Question 1

Which patient do you plan to teach regarding water restriction?  A 23-year-old with extracellular fluid volume (ECV) deficit   A 34-year-old with hyponatremia  A 47-year-old with hypercalcemia  A 69-year-old with metabolic acidosis

Accepted Answer

A 34-year-old with hyponatremia

Question 2

When you assess pain and redness at a vascular access device (VAD) site, which action do you take first?  Apply a warm, moist compress  Monitor the patient\'s blood pressure  Aspirate the infusing fluid from the VAD   Stop the infusion and discontinue the intravenous infusion

Accepted Answer

Stop the infusion and discontinue the intravenous infusion

Question 3

When delegating input and output (I&O) measurement to nursing assistive personnel, you instruct them to record what information for ice chips?  The total volume  Two-thirds of the volume  One-half of the volume   One-quarter of the volume

Accepted Answer

One-half of the volume

Question 4

You assess four patients. Which patient has greatest risk for hypomagnesemia?  A 72-year-old with chronic alcoholism  A 79-year-old with bone cancer  A 41-year-old with hypernatremia  A 46-year-old with respiratory acidosis

Accepted Answer

A 72-year-old with chronic alcoholism

Question 5

Which assessment do you interpret as a transfusion reaction?  Crackles in dependent parts of lungs  High fever, severe hypotension  Anxiety, itching, confusion   Chills, tachycardia, and flushing

Accepted Answer

Chills, tachycardia, and flushing

Question 6

What assessment do you make before hanging an intravenous (IV) fluid that contains potassium?  Urine output   Arterial blood gases  Fullness of neck veins   Level of consciousness

Accepted Answer

Urine output

Question 7

The health care provider\'s order is 500 mL 0.9% NaCl intravenously over 4 hours. Which rate do you program into the infusion pump?  125 mL/hr   167 mL/hr  200 mL/hr  1000 mL/hr

Accepted Answer

125 mL/hr

Question 8

Your older-adult patient is receiving intravenous (IV) 0.9% NaCl. You detect new onset of crackles in the lung bases. What is your priority action?  Notify a health care provider  Record in medical record  Decrease the IV flow rate  Discontinue the IV site

Accepted Answer

Decrease the IV flow rate

Question 9

A patient is admitted to the hospital with severe dyspnea and wheezing. Arterial blood gas levels on admission are pH 7.26, PaCO2, 55 mm Hg,PaO2, 68 mm Hg,and HCO3-, 24. You interpret these laboratory values to indicate:  Metabolic acidosis.  Metabolic alkalosis.  Respiratory acidosis.   Respiratory alkalosis.

Accepted Answer

Respiratory acidosis.

Question 10

Which assessment do you use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) deficit?  Dryness of mucous membranes  Presence or absence of edema  Fullness of neck veins when supine   Fullness of neck veins when upright

Accepted Answer

Fullness of neck veins when supine

Question 11

Your patient is hyperventilating from acute pain and hypoxia. Interventions to manage his pain and oxygenation will decrease his risk of which acid-base imbalance?  Metabolic acidosis  Metabolic alkalosis  Respiratory acidosis   Respiratory alkalosis

Accepted Answer

Respiratory alkalosis

Question 12

What is the correct order for discontinuing intravenous (IV) access?  1. Perform hand hygiene and apply gloves. 2. Explain procedure to patient. 3. Remove IV site dressing and tape. 4. Use two identifiers to ensure correct patient. 5. Stop the infusion and clamp the tubing. 6. Carefully check the health care provider\'s order. 7. Clean the site, withdraw the catheter, and apply pressure.  6, 4, 2, 1, 5, 3, 7   4, 6, 2, 1, 5, 3, 7  6, 4, 2, 5, 3, 1, 7   6, 2, 4, 1, 3, 7, 5

Accepted Answer

6, 4, 2, 1, 5, 3, 7

Question 13

An intravenous (IV) fluid is infusing more slowly than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select all that apply.)  Infiltration at vascular access device (VAD) site   Patient lying on tubing   Roller clamp wide open   Tubing kinked in bedrails   Circulatory overload

Accepted Answer

Infiltration at vascular access device (VAD) site Roller clamp wide open Circulatory overload

Question 14

Your patient has severe hypercalcemia. What are your priority nursing interventions? (Select all that apply.)  Fall prevention interventions   Teaching regarding sodium restriction   Encouraging increased fluid intake  Monitoring for constipation   Explaining how to take daily weights

Accepted Answer

Teaching regarding sodium restriction  Explaining how to take daily weights

Question 15

Your patient has hypokalemia with stable cardiac function. What are your priority nursing interventions? (Select all that apply.)  Fall prevention interventions   Teaching regarding sodium restriction   Encouraging increased fluid intake   Monitoring for constipation   Explaining how to take daily weights

Accepted Answer

Fall prevention interventions  Explaining how to take daily weights

Question 16

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

Accepted Answer

Apply a tourniquet to the selected arm 4 to 6 inches above the proposed site.

Question 17

2. When preparing to insert avenous access device, how canthe nurse encouragepatient compliance with the procedure?  Assess the patient\'s understanding of the placement of the device.  Insert the access device as quickly as possible.  Ask the patient to select the arm preferred for access.  Apply a topical anesthetic to the area before inserting the device.

Accepted Answer

Assess the patient\'s understanding of the placement of the device.

Question 18

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

Accepted Answer

Checking for a radial pulse once the tourniquet has been applied

Question 19

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

Accepted Answer

Superficial dorsal vein

Question 20

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

Accepted Answer

Cleanse the area by first swabbing horizontally, then vertically with the applicator for about 30 seconds.

Question 21

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

Accepted Answer

Anchor the vein by placing a thumb 1 to 2 inches below the site.

Question 22

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

Accepted Answer

Instruct the patient to expect a sharp, quick stick.

Question 23

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

Accepted Answer

All of the above

Question 24

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

Accepted Answer

Lower the catheter until it is flush with the skin.

Question 25

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

Accepted Answer

\"Let me know when you notice that the IV bag contains less than 100 milliliters.\"

Question 26

1. 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?  Reminds the nurse to document the insertion of the device  Proves that the access site was assessed  Informs the nurse and other staff when the next dressing change is due  Reminds the nurse when to change the infusion tubing

Accepted Answer

Informs the nurse and other staff when the next dressing change is due

Question 27

2. Which action will the nurse take to minimize a patient\'s risk for injury when applying a dressing to an infusion site?  Use aseptic technique throughout the process.  Apply a skin protectant to the skin before the intervention.  Apply a transparent dressing that allows for visualization of the site.  Explain the process to the patient before implementation.

Accepted Answer

Use aseptic technique throughout the process.

Question 28

3. 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?  Assess the site.  Instruct the NAP on how to change the dressing.  Remove the device, and insert a new one.  Reinforce the dressing with more gauze.

Accepted Answer

Assess the site.

Question 29

4. 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?  Apply a transparent dressing to the insertion site.  Use a catheter stabilizing device when applying the dressing.  Apply the dressing distal to the tubing and catheter hub connector.  Secure the tubing to the patient\'s dressing with 1-inch tape.

Accepted Answer

Apply the dressing distal to the tubing and catheter hub connector.

Question 30

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

Accepted Answer

Avoid encircling the arm with tape

Question 31

1. 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?  Restart the IV in another location less affected by the patient\'s positioning.  Include this information in the shift report regarding this patient.  Assess the flow rate every 1 to 2 hours.  Instruct the patient to avoid positioning the arm in ways that alter the flow rate of the solution.

Accepted Answer

Restart the IV in another location less affected by the patient\'s positioning.

Question 32

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

Accepted Answer

Regulate the flow rate of the infusion

Question 33

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

Accepted Answer

\"Let me know if you notice that the dressing has become damp.\"

Question 34

4. 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?  1  2  3  4

Accepted Answer

1

Question 35

5. 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?  Apply a cool compress.  Apply a warm compress.  Apply a pressure dressing.  Apply an elastic compression wrap.

Accepted Answer

Apply a warm compress.

Question 36

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

Accepted Answer

Visualize the tip of the IV device.

Question 37

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

Accepted Answer

\"Let me know if you notice any bleeding on the site dressing.\"

Question 38

3. What might the nurse do to improve a patient\'s cooperation during the removal of an IV access device?  Describe the entire procedure to the patient.  Assure the patient that you will remove the IV catheter quickly.  Assure the patient that the procedure will take only about 5 minutes.  Tell the patient that the procedure will cause only a slight burning sensation.

Accepted Answer

Describe the entire procedure to the patient.

Question 39

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

Accepted Answer

Keep the hub parallel to the skin.

Question 40

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

Accepted Answer

Apply firm pressure to the site with sterile gauze for 10 minutes.

Question 41

1. 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?  \"Assess the IV site frequently for signs of inflammation.\"  \"Be sure not to obscure the insertion site with the dressing.\"  \"Let me know when you notice that the IV bag contains less than 100 mL.\"  \"Tell the patient to notify me if the IV site is painful, swollen, or red.\"

Accepted Answer

\"Let me know when you notice that the IV bag contains less than 100 mL.\"

Question 42

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

Accepted Answer

Calculate the hourly volume of normal saline the patient should receive.

Question 43

3. 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?  25 drops/minute  30 drops/minute  35 drops/minute  40 drops/minute

Accepted Answer

25 drops/minute

Question 44

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

Accepted Answer

Infusing D5W at a rate of 125 mL/hour until the health care provider changes the order

Question 45

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

Accepted Answer

Using a volume-control device for the infusion

Question 46

1. 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?  \"Assess the IV site for signs of inflammation.\"  \"Be sure to changethe dressing on the IV site.\"  \"I\'ll check the IV site and pump.\"  \"Turn off the alarm.\"

Accepted Answer

\"I\'ll check the IV site and pump.\"

Question 47

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

Accepted Answer

The flow of fluid would stop.

Question 48

3. 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?  125 mL  250 mL  500 mL  625 mL

Accepted Answer

500 mL

Question 49

4. 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?  First verify that the fluid is dripping, and then check the level of fluid remaining in the container every hour.  Ask another nurse to assess the programming of the pump.  Set the pump alarm to sound when half ofthe fluid has infused.  Check the IV site for complications.

Accepted Answer

First verify that the fluid is dripping, and then check the level of fluid remaining in the container every hour.

Question 50

5. Which information is not necessary for the nurse toinclude when documenting the use of an electronic infusion device (EID) for an intravenous infusion?  Location of the insertion site  Time at which the infusion began  Patient\'s pulse and heart rate  Hourly volume flow rate of the infusion

Accepted Answer

Patient\'s pulse and heart rate

Question 51

1. 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?  Begin the process again.  Add more fluid to the drip chamber.  Inject a syringe of saline into the tubing to vent the air bubbles.  Close the clamp, stretch the tubing downward, and flick the tubing.

Accepted Answer

Close the clamp, stretch the tubing downward, and flick the tubing.

Question 52

2. Which action can the nurse take to minimize the patient\'s risk for infection when applying new tubing to a primary IV infusion?  Using aseptic technique throughout the process  Changing the tubing each shift  Changing the tubing at the same time a new primary fluid bag is hung when possible  Both selections 1 and 3 are appropriate to minimize the patient\'s risk for infection

Accepted Answer

Both selections 1 and 3 are appropriate to minimize the patient\'s risk for infection

Question 53

3. 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?  Reconnect the extension set.  Clean the end with an alcohol swab, and reconnect it.  Pull the IV from the site, and insert a new catheter.  Change the extension set tubing.

Accepted Answer

Change the extension set tubing.

Question 54

4. 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?  Change the tubing with each new infusion bag.  Wear clean treatment gloves when changing the tubing.  Recheck the drip rate by counting the drops for 1 full minute.  Assess the condition of the patient\'s insertion site for possible infiltration.

Accepted Answer

Recheck the drip rate by counting the drops for 1 full minute.

Question 55

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

Accepted Answer

\"Let me know when the IV bag is almost empty.\"

Question 56

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

Accepted Answer

\"Be sure to notify me if the patient reports that the IV site is painful or swollen.\"

Question 57

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

Accepted Answer

Use aseptic technique throughout the process.

Question 58

3. 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?  Apply an IV site-protection device over the site, such as House Ultra Dressing,  Apply restraints to the patient.  Check the patient frequently.  Instruct the patient to avoid dislodging the IV catheter.

Accepted Answer

Apply an IV site-protection device over the site, such as House Ultra Dressing,

Question 59

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

Accepted Answer

Discontinue the infusion.

Question 60

5. 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 aninfusion site on the arm?  Encircle the arm with tape.  Secure the tubing and catheter hub with tape.  Secure the tubing in two different locations on the arm.  Label the dressing with the date and time of application.

Accepted Answer

Secure the tubing in two different locations on the arm.

Question 61

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

Accepted Answer

Infuse the antibiotic through another lumen of the multi-lumen central line.

Question 62

2. 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?  Discontinue the present CPN solution, and clamp the catheter hub.  Continue the present CPN solution, but readjust the flow to a keep-vein-open (KVO) rate.  Hang an infusion of 0.9% normal saline at the same infusion rate as the CPN.  Hang an infusion of 10% dextrose in water at the same infusion rate as the CPN.

Accepted Answer

Hang an infusion of 10% dextrose in water at the same infusion rate as the CPN.

Question 63

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

Accepted Answer

Change the CPN infusion tubing at least once every 24 hours.

Question 64

4. 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?  Warm the infusion in the microwave.  Vigorously shake the bag.  Contact the pharmacy for a new infusion bag.  Increase the infusion rate on the pump.

Accepted Answer

Contact the pharmacy for a new infusion bag.

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