Week 3 Clinical Skills

Question 1

When preparing to move a patient in bed, what will the nurse do first?

A. Assemble adequate help to move the patient.
B. Assess the patient’s ability to help with moving.
C. Determine the patient’s weight.
D. Decide on the most effective means of moving the patient.

Answer 1

B. Assess the patient’s ability to help with moving.

Question 2

When preparing to move a patient in bed with the help of an assistant, which posture will both caregivers use to ensure their own safety?

A. Stand with the knees locked.
B. Stand with the feet together.
C. Flex the hips and knees.
D. Shift the body weight from the front leg to the back leg.

Answer 2

C. Flex the hips and knees.

Question 3

A patient who weighs 200 lbs. needs to be moved up in bed with the aid of a friction-reducing device. The nurse will prepare for this move by assembling how many caregivers?

A. A minimum of two
B. None, since the device does all the lifting during the move
C. At least three
D. The nurse can carry out this move without assistance

Answer 3

C. At least three

Question 4

In which position will the nurse place the patient to move him or her up in bed?

A. Supine with the head of the bed at a 30-degree angle
B. Sitting in the bed
C. Supine with the head of the bed flat
D. Prone with the head of the bed flat

Answer 4

C. Supine with the head of the bed flat

Question 5

A patient will be moved up in bed with the use of a friction-reducing device. How will the nurse place this device under the patient?

A. Lift the patient to place the device directly under him or her.
B. Remove the drawsheet, and replace it with the device.
C. Roll the patient from side to side, and place the device under the drawsheet.
D. Sit the patient up in the bed, and place the device behind the shoulders.

Answer 5

C. Roll the patient from side to side, and place the device under the drawsheet.

Question 6

A patient is receiving an infusion of IVIG. The medication was appropriately reconstituted and is at room temperature. Forty minutes after the infusion starts, the patient complains of chills and rigors and has a temperature of 39°C (102.2°F). What is the most appropriate action?

A. Provide a warm blanket, administer medications as ordered, and continue the infusion.
B. Reassure the patient that these symptoms are normal during IVIG infusion.
C. Stop the infusion and notify the practitioner, then administer medications as prescribed.
D. Stop the infusion and wait 5 minutes to resume it.

Answer 6

C. Stop the infusion and notify the practitioner, then administer medications as prescribed.

Question 7

While being assessed before an IVIG infusion, the patient reports having diarrhea three days ago (which is now resolved), not drinking the usual amount of fluid, and experiencing some light-headedness and a dry mouth. What is the most appropriate action?

A. Proceed with preparing and administering IVIG.
B. Notify the practitioner and anticipate the need for IV fluids.
C. Administer IV fluids in the same IV as the IVIG infusion.
D. Obtain a stool specimen for culture and sensitivity.

Answer 7

B. Notify the practitioner and anticipate the need for IV fluids.

Question 8

A patient has been prescribed IVIG, and the pharmacy delivers a brand of IVIG that is not the patient’s usual IVIG. It does not match the written order. What is the appropriate action?

A. Prepare to administer half the dose of IVIG and reassess the patient for an adverse reaction.
B. Proceed with reconstituting and administering the delivered IVIG as prescribed.
C. Premedicate the patient as prescribed before administering the IVIG.
D. Notify the pharmacy to obtain the correct IVIG product as prescribed.

Answer 8

D. Notify the pharmacy to obtain the correct IVIG product as prescribed.

Question 9

During an IVIG infusion, a patient begins to complain of nausea. What is the most appropriate intervention?

A. Administer an IV fluid bolus, then continue the IVIG infusion at the previous rate.
B. Stop the infusion, notify the practitioner, and administer antiemetics as prescribed.
C. Provide comfort measures, such as changing the patient’s position or providing heating pads.
D. Stop the infusion and restart it when the nausea subsides.

Answer 9

B. Stop the infusion, notify the practitioner, and administer antiemetics as prescribed.

Question 10

When discussing discharge instructions after an IVIG infusion, the patient wants to reschedule the next infusion because of an upcoming vacation. What is the most appropriate response?

A. Instruct the patient to call to arrange for the next infusion upon returning home.
B. Arrange for the patient to obtain a serum IgG level before leaving town.
C. Schedule a new date and time for the next infusion at the patient’s request.
D. Reeducate the patient regarding the importance of adhering to a strict infusion schedule.

Answer 10

D. Reeducate the patient regarding the importance of adhering to a strict infusion schedule.

Question 11

The nurse is assessing a 76-year-old patient before an IVIG infusion. The patient’s daughter reports that the patient seems to have had decreased urine output for the past week. What is the most appropriate action?

A. Notify the practitioner before starting the infusion.
B. Obtain a urine specimen for analysis.
C. Reassure the patient and daughter that there is no concern.
D. Proceed with the IVIG infusion as prescribed.

Answer 11

A. Notify the practitioner before starting the infusion.

Question 12

When it is time to begin the IVIG infusion, the nurse realizes the dose is still in the freezer. What should be the next action?

A. Wait until the IVIG is in a cold liquid state, then administer it.
B. Allow the IVIG to warm naturally to room temperature, then begin infusing.
C. Microwave the solution to warm it to room temperature, then begin infusing.
D. Do not begin the infusion; instead, call the practitioner.

Answer 12

D. Do not begin the infusion; instead, call the practitioner.

Question 13

A patient has an 18-G peripheral IV in the left arm with a liter of 0.9% sodium chloride solution infusing at 100 ml/hr. How should the nurse infuse the scheduled dose of IVIG?

A. Piggybacked into the infusing IV solution
B. Through a separate dedicated IV site
C. Concurrently through the same pump as the 0.9% sodium chloride solution
D. Intermittently with the 0.9% sodium chloride solution

Answer 13

B. Through a separate dedicated IV site

Question 14

A patient is receiving the very first dose of IVIG. The nurse anticipates administering which medication before the infusion?

A. Methylprednisolone
B. Diphenhydramine
C. Ondansetron
D. None

Answer 14

D. None

Question 15

A patient who weighs 200 kg (441 lb) reports a weight loss of 20 kg (44 lb) since the last IVIG treatment. What should be the nurse’s next action?

A. Call the practitioner for a dose change.
B. Administer the previously ordered dose of IVIG.
C. Weigh the patient to verify the current weight.
D. Administer a dose of IVIG 10% less than the previous dose.

Answer 15

C. Weigh the patient to verify the current weight.

Question 16

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 16

D. Place water-soluble lubricant onto the open sterile catheter package.

Question 17

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 bpm.

Answer 17

C. After oxygen delivery device has been reapplied on completion of the procedure, patient’s pulse oximetry reading falls to 88%.

Question 18

While suctioning the nasotracheal airway, the nurse notes that a patient’s pulse rate has fallen from 102 bpm to 80 bpm. 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 18

C. Discontinue suctioning by removing the suction catheter.

Question 19

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 19

B. Remove the catheter.

Question 20

How does the nurse evaluate the effect of nasotracheal suctioning on a patient’s respiratory status?

A. Asking the patient about symptoms of respiratory difficulty.
B. Comparing respiratory assessment data from before and after the suctioning procedure.
C. Confirming that the patient’s pulse oximetry value is >90%.
D. Auscultating the patient’s chest after suctioning.

Answer 20

B. Comparing respiratory assessment data from before and after the suctioning procedure.

Question 21

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 21

B. Place the patient in a semi-Fowler’s or sitting position.

Question 22

After oropharyngeal suctioning, what does the nurse do with the supplies?

A. Place the rigid 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 22

A. Place the rigid catheter in a clean, dry area.

Question 23

When preparing to suction a patient’s oral cavity, why would the nurse first suction a small amount of sterile 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 23

B. To ensure that the catheter’s suction is functioning properly

Question 24

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 24

B. Keep the oxygen mask near the patient’s face during the suctioning procedure.

Question 25

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 25

A. Comparing presuctioning and postsuctioning respiratory assessment data