Skin integrity & Wound, Nutrition, Intravenous, O2, Pain (Test 3)

Question 1

A patient who had surgery yesterday has the initial dressing covering the surgical site. What is the nurse’s responsibility in assessing this patient’s wound?

a. ) Remove the dressing, inspect the wound, and reapply a new dressing.
b. ) Inspect the wound and reapply the surgical dressing every 2 hours.
c. ) Inspect the wound, and keep the dressing off until the health care provider arrives.
d. ) Wait until the health care provider orders the removal of the surgical dressing.

Answer 1

D, The nurse would want to wait until the provider orders the dressing to be removed to ensure that the initial dressing is ready to come off.

Question 2

Which wound would be allowed to heal by secondary intention?

a. ) Cleft lip repair
b. ) Infected hysterectomy incision
c. ) Exploratory laparoscopy incision
d. ) Facial laceration caused by a pocket knife

Answer 2

B

Question 3

Before performing a wound assessment, which nursing action would reduce the patient’s risk for infection?

a. ) Taking the patient’s temperature
b. ) Applying clean gloves
c. ) Assessing the wound for drainage
d. ) Assessing the dressing for drainage

Answer 3

B, duhhh

Question 4

Which intervention can the nurse delegate to nursing assistive personnel (NAP) in caring for a patient with a wound?

a. ) Assessing the site for signs of redness or swelling
b. ) Reporting the presence of wound odor
c. ) Removing a soiled outer dressing
d. ) Opening sterile dressings during the dressing change

Answer 4

B

Question 5

The nurse notes that a patient’s surgical wound is healing slowly. Which health problem would contribute to slow wound healing?

a. ) Osteoarthritis
b. ) Glaucoma
c. ) Deafness
d. ) Diabetes mellitus

Answer 5

D

Question 6

When irrigating a wound, how would the nurse know the right amount of pressure to apply?

a. ) Calculate the wound size.
b. ) Follow the general rule of keeping the pressure between 4 and 15 psi.
c. ) Keep the pressure strong enough to cause moderate pain.
d. ) Gentle enough that it does not create a splash off of the wound.

Answer 6

B, more than 15 psi can cause tissue damage

Question 7

Which action should the nurse avoid before irrigating a patient’s foot wound?

a. ) Assess the patient for a history of allergies to tape and irrigating solution.
b. ) Review the provider’s orders for the type of irrigating solution to be used.
c. ) Assess the patient’s pain on a scale of 0 to 10.
d. ) Warm the irrigant to body temperature in the microwave.

Answer 7

D, use a basin of hot water to warm the prescribed solution to body temperature

Question 8

Which device is used for wound irrigation?

a. ) 19-gauge needle attached to a 10-mL syringe
b. ) 19-gauge needle attached to a 35-mL syringe
c. ) Sterile container held 30.5 cm (12 inches) above the wound
d. ) Foley irrigating syringe

Answer 8

B

Question 9

Which imaging study or diagnostic test would the nurse review to determine if the pressure ulcer on a patient’s left heel is infected?

a. ) White blood cell count
b. ) Complete blood count
c. ) X-ray of left foot
d. ) Culture and sensitivity test

Answer 9

D

Question 10

A nurse is irrigating a patient’s abdominal wound 2 days postoperatively. Which finding would need to be reported to the health care provider?

a. ) Drainage that was not present previously
b. ) Redness at the abdominal suture line
c. ) Granulation tissue in the wound bed
d. ) The patient reports less pain

Answer 10

A, indicates possible wound infection

Question 11

A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient’s pain?

a. ) Premedicate the patient with a prescribed analgesic 30 minutes before the intervention.
b. ) Use a distraction technique to divert the patient’s attention during the procedure.
c. ) Position the patient comfortably before the intervention.
d. ) Thoroughly explain the procedure to the patient.

Answer 11

A

Question 12

Which action reduces the nurse’s risk for infection when changing the dressing of an infected abdominal wound?

a. ) Begin antibiotic therapy before the dressing change.
b. ) Use appropriate personal protective equipment (PPE).
c. ) Adhere to sterile technique during the intervention.
d. ) Complete the dressing change in an effective, timely way.

Answer 12

B

Question 13

What is the nurse’s best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago?

a. ) Notify the surgeon of the bleeding.
b. ) Remove the dressing, and assess the wound.
c. ) Assess the patient for signs of shock.
d. ) Further assess the patient and the wound.

Answer 13

D, Completing a further wound assessment and gathering more detailed information about the patient and his or her wound, such as pain level and amount of blood, would be the most appropriate action for the nurse to take.

Question 14

When changing a patient’s surgical dressing 24 hours postoperatively, when would the nurse apply sterile gloves?

a. ) After performing hand hygiene at the start of the procedure
b. ) Before removing the inner dressing
c. ) After removing the original dressing materials and performing hand hygiene a second time
d. ) Just before cleansing the wound with sterile water

Answer 14

C

Question 15

Which action would minimize the risk for cross-contamination while cleansing an infected abdominal surgical wound?

a. ) Cleansing the wound with sterile water
b. ) Blotting the incision with dry gauze
c. ) Wearing sterile gloves to cleanse the wound
d. ) Using a new gauze pad for each stroke while cleansing the wound

Answer 15

D

Question 16

What is the proper method for cleansing the evacuation port of a wound drainage system?

a. ) Cleanse it with normal saline.
b. ) Wash it with soap and warm water.
c. ) Rinse it with sterile water.
d. ) Wipe it with an alcohol sponge.

Answer 16

D

Question 17

What is the nursing action to set up suction for a hemovac drainage system?

a. ) Set the suction to lowest level possible.
b. ) Hemovacs are always set to medium suction.
c. ) Connect to the wall on intermediate suction.
d. ) Compress the hemovac, creating suction.

Answer 17

D, For the Hemovac to create suction, the nurse should compress it firmly and replace the plug.

Question 18

When emptying a Jackson-Pratt drain, which issue should nursing assistive personnel (NAP) report immediately to the nurse as a potential abnormality?

a. ) The drainage is odorless.
b. ) The drainage is straw colored.
c. ) The patient doesn’t like looking at the drainage tubing.
d. ) The amount of drainage was greater today than yesterday.

Answer 18

D

Question 19

Which action might the nurse perform to ensure that the wound drainage tubing does not pull on the insertion site?

a. ) Attach the tubing to the patient’s gown with a safety pin.
b. ) Tape the tubing to the patient’s bed.
c. ) Attach the tubing to the nearest side rail.
d. ) Loop the tubing through the bed frame.

Answer 19

A

Question 20

Which action would maximize the suction produced by the Jackson-Pratt drainage system after the system has been emptied?

a. ) Pinning the tubing to the patient’s hospital gown
b. ) Compressing the bulb while replacing the port cap
c. ) Emptying the drainage container only when it is 90% full
d. ) Placing the drainage container below the wound site

Answer 20

B

Question 21

Which practice protects the nurse from infection when changing the dressing on an infected pressure ulcer?

a. ) Begin antibiotic therapy before the dressing change.
b. ) Use appropriate personal protective equipment.
c. ) Adhere to sterile technique during the intervention.
d. ) Complete the dressing change in an effective, efficient manner.

Answer 21

B

Question 22

The wound bed of a patient’s pressure ulcer is red. What does this finding indicate to the nurse?

a. ) Necrotic tissue
b. ) Presence of slough
c. ) Granulation tissue
d. ) Development of an infection

Answer 22

C

Question 23

Which measurements would the nurse use to calculate the surface area of a patient’s pressure ulcer?

a. ) Height and weight
b. ) Length and width
c. ) Length and depth
d. ) Width and depth

Answer 23

B

Question 24

How would the nurse safely apply an enzyme debridement ointment?

a. ) Daub ointment on dead tissue at the wound edges.
b. ) Put ointment on a tongue blade, and gently spread it on the center of the wound.
c. ) Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin.
d. ) Apply a gauze dressing to ensure contact with the ointment.

Answer 24

C

Question 25

Which action can the nurse delegate to nursing assistive personnel (NAP) to help prevent the development of pressure ulcers in an older adult patient? a. ) Reposition the patient at least every 2 hours. b. ) Assess the patient’s bony prominences every shift. c. ) Educate the family about the importance of healthy skin. d. ) Assist the patient in the selection of high-protein foods.

Answer 25

A

Question 26

What would the nurse do if he or she were not able to insert a nasogastric tube in either of a patient’s nares? a. ) Ask another nurse to attempt the insertion. b. ) Document the attempts in the patient’s medical record. c. ) Notify the physician that the attempts were unsuccessful. d. ) Allow the patient to rest for 30 minutes before resuming the process.

Answer 26

C

Question 27

What would the nurse do if he or she encountered resistance when inserting a nasogastric tube? a. ) Ask the patient to cough. b. ) Withdraw the tube to the nasopharynx. c. ) Encourage the patient to swallow. d. ) Instruct the patient to hyperextend the neck.

Answer 27

B, If the patient starts to cough, experiences a drop in oxygen saturation, or shows other signs of respiratory distress, withdraw the tube into the posterior nasopharynx until normal breathing resumes. Do not force the tube or push it against resistance.

Question 28

Which patient does not have a medical condition that contraindicates placement of a nasogastric tube? a. ) A 28-year-old patient who fractured a femur after heavy drinking b. ) A 73-year-old patient who is on anticoagulation therapy. c. ) A 54-year-old patient who broke a cheekbone in a fall d. ) A 67-year-old patient with a history of unexplained nosebleeds

Answer 28

A

Question 29

What might the nurse do to reduce the patient’s discomfort before inserting a nasogastric tube? a. ) Examine each naris for patency and skin breakdown. b. ) Place the patient in the high-Fowler’s position. c. ) Anesthetize the throat. d. ) Have the patient take a few sips of water.

Answer 29

A

Question 30

Which intervention might the nurse delegate to nursing assistive personnel (NAP) when inserting a nasogastric tube? a. ) Positioning the patient in a high-Fowler’s position b. ) Assessing the patient’s abdomen for bowel sounds c. ) Determining any history of unexplained nosebleeds d. ) Educating the patient about the need for the intervention

Answer 30

A

Question 31

Why does the nurse elevate the head of the bed to 30 degrees for a patient receiving an intermittent tube feeding? a. ) Elevating the head of the bed reduces the risk for aspiration. b. ) Proper elevation of the head of the bed promotes the patient’s digestion. c. ) Acid reflux is reduced when the head of the bed is elevated at least 30 degrees. d. ) Nutrients are absorbed more efficiently when the head of the bed is elevated.

Answer 31

A

Question 32

What is the proper response to the nurse’s observation that the patient’s closed-system enteral feeding has 150 mL of formula remaining and that the infusion order rate is for 50 mL/hr? a. ) Recalculate the present drip factor for accuracy. b. ) Terminate the fluid, and prepare to hang a new bag of formula. c. ) Plan to check the feeding for completion within the next 3 hours. d. ) Check with the pharmacy to see if the formula has been hanging too long.

Answer 32

C

Question 33

After unsuccessfully attempting to flush a nasogastric (NG) tube with water, what is the most appropriate action for the nurse to take? a. ) Flush the tube with ginger ale. b. ) Use apple juice to flush the tube. c. ) Obtain a product designed to unclog NG tubes. d. ) Force-flush the system with sterile normal saline.

Answer 33

C

Question 34

How could the nurse assess the patency of a nasogastric (NG) tube being used for enteral nutrition? a. ) Elevate the head of the patient’s bed to at least 30 degrees. b. ) Use an intravenous fluid infusion set. c. ) Check the gastric residual volume. d. ) Monitor the amount of intake the patient tolerates in an 8-hour period.

Answer 34

C

Question 35

Which nursing action is appropriate when feeding gastric residual is 50 mL? a. ) Return it to the stomach via the feeding tube. b. ) Dispose of the residual contents down the commode. c. ) Discard the stomach contents as a liquid biohazard. d. ) Return half of the volume to the stomach, and discard the rest.

Answer 35

A, If the volume of the residual stomach contents is less than 250 mL, it can be returned to the stomach via the feeding tube.

Question 36

How might the nurse minimize the patient’s anxiety when removing a nasogastric tube? 1. ) Administer a mild sedative prescribed by the patient’s health care provider. 2. ) Ask the patient’s caregiver to emotionally support the patient during the removal. 3. ) Provide reassurance of what will happen during the procedure and talk the patient through the process. 4. ) Instruct the patient to take deep, calming breaths while revisiting a pleasant memory.

Answer 36

C

Question 37

What is the initial step in preparing to perform a gastric occult blood test for a patient with recurrent vomiting? a. ) Determine the patient’s ability to help obtain the specimen. b. ) Gather a Gastroccult slide and developing solution. c. ) Review the medications the patient is currently taking. d. ) Perform hand hygiene, and apply treatment gloves.

Answer 37

C, Reviewing possible causes of the patient’s recurrent vomiting is the most appropriate first step. Anticoagulants increase the risk of gastrointestinal (GI) tract bleeding, even from minor mucosal trauma, and long-term use of steroids, nonsteroidal antiinflammatory drugs (NSAIDs), and acetylsalicylic acid (aspirin) can irritate the mucosa.

Question 38

Why might the nurse delegate to nursing assistive personnel (NAP) the skill of performing a gastric occult blood test for a patient who has vomited? a. ) The task is easy to demonstrate to NAP. b. ) The likelihood of a positive result is minimal. c. ) This skill may be delegated if performed on vomited stomach contents. d. The agency trains NAP to perform only NG tube testing.

Answer 38

B, The skill of performing a Gastroccult test may be delegated to NAP only if the specimen is taken from stomach contents the patient has vomited. For example, NAP may obtain a specimen from the contents of the patient’s emesis basin.

Question 39

Which statement best illustrates correct interpretation of a positive gastric occult blood test? a. ) “We don’t need to retest the patient right now, because the sample turned green after about 60 seconds.” b. ) “If the test sample turns blue, it is positive for blood.” c. ) “The monitor area needs to turn blue within 30 seconds.” d. ) “Because it was positive, I notified the patient’s physician.”

Answer 39

B

Question 40

The health care provider writes an order for a culture specimen to be collected from a patient with a dog bite wound. What would the nurse do first? a. ) Explain the purpose of the test to the patient. b. ) Assess the level of the patient’s pain at the wound site. c. ) Assess the patient for signs and symptoms of infection. d. ) Review the order to determine the type of specimen to be collected.

Answer 40

D, The nurse would first review the health care provider’s order for specimen collection, because the equipment needed and the technique selected depend on whether anaerobic or aerobic bacteria are to be cultured from the wound.

Question 41

Which action would the nurse take to reduce the risk for wound infection when collecting a specimen for culture? a. ) Collect the specimen while wearing sterile gloves. b. ) Collect the specimen after washing the wound with sterile water. c. ) Collect the specimen before cleansing the wound. d. ) Collect the specimen after administering prescribed pain medication.

Answer 41

A

Question 42

Which question might the nurse ask the patient when an aerobic wound culture has been ordered? a. ) “Do you have any pain at the wound site?” b. ) “Have you ever collected a specimen from your wound before?” c. ) “Have you had any trouble breathing?” d. ) “Have your blood counts been high recently?”

Answer 42

A, Medications can be given to ease comfort

Question 43

Which instruction might the nurse give to the NAP to help ensure that a wound culture specimen will be transported properly? a. ) “Wear sterile gloves when holding the specimen.” b. ) “Take this specimen to the lab immediately.” c. ) “Borrow a specimen collection kit from another unit if we’re out of them.” d. ) “Keep the specimen tube horizontal.”

Answer 43

B

Question 44

Which nursing action demonstrates proper procedure in the collection of a wound culture specimen? a. ) Wearing clean gloves to remove soiled dressings b. ) Using a circular motion to cleanse the wound before collecting the specimen c. ) Completing the lab requisition form in a timely manner after collecting the specimen d. ) Sending the specimen to the lab within 30 minutes of collecting it

Answer 44

A

Question 45

Which statement might the nurse make to nursing assistive personnel (NAP) when caring for a patient with a dressed central venous access device (CVAD) site? a. ) “Assess the site frequently for signs of inflammation.” b. ) “Be sure to change the transparent dressing on the site once every 7 days.” c. ) “Let me know immediately if the patient’s dressing becomes damp.” d. ) “Make sure the patient knows to notify me if the site becomes painful or swollen.”

Answer 45

C

Question 46

Which action would the nurse take to minimize the patient’s risk for infection when changing the dressing on a CVAD? a. ) Use sterile technique throughout the process. b. ) Apply a stabilization device if the initial sutures are no longer intact. c. ) Apply a mask to the patient during the procedure. d. ) Change the transparent dressing every 48 hours.

Answer 46

A

Question 47

How can the nurse minimize the risk of dislodging the catheter when removing a dressing? a. ) Lower the patient’s head during the dressing change. b. ) Remove the transparent dressing or tape and gauze in the direction of catheter insertion. c. ) Apply skin protectant while the stabilization device is off. d. ) Cleanse the insertion site quickly and gently in concentric circles.

Answer 47

B

Question 48

What will the nurse do after removing the soiled dressing from a patient’s CVAD device? a. ) Cleanse the site with soap and water. b. ) Use 2% chlorhexidine swabs to cleanse the site. c. ) Apply a skin protectant. d. ) Remove the catheter stabilization device, if present.

Answer 48

D

Question 49

What is the most important way in which the nurse can reduce the risk for infection in a patient with a CVAD that has a gauze dressing? a. ) Change the dressing every 48 hours. b. ) Apply sterile gloves to remove the original dressing. c. ) Cleanse the catheter and insertion site with sterile saline. d. ) Label the dressing with the date and time of application and the nurse’s initials.

Answer 49

A

Question 50

When drawing blood from a patient’s central venous access device (CVAD), what can the nurse do to minimize pressure on the device during flushing? a. ) Clamp the device. b. ) Use a 3-mL syringe for the flush. c. ) Use a 10-mL syringe for the flush. d. ) Cleanse the catheter hub with an alcohol swab.

Answer 50

C

Question 51

When drawing blood from a central venous access device (CVAD) in which all ports are patent, it is recommended that the nurse select which lumen? a. ) The shortest b. ) The longest c. ) The proximal port d. ) The distal port

Answer 51

D

Question 52

Which action can the nurse take to ensure a quality blood sample when drawing blood from a patient’s central venous access device (CVAD) site? a. ) Allow fluid infusions to continue to flow right up to the time of the sample. b. ) Flush the catheter after aspirating for blood return. c. ) Ensure that the patient has been resting quietly for at least 15 minutes before taking the sample. d. ) Discard the first 4 to 5 mL of blood drawn.

Answer 52

D

Question 53

After drawing blood from a patient’s central venous access device (CVAD), what would the nurse do to ensure that the device resumes proper functioning? a. ) Discard the initial 5 mL of aspirated blood. b. ) Apply an antiseptic to the injection cap. c. ) Wear clean treatment gloves during the procedure. d. ) Flush the catheter with preservative-free 0.9% sodium chloride, per agency policy.

Answer 53

D, Flushing the catheter with preservative-free 0.9% sodium chloride minimizes the risk of clot formation at the catheter tip and ensures continued proper functioning of the device.

Question 54

After drawing blood from a central venous access device (CVAD), which action would minimize the patient’s risk for infection when reconnecting prescribed intravenous fluids? a. ) Wearing clean gloves b. ) Changing the IV tubing c. ) Cleansing the IV needleless connector and the end of the IV tubing with a 2% chlorhexidine swab d. ) Aspirating for blood return before flushing the catheter

Answer 54

C

Question 55

How would the nurse assess a patient’s central venous access device (CVAD) for damage or breakage? a. ) Assess the patient’s neck veins for distention. b. ) Palpate the patient’s arm. c. ) Check the catheter for pinholes and tears. d. ) Palpate the area around the insertion site.

Answer 55

C

Question 56

The nurse is concerned that a patient’s central venous access device (CVAD) may have become dislodged. How might the nurse assess for this complication? a. ) Check for blood return. b. ) Palpate the skin for coiling. c. ) Listen for gurgling sounds. d. ) Assess for pain at the site.

Answer 56

B

Question 57

When caring for a patient who has a CVAD, which sign may indicate infection at the insertion site? a. ) Occlusion alarm sounds on infusion pump b. ) Patient’s oral temperature gradually increases c. ) Patient’s neck veins become distended d. ) The nurse cannot achieve blood return

Answer 57

B

Question 58

Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a CVAD? a. ) “Assess the site frequently for signs of inflammation.” b. ) “Be sure to change the transparent dressing on the site once every 7 days.” c. ) “Let me know immediately if the patient’s dressing becomes damp.” d. ) “Make sure the patient knows to notify me if the site is painful or swollen.”

Answer 58

C

Question 59

While palpating the skin around a patient’s CVAD insertion site, the nurse elicits a crackling sound. What might this finding indicate? a. ) Catheter occlusion b. ) Infection c. ) Skin erosion d. ) Subcutaneous emphysema

Answer 59

D, A crackling sound or sensation probably indicates subcutaneous emphysema as a manifestation of pneumothorax, hemothorax, air embolism, or hydrothorax.

Question 60

When pouching a patient’s colostomy, which action reduces the patient’s risk for injury? a. ) Measuring output when emptying the contents of the pouch b. ) Maintaining the patient’s bowel elimination function c. ) Promoting the patient’s autonomy with bowel elimination care d. ) Protecting the skin from irritation caused by fecal drainage

Answer 60

D

Question 61

When changing the pouching system, which routine step best minimizes irritation of the skin surrounding the stoma? a. ) Using adhesive remover b. ) Emptying the ostomy bag only when full c. ) Avoiding unnecessary changes of the pouching system d. ) Wearing clean gloves

Answer 61

C

Question 62

Which initial nursing action would best help the patient learn self-care of a colostomy pouching system? a. ) Giving the patient handouts on self care of a colostomy b. ) Allowing the patient to examine an ostomy device c. ) Identifying a family member who can participate in the ostomy appliance process d. ) Giving the patient a mirror to watch the nurse provide care

Answer 62

D

Question 63

Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a newly established colostomy? a. ) “Be sure to pat-dry the skin surrounding the stoma before applying the new pouch.” b. ) “Alert me immediately if you see any blood in the fecal matter in the pouch.” c. ) “Using the stoma guide, cut the pouch opening about one-eighth of an inch bigger than the stoma.” d. ) “Remember to change your gloves after cleaning the stoma and the surrounding skin.”

Answer 63

B

Question 64

What will the nurse do to protect the peristomal skin of a patient with a urostomy? a. ) Clean the skin around the stoma with soap and hot water. b. ) Apply lotion to the skin around the stoma. c. ) Wipe the skin with alcohol swabs before applying the device. d. ) Clean the skin with warm water and pat dry.

Answer 64

D

Question 65

Which action would be the nurse’s priority when caring for a patient with a urostomy who had no urine output for 4 hours? a. ) Change the ostomy device. b. ) Document the output. c. ) Catheterize the patient. d. ) Notify the health care provider.

Answer 65

D

Question 66

Which technique is most accurate in identifying an appropriate vein site for IV catheter insertion into the arm? a. ) Remove any clothing that is covering the arm. b. ) Apply a warm washcloth to the arm at the proposed site. c. ) Elevate the selected arm on a pillow for 2 to 3 minutes. d. ) Apply a tourniquet to the selected arm 4 to 6 inches above the proposed site.

Answer 66

D

Question 67

When preparing to insert a venous access device, how can the nurse encourage patient compliance with the procedure? a. ) Assess the patient’s understanding of the placement of the device. b. ) Insert the access device as quickly as possible. c. ) Ask the patient to select the arm preferred for access. d. ) Apply a topical anesthetic to the area before inserting the device.

Answer 67

A

Question 68

Which action minimizes the patient’s risk for injury when inserting a venous access device into the arm? a. ) Wearing clean gloves during the procedure b. ) Using a larger vein found on the palmar (ventral) side of the wrist c. ) Checking for a radial pulse once the tourniquet has been applied d. ) Priming the extension tubing after attaching it to the newly placed venous access device

Answer 68

C, Assessing for a radial pulse after the tourniquet is in place ensures that circulation to the distal extremity has not been compromised.

Question 69

The nurse is preparing to insert a venous access device into a newly admitted 75-year-old patient. Which vein is not an inappropriate choice for IV insertion in this patient? a. ) Basilic vein b. ) Cephalic vein c. ) Superficial dorsal vein d. ) Median cubital vein

Answer 69

C, Superficial veins located on the dorsal surface of the hand must be avoided because of the risk for infiltration due to excessive movement. They are also more fragile in older adults.

Question 70

The nurse is using chlorhexidine to prepare the site before inserting a venous access device into the median cubital vein of a 60-year-old patient. Which action is correct? a. ) Wash the site with soap and water. b. ) Allow the site to dry 1 to 2 minutes after cleansing it with chlorhexidine. c. ) Cleanse the site using a circular motion, starting at the insertion site and working outward. d. ) Cleanse the area by first swabbing horizontally, then vertically with the applicator for about 30 seconds.

Answer 70

D

Question 71

Which action would the nurse perform to best ensure effective insertion of a venous access device into a patient’s arm? a. ) Anchor the vein by placing a thumb 1 to 2 inches below the site. b. ) Insert the device tip at a 45-degree angle distal to the proposed site. c. ) Place the patient’s left arm in a dependent position for 5 minutes before assessment. d. ) Apply a tourniquet to the left antecubital fossa 8 to 12 inches above the proposed site.

Answer 71

A, This action stabilizes the vein, increasing the possibility of a successful insertion.

Question 72

How might the nurse prepare a patient to anticipate some discomfort when inserting a venous access device? a. ) Instruct the patient to expect a sharp, quick stick. b. ) Insert the access device as quickly as possible. c. ) Apply a topical anesthetic to the area before inserting the device. d. ) Promise that the procedure will not hurt once the device has been inserted.

Answer 72

A, Educating the patient to have reasonable expectations about the possible discomfort will best prepare him or her for it.

Question 73

Which of the following technique(s) is/are best for minimizing a patient’s risk for injury when inserting a venous access device? a. ) Inserting the needle with the bevel up b. ) Using a vein on the dorsal surface of the arm c. ) Holding the skin taut directly below the site d. ) All of the above

Answer 73

D

Question 74

The nurse is inserting an over-the-needle catheter into a newly admitted patient. What will the nurse do after confirming blood return? a. ) Loosen or remove the tourniquet. b. ) Advance the catheter 1 inch into the vein. c. ) Lower the catheter until it is flush with the skin. d. ) Thread the catheter into the vein up to the hub.

Answer 74

C, Lowering the catheter until it is flush with the skin minimizes the risk of passing the needle through the opposite vessel wall.

Question 75

Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with an intravenous access device? a. ) “Assess the IV site frequently for signs of inflammation.” b. ) “Be sure not to obscure the insertion site with the dressing.” c. ) “Let me know when you notice that the IV bag contains less than 100 milliliters.” d. ) “Explain the symptoms of infection to the patient.”

Answer 75

C

Question 76

Why is it important to label the gauze dressing covering the site of an intravenous access device with the date, time, and nurse’s initials? a. ) Reminds the nurse to document the insertion of the device b. ) Proves that the access site was assessed c. ) Informs the nurse and other staff when the next dressing change is due d. ) Reminds the nurse when to change the infusion tubing

Answer 76

C, every 48 hrs

Question 77

The nursing assistive personnel (NAP) reports to the nurse that a patient’s intravenous access device dressing is wet. What would the nurse do first? a. ) Assess the site. b. ) Instruct the NAP on how to change the dressing. c. ) Remove the device, and insert a new one. d. ) Reinforce the dressing with more gauze.

Answer 77

A, The nurse would first assess the site to check for infiltration and to see if the IV has become dislodged.

Question 78

When applying a dressing to an infusion site on a patient’s left forearm, what will the nurse do to ensure proper maintenance of the tubing? a. ) Apply a transparent dressing to the insertion site. b. ) Use a catheter stabilizing device when applying the dressing. c. ) Apply the dressing proximal to the tubing and catheter hub connector. d. ) Secure the tubing to the patient’s dressing with 1-inch tape.

Answer 78

C, Applying the dressing proximal to the tubing and catheter hub connector will allow the tubing to be disconnected and changed when indicated

Question 79

Which action will the nurse take to minimize a patient’s risk for injury when applying a gauze dressing to an infusion site? a. ) Avoid encircling the arm with tape b. ) Not secure the tubing and catheter hub with tape c. ) Secure the tubing in two different locations on the arm d. ) Label the dressing with the date and time of application

Answer 79

A, can impede circulation

Question 80

The nurse consistently observes that the positioning of a confused patient’s arm has a direct effect on the flow rate of the intravenous (IV) solution. What might the nurse do to ensure infusion of the patient’s IV fluid at a consistent rate? a. ) Restart the IV in another location less affected by the patient’s positioning. b. ) Include this information in the shift report regarding this patient. c. ) Assess the flow rate every 1 to 2 hours. d. ) Instruct the patient to avoid positioning the arm in ways that alter the flow rate of the solution.

Answer 80

A

Question 81

Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a venous access device? a. ) “Assess the IV site frequently for signs of inflammation.” b. ) “Be sure not to obscure the insertion site with the dressing.” c. ) “Let me know if you notice that the dressing has become damp.” d. ) “Make sure the patient knows to notify me if the IV site becomes painful, swollen, or red.”

Answer 81

C

Question 82

What might the nurse do to minimize the risk for injury in a patient receiving IV therapy? a. ) Regulate the flow rate of the infusion. b. ) Assess the patient frequently for pain at the IV site. c. ) Monitor the IV site frequently for signs of infiltration and phlebitis. d. ) Educate the patient regarding symptoms of infiltration and phlebitis.

Answer 82

A

Question 83

The nurse observes erythema at the insertion site of a patient’s IV infusion device. When asked, the patient denies pain at the site. Using the phlebitis scale, what score does the nurse give the injury? a) 1 b. ) 2 c. ) 3 d. ) 4

Answer 83

A, indicated redness at site

Question 84

A patient’s IV site has developed phlebitis scored as a 4 on the phlebitis scale. What would the nurse do to help treat the site? a. ) Apply a cool compress. b. ) Apply a warm compress. c. ) Apply a pressure dressing. d. ) Apply an elastic compression wrap.

Answer 84

B

Question 85

What would the nurse do to assess a patient’s risk for embolus when removing a venous access device? a. ) Inspect the site for redness. b. ) Visualize the tip of the IV device. c. ) Palpate the site for possible edema. d. ) Ask the patient to rate any pain at the site.

Answer 85

B, Damage to the tip of the device, resulting in a portion of the device remaining in the vessel, may cause an embolus to form.

Question 86

Which instruction might the nurse give to nursing assistive personnel (NAP) when caring for a patient whose IV access device is to be removed? a. ) “Remember to wear gloves to minimize the risk for infection.” b. ) “Be sure to keep pressure on the site for at least 2 to 3 minutes.” c. ) “Let me know if you notice any bleeding on the site dressing.” d. ) “Make sure the patient knows to notify me if the IV site becomes painful.”

Answer 86

C

Question 87

Which action will best minimize the patient’s risk for vein injury when removing an IV access device from a patient’s arm? a. ) Keep the hub parallel to the skin. b. ) Cleanse the site with an antibacterial swab. c. ) Cut the dressing to facilitate its removal. d. ) Turn the IV tubing roller clamp to the “off” position.

Answer 87

A

Question 88

What will the nurse do to prevent possible complications after removing an IV access device in a patient on anticoagulant therapy? a. ) Instruct the patient to report immediately any sign of bleeding on the site dressing. b. ) Perform hand hygiene and wear clean gloves while removing the device. c. ) Encourage the patient to keep a cold compress on the site for 15 minutes. d. ) Apply firm pressure to the site with sterile gauze for 10 minutes.

Answer 88

D, Applying firm pressure will facilitate clotting. Maintaining pressure at the site for 5 to 10 minutes is recommended because the patient is receiving medication that prolongs the amount of time it takes for blood to clot.

Question 89

Which instruction to nursing assistive personnel (NAP) reflects the nurse’s correct understanding of the NAP’s role in caring for a patient receiving intravenous (IV) fluids by gravity drip? a. ) “Assess the IV site frequently for signs of inflammation.” b. ) “Be sure not to obscure the insertion site with the dressing.” c. ) “Let me know when you notice that the IV bag contains less than 100 mL.” d. ) “Tell the patient to notify me if the IV site is painful, swollen, or red.”

Answer 89

C

Question 90

The provider has ordered that a patient be given 1000 mL of IV normal saline to run over 12 hours. What is the first step in the calculation of the rate of infusion? a. ) Calculate the hourly volume of normal saline the patient should receive. b. ) Determine the drop factor of the tubing that will be used for the infusion. c. ) Calculate the drops per minute at which the tubing will be regulated. d. ) Determine the drops per mL that the tubing will deliver.

Answer 90

A

Question 91

The provider orders that a patient be given 1000 mL of IV normal saline to run over 10 hours. The drop factor of the selected tubing is 15. What is the correct rate of infusion in drops per minute? a. ) 25 drops/minute b. ) 30 drops/minute c. ) 35 drops/minute d. ) 40 drops/minute

Answer 91

A

Question 92

The nurse receives an order to infuse 1000 mL of D5W at 125 mL continuously. Which of the following actions by the nurse indicates correct interpretation of this order? a. ) Infusing D5W 1000 mL for 8 hours and then discontinuing the infusion b. ) Infusing D5W at a rate of 125 mL/hour for 24 hours and then discontinuing the infusion c. ) Infusing D5W at a rate of 125 mL/hour until the health care provider changes the order d. ) Calling the health care provider to clarify the order

Answer 92

C

Question 93

Which action by the nurse helps to ensure patient safety when administering IV fluids by gravity to very young children? a) Using microdrip tubing for the infusion b. ) Using macrodrip tubing for the infusion c. ) Using a volume-control device for the infusion d. ) Not infusing more than 25 mL/hour of IV fluids

Answer 93

C

Question 94

Which response might the nurse give to nursing assistive personnel (NAP) who reports that the alarm is sounding on a patient’s electronic infusion device? a. ) “Assess the IV site for signs of inflammation.” b. ) “Be sure to change the dressing on the IV site.” c. ) “I’ll check the IV site and pump.” d. ) “Turn off the alarm.”

Answer 94

C

Question 95

How would the infusion of intravenous (IV) fluids be affected if the tubing were unintentionally dislodged from the chamber of the control mechanism of the electronic infusion device (EID)? a. ) The infusion would slow to a “keep vein open” rate. b. ) The patient would receive a bolus of fluid. c. ) The infusion would continue at the prescribed rate. d. ) The flow of fluid would stop.

Answer 95

D, The fluid would stop, because an anti-free-flow safeguard on the EID tubing would stop the flow of fluids.

Question 96

A patient is prescribed 1000 mL of intravenous (IV) normal saline to run over 8 hours. The initial fluid is hung at 0800. How many milliliters of fluid will have infused by 1200? a. ) 125 mL b. ) 250 mL c. ) 500 mL d. ) 625 mL

Answer 96

C

Question 97

The nurse calculates that the patient is to receive 125 mL of intravenous (IV) normal saline per hour. After programming the infusion pump to deliver at that rate, how would the nurse ensure accurate fluid administration? a. ) First verify that the fluid is dripping, and then check the level of fluid remaining in the container every hour. b. ) Ask another nurse to assess the programming of the pump. c. ) Set the pump alarm to sound when half of the fluid has infused. d. ) Check the IV site for complications.

Answer 97

A

Question 98

Which information is not necessary for the nurse to include when documenting the use of an electronic infusion device (EID) for an intravenous infusion? a. ) Location of the insertion site b. ) Time at which the infusion began c. ) Patient’s pulse and heart rate d. ) Hourly volume flow rate of the infusion

Answer 98

C

Question 99

After changing the intravenous tubing on a patient’s primary infusion, the nurse notes air bubbles in the tubing. How would the nurse remove them? a. ) Begin the process again. b. ) Add more fluid to the drip chamber. c. ) Inject a syringe of saline into the tubing to vent the air bubbles. d. ) Close the clamp, stretch the tubing downward, and flick the tubing.

Answer 99

D

Question 100

Which action can the nurse take to minimize the patient’s risk for infection when applying new tubing to a primary IV infusion? a. ) Using aseptic technique throughout the process b. ) Changing the tubing each shift c. ) Changing the tubing at the same time a new primary fluid bag is hung when possible d. Both selections A and C are appropriate to minimize the patient’s risk for infection

Answer 100

D

Question 101

While changing a patient’s hospital gown, the extension set on the IV infusion becomes disconnected and ends up on the bed linens. What would the nurse do? a. ) Reconnect the extension set. b. ) Clean the end with an alcohol swab, and reconnect it. c. ) Pull the IV from the site, and insert a new catheter. d. ) Change the extension set tubing.

Answer 101

D

Question 102

What would the nurse do to ensure the correct administration of gravity drip intravenous (IV) fluid after changing the tubing on a patient’s primary infusion? a. ) Change the tubing with each new infusion bag. b. ) Wear clean treatment gloves when changing the tubing. c. ) Recheck the drip rate by counting the drops for 1 full minute. d. ) Assess the condition of the patient’s insertion site for possible infiltration.

Answer 102

C

Question 103

Which instruction would the nurse give to nursing assistive personnel (NAP) when caring for a patient who is receiving IV fluids? a. ) “If the IV tubing gets disconnected, quickly reconnect it for me and let me know.” b. ) “It’s okay for you to turn off the pump alarm when it beeps.” c. ) “Let me know when the IV bag is almost empty.” d. ) “Please check the IV site for me, and let me know if it’s tender.”

Answer 103

C

Question 104

Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with an intravenous (IV) site dressing? a. ) “Assess the IV site frequently for signs of inflammation.” b. ) “Be sure not to obscure the insertion site with the dressing.” c. ) “If the gauze dressing looks damp, replace it with a dry 4 x 4 gauze.” d. ) “Be sure to notify me if the patient reports that the IV site is painful or swollen.”

Answer 104

D

Question 105

How will the nurse minimize the risk for infection when changing a patient’s IV catheter site dressing? a. ) Use aseptic technique throughout the process. b. ) Pull the tape toward the insertion site. c. ) Remove both the gauze dressing and the tape one layer at a time. d. ) Explain the process to the patient.

Answer 105

A

Question 106

The nurse is concerned that a confused patient’s erratic movements may compromise the intravenous (IV) insertion site. Which action can the nurse take to protect the patient and the site from injury? a. ) Apply an IV site-protection device over the site, such as House UltraDressing. b. ) Apply restraints to the patient. c. ) Check the patient frequently. d. ) Instruct the patient to avoid dislodging the IV catheter.

Answer 106

A

Question 107

Which action would the nurse take if an intravenous (IV) insertion site appeared red, warm, and swollen? a. ) Assess for blood return. b. ) Discontinue the infusion. c. ) Change the existing dressing. d. ) Secure the tubing with more tape.

Answer 107

B

Question 108

How can the nurse ensure that a patient’s IV tubing will not tug on the infusion catheter after a transparent dressing is applied to an infusion site on the arm? a. ) Encircle the arm with tape. b. ) Secure the tubing and catheter hub with tape. c. ) Secure the tubing in two different locations on the arm. d. ) Label the dressing with the date and time of application.

Answer 108

C

Question 109

Which instruction reflects the nurse’s correct understanding of the role of nursing assistive personnel (NAP) in caring for a patient receiving an intravenous (IV) antibiotic medication by piggyback? a. ) “Assess the IV site frequently for signs of infiltration.” b. ) “Let me know immediately if the patient complains of pain at the IV site.” c. ) “Notify the physician that the patient is allergic to the medication prescribed.” d. ) “Remember to hang the piggyback medication higher than the primary solution.”

Answer 109

B

Question 110

When administering an IV piggyback medication to infuse by gravity, how can the nurse ensure that the medication will flow properly? a. ) Use an infusion pump to regulate the flow rate of the piggyback medication. b. ) Hang the piggyback medication higher than the primary fluid. c. ) Attach the piggyback medication to the most proximal insertion port on the primary tubing. d. ) Use a secondary infusion set for the piggyback tubing.

Answer 110

B

Question 111

What is the best way to protect a patient from an IV site injury when giving an antibiotic medication by piggyback? a. ) Use a site into which a primary solution is already infusing. b. ) Assess the IV site before initiating the IV piggyback medication. c. ) Select a relatively small vein to infuse the IV medication. d. ) Instruct NAP to notify you immediately if the insertion site appears swollen.

Answer 111

B

Question 112

What is the best way to prevent infection and conserve resources when terminating an IV piggyback medication infusion in a patient who also has a primary fluid infusion? a. ) Remove the tubing from the primary line Y-site port, and cap the end. b. ) Leave both the piggyback tubing and the bag attached to the primary line Y-site port until the next scheduled dose. c. ) Place an unopened secondary setup at the bedside, and discard the used one. d. ) Change both the primary and secondary tubing upon terminating the piggyback infusion.

Answer 112

B

Question 113

Which nursing intervention is most important in ensuring safe infusion of a medication delivered by IV piggyback through a saline lock? a. ) Use the most proximal insertion port on the primary tubing. b. ) Hang the piggyback solution higher than the primary infusion solution. c. ) Use a pump to regulate the infusion rate of the piggyback medication. d. ) Flush the saline lock with sodium chloride solution before initiating the infusion.

Answer 113

D, Flushing the saline lock with 0.9% sodium chloride solution to assess for placement and patency before initiating a piggyback infusion reduces the likelihood of infiltration and extravasation.

Question 114

Which step to protect the patient from infection is of special concern when preparing a mini–infusion pump to deliver an analgesic? a. ) Ensure that the syringe is secure within the mini–infusion pump. b. ) Identify any history of allergic reaction to the prescribed analgesic. c. ) Use an antiseptic swab to wipe the proximal injection port on the primary tubing. d. ) Carefully depress the syringe plunger to fill the tubing with medication.

Answer 114

C

Question 115

What is the most important nursing intervention to ensure the patient’s safety when initiating infusion of an analgesic by mini–infusion pump? a. ) Checking the flow rate of the primary infusion b. ) Staying with the patient during the first few minutes of the infusion c. ) Explaining the purpose of the medication to the patient d. ) Documenting the patient’s expected response to the analgesic

Answer 115

B

Question 116

What can the nurse do to help protect the patient from infiltration of IV medication? a. ) Use the most proximal insertion port on the existing primary tubing. b. ) Ensure that the syringe has been securely loaded into the mini–infusion pump. c. ) Set the pump to deliver the medication over the prescribed time period. d. ) Check the IV site for placement before and after the infusion.

Answer 116

D

Question 117

Which patient safety issue is specific to administration of medication by IV bolus? a. ) Determining that the medication is compatible with the IV solution b. ) Checking for patient allergies before giving the medication c. ) Identifying the patient using two identifiers d. ) Checking the medication against the medication administration record (MAR) three times

Answer 117

A

Question 118

What is the most important action the nurse can take to protect the patient when administering a narcotic analgesic by IV bolus? a. ) Injecting the medication at the prescribed rate b. ) Observing the insertion site after giving the medication c. ) Instructing the patient about side effects to report to the nurse d. ) Using an alcohol swab to wipe the insertion port on the primary tubing

Answer 118

A

Question 119

If the nurse does not see blood return when aspirating the saline lock in preparation for an IV bolus medication, what is the next step? a. ) Attempt to aspirate the site again. b. ) Prepare to access another IV site. c. ) Assess the saline lock site for signs of phlebitis. d. ) Assess the site for swelling or coolness while flushing the saline lock with normal saline.

Answer 119

D, Blood return may be absent with a smaller-gauge catheter. Infusing normal saline while checking for infiltration ensures that the catheter tip is both patent and in the vein

Question 120

A patient for whom an intravenous antibiotic is prescribed has a multilumen central line in place for central parenteral nutrition (CPN). What should the nurse do? a. ) Infuse the antibiotic through another lumen of the multilumen central line. b. ) Interrupt the CPN infusion only long enough to administer the antibiotic. c. ) Rearrange the antibiotic administration schedule so it does not interfere with the CPN. d. ) Ask the prescriber if the route of administration for the antibiotic can be changed.

Answer 120

A

Question 121

A patient’s central parenteral nutrition (CPN) order has been changed to a different solution, and the present solution is to be discontinued immediately. What should the nurse do until the new solution is delivered by the pharmacy? a. ) Discontinue the present CPN solution, and clamp the catheter hub. b. ) Continue the present CPN solution, but readjust the flow to a keep-vein-open (KVO) rate. c. ) Hang an infusion of 0.9% normal saline at the same infusion rate as the CPN. d. ) Hang an infusion of 10% dextrose in water at the same infusion rate as the CPN.

Answer 121

D, If CPN must be discontinued suddenly, a solution of 10% dextrose in water can be given at the same infusion rate in order to prevent hypoglycemia.

Question 122

Which action will best minimize a patient’s risk for infection while receiving central parenteral nutrition (CPN)? a. ) Infuse the CPN only with a filter in the line. b. ) Assess the patient frequently for signs and symptoms of infection. c. ) Change the CPN infusion tubing at least once every 24 hours. d. ) Frequently inspect the patient’s central venous access site.

Answer 122

C

Question 123

When preparing to infuse a bag of parenteral nutrition through a patient’s central line, the nurse notices that the solution has coalesced. What is his or her best response? a. ) Warm the infusion in the microwave. b. ) Vigorously shake the bag. c. ) Contact the pharmacy for a new infusion bag. d. ) Increase the infusion rate on the pump.

Answer 123

C

Question 124

Which nursing action will best ensure the safety of a patient who is about to receive an infusion of parenteral nutrition? a. ) Assess the patient’s blood glucose level by fingerstick. b. ) Verify the physician’s order for central parenteral nutrition (CPN) and the flow rate. c. ) Confirm that the CPN infusion pump’s alarm system is functioning properly. d. ) Instruct the patient concerning the purpose for administering the CPN solution.

Answer 124

B

Question 125

While checking a blood product prior to administration, the nurse is called away to assist with another procedure. What should the nurse do with the blood product? a. ) Return it to the blood bank until it can be administered. b. ) Ask another nurse to administer it to the patient. c. ) Ask nursing assistive personnel (NAP) to place it in the unit refrigerator if you expect to be gone less than 30 minutes. d. ) Leave it in the patient’s room.

Answer 125

A, An infusion of blood or blood products must be initiated within 30 minutes of obtaining the unit from the blood bank. If the infusion cannot be initiated within that period, the blood must be returned to the blood bank until the infusion can be initiated.

Question 126

While checking a blood product prior to administration, the nurse notices that the birth date on the blood bag and requisition do not match the birth date on the patient’s identification bracelet. Which is the correct action for the nurse to take? a. ) Be especially vigilant for adverse reactions during the infusion. b. ) Ask the patient to state his or her birth date. c. ) Correct the birth date on the blood bag and requisition. d. ) Return the blood to the blood bank.

Answer 126

D, If there is any discrepancy in the patient’s birth date or other identifying information, the product must not be administered. Notify the blood bank and other appropriate personnel, as indicated by your agency’s policy. Return the blood to the blood bank until the discrepancy has been resolved.

Question 127

An adult patient is prescribed to receive a unit of packed red blood cells. Which size intravenous catheter does the patient need to safely receive this blood? a. ) 30-gauge b. ) 25-gauge c. ) 18-gauge d. ) 10-gauge

Answer 127

C, Blood should be administered to an adult using a 14- to 24-gauge short peripheral catheter.

Question 128

The nurse is preparing to administer a unit of blood to a patient in the emergency department and discovers that he is not wearing an identification bracelet. What should the nurse do? a. ) Identify the patient by asking him to produce a photo ID, such as a driver’s license. b. ) Administer the blood only if you have been caring for the patient and can be certain of his identity. c. ) Return the unit to the blood bank. d. ) Identify the patient by asking a family member to identify him.

Answer 128

C

Question 129

While checking a blood bag prior to infusion, the nurse notes that the patient’s blood type is A+ and the donor’s blood type is O+. Which action would the nurse take? a. ) Administer the blood. b. ) Return the blood to the blood bank. c. ) Notify the physician. d. ) Ask the patient if anyone in the family has blood type A+.

Answer 129

A

Question 130

A patient prescribed to receive two units of packed red blood cells is to receive a dose of intravenous medication between the two units. How would the nurse administer the medication? a. ) In the IV line for the blood product during the transfusion b. ) In the IV line for the blood product when the line is flushed with normal saline c. ) In oral form d. ) Through another IV line

Answer 130

D, The nurse would maintain a separate access line if IV solutions or medications are to be administered. Medication is never injected into the same IV line used for a blood component. The blood product may be incompatible with the medication, and the blood component could become contaminated if the same IV line is used for another purpose.

Question 131

The nurse is preparing equipment to administer a unit of blood to a patient. Which type of fluid would the nurse piggyback with the blood transfusion? a. ) 0.45% normal saline b. ) 0.9% normal saline c. ) Dextrose 5% and 0.45% normal saline d. ) Dextrose 5% and 0.9% normal saline

Answer 131

B, no other solution can be used with blood products

Question 132

A patient is to receive one unit of packed red blood cells over 2 hours. Which rate is the usual flow rate for the first 15 minutes of a blood transfusion? a. ) 1 mL/min b. ) 2 mL/min c. ) 10 mL/min d. ) 25 mL/min

Answer 132

B

Question 133

A patient is to receive 3 units of packed red blood cells over 8 hours. What will the nurse do to maintain the patency of the patient’s IV access line after each of the first two units of blood has transfused? a. ) Infuse 0.9% normal saline at 100 mL/hour. b. ) Infuse dextrose 5% and 0.9% normal saline at the KVO (keep-vein-open) rate. c. ) Infuse 0.9% normal saline at the KVO rate. d. ) Cap the intravenous line.

Answer 133

C

Question 134

A patient received two 300-mL units of packed red blood cells, and the line was flushed with 25 mL of solution between the units. What is the total amount of fluid the nurse will document having provided to the patient? a. ) 675 mL b. ) 650 mL c. ) 625 mL d. ) 600 mL

Answer 134

C

Question 135

A patient receiving a unit of blood complains of feeling cold and begins to have shaking chills. What is the nurse’s first action? a. ) Measure the patient’s temperature. b. ) Measure the patient’s blood pressure. c. ) Stop the transfusion. d. ) Place a warmed blanket over the patient.

Answer 135

C

Question 136

A patient has a blood transfusion reaction, and the transfusion is stopped. What should the nurse do with the remaining blood and transfusion administration set? a. ) Return both to the blood bank. b. ) Return the blood to the blood bank, and discard the tubing. c. ) Discard both the blood and tubing. d. ) Send the blood and the tubing to the laboratory for analysis.

Answer 136

A

Question 137

A patient receiving a unit of blood begins to show signs of a transfusion reaction. How frequently should the nurse monitor the patient’s vital signs after stopping the transfusion? a. ) Every 5 minutes b. ) Every 15 minutes c. ) Every 30 minutes d. ) Every hour

Answer 137

B

Question 138

A patient experiencing a blood transfusion reaction is prescribed to receive epinephrine. What is the purpose of this medication when given for this indication? a. ) To relieve respiratory distress b. ) To block histamine receptors c. ) To reduce circulatory overload d. ) To combat bacterial infection

Answer 138

A

Question 139

It is determined that a patient who received a blood transfusion received an infection from the blood. Whom should the nurse notify of this infection? a. ) Blood bank and infection control department b. ) State health department c. ) U.S. Centers for Disease Control and Prevention d. ) Centers for Medicare and Medicaid or the patient’s private insurer

Answer 139

A, The nurse should report sepsis and other transfusion-related infections to the blood bank and to the agency’s infection control department.

Question 140

When preparing to apply elastic stockings, why does the nurse assess for skin discoloration? a. ) To identify the potential risk for deep vein thrombosis (DVT) b. ) To identify improper patient positioning c. ) To select the proper stocking size d. ) To determine whether a sequential compression device is needed

Answer 140

A

Question 141

Which condition is not associated with venous stasis, part of Virchow’s triad? a. ) Pregnancy b. ) Obesity c. ) Anxiety d. ) Immobility

Answer 141

C

Question 142

Why does the nurse remove the patient’s elastic stockings at least once per shift? a. ) To permit the skin to breathe. b. ) To wash the legs with a disposable bath product. c. ) To air out the stockings and allow sweat to evaporate. d. ) To check the skin for irritation or breakdown.

Answer 142

D

Question 143

After determining the proper size stocking and assessing the patient’s circulatory status, a nurse delegates the application of elastic stockings to nursing assistive personnel (NAP). The nurse discovers that the NAP has been using moisturizer on the patient’s legs before applying the stockings. What is the best action by the nurse? a. ) Explain that moisturizer may cause excessive skin softening, which can lead to skin breakdown. b. ) Instruct NAP to use a small amount of cornstarch or powder. c. ) Ask the patient if she is allergic to the moisturizer. d. ) Inspect the patient’s skin for color variations.

Answer 143

B

Question 144

Why might a sequential compression device (SCD) be applied to the legs of an immobile patient? a. ) To stimulate circulation in the deep arterial vascular system b. ) To help prevent deep vein thrombosis (DVT) c. ) To aid peripheral circulation to reduce the risk of skin breakdown d. ) To assist in passive range-of-motion exercise of the patient's lower extremities

Answer 144

B

Question 145

While preparing to apply an SCD for a postoperative patient, the nurse realizes that which assessment observation contraindicates the application of the device? a. ) Having a low-grade fever b. ) Taking a prescribed anticoagulant c. ) Having dermatitis on the legs d. ) Wearing elastic stockings

Answer 145

C, The presence of dermatitis or skin ulcers on the leg, or having had a recent skin graft to the leg, contraindicates the application of an SCD, since use of the device is likely to further alter skin integrity.

Question 146

The nurse has applied an SCD to a postoperative patient. The most appropriate way for the nurse to confirm proper fit is to do what? a. ) Ask the patient if the device is causing any pain. b. ) Ensure that two fingers will fit between the patient's leg and the device. c. ) Follow the manufacturer's instructions for the application of the device. d. ) Ask another nurse to check the patient for proper application of the device.

Answer 146

B

Question 147

The nurse is preparing to delegate the application of an SCD to nursing assistive personnel (NAP). Which statement by the NAP requires follow-up by the nurse? a. ) "I will check for a green light on the mechanical unit.” b. ) "I will remove the SCD before ambulating the patient." c. ) "I will tell you if I see any signs of itching, redness, or irritation on the patient's legs." d. ) "I will measure the patient's legs to determine what size SCD sleeve to use."

Answer 147

D, Measuring the patient's legs to determine the appropriate size SCD sleeve to apply is an intervention that cannot be delegated, so this statement does require the nurse to follow up.

Question 148

When preparing to delegate the application of an SCD to NAP, the nurse must do what first? a. ) Ask the NAP to demonstrate the proper application of the SCD b. ) Assess the patient's lower extremities for signs and symptoms of impaired circulation c. ) Assess the patient's need for an SCD d. ) Explain that the device is not to be removed

Answer 148

B

Question 149

What would the nurse do first when preparing to begin oxygen therapy for a patient? a. ) Educate the NAP about the oxygen orders. b. ) Review the medical prescription for delivery method and flow rate. c. ) Place a “No Smoking” sign outside of the hospital room. d. ) Ensure that suction equipment is present in the room.

Answer 149

B

Question 150

When preparing the patient’s environment for safe oxygen therapy, which intervention is a priority to minimize the patient’s risk for injury? a. ) Place appropriate signage to alert staff and visitors to the presence of oxygen in the patient’s room. b. ) Instruct nursing assistive personnel (NAP) to immediately correct or report safety hazards. c. ) Inspect all electrical equipment in the patient’s room for the presence of safety-check tags. d. ) Ensure that the patient receives the prescribed amount of oxygen via the appropriate method.

Answer 150

C

Question 151

When a patient is receiving oxygen at home, which instruction to the family would help them understand how to use the oxygen safely? a. ) Increase the oxygen level as needed for the patient’s comfort. b. ) Store extra oxygen cylinders horizontally. c. ) Place a “No Smoking” sign at the entrance to the house. d. ) Keep oxygen 5 feet (about 1.5 meters) away from anything that could generate a spark.

Answer 151

C

Question 152

What would the nurse do first when preparing to educate the patient about safe administration of oxygen therapy at home? a. ) Evaluate the patient’s understanding of the combustible nature of oxygen. b. ) Arrange for a capable family member to be present during the initial discussion. c. ) Collect written information to present to the patient as supplemental instructional materials. d. ) Assess the patients emotional readiness and physical ability to provide autonomous care.

Answer 152

D

Question 153

Which statement by the patient would indicate that he or she understands the safe use of oxygen? a. ) “The nurse told me that my oxygen saturation must be maintained at 85% or above.” b. ) “I know that oxygen is a medication I can adjust whenever I need to.” c. ) “I’ll alert the nurse immediately if I have any increased difficulty breathing.” d. ) “I often experience difficulty breathing for no apparent reason, but that is expected.”

Answer 153

C

Question 154

What would be the nurse’s priority in order to minimize a patient’s risk for injury during oxygen therapy? a. ) Advising the patient to call for assistance before getting out of bed b. ) Instructing nursing assistive personnel (NAP) to immediately correct the flow rate if the oxygen regulator is not set as prescribed c. ) Observing the six rights of medication administration d. ) Monitoring the patient for signs of hypoxia

Answer 154

C

Question 155

What can the nurse do to evaluate a patient’s response to continuous oxygen therapy delivered at 4 L/min by nasal cannula? a. ) Regularly measure and trend the patient’s pulse oximetry (SpO2) values. b. ) Evaluate venous blood levels every morning. c. ) Monitor the patient’s arterial blood gas (ABG) levels hourly. d. ) Assess the patient for compliance with the prescribed therapy.

Answer 155

A

Question 156

What should the nurse do when a patient is ordered to receive 4 L/min oxygen by nasal cannula? a. ) Encourage oral fluids. b. ) Restrict fluids. c. ) Ensure that humidification is present. d. ) Measure blood pressure every hour.

Answer 156

C

Question 157

When caring for a patient receiving oxygen by nasal cannula, which of the following is a priority to help maintain good skin integrity? a. ) Frequently applying moisturizing lotion to facial areas that come into contact with the cannula b. ) Removing the cannula every 2 hours for no longer than 10 minutes c. ) Assessing the patient’s external ears, nares, and nasal mucosa for breakdown at least once per shift d. ) Instructing the patient to inform staff of any problems with facial dryness or cracking

Answer 157

C

Question 158

When caring for a patient who is receiving oxygen by simple face mask, which action ensures that the rate of oxygen being delivered is appropriate? a. ) Frequently asking the patient how he or she is breathing b. ) Ensuring that the oxygen tubing is pulled tight, with little or no slack c. ) Securing the oxygen tubing to the patient’s clothing to prevent tugging d. ) Assessing for proper placement of the mask on the patient’s face

Answer 158

D

Question 159

When caring for a patient for whom oxygen by nonrebreathing mask has been ordered, which action ensures appropriate oxygen delivery? a. ) Looping the oxygen tubing around the side rail of the bed b. ) Assessing breath sounds every shift c. ) Securing the tubing snugly to the patient’s gown d. ) Assessing that the reservoir bag stays inflated

Answer 159

D

Question 160

When caring for a patient who is receiving supplemental oxygen by face tent, which action ensures that the oxygen is flowing? a. ) Testing the closing capacity of the mask’s valves b. ) Routinely monitoring the seal over the patient’s mouth and nose c. ) Ensuring that a mist is always present d. ) Regularly verifying that the mask is positioned loosely

Answer 160

C

Question 161

What would the nurse do when receiving an order to increase the delivery rate of a patient’s oxygen per nasal cannula from 1 L/min to 3 L/min? a. ) Encourage the patient to take deeper breaths in order to get more oxygen b. ) Change the device from nasal cannula to simple face mask c. ) Ensure that humidification is present d. ) Adjust the float ball on the flow meter to 3 L/min.

Answer 161

D

Question 162

What would the nurse do first to ease breathing for a patient with mild dyspnea? a. ) Administer oxygen at 2 L/min by nasal cannula. b. ) Help the patient into an upright sitting position. c. ) Monitor the patient’s pulse oximetry level. d. ) Determine if the patient has a history of respiratory pathology.

Answer 162

B

Question 163

During an admission interview, a patient who is required to stay in the supine position reports, “I can’t breathe well while I’m lying down.” What would the nurse do first to help this patient? a. ) Notify the health care provider of the patient’s complaint. b. ) Request that the health care provider prescribe oxygen therapy. c. ) Interview the patient concerning the onset of this problem. d. ) Instruct the patient to use two bed pillows when lying supine.

Answer 163

D

Question 164

The nurse is caring for a patient who is recovering from a left partial lobectomy. Which action would be most helpful in re-expanding the affected lung? a. ) Placing the patient in a right side-lying position b. ) Encouraging the patient to deep breathe and cough every hour c. ) Regularly assessing the patient’s ability to breathe comfortably d. ) Providing medication to manage postoperative pain of greater than 3 on a 0-to-10 scale

Answer 164

A, Placing the patient in a right side-lying position will facilitate re-expansion of the affected lung. The unaffected lung should be next to the bed, and the affected lung should be up.

Question 165

What is the purpose of splinting the abdomen with a small pillow during controlled coughing? a. ) To minimize chest discomfort caused by the coughing b. ) To expand lung capacity during the inspiratory phase of the cough c. ) To maximize transdiaphragmatic pressure during the expiratory phase of the cough d. ) To focus the patient’s attention on the abdominal muscles used during the cough

Answer 165

C

Question 166

What would the nurse do routinely to monitor oxygenation in a patient receiving BiPAP? a. ) Assess the patient’s level of consciousness every 4 hours. b. ) Monitor the patient’s pulse oximetry readings. c. ) Verify the pressure settings for both inspiratory and expiratory pressure. d. ) Evaluate daily arterial blood gases (ABGs)

Answer 166

B

Question 167

How can the nurse best minimize a patient’s risk for infection during tracheostomy care? a. ) Adhere to sterile technique when appropriate. b. ) Frequently assess for signs of local or systemic infection. c. ) Monitor for indications that tracheostomy care is needed. d. ) Instruct nursing assistive personnel (NAP) to report any changes in color or odor of tracheal drainage.

Answer 167

A

Question 168

Which nursing action shows the most effective planning for emergency care of a patient with a tracheostomy? a. ) Having a spare oxygen mask at the patient’s bedside b. ) Keeping an obturator and a tracheostomy tube at the patient’s bedside c. ) Reviewing the agency’s policy regarding tracheostomy care d. ) Instructing the family to call immediately if the patient has difficulty breathing

Answer 168

B

Question 169

Which intervention reduces the risk for skin breakdown in a patient with a new tracheostomy? a. ) Cleaning the stoma with hydrogen peroxide and drying thoroughly b. ) Cleaning and assessing the skin around the stoma c. ) Assessing temperature and reporting skin breakdown immediately d. ) Allowing the patient to re-oxygenate after each tracheal suctioning

Answer 169

B

Question 170

Which action may be delegated to nursing assistive personnel (NAP) regarding the care of a patient with a tracheostomy? a. ) Performing tracheostomy care for a patient whose tracheostomy was placed 1 week ago b. ) Removing the outer cannula and placing the obturator c. ) Holding the tracheostomy tube while the nurse changes the neck ties d. ) Monitoring oxygen saturation levels and placing oxygen if needed

Answer 170

C

Question 171

Which action would the nurse perform when preparing to suction a patient’s oropharynx? a. ) Apply sterile gloves. b. ) Place the patient in a semi-Fowler's or sitting position. c. ) Remove the nasal cannula. d. ) Flush the suction catheter with 200 mL of warm tap water.

Answer 171

B

Question 172

After oropharyngeal suctioning, what does the nurse do with the supplies? a. ) Place the Yankauer catheter in a clean, dry area. b. ) Place all disposable equipment into the wrapper of the suction catheter before discarding it in a trash receptacle. c. ) Fold the paper drape with the outer surface inward, and dispose of it in a biohazard receptacle. d. ) Place dirty gloves in the biohazard receptacle in the patient’s room.

Answer 172

A

Question 173

When preparing to suction a patient’s oral cavity, why would the nurse first suction a small amount of water through the catheter? a. ) To moisten the exterior of the plastic catheter b. ) To ensure that the catheter’s suction is functioning properly c. ) To minimize friction as the catheter moves within the oral cavity d. ) To avoid startling the patient with the sound created by the suction

Answer 173

B

Question 174

What is a priority intervention when performing oropharyngeal suctioning for a patient who is receiving oxygen by face mask? a. ) Complete the suctioning process in 20 seconds or less. b. ) Keep the oxygen mask near the patient’s face during the suctioning procedure. c. ) Encourage the patient to take several deep breaths before suctioning begins. d. ) Increase the oxygen flow rate by 1 L/min for 3 minutes before suctioning.

Answer 174

B

Question 175

Which action is most useful in evaluating the effectiveness of oropharyngeal suctioning? a. ) Comparing presuctioning and postsuctioning respiratory assessment data b. ) Confirming that the patient’s pulse oximetry value is >90% c. ) Asking the patient to report any symptoms of dyspnea d. ) Assessing the patient’s skin for signs of cyanosis

Answer 175

A

Question 176

Which action is part of the preparation for nasotracheal suctioning? a. ) Place the patient in a supine position. b. ) Preoxygenate the patient with 100% oxygen. c. ) Suction 100 mL of warm tap water to flush the suction catheter. d. ) Place water-soluble lubricant onto the open sterile catheter package.

Answer 176

D

Question 177

Which response would the nurse report immediately if it occurred in association with nasotracheal suctioning? a. ) Patient complains of discomfort during the procedure b. ) Patient has a severe bout of nonproductive coughing and complains of sore throat c. ) After oxygen delivery device has been reapplied on completion of the procedure, patient’s pulse oximetry reading falls to 88% d. ) Patient’s pulse rate increases by 10 beats/min

Answer 177

C

Question 178

While suctioning the nasotracheal airway, the nurse notes that a patient’s pulse rate has fallen from 102 beats/min to 80 beats/min. What is the best course of action? a. ) Encourage the patient to take several deep breaths. b. ) Interrupt suction to the catheter for at least 10 seconds. c. ) Discontinue suctioning by removing the suction catheter. d. ) Assess the patient’s pulse oximetry reading to see if oxygenation is adequate.

Answer 178

C

Question 179

As a nasotracheal catheter is inserted to suction the airway, a patient begins to gag and says, “I feel like I’m going to throw up.” What is the nurse’s best response? a. ) Complete the catheter insertion in 5 seconds or less. b. ) Remove the catheter. c. ) Encourage the patient to take several deep breaths to minimize the nausea. d. ) Stop advancing the catheter, and allow the patient to rest for several minutes.

Answer 179

B

Question 180

Why might the collection of a sputum specimen be delayed up to 2 hours? a. ) The patient is taking an afternoon nap. b. ) The patient has just finished eating lunch. c. ) Pain medication has just been administered. d. ) The family is visiting.

Answer 180

B

Question 181

Which criterion makes it appropriate for the nurse to delegate to nursing assistive personnel (NAP) the skill of collecting a sputum specimen? a. ) The skill takes little time to complete. b. ) The likelihood of infection is minimal. c. ) The patient can produce the specimen by coughing. d. ) The agency offers training in this skill for NAP.

Answer 181

C

Question 182

What is the role of nursing assistive personnel (NAP) when a sputum specimen is collected by means of nasotracheal suctioning? a. ) Manipulating the suction catheter b. ) Setting up the sterile field c. ) Applying sterile gloves d. ) Transporting the specimen to the lab

Answer 182

D

Question 183

Which action would help to ensure that the results of a suctioned sputum specimen culture are reliable? a. ) Placing the specimen in a biohazard bag b. ) Obtaining the specimen when the patient coughs without prompting c. ) Wearing sterile gloves to suction the patient d. ) Refrigerating the specimen until it can be taken to the lab

Answer 183

D

Question 184

Which action by the nurse would most effectively reduce the patient’s risk for injury when collecting a sputum specimen by means of nasotracheal suctioning? a. ) Lubricating the catheter with sterile water b. ) Performing the procedure using aseptic technique c. ) Positioning the patient in a semi- to high-Fowler’s position d. ) Assessing the patient’s degree of anxiety regarding the intervention

Answer 184

A

Question 185

What is the primary purpose of the preoperative assessment? a. ) To compare all assessment data with expected normal values b. ) To notify the surgeon of abnormal laboratory results c. ) To obtain baseline vital sign values d. ) To identify conditions or factors that may compromise the surgical outcome

Answer 185

D

Question 186

What is the best way for the nurse to assess a preoperative patient for possible latex allergy? a. ) Review the medical record for documentation of a latex allergy. b. ) Ask the family whether the patient has ever had a reaction to latex. c. ) Ask the patient if he or she has a latex allergy or is not allowed to use anything made of rubber. d. ) Specifically mention latex gloves and balloons when asking about items to which the patient may have had an allergic reaction.

Answer 186

C

Question 187

Which part of the preoperative assessment might the nurse delegate to the nursing assistive personnel (NAP)? a. ) Encourage NAP to keep the patient in a comfortable position. b. ) Direct the NAP to perform a complete health history. c. ) Ask the NAP to find out if the patient has any allergies. d. ) Ask the NAP to determine if the patient is at risk for falling.

Answer 187

A

Question 188

On which areas would the nurse focus when completing a preoperative physical examination? a. ) Heart and lungs b. ) Head to toe c. ) Operative body area or system d. ) Areas with abnormalities

Answer 188

C

Question 189

During a preoperative assessment, why would the nurse ask the patient about his or her response to previous surgeries? a. ) To predict the patient’s response to anesthesia b. ) To identify anatomic and physiologic alterations that may affect care c. ) To help estimate the amount of time the patient will be hospitalized d. ) To determine the amount of pain medication the patient will need

Answer 189

A

Question 190

What is the primary purpose of promoting preoperative family participation? a. ) To prepare family members for the role of patient advocate b. ) To reduce the level of presurgical anxiety for family and patient c. ) To identify important cultural factors influencing the patient's perception of health and healing d. ) To evaluate the family’s interest in and ability to provide postsurgical care and support to the patient

Answer 190

B

Question 191

How will the nurse ensure privacy when discussing a patient’s surgical needs with the family? a. ) Include the family in discussions only if the patient makes the request b. ) Discuss the patient’s right to privacy with all family members who wish to participate. c. ) Secure the patient’s permission to include family members in the presurgical counseling sessions d. ) Reassure the patient that he or she will be consulted concerning any surgery-related decision.

Answer 191

C

Question 192

Which statement or question by the nurse illustrates the role of nursing assistive personnel (NAP) in providing preoperative instruction to the family of a patient scheduled for surgery? a. ) “Do the family members have any language barriers?” b. ) “Let me know when the patient’s family is visiting with the patient.” c. ) “Which family member seems to be the patient’s primary caregiver?” d. ) “Please give the family a copy of the preoperative literature for cataract surgery.”

Answer 192

B

Question 193

The family of a surgical patient is concerned about being able to provide the care the patient will need after surgery. What is the nurse’s best response? a. ) “I’ll have social services look into the possibility of short-term rehabilitative care.” b. ) “Don’t worry—your father’s recovery should be relatively quick and his need for care minimal.” c. ) “What do you see as being the problem your family has with providing the care he needs?” d. ) “Are you open to having a home health agency work with you to help provide care?”

Answer 193

D

Question 194

How can the nurse evaluate a family’s anxiety concerning its role in providing the patient’s postsurgical care? a. ) Observe the rapport among various family members and the patient. b. ) Interview family members individually about their role in the patient’s recovery. c. ) Ask the family to identify specific areas of concern. d. ) Determine how much help the family will need.

Answer 194

C

Question 195

Why might a nurse teach a patient scheduled for surgery how to do postoperative exercises? a. ) To maximize a sense of well-being b. ) To minimize postoperative complications c. ) To identify cultural factors that reflect the patient’s perception of pain d. ) To evaluate the patient’s ability to participate in postoperative activities

Answer 195

B

Question 196

Which instruction might a nurse give a patient in order to protect a surgical incision when turning in bed? a. ) Hold your breath when turning. b. ) Use a pillow to splint the incision. c. ) Take pain medication 30 minutes before turning. d. ) Keep both legs straight when turning.

Answer 196

B

Question 197

The nurse is concerned that a patient will not be able to turn independently in bed after having surgery. What must the nurse do to help this patient? a. ) Reinstruct the patient in proper turning techniques. b. ) Document that the patient refuses to turn independently. c. ) Communicate that the staff must turn the patient after surgery. d. ) Restrict turning unless absolutely necessary.

Answer 197

C

Question 198

At what point would the patient sign the consent form for a surgical procedure? a. ) After the surgeon explains the procedure b. ) During the preoperative consultation at the surgeon’s office c. ) After receiving preoperative medication d. ) At the completion of the physical examination

Answer 198

A

Question 199

A patient scheduled for same-day surgery tells the nurse that he had a “few sips” of coffee while driving to the hospital. What would the nurse do first with this information? a. ) Document that the patient had coffee b. ) Notify the operating room c. ) Notify the surgeon d. ) Inform the recovery room nurse

Answer 199

C, The procedure may need to be reschedule. Need to follow NPO

Question 200

After the nurse provides a patient with preoperative medication, the patient needs to void. What would the nurse do? a. ) Walk the patient to the bathroom. b. ) Insert an indwelling urinary catheter. c. ) Insert an intermittent urinary catheter. d. ) Provide the patient with a bedpan.

Answer 200

D

Question 201

What is the primary way in which the nurse can lower a patient’s risk for postsurgical complications? a. ) Adequately prepare the patient for discharge from the agency. b. ) Provide continuity of nursing care throughout the patient’s stay at the agency. c. ) Identify deviations from normal that may interfere with the recovery process. d. ) Evaluate the patient’s emotional reaction to the surgical process.

Answer 201

C, such as vital signs

Question 202

When reviewing ordered pain medicine for a postoperative patient whose pain is not currently controlled, which nursing action has priority? a. ) Asking the family member if the patient seems to be in pain b. ) Reviewing the surgeon’s preoperative pain medication order c. ) Examining the patient’s medical record for analgesics used with previous surgeries d. ) Asking the postanesthesia care unit (PACU) nurse when the patient last received pain medication

Answer 202

D

Question 203

When a patient returns to the unit from the PACU, how would the nurse assess possible urinary retention? a. ) Straight-catheterize the patient. b. ) Complete a bladder scan. c. ) Encourage the patient to void. d. ) Check the chart for lab values specific to urinary function.

Answer 203

B

Question 204

What is the nurse’s primary goal for appropriate, effective pain management when considering the patient’s risk for injury? a. ) To minimize the potential for analgesic-induced dependency b. ) To evaluate the effect of pain on the patient’s ability to provide self-care c. )To maximize pain relief while maintaining the patient’s ability to function d. ) To identify the patient’s need for both physical and emotional pain relief

Answer 204

C

Question 205

What is one step the nurse would take if a patient receiving patient-controlled analgesia (PCA) were difficult to arouse? a. ) Assess the infusion tubing to make sure it has not become occluded. b. ) Check the infusion site for infiltration and any symptoms of infection. c. ) Assess respiration, and then notify the health care provider immediately. d. ) Check the infusion of maintenance fluid to make sure the correct rate is running.

Answer 205

C, If a patient on PCA were difficult to arouse, a possible sign of life-threatening respiratory depression, the nurse would assess respiration (if none, would need to call code) and then notify the health care provider immediately and be prepared to administer an antidote, such as an opioid-reversing agent. The nurse would take other measures as well, such as monitoring the patient’s vital signs and administering oxygen if indicated.

Question 206

What will the nurse do when discontinuing patient-controlled analgesia? a. ) Ensure that the main intravenous line is intact. b. ) Pull the intravenous access device from the patient. c. ) Tell the patient that pain medication has been discontinued. d. ) Change the PCA pump infusion rate to keep vein-open status.

Answer 206

A

Question 207

What would the nurse do if material aspirated from a patient’s nasogastric tube resembled coffee grounds in color and texture? a. ) Check the tube placement. b. ) Assess the pH of the contents. c. ) The nurse must check NG tube placement before providing a scheduled tube feeding. d. ) Irrigate the tube with water.

Answer 207

C

Question 208

What would the nurse do before providing the patient with a scheduled intermittent feeding through a nasogastric (NG) tube? a. ) Listen to bowel sounds. b. ) Listen to lung sounds. c. ) Check NG tube placement. d. ) Turn the patient onto his or her left side.

Answer 208

C

Question 209

When checking gastric aspirate from an NG tube, the nurse assesses a pH of 7. What would the nurse do next? a. ) Nothing, since this is an expected pH value b. ) Advance the tube c. ) Anticipate a chest x-ray d. ) Pull back on the tube

Answer 209

C, Normal gastric pH is 5 or less. A pH greater than 7 could mean that the tube is in the small intestine or lung. The nurse must notify the health care provider and anticipate a chest x-ray for placement verification.