urethra. Balloon should be deflated, and the catheter should be removed and replaced. Pushing on the catheter or adding more water to the balloon can cause further urethral spasm and damage. Repositioning the client would not adequately address the problem. The best course of action is to remove the current catheter and insert a new one, using sterile technique.

Question 73

The nurse is inserting an indwelling urinary catheter for a female client. The nurse notes that no urine flow is obtained and that the catheter appears to be in the vaginal orifice. What is the next step by the nurse?

Answer 73

Leave the misplaced catheter in place as a marker and repeat the procedure with a new catheter.
Rationale:Leaving the catheter in place can help mark the correct area for the nurse. A new catheter should be used in to prevent cross-contamination and decrease the risk of infection. A bladder ultrasound is not indicated in this case.

Question 74

The nurse is caring for a female client with an indwelling urinary catheter. The nurse notes that the catheter is not draining. What is the correct action by the nurse?

Answer 74

Check the catheter tubing for kinks or twisting.
Rationale:The catheter should first be checked for kinks or twisting that may be causing it not to drain. The catheter should not be pushed upward as this could cause damage to the urethra. The balloon should not be refilled with water as this could cause damage to the urethra. The catheter may need to be replaced if kinks or twisting are not evident. A condom catheter is only indicated for a male client.

Question 75

The nurse is inserting an indwelling urinary catheter for a female client. Despite several tries, the nurse cannot get the catheter to advance into the bladder. What is the next action by the nurse?

Answer 75

Notify the client’s health care provider.
Rationale:If attempts have been made to advance the catheter, the nurse should stop and notify the client’s health care provider. Drinking water or checking for tubing kinks would not affect catheter advancement. There is nothing to indicate that the client refused the procedure.

Question 76

When placing an indwelling urinary catheter, where should the nurse hold the catheter?

Answer 76

2 to 3 in (5 to 7.5 cm) from the tip of the catheter
Rationale:By holding the catheter 2 to 3 in (5 to 7.5 cm) from the tip, it allows for adequate control while decreasing risk of contamination. The catheter should not be held directly at the tip or at 1 in (2.5 cm) to facilitate insertion. Holding the catheter 4 to 5 in (10 to 12.5 cm) from the tip will not allow for good control and increases risk of contamination.

Question 77

The nurse prepares for insertion of an indwelling urinary catheter for a male client. The nurse is right-handed. Where should the nurse stand to perform the procedure?

Answer 77

on the client’s right side
Rationale:Proper positioning allows for ease of use of the dominant hand for catheter insertion. Therefore, the nurse should not stand on the left side of the client. The nurse should not be positioned at the end of the bed as this will not allow for ease of use of the dominant hand for catheter insertion.

Question 78

The nurse is attempting to insert a urinary catheter into a female client’s bladder and realizes the catheter has been inserted into the vagina. Which action is most appropriate?

Answer 78

Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter.
Rationale:Leaving the catheter in place as a marker assists in the correct placement of the second catheter into the bladder. It is not necessary to contact the health care provider. The vagina is not sterile, so insertion of a sterile catheter poses little risk for infection. Asking the client to bear down is not necessary because the catheter is not typically completely inserted. Removing the catheter from the vagina and attempting to insert it into the bladder will cause cross-contamination.

Question 79

Prior to indwelling urinary catheter insertion for a female client, how should the nurse cleanse the perineal area?

Answer 79

Wipe from above urinary orifice downward toward sacrum.
Rationale:Wiping from above urinary orifice downward toward sacrum helps to cleanse the perineum from least to most contaminated area. The other options do not cleanse the perineum from least to most contaminated area.

Question 80

The nurse is caring for a client with an indwelling urinary catheter. For this client, the nurse plays a key role in prevention of which most common complication?

Answer 80

catheter-associated urinary tract infections
Rationale:Catheter-associated urinary tract infections are the most common complication of urinary catheters. The nurse plays a key role in prevention of this complication from sterile catheter insertion technique to regular catheter care. The client with an indwelling urinary catheter should not regularly be experiencing uncontrolled suprapubic pain or unsuppressed bladder spasms. If the client does, this should be reported. A client with an indwelling urinary catheter should not have urinary retention if the catheter is draining properly.

Question 81

The nurse has finished cleaning a client’s surgical wound. What would be the nurse’s next action in this procedure?

Answer 81

Pat the wound dry with a sterile gauze sponge.
Rationale:The next step after cleaning a client’s wound is to dry the wound with a sterile gauze sponge in the same manner in which it was cleaned, moving from top to bottom and from the inside to the outside of the wound. Moisture provides a medium for the growth of microorganisms. The nurse should not air dry the wound but pat it dry with a sterile gauze. Measuring the wound should happen after removing the old dressing. At that time the nurse should assess the wound, wound bed, drainage, and measure the wound. Positioning of the client should happen before beginning the procedure.

Question 82

After setting up a sterile field and putting on sterile gloves, the nurse prepares to clean a client’s surgical wound. Which cleaning technique would the nurse use to prevent contamination of the wound? The nurse cleans the wound from the:

Answer 82

top to the bottom using a new gauze for each wipe.
Rationale:The nurse would clean the wound from the top to the bottom and from the center to the outside using a new gauze for each wipe. This method ensures that the cleaning is from the least to the most contaminated area and a previously cleaned area is not contaminated again. Cleaning from outside to center, from side to side, or from distal to proximal increases the risk of contaminating the wound as the nurse is starting in the most contaminated area and cleaning into the wound.

Question 83

The nurse is changing the dressing on a client’s surgical wound and notices that part of the dressing is sticking to the underlying skin. What is the recommended nursing intervention in this situation?

Answer 83

Use small amounts of sterile saline to help loosen and remove the dressing.
Rationale:If part of the dressing sticks to the skin, the nurse would use small amounts of sterile saline to loosen and remove the dressing. Sterile saline moistens the dressing for easier removal and minimizes damage and pain.

Question 84

The nurse is removing the dressing from an abdominal surgical wound during wound care and notices that the wound edges are not intact, there are multiple staples on the dressing, and the surrounding tissue is red with purulent drainage. The chart reports that the incision was clean and dry with the approximated edges and staples intact upon the last assessment. What would be the first recommended nursing intervention in this situation?

Answer 84

Assess for pain, shortness of breath, and abdominal pressure.
Rationale:When excessive drainage appears on the dressing, the nurse would first assess the client for pain, shortness of breath, and abdominal pressure, and then place the client in the supine position to reduce pressure on the abdomen. The nurse would then place a dry, sterile dressing on the wound site and assess vital signs, while reassuring the client that while the wound condition has changed, he/she is all right and the health care provider will be notified immediately.

Question 85

The nurse is preparing to perform wound care. Which intervention should be implemented to protect the nurse from injury?

Answer 85

Raise the bed to elbow height.
Rationale:The nurse would adjust the bed to a comfortable working position, usually elbow height. Having the bed at the proper height prevents back and muscle strain for the nurse. Maintaining a sterile field prevents risk of infection for the client. Positioning the client is to make the wound accessible for care. Gathering equipment helps the nurse be organized, not prevent injury.

Question 86

The nurse assesses the surgical dressing of a client who has just arrived from the post-anesthesia care unit (PACU) and observes the dressing has a moderate area of serous drainage on it. What is the best action by the nurse?

Answer 86

Reinforce the dressing and assess site frequently
Rationale:Because bleeding is expected during the first 12 to 24 hours after surgery, the best action by the nurse is to reinforce the dressing and assess the site frequently. Because this is the first surgical dressing that was applied by the surgeon, only the surgeon should change the dressing. Bleeding is expected and, therefore, the health care provider does not need to the notified. Calling a rapid response is not needed in this situation.

Question 87

The nurse is changing the dressing on a client’s surgical wound. After the old dressing is removed, the nurse notices that the client’s skin is red and blistered where the dressing had been secured with tape. Which would be an appropriate action by the nurse?

Answer 87

Replace the dressing with a larger one.
Rationale:When replacing a dressing that has caused blisters on the underlying skin, the nurse would cleanse the area thoroughly, being careful not to aggravate the reddened and blistered areas, and could place a new, larger dressing over the wound so that the blistered area is not further aggravated by tape.

Question 88

The nurse is planning to replace a client’s wound dressing. The deep wound bed is to remain moist and requires packing. Which action is appropriate?

Answer 88

Loosely pack the dampened dressing material to prevent too much pressure on the wound bed.
Rationale:Gently press to loosely pack the moistened gauze into the wound. Avoid overpacking the gauze; loosely pack to prevent too much pressure in the wound bed, which could impede wound healing. The nurse should not instill normal saline or fill the wound with sterile saline gel, as these will not be effective in keeping the wound moist. Inserting rolled gauze into the wound will likely put too much pressure on the wound bed.

Question 89

The nurse is changing the dressing of a client whose skin has been irritated by the frequent removal of adhesive tape that holds the dressing in place. Which would be a recommended nursing intervention?

Answer 89

Use Montgomery straps instead of adhesive tape to hold the dressing in place.
Rationale:When a client’s skin around a wound has been irritated by frequent removal of tape, the nurse would consider using Montgomery straps, non-allergenic tape, or dressing ties, instead of adhesive tape, to hold the dressing in place. A skin barrier could also be used on the skin around the wound (not on the wound itself). Alcohol wipes or antimicrobial wipes would not be used, as they would further irritate the skin.

Question 90

When removing a client’s surgical wound dressing, the nurse notes that there is wound separation and rupture. What is the term for this wound complication?

Answer 90

Dehiscence.
Rationale:Dehiscence is the term for the accidental separation of wound edges, especially a surgical wound. Ecchymosis is discoloration of an area resulting from the infiltration of blood into the subcutaneous tissue. A sinus tract is a cavity or tunnel underneath a wound that has the potential for infection, and undermining occurs when there are areas of tissue destruction underneath intact skin along the margins of a wound.

Question 91

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate?

Answer 91

Reduce the time interval between dressing changes.
Rationale:Allowing the dressing material to dry will disrupt healing tissue. Therefore, the time interval between dressing changes should be reduced to prevent the dressing from drying out. Too much moisture in the dressing may cause maceration. Shortening the time interval between dressing changes is more appropriate than increasing dressing moisture. There is no indication that too much packing material was used. A hydrocolloid dressing in not indicated.

Question 92

The nurse is preparing to clean a client’s surgical wound. What would the nurse assess before beginning the procedure?

Answer 92

The client’s comfort and effectiveness of pain medication
Rationale:Prior to cleaning a client’s wound, the nurse would assess the client’s level of comfort and the need for analgesics before wound care. Wound care may cause pain for some clients. The color of any drainage on wound dressings would be assessed during the wound care procedure. Assessing physical limitations, temperature, and pulses may be appropriate, but these assessments are not directly related to the procedure for cleaning a wound. The procedure for cleaning the wound is the same for a client with or without physical limitations.

Question 93

The nurse is observing a student nurse suction a client with a tracheostomy using an open system. Which action by the student nurse will require additional instruction by the nurse? The student nurse:

Answer 93

uses a manual resuscitation bag to give the client 2 big breaths before beginning.
Rationale:Additional instruction would be needed when the student nurse only gives the client 2 breaths to hyperventilate him or her before the procedure. The student nurse should deliver 3 to 6 breaths to hyperventilate the client, which helps in preventing hypoxemia during the procedure. Adjusting the wall suction to 130 mm Hg on a wall unit, using the nondominant hand to connect the suction tubing to the suction catheter, and pausing for 30 to 60 seconds between suction attempts and encouraging the client to cough are all appropriate actions.

Question 94

The nurse is inserting the suction catheter into a client’s tracheostomy and suddenly meets resistance. Which action would be most appropriate?

Answer 94

Withdraw the catheter at least 0.5 in (1.25 cm).
Rationale:If resistance is met when inserting the suction catheter, the carina or tracheal mucosa has been hit. Therefore, the nurse should withdraw the catheter at least 0.5 in (1.25 cm) before applying suction. Continuing to insert the catheter, applying suction or rotating the catheter is inappropriate at this time.

Question 95

The nurse is preparing to suction a client who has a tracheostomy after cardiac surgery. To help minimize the client’s anxiety, which statement made by the nurse is most therapeutic?

Answer 95

“If you experience any difficulty, squeeze my hand and I will stop to allow you to rest a bit.”

Rationale:The most therapeutic response by the nurse is “If you experience any difficulty, squeeze my hand and I will stop to allow you to rest a bit.” This statement puts the client in control by allowing the client to signal the nurse to stop at any time by squeezing the nurse’s hand. The nurse should also explain the procedure to alleviate the client’s fears, since any procedure that compromises respiration can be frightening to the client. Stating that the nurse has done this many times and describing how other clients reacted to it does not treat this client as an individual. These statements also do not show understanding that all clients are individuals and can experience pain and anxiety very differently. Stating that the client will experience more pain if the client does not relax is likely to make the client more anxious and fearful. Telling the client that once started, the nurse will not stop the procedure takes all control away from the client.

Question 96

The nurse is suctioning a client’s tracheostomy using an open system. For which action should the nurse use the gloved, dominant hand?

Answer 96

manipulating the suction catheter
Rationale:When suctioning a tracheostomy, the gloved, dominant hand remains sterile and is used to manipulate and handle the suction catheter. The gloved, nondominant hand is used to control the suction valve, connect the suction tubing to the suction catheter, and hyperventilate the client with a manual resuscitation bag.

Question 97

Which client is most likely to need administration of pain medication before being suctioned via the tracheostomy?

Answer 97

client who had abdominal surgery
Rationale:The client who had abdominal surgery is most likely to require the administration of pain medication before being suctioned. Suctioning will likely cause the client to cough; coughing requires the use of the abdominal muscles, which can be painful after surgery in that area. While any client may need pain medication before suctioning, the conditions of diabetes mellitus, a toe amputation, and bilateral pneumonia are less likely than abdominal surgery to cause pain when coughing. Clients with these conditions are thus less likely to need pain medication before suctioning via a tracheostomy.

Question 98

When preparing to suction a client’s tracheostomy, which action by the nurse best helps to prevent the introduction of microorganisms into the respiratory tract?

Answer 98

using only the dominant hand to handle and manipulate the catheter
Rationale:The nurse should use the dominant hand to control and manipulate the suction catheter, keeping the dominant hand sterile during the procedure to prevent accidentally introducing microorganisms into the respiratory tract. Gently rotating the suction catheter is done to facilitate the removal of secretions and is not related to preventing infection. Suction should only be applied while slowly removing the suction catheter, not during insertion. Moreover, suctioning is done to remove secretions and clear the client’s airway, not to prevent the introduction of microorganisms. The nurse should use the thumb of the nondominant hand, which is considered clean, but not sterile, to open and close the suction port.

Question 99

The nurse is suctioning a client with a tracheostomy using an open system device. Which action will the nurse implement specifically to help prevent trauma to the tracheal tissue?

Answer 99

Apply suction at 110 to 130 mm Hg from the wall unit.
Rationale:To help prevent trauma to the tracheal tissues, the nurse should apply suction at 110 to 130 mm Hg from a wall unit or 10 to 15 cm on a portable unit. Using higher pressures when suctioning via a tracheostomy can cause trauma to the tracheal tissue. The nurse limits the number of suction passes and hyperventilates the client prior to the procedure to help prevent hypoxemia during the procedure, not to prevent trauma to the tissues. The nurse maintains strict aseptic technique to help prevent infection, not to prevent trauma to the tissues.

Question 100

When suctioning a client with a tracheostomy using an open system, which actions by the nurse would help to prevent hypoxemia during the procedure? Select all that apply.

Answer 100

Hyperventilate the client with 3 to 6 breaths before suctioning., Pause for 30 to 60 seconds between suctioning attempts., Limit suctioning to 10 to 15 seconds each time.
Rationale:To reduce the risk of hypoxemia, the nurse would pause for 30 to 60 seconds between suctioning attempts, limit suctioning to 10 to 15 seconds each time, and hyperventilate the client with 3 to 6 breaths before suctioning. Maintaining sterile technique and using sterile saline to clear the tubing prevents the accidental introduction of pathogens, but do not prevent hypoxemia.

Question 101

Place in order, from first to last, the actions the nurse will perform when preparing to suction an alert client via tracheostomy using an open system. Use all options.

Answer 101

1)Explain the procedure to the client.
2)Adjust the bed and position the client.
3)Adjust the wall suction to the appropriate level.
4)Open sterile packages and set up sterile field.
5)Don sterile gloves.
6)Auscultate the client’s lung sounds for evaluation of the intervention.
Rationale:When preparing to suction a client, of the actions listed, the nurse should first explain the procedure to the client, then adjust the bed to a good working height and position the client in a semi-fowler’s position. Then, the nurse should adjust the wall suction and connect the suction tubing ensuring the connecting end is within easy reach. Next, the nurse should open sterile packages using aseptic technique and set up the sterile field. The nurse should then don sterile gloves and perform the procedure. After the procedure, the nurse should auscultate the client’s lung sounds to evaluate if the intervention was effective.

Question 102

The nurse has assessed a client with a tracheostomy and decided that suctioning is needed. Which action will the nurse implement to help prevent complications?

Answer 102

Limit suctioning passes to no more than three per episode.
Rationale:When suctioning a client, the nurse should not attempt more than three suctioning passes per episode, because excessive suction passes can cause hypoxemia and contribute to other complications. The nurse need only allow a 30-second to 1-minute interval between suctioning to allow for reventilation and reoxygenation of airways. The trachea is considered sterile and therefore should be suctioned first, before the oropharynx or mouth. Suctioning the oropharynx or mouth first contaminates the suction catheter and risks introducing pathogens into the trachea.

Question 103

The nurse is preparing to suction the tracheostomy of a client. The nurse would place which client in the lateral position, facing the nurse?

Answer 103

unconscious client, after abdominal surgery
Rationale:The lateral position is used for clients who are unconscious, because this position prevents the airway from becoming obstructed and promotes drainage of secretions. The other client examples would be placed in the semi-Fowler’s position, which helps the client to cough and makes breathing easier. The nurse would use interventions to calm a client who is confused or uncooperative prior to suctioning the tracheostomy.

Question 104

The nurse has just confirmed proper placement of a nasogastric tube. Which action should the nurse take next?

Answer 104

Apply skin barrier to the tip and end of the nose.
Rationale:Skin barrier improves adhesion and protects the skin. Applying the skin barrier should occur before taping the tube to the client’s nose, measuring the length of exposed tube, or lubricating the lips.

Question 105

The nurse is slowly advancing a nasogastric (NG) tube when the client begins to gasp and is unable to vocalize. Which has likely occurred?

Answer 105

The NG tube is in the client’s airway.
Rationale:The tube is in the airway if the client shows signs of distress and cannot speak or hum. Excessive coughing and gagging may occur if the tube has curled in the back of throat. A vasovagal reaction is typically manifested by lightheadedness and fainting, not by gasping and an inability to vocalize. There is no indication that the client is forcefully resisting the procedure.

Question 106

The nurse is preparing to insert a nasogastric (NG) tube into an adult client. Place the following steps in the correct order. Use all options.

Answer 106

1)Place the client in high Fowler’s position.
2)Measure the intended length to insert the NG tube.
3)Lubricate the tube tip with water-soluble lubricant.
4)Direct the tube upward and backward along the floor of the nose.
5)Instruct the client to place the chin onto the chest.
6)Advance the tube while the client swallows.
Rationale:An upright position is more natural for swallowing and protects against bronchial intubation aspiration, if the client should vomit. Therefore, the high Fowler’s position is recommended for the client. Measurement ensures that the tube will be long enough to enter the client’s stomach. Lubrication reduces friction and facilitates passage of the tube into stomach. Following the normal contour of the nasal passage while inserting the tube reduces irritation and the likelihood of mucosal injury. Bringing the head forward helps close the trachea and open the esophagus. Swallowing helps advance the tube, causes the epiglottis to cover the opening of the trachea, and helps to eliminate gagging and coughing.

Question 107

After measuring from the client’s nostril to the ear lobe, how does the nurse continue to measure the length of the nasogastric (NG) tube to be inserted for a client?

Answer 107

to the xiphoid process
Rationale:The nurse measures the distance to insert the NG tube by placing the tip of the tube at client’s nostril and extending to the tip of the ear lobe and then to the tip of the xiphoid process. This measurement ensures that the tube will be long enough to enter the client’s stomach without needless coiling. Measuring to the mammary line is too short by about 1 in (2.5 cm) and to the tenth intercostal space or the umbilicus is too long.

Question 108

A nurse is assessing a client who has recently had bowel surgery and will be receiving a nasogastric tube. Which finding would most likely contraindicate placement of a nasogastric (NG) tube by the nurse in this client?

Answer 108

History of facial fractures
Rationale:Clients with facial fractures or facial surgeries present a higher risk for misplacement of the tube into the brain. Many institutions require a health care provider to place NG tubes in these clients, which would contraindicate the nurse placing the tube. The nurse should assess the patency of the client’s nares by asking the client to occlude one nostril and breathe normally through the other. However, the nurse does this to select the nostril through which air passes more easily, not because one nare being less patent than the other is a contraindication for NG tube placement by the nurse. Abdominal distention does not contraindicate NG tube placement. Monitoring bleeding in the gastrointestinal (GI) tract is one of the indications for NG tube placement, so bleeding in the GI tract is not a contraindication.

Question 109

After putting on gloves, the nurse lubricates the nasogastric (NG) tube prior to insertion into the client’s nares. Which lubricant is appropriate to use?

Answer 109

water-soluble lubricant
Rationale:The nurse would lubricate the tip of the tube with water-soluble lubricant. Lubrication reduces friction and facilitates passage of the tube into the stomach. Water-soluble lubricant will not cause pneumonia if the tube accidentally enters the lungs. Saline and water are not considered lubricants. Jelly-based lubricants can be dangerous, particularly if aspirated.

Question 110

Which documentation does the nurse complete after inserting a client’s nasogastric (NG) tube?

Answer 110

measurement of the exposed tube
Rationale:The nurse would document the size and type of NG tube that was inserted, the nare used for insertion, the measurement of the exposed tube, the characteristics of the drainage in the tube, and the client’s reaction to the procedure. It is not relevant to know how long the NG insertion took or how difficult it was, unless there was trauma. Placing an NG tube is procedure that is not expected to alter the client’s vital signs, and it will not immediately alter the client’s bowel sounds.

Question 111

The nurse has begun inserting the nasogastric (NG) tube when the client coughs. After assessing that the client can speak without difficulty, what does the nurse do next?

Answer 111

Proceed with nasogastric tube placement.
Rationale:The nurse first ensures that any coughing is related to the gag reflex rather than accidental placement of the NG tube into the airway. When the client breathes and speaks adequately, placement may continue. The nurse has performed the necessary respiratory assessment by ensuring the client can speak well. There is no reason to begin again with the other nostril or to notify the health care provider.

Question 112

Following insertion of a nasogastric tube, the nurse needs to stabilize the tubing for the client. Which action is appropriate for the nurse to take?

Answer 112

Secure the tubing with a safety pin to the client’s gown at shoulder level.
Rationale:The nurse would secure the tube to the client’s gown at the sleeve by using a safety pin, and perhaps a rubber band, ensuring that the air vent is above the level of the stomach. Securing the tube prevents tension and tugging on the tube. Securing the tube in any other place and in any other manner or failure to secure the tube at all can allow the tube to be accidentally removed, possibly requiring reinsertion.

Question 113

The nurse is preparing to replace a chest drainage system that has become full. What actions will the nurse implement for this procedure? Select all that apply.

Answer 113

Remove the suction from the current drainage system., Add sterile water to the water seal chamber in the new system., Clamp the chest tube 1.5 to 2.5 in (3.75 to 6.25 cm) from the insertion site., Keep the end of the chest tube sterile while inserting the end of the new drainage system.
Rationale:When preparing to change out the system, the nurse should gather and prepare all supplies, including the water seal chamber of the new system, and explain the procedure to the client. The nurse should clamp the chest tube 1.5 to 2.5 in (3.75 to 6.25 cm) from the insertion site to provide a more complete seal and prevent air from entering the pleural space through the chest tube. The nurse should also remove the suction form the current drainage system to permit application of suction to the new system. The end of the chest tube must be kept sterile when inserting the end of the new drainage system to prevent pathogens from entering the system and putting the client at increased risk of complications. The chest tube is sutured in place; the nurse should not pull or tug on the chest tube as this could dislodge it. Instead, the nurse should gently twist the tubing at the connection site to disconnect it.

Question 114

The nurse is caring for a client with a chest tube and chest drainage system. Which action is most appropriate for the nurse to implement?

Answer 114

Documents the amount of drainage each shift by marking it on the container.
Rationale:The nurse should document the amount of drainage each shift by marking it on the container. The amount and type of drainage should be measured at the end of each shift; and the date, time, and drainage level should be marked on the container or on a small piece of tape attached to the container. Securing the system at the client’s chest level would be incorrect. To allow for proper drainage, the system should be kept below the client’s chest level to allow drainage to flow via gravity out of the tubing into the drainage collection system. This is also why the tubing should not be looped. Connections should not be easy to disconnect and should be taped securely to help prevent accidental disconnections.

Question 115

The nurse observes continuous vigorous bubbling in the water seal chamber of a chest drainage system. What should the nurse do next?

Answer 115

Assess the tubing for loose connections and air leaks.
Rationale:Constant bubbles in the water seal chamber after the initial insertion period indicate an air leak in the system and the nurse should immediately check for any loose connections or signs of air leaks. If the nurse cannot determine the source of the air and fix the problem, then the nurse should notify the health care provider. The nurse should never clamp the tubing unless changing out the system or unless there is a prescription by the health care provider to do so. Clamping the tubing can cause increased thoracic pressure.

Question 116

The nurse is caring for a client who has a chest tube in place that is draining blood from a hemothorax. Which item should the nurse place in the client’s room to respond appropriately to accidental disconnection of the chest tube from the drainage device?

Answer 116

An unopened bottle of sterile water
Rationale:If the chest tube becomes disconnected from the drainage system, the nurse should insert the open end into the bottle of sterile water to create a new water seal. This prevents more air from entering the pleural space through the chest tube but allows for any air that does enter the pleural space, through respirations, to escape once pressure builds up. Sterile water decreases the chance of contamination of the chest tube. A Heimlich valve cannot be used if much drainage is required, and it is more difficult to connect it to the chest tube than it would be to insert the chest tube into sterile water. Chest tubes should never be clamped except to change the drainage system quickly. Sustained clamping may cause a tension pneumothorax. In this case, the drainage device, not the chest tube itself, would need to be replaced; thus, a spare chest tube insertion kit would not be needed.

Question 117

A nurse is assessing a client who recently had a chest tube inserted. Which finding should the nurse consider to be abnormal?

Answer 117

Constant bubbles in the water-seal chamber 1 hour after insertion
Rationale:Constant bubbles in the water-seal chamber after initial insertion indicate an air leak in the system. Leaks can occur within the drainage unit, or at the insertion site. Fluctuation of the water level in the water-seal chamber with inspiration and expiration is an expected and normal finding. Bubbles in the water-seal chamber after the initial insertion of the tube or when air is being removed are a normal finding.

Question 118

The nurse is providing care for several clients on a busy floor. The nurse receives a prescription to administer a transfusion of packed red blood cells for a client with decreased hemoglobin. Which action should the nurse take before entering the client’s room to begin the transfusion?

Answer 118

Arrange for another nurse to monitor the nurse’s other assigned clients.
Rationale:Before administering a blood transfusion, the nurse should arrange for another nurse to monitor the nurse’s other assigned clients for at least 15 minutes, because the nurse will need to remain with the client receiving the transfusion during this time to monitor for transfusion reaction. Verifying the client’s name and date of birth with another nurse is important to avoid error and should happen at the bedside in the presence of the client medical record, client identification band, and the label of the blood product, not prior to entering the room. It is important for the nurse to obtain the client’s vital signs immediately prior to starting the transfusion to obtain a baseline. Reviewing a prior assessment is not adequate. Changes in vital signs may indicate a transfusion reaction. The nurse will prime the blood administration set with normal saline solution only to prevent clumping of red blood cells and hemolysis.

Question 119

The nurse is preparing to initiate an infusion of packed red blood cells (PRBCs). While observing the information on the blood bag, it is essential to verify which information with another nurse? Select all that apply.

Answer 119

Number on the client’s identification band, Name on the client’s identification band
Rationale:Two nurses must compare and validate the following information with the medical record, client identification band, and the blood product label: medical prescription for transfusion of blood product, informed consent, client identification number, client name, blood group and type, and expiration date. The client’s vital signs and room number and the patency of the venous access device are not required to be validated by two nurses.

Question 120

A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse?

Answer 120

Stop the transfusion and infuse normal saline using a new administration set.
Rationale:A client who reports difficulty breathing during a blood transfusion may be having a transfusion reaction. The first action is to stop the transfusion and infuse normal saline using a new administration set. Changing the administration set prevents the client form receiving more of the blood that is causing the reaction. After stopping the transfusion and infusing normal saline using a new administration set, the nurse should check the client’s vital signs and notify the health care provider of the reaction.

Question 121

Which finding best indicates to the nurse that the client has a therapeutic outcome from a blood transfusion?

Answer 121

The client has a steady gait while ambulating to void.
Rationale:The expected outcome is best indicated by evidence of a stabilized cardiac output and fluid balance. This is observed through a lack of dizziness and steady gait and increased urine output. An increased blood pressure is a positive indicator; however, a blood pressure of 90/48 mm Hg is lower than desired. The client’s positive color can indicate improved peripheral perfusion, or the client may be flushing as an effect of the transfusion. The absence of adverse effects, though desired, is not the best indicator of a therapeutic outcome.

Question 122

The nurse is assuming care for a client who is receiving an infusion of packed red blood cells (PRBCs). The PRBCs were hung 4 hours ago, and 100 mL is left to infuse. Which action is most appropriate?

Answer 122

Discontinue the infusion and record the volume left in the blood bag.
Rationale:Transfusions must be completed within 4 hours due to the potential for bacterial growth in a blood product at room temperature.