question

A nurse is caring for a patient who has a tracheostomy. Which of the following must the nurse use when administering oxygen to this patient?

answer

A tracheostomy collar Rationale • A tracheostomy collar is designed to provide high humidity and the oxygen concentration prescribed for the patient. It is a small oxygen-delivery apparatus that fits over the tracheostomy site and is held in place by an adjustable elastic strap that fits around the patient's neck

question

A nurse is caring for a patient who is dyspneic and slightly cyanotic, with a respiratory rate of 28/min. The nurse determines that the patient has impaired gas exchange during which of the following phases of the nursing process?

answer

Diagnosis Rationale During the diagnosis phase, the nurse analyzes and interprets data gathered from the nursing assessment to formulate a nursing diagnosis, in this case, impaired gas exchange

question

A nurse should recognize that which of the following is an indication for oxygen therapy?

answer

Tachypnea SaO2 90% rationale: Oxygen therapy is indicated for patients who are at risk for or have developed hypoxia. In the early stages of hypoxia, heart failure and arterial oxygen saturation (SaO2) falls below 94%

question

o A nurse is caring for a critically ill patient with COPD who requires delivery of a precise concentration of oxygen. Which of the following types of oxygen-delivery device is indicated for this patient?

answer

Venturi mask rationale: used for criticall ill patients who require administration of a specific concentration of oxygen. Because this device delivers a precise oxygen concentration and carbon dioxide buildup is minimal, it is commonly used for patients who have COPD

question

A home health nurse is instructing a patient who has just started receiving oxygen therapy via mask. The nurse should emphasize that the patient must:

answer

Reposition the elastic band frequently rationale: • Tubing and elastic bands that are part of oxygen-delivery devices can cause pressure on the skin that can lead to breakdown. Padding them and changing their position often can help prevent this complication.

question

A patient has been receiving oxygen PRN via nasal cannula for 4 hours. Which of the following assessment findings helps indicate that oxygen therapy has been effective?

answer

Respiratory rate 14/min rationale: The normal range of respirations is 12-16/min. stabilization of the respiratory rate, especially if the patient was previously tachypneic, is an indication that oxygen therapy is effective

question

A nurse is caring for a critically ill patient with COPD who requires delivery of a precise concentration of oxygen. Which of the following types of oxygen-delivery device is indicated for this patient?

answer

Venturi mask Rationale: Used for critically ill patients who require administration of a specific concentration of oxygen. Because this device delivers a precise oxygen concentration and carbon dioxide buildup is minimal, it is commonly used for patients who have COPD.

question

A home health nurse is instructing a patient who has just started receiving oxygen therapy via mask. The nurse should emphasize that the patient must:

answer

Reposition the elastic band frequently rationale: Tubing and elastic bands that are part of oxygen-delivery devices can cause pressure on the skin that can lead to breakdown. Padding them and changing their position often can help prevent this complication.

question

A patient has been receiving oxygen PRN via nasal cannula for 4 hours.Which of the following assessment findings helps indicate that oxygen therapy has been effective?

answer

Respiratory rate 14/min Rationale: The normal range of respirations is 12-16/min. stabilization of the respiratory rate, especially if the patient was previously tachypneic, is an indication that oxygen therapy is effective

question

A patient admitted with community-acquired pneumonia has been receiving oxygen therapy for several days. Which of the following assessment findings indicates an adverse effect of oxygen therapy?

answer

Cracks in the oral mucosa Rationale: Oxygen, especially when delivered long-term and/or without sufficient humidification, is extremely drying and can cause cracks in the nasal and oral mucosa.

question

Administering oxygen therapy with a nonrebreather mask has which of the following advantages?

answer

Offers the highest oxygen concentration of the low-flow systems

question

A patient who is prescribed oxygen therapy 24 hr./day is concerned about being confined to bed. Which of the following should the nurse do to provide mobility for this patient?

answer

Make sure the patient has up to 50 feet of connecting tubing

question

Oxygen therapy is prescribed for a patient who is brought to an emergency department in the early stages of hypozia. When assessing this patient, the nurse should expect to find which of the following clinical indicators?

answer

Elevated blood pressure

question

A nurse is providing discharge teaching to a patient who will continue oxygen therapy at home. The nurse should instruct the patient that turning the knob on the oxygen flow meter all the way to the right?

answer

Stops the flow of oxygen

question

A nurse is likely to receive an order for urinary catheterization of a newly admitted patient who:

answer

Is in the ICU for a gastrointestinal bleed Precise measurement of urinary output is crucial for managing fluid balance in patients who are critically ill

question

A nurse is assessing a patient's indwelling catheter drainage at the end of shift and notes the output is considerable less than the fluid intake. Which of the following actions should the nurse take first after checking for kinks?

answer

Milk the catheter

question

Which of the following actions should a nurse take when removing a patient's indwelling urinary catheter?

answer

Deflate the balloon completely before removal

question

A nurse who is preparing to insert a straight urinary catheter for a male patient should...

answer

Apply light traction to the penis

question

A nurse is applying a condom catheter for an older adult patient who is uncircumcised. Which of the following is an appropriate step in the procedure?

answer

Leaving a space between the penis and catheter's tip rationale: A space of 2.5 to 5 cm (1-2 in) should be left between the tip of the penis and the end of the catheter. This space helps prevent irritation of the tip of the penis and allows full drainage of urine

question

A nurse is preparing to insert an indwelling urinary catheter for a female patient. When beginning the insertion procedure, the nurse should instruct the patient to

answer

Bear down rationale: Bearing down as if to void relaxes the external sphincter and aids in the insertion procedure. This is the appropriate instruction for the patient.

question

When providing perineal care for a female patient who has an indwelling catheter, which of the following areas should the nurse cleanse last?

answer

The anus Rationale: The basic aseptic principle applicable to perineal care is to cleanse from the area of least contamination to the area that is the most contaminated. The anal area is typically contaminated with coliform bacteria and should be cleansed last.

question

A nurse is preparing to administer an oil retention enema to a patient who has constipation. The nurse explains that the patient should try to retain the instilled oil for...

answer

At least 30 min, but preferable as long as he can

question

While a nurse is administering a cleansing enema, the patient reports abdominal cramping. Which of the following is the appropriate intervention?

answer

Lower the enema fluid container Rationale: Some abdominal cramping is to be expected during enema administration. To ease the patient's discomfort, the nurse should slow the rate of instillation by reducing the height of the enema fluid container

question

A nurse is preparing an older adult patient for an enema. The nurse should assist the patient to which of the following positions?

answer

Left lateral with the right leg flexed

question

A nurse is preparing to administer the first of two large-volume, cleansing enemas prescribed for a patient in preparation for a diagnostic procedure. Which of the following an appropriate step in the procedure?

answer

Warm the enema solution prior to instillation Rationale: It is important to warm the enema solution because cold fluid can cause abdominal cramping. The solution should not be too hot, though, because hot fluid can injure the intestinal mucosa

question

A nurse is preparing to administer a cleansing enema to a patient who is prone to fecal incontinence due to poor sphincter control and is unlikely to retain the enema solution. Which of the following interventions is appropriate for this patient?

answer

Place the patient in the dorsal recumbent position on a bedpan

question

A nurse is administering a return-flow enema to a patient should instill 100 mL of enema fluid and then...

answer

Lower the container to allow the solution to flow back out

question

A patient who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should anticipate receiving an order from the provider for which of the following types of enemas?

answer

Return flow

question

A nurse is administering an enema medicated with sodium polysysterne sulfonate to an older adult patient who has hyperkalemia. The nurse should insert the tip of the rectal tube...

answer

7.5 cm to 10 cm (3-4 in)

question

A nurse is preparing to obtain a blood sample from a patient who has a triple-lumen central catheter in place for multiple therapies. Which of the following is an appropriate action for the nurse to take?

answer

Turn off the distal infusions for 1 to 5 minutes before obtaining the blood sample

question

A patient who has sustained trauma from a motor-vehicle crash is transported to an emergency department. The provider determines the need for immediate central venous access for fluid and blood replacement and prophylactic antibiotic therapy. The appropriate central venous access device for this patient is:

answer

A non-tunneled percutaneous central catheter rationale: Ideal for emergency situations (short term)

question

An older adult patient who adheres to a regular cardiovascular rehabilitation schedule that includes water aerobics and swimming requires long-term central venous access. Which of the following central venous access devices is the best choice for allowing him to continue his aquatic program?

answer

An implanted port

question

A nurse caring for a patient who has gastric cancer is initiating an infusion of parenteral nutrition via the patient's implanted port. Which of the following is an appropriate action for the nurse to take?

answer

Cover the device and the needle with a sterile transparent dressing (needle must be first supported and anchored, then the port and the needle are covered with a transparent dressing)

question

A nurse is caring for a patient who has a central venous catheter and suddenly develops dyspnea, tachycardia, and dizziness. The nurse suspects air embolism and clamps the catheter immediately. The nurse should reposition the patient in which of the following positions?

answer

On his left side in Trendelenburg position (helps trap the air in the apex of the right atrium rather than allowing it to enter the right ventricle)

question

A nurse is preparing to flush a patent's peripherally inserted central catheter (PICC). Because the patient's catheter has a valved tip, the nurse:

answer

Uses non-heparinized saline solution for the flush (there is no blood back-up)

question

A nurse is caring for a patient who as a central venous access device in place. Which of the following routine measures should the nurse use specifically to prevent lumen occlusion?

answer

Clamping the extension tubing while removing a syringe from the injection cap

question

A nurse is caring for a patient who has a central venous catheter. When flushing the catheter, the nurse uses a 10-mL syringe to prevent which of the following complications associated with central vascular access devices?

answer

Catheter rupture

question

A nurse is teaching a patient with a new ileostomy about incorporating preventive strategies at home. To prevent excoriation and breakdown of the peristomal skin, the nurse should instruct the patient to:

answer

Empty the pouch when it is no more than half full

question

While a nurse is teaching a patient how to replace her ostomy pouching system, the patient reports that removing the skin barrier is sometimes painful. Which of the following should the nurse suggest?

answer

Push the skin away from the barrier whole removing it

question

A nurse is providing preoperative teaching for a patient who has colon cancer. The surgeon informed the patient that his entire large intestine and rectum will be removed. The nurse should explain the type of ostomy he will have is...

answer

Ileostomy

question

A nurse is obtaining health history from a young adult patient who has a colostomy. The patient reports frequent episodes of loose stools over the last month, but has no signs of infection or bowel obstruction. He reports that his concerns about leakage have limited his social activities. Which of the following should the nurse recommend?

answer

Consume foods that are low in fiber content

question

A nurse is providing preoperative teaching for an older adult patient who has diverticulitis and is scheduled for a creation of a double-barrel colostomy in the sigmoid colon. Which of the following instructions should the nurse include in the teaching?

answer

Tape a dry gauze pad over the distal stoma to collect drainage (distal stoma secretes mucus)

question

A nurse is teaching a patient how to apply an extended-wear skin barrier. Which of the following strategies should the nurse instruct the patient to use for maximal adherence?

answer

Press gently around the barrier for 1 to 2 minutes

question

A patient who has bladder cancer tells the nurse that, of the various urinary diversion options the surgeon presented, she prefers one that will allow her to have some control over urinary elimination. The nurse should explain the option that will allow that is:

answer

Kock's pouch (does not require an external drainage collection device because the patient self-catheterizes every 2 to 4 hours to remove urine)

question

A nurse is replacing the ostomy appliance for a patient whose newly created colostomy is functioning. After removing the pouch, which of the following should the nurse do first:

answer

Cleanse the stoma and the peristomal skin

question

A nurse is caring for a patient who sustained trauma to his head and neck and will require long-term airway support. Which of the following devices will be required for home health care for this patient? a. Nasopharyngeal airway b. Oropharyngeal airway c. Endotracheal tube d. Tracheostomy tube

answer

Tracheostomy tube

question

A nurse is preparing to suction secretions from the mouth of a patient who has dysphagia. Which of the following is the appropriate suction device or method for the nurse to use? a. In-line suctioning b. Yankauer catheter c. Bulb syringe d. Open suctioning

answer

Yankauer catheter (helps clear secretions from the mouth)

question

A nurse is caring for a patient who has a tracheostomy tube with an inner cannula in place. Which of the following supplies should the nurse use to dry the inner cannula of the patient's tracheostomy tube after cleaning it? a. paper towels b. cotton-tipped applicators c. folded pipe cleaners d. facial tissues

answer

Folded pipe cleaners

question

A nurse is caring for a patient who has a tracheostomy tube in place. During tracheostomy care, which of the following should the nurse place underneath the flanges of the outer cannula? a. commerically prepared transparent dressing b. cotton-filled gauze square c. comercially prepared fenestrated dressing d. twill tape

answer

Commercially prepared fenestrated dressing

question

A nurse is performing chest physiotherapy for a patient who needs help mobilizing and expectorating thick pulmonary secretions. To increase the turbulence of the air the patient exhales, the nurse should use which of the following techniques? a. vibration b. percussion c. nebulization d. postural drainage

answer

Vibration

question

A nurse is suctioning a patient's airway using in-line suctioning. When using this method, it is appropriate for the nurse to: a. hyperoxygenate the patient before disconnecting the venilator b. apply suction pressure while advancing the catheter c. wear a face shield during the procedure d. reuse the catheter repeatedly

answer

Reuse the catheter repeatedly (with in-line suctioning, the catheter attaches to the ventilator tubing and does not have to be replaced until the system is replaced)

question

A nurse is preparing to perform endotracheal tube care and plans to use tape to secure the tube. Which of the following is an appropriate preparatory action for this procedure? a. cut a piece of tape that reaches posterioly from naris to naris b. have a tincture of benzoin ready to apply to the patient's face c. prepare an astringent solution for cleaning the patient's face d. open a package of sterile gloves so they are ready to use

answer

Have a tincture of benzoin ready to apply to the patient's face

question

A nurse is caring for a patient who has a cuffed endotracheal tube in place. Which of the following is an appropriate component of ET tube care for this patient? a. Repositioning the ET tube in the patient's mouth every 8 hours b. Providing oral and nasal care every 12 hr c. applying the securing tape over the patient's ears d. maintaing a cuff pressure of 30 mm Hg

answer

Repositioning the ET tube in the patient's mouth every 8 hours

question

When using chilled normal saline solution during gastric lavage, the nurse should watch for which of the following complications?

answer

Hypothermia (rapid infusion may cause hypothermia)

question

A nurse is caring for a patient who has a nasogastric tube connected to suction. Which of the following should indicate to the nurse that the tube has become occluded?

answer

Patient's report of nausea

question

A patient recovering from gastric surgery remains NPO and has a nasogastric tube connected to suction. Which of the following actions should the nurse take to prevent dry mucous membranes?

answer

Provide frequent mouth care

question

During report, a nurse is informed that a patient has a nasogastric tube connected to continuous suction. The nurse should recognize that this patient must have which of the following types of tube?

answer

Salem pump (only type of tube that allows for continuous suction)

question

A nurse is performing a nasogastric intubation. Which of the following actions should the nurse take immediately after inserting the tube to the predetermined length?

answer

Inspect the oropharynx with a penlight and a tongue blade (check for kinks and to ensure that the tube is not coiled)

question

A nurse should recognize that nasogastric intubation is indicated to relieve gastric distention for which of the following patients?

answer

A 40-year-old patient with a postoperative bowel obstruction (removal of secretions)

question

A nurse is caring for a patient who has a newly inserted nasogastric tube. Which of the following methods is appropriate for verifying the initial placement?

answer

X-ray examination of the chest and the abdomen

question

A drug's generic name is the...

answer

same as nonproprietary name

question

A pt drinks 8oz. Which is the correct conversion of pt's intake?

answer

240 mL

question

Which of the following represents the correct administration of the prescribed medication?

answer

amoxicilin 1g PO; two 500mg tablets To determine the direct dosage, start with the amount prescribed (1g); To determine how many tablets to give, divide the dose ordered by the dose on hand and multiply the result by the amount on hand.

question

Which of the follwoing is the most appropriate documentation of a pt's response to a pain med?

answer

The pt reports pain decreased to 3/10, 30 minutes after medication administration.

question

Which of the following is your highest priority action for ensuring overall safety during medication administration?

answer

Identify the pt. by two acceptable methods this is a good practice when you have to perform a calculation; however, it is impractical for overall safety on an ongoing basis. Also, confirming the dose is only one aspect of safe medication administration

question

Which of the follwoing demonstrates the correct use of one of the six rights of med administration?

answer

administering a pt's med by the route the provider prescribed

question

you are giving a pt several PO medication to take. The pt tells you that she can only take one pill at time. It is appropriate to...

answer

remain at the bedside until you are sure the pt has taken all of the meds it is your responsibility to remain with pt and observe that med is taken; unacceptable to leave meds unattended for any period of time

question

With which route of drug administration are there no barriers to absorption?

answer

Intravenous Any barriers to absorption are bypassed; the drug is completely and instantaneously absorbed

question

You are reading the physcian's orders and note date and time of the prescriptions, as well as the physician's signature. Which of the following prescriptions is complete?

answer

Digoxin (lanoxin) 1.25 mg PO daily has med dose, route and frequency

question

You have a handwritten medication order that is difficult to read. Which of the follwoing is the most appropriate action to take to avoid an error in medication administration?

answer

Call the medical provider for clarification of the order

question

An uncommon, unexpected, or individual drug response thought to result from a genetic predisposition is called?

answer

idiosyncratic effect

question

Which of the follwoing pts is exhibiting drug tolerance?

answer

A pt requires an increased dose of a med to achieve continued therapeutic benefit.

question

A nurse is caring for pt who has been prescribed a fluticasone propinate (flovent HFA) inhaler with a spacer. The pt asks the nurse why a spacer is needed with the inhaler. Which of the following repsonses by the nurse is correct?

answer

More medication is delivered to the lungs when you use a spacer? A spacer slows down and breaks up the medication, allowing the pt to better control the flow of med. This decreases the amount of med deposited in the oropharynx

question

A pt is to receive 12.5 mg of prenisone by mouth daily. The med is available in 5mg tablets. How many tablets should the nurse administer for each dose?

answer

2.5

question

A nurse will be administering several medications to pt who is receiving enteral feedings through a small bore nasogastric tube. The nurse administers the med correctly by.

answer

infusing each med by gravity and flushing with water before and after instillation

question

A pt is to recieve his daily isoniazid (INH) dosage for TB. He states he is feeling nauseated with this medication and refuses to take it. The nurse knows that the correct way to indicate this refusal to...

answer

document the reason for refusal along with the date and time in the pt's medical record

question

Which of the following should a nurse assess before administering medications through a NG tube?

answer

amount of residual volume left in stomach

question

A nurse is teaching the daughter of an older adult pt how to instill eye drops in the pt's right eye. Which of the following statements indicates that the daughter has understood directions?

answer

I will pull down her lower eyelid and drop the medication inside

question

A nurse is administering aspirin 82 mg PO daily as prescribed. The med is scheduled for 0800 hrs. Which of the following demonstrates proper use of one of the 6 rts of medication adminstration?

answer

The nurse documents that the aspirin was given at 0825. All routinely ordered meds should be given 30 min before/after the prescribed time

question

For which of the following inhalation med delivery methods is it important for nurse to assess the pt's ability to inhale deeply before administering the med?

answer

Dry power inhaler (DPI) this method has no propellant and requires deep inhalation to trigger the release of med

question

A nurse is preparing to instill antibiotic ear drops into a toddler's ear. Which of the following techniques should the nruse use when administering ear drops?

answer

Pull the pt's auricle down and back to open the canal when administering ear drops. the auricle should pulled down and backfor young children, up and out for adults

question

Which of the following terms indicates a med is given by injection?

answer

parenteral

question

A nurse is administering a subQ injection to a pt. Which of the following data should the nurse recognize as the highest priority to prevent potential complications?

answer

identify if the pt has allergies to the med

question

A nurse is preparing to administer an insulin injection to a pt. Which of the following is appropriate?

answer

rotate injection sites to avoid injury

question

The proper needle lenth when giving a IM injection in the ventrogluteal area to an average-sized adult is which of the following?

answer

1 1/2 inch

question

A nurse is preparing to give an IM injection into the left ventrogluteal muscle. Which of the following should the nurse do to locate the appropriate site?

answer

With the heel of the hand on the greater trochanter, point the index finger up toward the anterior superio iliac spine, extending the other fingers back along hte iliac crest

question

A nurse is preparing to adminster an intradermal injection. Which of the following should the nurse do to ensure proper technique?

answer

use a tuberculin syringe with a 3/8 to 5/8 inch, 25-27 guage needle

question

A nurse administers the first dose of the pt's prescribed antibiotic via IV piggback. During the first 10-15 min of administration of a med, the nurse gives priority to which of the following assessments?

answer

pt for systemic allergic reaction

question

A nurse is about to administer an IV med directly into the vein. The nurse should understand that the disadvantage of parentally adminstered meds is that they

answer

are irreversible

question

A nurse is caring for a pt with a peripherally inserted central catheters (PICC line). Which of the following is true about this type of IV route?

answer

A PICC line is a long catheter inserted through the veins of the antecubital fossa

question

A pt was admitted to the hospital for same day surgery and has orders for continous intravenous therapy. Before performing a venipuncture, the nurse should...

answer

inspect the IV solution for fluid color, clarity and expiration date

question

A nurse is assessing a pt receiving IV normal saline at 125 mL/hr. Which of the following should the nruse recognize as a possible complication related to the IV therapy?

answer

Pt reports cough and shortness of breath Sign of fluid overload. Slow the IV and notify the provider.

question

A nurse is caring for pt who is recieving D5W with 20 mEq of KCL at 75 ml/hr. The provider has prescribed 1 g ceftriaxone IV. When preparing to administer this med by IV piggyback, which of the following data is the highest priority for the nurse to collect?

answer

The med's compatibility wiht the primary IV solution If med is not compatible w/ primary solution, a precipitate can form in the IV tubing, preventing med administration.

question

A nurse is caring for a pt recieving .9% NaCl at 75mL/hr through a triple lumen central venous catheter. The pump is alarming that there is an occlusion. Which of the following is the first thing the nurse should do?

answer

Check the line at or above the hub for kinked tubing that is creating resistance to flow

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