Week 1 Clinical Skills

Question 1

Which action by the nurse ensures patient safety when administering an intramuscular injection?

A. Putting on clean gloves before administration
B. Rotating injection sites
C. Aspirating for blood return when administering a vaccine
D. Injecting the medication quickly

Answer 1

B. Rotating injection sites

Question 2

When preparing an intramuscular injection, what can the nurse do to reduce the patient’s risk for infection?

A. Wear clean gloves.
B. Use a 3-ml syringe.
C. Clean the injection site with an alcohol swab.
D. Massage the injection site.

Answer 2

C. Clean the injection site with an alcohol swab.

Question 3

What can the nurse do to minimize the patient’s risk fr injury when delivering an intramuscular injection?

A. Instruct the patient to relax.
B. Insert the needle at a 45-degree angle.
C. Pull back on the plunger after inserting the needle.
D. Pull the skin taut at the injection site when inserting the needle.

Answer 3

C. Pull back on the plunger after inserting the needle.

Question 4

Which site is most commonly used for intramuscular injections?

A. Ventrogluteal
B. Abdominal
C. Deltoid
D. Dorsogluteal

Answer 4

A. Ventrogluteal

Question 5

Which action by the nurse helps to ensure that the medication is delivered into the muscle when administering an intramuscular injection?

A. Using a 1-inch needle
B. Inserting the needle at a 45- to 60-degree angle
C. Withdrawing the needle immediately after delivering the medication
D. Aspirating for blood return before injecting the medication

Answer 5

D. Aspirating for blood return before injecting the medication

Question 6

When administering an intradermal injection, which outcome would require the nurse to withdraw the needle and begin again?

A. Aspiration of blood prior to injecting the medication
B. Inability to feel resistance when injecting the medication
C. Formation of a 6-mm bleb at the injection site
D. Appearance of a lesion resembling a mosquito bite at the injection site

Answer 6

B. Inability to feel resistance when injecting the medication

Question 7

Which statement might the nurse make to nursing assistive personnel (NAP) when caring for a patient who is prescribed an intradermal injection?

A. “Be sure to wear clean gloves during the injection.”
B. “Tell him it’s OK; the site should look like a mosquito bite.”
C. “Immediately report any patient complaints of itching or dyspnea.”
D. “Remind the patient to come back in 48 to 72 hours so we can evaluate the site.”

Answer 7

C. “Immediately report any patient complaints of itching or dyspnea.”

Question 8

Which finding tells the nurse that a patient may have had a positive reaction to a tuberculin test?

A. A raised wheal the size of a mosquito bite
B. A bruised area 10 mm or greater in diameter
C. A hard, raised area 15 mm or greater in diameter
D. A flat, reddened area 5 mm or greater in diameter

Answer 8

C. A hard, raised area 15 mm or greater in diameter

Question 9

In which site would it be inappropriate to administer an intradermal injection?

A. Lower abdomen of an obese patient
B. Upper back of a patient who is on bed rest
C. Right deltoid of a high school softball pitcher
D. Left forearm of a patient with right-sided weakness

Answer 9

C. Right deltoid of a high school softball pitcher

Question 10

How can the nurse determine that the needle tip for an intradermal injection is in the dermis?

A. A bleb the size of a mosquito bite will appear.
B. The needle will enter at a 5- to 15-degree angle.
C. The bulge of the needle tip will be visible through the skin.
D. The needle will penetrate through the epidermis to a depth of about ⅛ inch.

Answer 10

C. The bulge of the needle tip will be visible through the skin.

Question 11

Which action would the nurse take to diminish tissue irritation when administering a subcutaneous injection to a patient of average size?

A. Massage the site after administration.
B. Make sure the volume of the medication is less than 2 mL.
C. Administer the injection at a 45- to 90-degree angle.
D. Wear clean gloves while administering the injection.

Answer 11

B. Make sure the volume of the medication is less than 2 mL.

Question 12

Which needle would be most appropriate for the nurse to use when giving a subcutaneous injection to a patient of average height and weight?

A. 20-gauge, ½-inch
B. 22-gauge, 1-inch
C. 25-gauge, ⅜-inch
D. 27-gauge, 1-inch

Answer 12

C. 25-gauge, ⅜-inch

Question 13

What can the nurse do to minimize the discomfort of a subcutaneous injection?

A. Inject the medication rapidly.
B. Massage the injection site.
C. Cover the injection site with gauze pad after withdrawing the needle.
D. Inject the medication without pinching the skin.

Answer 13

C. Cover the injection site with gauze pad after withdrawing the needle.

Question 14

When preparing to administer heparin or insulin subcutaneously, which site is preferred?

A. Abdomen
B. Scapula
C. Deltoid muscle
D. Back of the upper arm

Answer 14

A. Abdomen

Question 15

What can the nurse do to ensure proper site selection for subcutaneous insulin injection?

A. Insert the needle at a 30-degree angle.
B. Select a different anatomical region for each injection.
C. Ask the patient to relax before inserting the needle.
D. Systematically rotate sites within the same anatomical location or area.

Answer 15

D. Systematically rotate sites within the same anatomical location or area.

Question 16

The nurse has selected a finger as the puncture site to measure the blood glucose level of a female patient with type 2 diabetes mellitus and peripheral vascular disease (PVD). Although all of the actions listed below are appropriate, which one would be of particular benefit to this patient given her medical history?

A. Reviewing her current medications
B. Inspecting the selected finger for bruising
C. Following standard precautions
D. Keeping the finger in a dependent position during the puncture

Answer 16

D. Keeping the finger in a dependent position during the puncture

Question 17

For which patient can the nurse delegate to nursing assistive personnel (NAP) the task of routine blood glucose monitoring?

A. Patient with non–insulin-dependent diabetes for whom steroid therapy has been ordered
B. Patient with type 2 diabetes who required insulin coverage at the last testing
C. Patient with type 1 diabetes who has had nausea and vomiting for 24 hours
D. Patient with type 2 diabetes who has had a closed reduction of a fracture of the right wrist

Answer 17

D. Patient with type 2 diabetes who has had a closed reduction of a fracture of the right wrist

The patient with the closed reduction of a fracture of the right wrist would affect his or her ability to self-perform blood glucose testing but would not affect his or her blood glucose level. The skill of blood glucose testing may therefore be delegated to NAP. The patient’s steroid therapy medication makes the blood glucose unstable, therefore the skill of blood glucose testing may not be delegated to NAP. The patient’s need for insulin coverage precludes the delegation of blood glucose testing to NAP. The patient’s nausea and vomiting make the blood glucose unstable, therefore the skill of blood glucose testing may not be delegated to NAP.

Question 18

A patient with type 2 diabetes mellitus tells the nurse that he has been testing his own blood glucose level six times per day for the past 3 years. What is the most appropriate action for the nurse to take?

A. Observe the patient’s testing technique for accuracy.
B. Advise the patient that he is not permitted to perform his own blood glucose testing.
C. Check with the patient’s health care provider concerning the patient’s self-testing.
D. Explain to the patient that a nurse must complete blood glucose testing.

Answer 18

A. Observe the patient’s testing technique for accuracy.

Question 19

For which situation would the procedure of glucose testing be interrupted?

A. The reagent strip code matches the code on the vial.
B. An unused lancet is not available.
C. The glucose meter beeps.
D. A drop of blood forms on the patient’s skin after it is punctured.

Answer 19

B. An unused lancet is not available.

Question 20

Which action would the nurse carry out first when performing a blood glucose test on a patient with type 1 diabetes mellitus?

A. Apply clean gloves to minimize the risk for contamination.
B. Assess the patient’s skin for possible puncture sites.
C. Ask the patient to wash his or her hands and forearms with warm, soapy water.
D. Determine the patient’s preferred puncture site.

Answer 20

B. Assess the patient’s skin for possible puncture sites.

Question 21

Which substance should the nursing assistant measure as part of a person’s intake?

A. Vomitus
B. Ice cream
C. Tube feeding
D. Intravenous (IV) fluid

Answer 21

B. Ice cream

Rationale: Intake is the amount of fluid taken it. It includes all oral fluids and foods that melt at room temperature, such as ice cream. The nurse measures and records IV fluids and tube feedings.

Question 22

Which substance should the nursing assistant measure as part of a person’s output?

A. Urine
B. Sputum
C. Perspiration
D. Formed stool

Answer 22

A. Urine

Question 23

When measuring intake and output, you may need to convert ounces (oz) to milliliters (mL). What does 1 oz equal?

A. 10 mL
B. 30 mL
C. 45 mL
D. 60 mL

Answer 23

B. 30 mL

Question 24

How should you measure intake and output?

A. With the graduate placed on the floor
B. With the graduate held up toward the light
C. In the urinal or other urine collection container
D. With the graduate at eye level on a flat surface

Answer 24

D. With the graduate at eye level on a flat surface

Question 25

When should you total the amounts recorded on the intake and output (I&O) record?

A. Once every 2 hours
B. At the end of the shift
C. As soon as you record them
D. Once at the same time every day

Answer 25

B. At the end of the shift

Question 26

Output is the amount of fluid lost. Output includes :

Answer 26

urine, vomitus, diarrhea, and wound drainage.