Question 1

The nurse prepares to insert a large-bore nasogastric tube for gastric decompression. After obtaining equipment, the nurse identifies the client, performs hand hygiene, applies clean gloves, assesses nares, and selects a naris. Place the remaining steps in the correct order. All options must be used. A)Advance tube to the marked point B)Ask client to flex head forward and swallow C)Gently insert tube just past nasopharynx D)Instruct client to extend neck back slightly E)Measure, mark, and lubricate tube F)Verify tube placement and anchor

Accepted Answer

11ecbb05_cb6f_b915_b433_5d90653d699d_MD0009_00 Steps for inserting a nasogastric tube for gastric decompression include the following: Perform hand hygiene and apply clean gloves (no need for sterile gloves)Place client in high Fowler's positionAssess nares and oral cavity and select narisMeasure and mark the tubeCurve 4-6" tube around index finger and releaseLubricate end of tube with water-soluble jellyInstruct client to extend neck back slightlyGently insert tube just past nasopharynx, aiming tip downwardRotate tube slightly if resistance is met, allowing rest periods for clientContinue insertion until just above oropharynxAsk client to flex head forward and swallow small sips of water (or dry if NPO)Advance tube to marked pointVerify tube placement and anchor - use agency policy and procedure to verify placement by anchoring tube in place and obtaining an abdominal x-ray. Aspirating gastric contents and testing the pH may also give an indication of placement (pH should be 5.5 or below). Auscultation of inserted air is acceptable for confirming tube placement initially, but is not definitive as it is not an evidence-based method. Nothing may be administered through the tube until x-ray confirmation is obtained, or this may cause aspiration. Perform hand hygiene and apply clean gloves (no need for sterile gloves) Place client in high Fowler's position Assess nares and oral cavity and select naris Measure and mark the tube Measure Curve 4-6" tube around index finger and release Lubricate end of tube with water-soluble jelly Instruct client to extend neck back slightly Gently insert tube just past nasopharynx, aiming tip downward Rotate tube slightly if resistance is met, allowing rest periods for client Continue insertion until just above oropharynx Ask client to flex head forward and swallow small sips of water (or dry if NPO) Advance tube to marked point Verify tube placement and anchor - use agency policy and procedure to verify placement by anchoring tube in place and obtaining an abdominal x-ray. Aspirating gastric contents and testing the pH may also give an indication of placement (pH should be 5.5 or below). Auscultation of inserted air is acceptable for confirming tube placement initially, but is not definitive as it is not an evidence-based method. Nothing may be administered through the tube until x-ray confirmation is obtained, or this may cause aspiration. Educational objective: Key steps when inserting a large-bore nasogastric tube include using clean gloves; inspecting nares; measuring, marking, and lubricating tube; instructing client to extend the neck back slightly; inserting tube past the nasopharynx and continuing advancement until just above oropharynx; asking the client to flex the head forward and swallow; advancing tube to marked point; and verifying tube placement using abdominal x-ray and anchoring.

Question 2

An experienced nurse precepts a graduate nurse in the intensive care unit while caring for a client with a right subclavian triple-lumen central venous catheter (CVC).  Which statement by the graduate nurse indicates understanding of the CVC?
A)"All 3 lumens come together, so all drugs infused through the CVC must be compatible."
B)"It is used to provide enteral nutrition to the client who cannot eat."
C)"Sterile gloves must be worn when administering drugs through the CVC."
D)"The lumen hub should be cleaned thoroughly with antiseptic prior to drug administration."

Accepted Answer

11ecbb05_cb6d_bd43_b433_5b9aae27d7e7_MD0009_00 A central line or central venous catheter (CVC) is inserted by the health care provider in a "central" vein (eg, subclavian, internal jugular, femoral) and is used to administer fluids, medications, and parenteral nutrition and for hemodynamic monitoring. Proper hand hygiene should be performed when caring for a CVC to prevent infection, and nonsterile gloves should be worn to protect the nurse from blood or body fluids at the port site as one or more lumens are often used to draw blood (Option C). The Centers for Disease Control and Prevention recommend that catheter hubs always be handled aseptically to prevent catheter-associated infections. The hubs should be disinfected with a hospital-approved antiseptic (eg, 70% alcohol sterile pads; > 0.5% chlorhexidine with alcohol; 10% povidone-iodine). Always allow the antiseptic to dry before using the hub/port (Option D). (Option A) CVCs may have multiple lumens. These are used to administer incompatible drugs simultaneously, for blood draws, and for hemodynamic monitoring. (Option B) Enteral nutrition is given only through the GI tract (orally or through a feeding tube). Parenteral nutrition is administered through the IV route via a central vein. Educational objective: A central venous catheter is used to administer fluids, for simultaneous infusion of incompatible drugs, for parenteral nutrition, and for hemodynamic monitoring. The nurse should always handle the lumen ports and hubs aseptically with facility-approved antiseptics to prevent catheter-associated infections.

Question 3

The nurse performs nasogastric (NG) tube insertion using a large-bore NG tube on a hospitalized client with a gastrointestinal bleed. During insertion, after the tube passes the nasopharynx, the client begins to cough and gag. Which action should the nurse take first? A)Ask the client to take several small sips of water B)Continue to slowly advance the tube until placement is reached C)Gently remove the tube and reinsert in the other naris if possible D)Pull back on the tube slightly and then pause to give the client time to breathe

Accepted Answer

11ecbb05_cb70_a376_b433_2fda7076775d_MD0009_00 During NG tube insertion, the tube sometimes slips into the larynx or coils in the throat, which can result in coughing and gagging. The nurse should withdraw the tube slightly and then stop or pause while the client takes a few breaths. After the client stops coughing, the nurse can proceed with advancement (Option B), asking the client to take small sips of water to facilitate advancement to the stomach (Option A). The client should not be asked to swallow during coughing or aspiration may occur. If resistance or obstruction occurs during tube advancement, the nurse should rotate the tube while trying to advance it. If resistance continues, the tube should be withdrawn and inserted into the other naris if possible (Option C). Educational objective: Coughing and gagging commonly occur during NG tube insertion if the tube coils in the throat or slips into the larynx. When this happens, the nurse should pull back on the tube slightly and then pause to give the client time to recover and breathe before advancing the tube.

Question 4

The nurse performs tracheostomy care for a client with a disposable inner cannula and tracheostomy dressing. Place the steps in the correct order. All options must be used. A)Clean around stoma with sterile water or saline; dry and replace sterile gauze pad B)Don mask, goggles, and clean gloves C)Don sterile gloves; remove old disposable cannula and replace with a new one D)Gather supplies and position client E)Remove soiled dressing

Accepted Answer

11ecbb05_cb70_ca87_b433_ed71d918465e_MD0009_00 When performing tracheostomy care, the nurse follows institution policy and observes principles of infection control and client safety. Sterile technique is used to prevent infection of the lower airway. The steps for performing the procedure for a client with a disposable inner cannula include the following: Gather supplies to the bedside, then place client in semi-Fowler's position, if not contraindicated, to promote lung expansion and oxygenation and prevent aspiration of secretions. Don personal protective equipment (mask, goggles, and clean gloves) to maintain universal precautions. Auscultate lungs and suction secretions if necessary. Remove soiled dressing and also remove clean gloves. Don sterile gloves; remove old disposable cannula and replace with a new one. While stabilizing the back plate with the nondominant hand, unlock (unclip) the old cannula with the dominant hand; remove gently by pulling it out in line with its curvature; pick up the new cannula, touching only the outer locking portion (to prevent contamination and maintain asepsis); insert; and lock (clip) into place. Clean around stoma with sterile water or saline, dry and replace sterile gauze pad to remove dried secretions, and dry around stoma well to limit the growth of microorganisms. Some tracheostomy tubes are sutured in place and do not require a dressing. If secretions are copious, apply a dressing.

Question 5

The caregiver of a toddler calls the clinic because the child has accidentally ingested one capsule of amitriptyline found in the medicine cabinet. The caregiver states that the child appears to be acting normally. Which response by the nurse is appropriate? A)"Give syrup of ipecac immediately and proceed to the hospital." B)"Please go directly to the nearest emergency department for evaluation." C)"Stay home and monitor the child closely for any symptoms." D)"You should come immediately to the clinic with the pill bottle."

Accepted Answer

11ecbb05_cb69_ecb0_b433_2781de6ffc07_MD0009_00 Amitriptyline is a tricyclic antidepressant (TCA) that can produce cardiac toxicity and neurological disturbances by altering cholinergic pathways, sodium channels, and calcium channels, causing symptoms such as atrioventricular block, hypotension, cardiac arrest, and seizure. TCAs have a narrow therapeutic index and rapid onset of action, so ingestion of even a small amount may be life-threatening for a toddler. Symptoms of toxicity are usually evident within hours of ingestion, but cardiac failure can develop days after. Neurological and hemodynamic assessments, as well as ECG monitoring in an emergency department setting, are recommended (Option B). (Option A) Syrup of ipecac is no longer routinely recommended for oral poisonings. The uncontrolled vomiting and vagal response induced can be harmful after ingestion of toxic substances. Treatments such as oral activated charcoal may be used in the inpatient setting to remove the ingested toxin if the client presents immediately after the ingestion. (Option C) The caregiver should not be instructed to stay home to monitor for symptoms due to the rapid onset of toxicity. (Option D) An outpatient clinic is not sufficiently staffed or equipped for acute management of amitriptyline toxicity. The nurse should refer the client to the nearest emergency department, which is the safest environment for monitoring and treatment. Educational objective: Amitriptyline is a tricyclic antidepressant (TCA) that can cause toxic cardiac and neurological effects in children, even in small doses. Children who have accidentally ingested TCAs should be evaluated immediately in an emergency department.

Question 6

The nurse helps the health care provider perform a thoracentesis at the bedside.  In which position does the nurse place the client to facilitate needle insertion and promote comfort?
A)Fetal position, lying on unaffected side with knees drawn to the abdomen and hands clasped around them
B)Lying on the affected side with head of the bed elevated to 30-45 degrees
C)Prone with head turned to the affected side and arms over the head, supported by a pillow
D)Upright leaning forward over the bedside table, with arms supported on pillows

Accepted Answer

11ecbb05_cb6e_ceb4_b433_4f5180d62b5b_MD0009_00 During a thoracentesis, a needle is inserted into the pleural space to remove fluid for diagnostic or therapeutic purposes. Before the procedure, the nurse places the client in an upright sitting position on the side of the bed, leaning forward over the bedside table, with arms supported on pillows. This position ensures that the diaphragm is dependent, facilitates access to the pleural space through the intercostal spaces, and promotes client comfort. (Option A) The fetal position is appropriate for a client having a lumbar puncture, not a thoracentesis. lumbar puncture (Option B) If unable to sit, the client can be positioned lying on the unaffected, not affected, side. (Option C) Prone position is not used for this procedure, is uncomfortable, and would make it more difficult for a client with dyspnea to breathe. Prone position Educational objective: Before a thoracentesis, the nurse places the client in an upright sitting position on the side of the bed, leaning forward over the bedside table, with arms supported on pillows. This position ensures that the diaphragm is dependent, facilitates access to the pleural space through the intercostal spaces, and promotes client comfort.

Question 7

The nurse prepares to insert an indwelling urinary catheter in a client who is disoriented to time, place, and person and cannot follow directions or commands. Which intervention is most important when inserting the urinary catheter? A)Ensure the client understands the procedure prior to implementation B)Maintain a sterile field and keep the urinary catheter sterile C)Place the catheter supply kit between the client's legs in the center of the bed D)Throw swabs used to clean the perineum directly into the biohazard bin

Accepted Answer

Maintaining sterility is key when inserting an indwelling urinary (Foley) catheter. Sterile technique (surgical asepsis) should be used to prevent catheter-associated urinary tract infections, the 2nd most common type of health care-associated infection. Proper placement of the kit and application of sterile gloves are important to maintaining sterility. The dominant hand should be kept sterile until the procedure is complete. Once the nondominant hand is placed on the client's genitalia (to spread the labia or grasp the penis) for cleansing, it should be kept in place until the catheter is inserted to prevent contamination. (Option A) The procedure should be explained to the client; however, this client is confused and likely will not understand. (Option C) The catheter kit may be placed between the client's legs if the client is cooperative. However, use of a clean bedside table is more effective in maintaining a sterile field when the client is confused and uncooperative. (Option D) Swabs should be disposed of in the trashcan or biohazard bin in accordance with hospital policy; however, maintaining a sterile field is a higher priority. Educational objective: Maintenance of sterile technique is a key outcome for indwelling urinary catheterization. A sterile field should be maintained during the entire procedure through proper placement of the kit and application of sterile gloves. The nondominant hand should be used for cleansing and kept in place to prevent contamination. The sterile dominant hand should be used for insertion.

Question 8

A female client is admitted to the emergency department after a motor vehicle collision. The client is unresponsive and on a mechanical ventilator. Which actions should the nurse perform? Select all that apply. A)Locate and remove any medication patches B)Locate possible medical alert band or necklace C)Remove rings and jewelry and lock in a secure location D)Remove tampon and replace with menstrual pad E)Take out contacts if no presence of eye trauma

Accepted Answer

The unconscious client requires a thorough head-to-toe assessment on admission to assess for foreign objects, devices, or belongings that have potential for harm. This includes checking for: Medical alert bracelets/necklaces: Indicating allergy status, emergency contact, or code status (Option B) Contact lenses: Remove to prevent corneal injury (Option E) Medication patches: To prevent drug interactions and determine conditions currently being treated Tampons (in female clients): Remove to prevent toxic shock syndrome or infection (Option D) Rings and jewelry: Remove to prevent constrictive injury or vascular damage if edema develops (Option C) (Option A) Medication patches should not be removed without first consulting the health care provider. Clients are often prescribed transdermal patches for chronic conditions (eg, clonidine for hypertension, nitroglycerin for angina). Removing and discarding a medication patch without additional information may harm the client. Educational objective: When caring for an unconscious client during admission, the nurse should assess for medical alert devices and any prescriptive materials (eg, medication patches, contact lenses). The nurse should remove personal belongings and foreign objects that could harm the client if not removed (eg, tampons, rings/jewelry).

Question 9

The nurse is caring for a pregnant client with a positive urine drug screen. When questioned about substance abuse, the client begins to throw objects at the nurse and yells, "I'm leaving this hospital right now before you call the police on me!" What is the best response by the nurse? A)"If you leave without receiving treatment, you and your baby will be in danger." B)"If you stay and continue to receive treatment, no one will call the police." C)"You have the right to refuse treatment and can leave after you fill out a form." D)"You should stay. You and I both have the same goal: to keep you and your baby safe."

Accepted Answer

Violence (eg, offensive language, physical aggression) may be precipitated by substance abuse, emotional stress, mental instability, or altered mentation from medical conditions. To de-escalate a violent situation and ensure the safety of the client and others, the nurse should: Remove other clients from the area. Keep a safe distance from the client with a clear path to safety. Maintain a calm demeanor, keeping the hands visible. Use clear, nonthreatening communication focusing on mutual goals (Option D). (Option A) During periods of extreme anxiety and stress, clients are prone to irrational thinking. The nurse should avoid reasoning (eg, explaining the dangers of refusing treatment) until the situation has been de-escalated and the client is no longer in crisis. (Option B) Bargaining with the client by providing false reassurance (eg, promising not to involve authorities) is nontherapeutic and may cause the client to lose trust in the nurse. (Option C) The client with impaired thinking from substance abuse is legally incompetent to leave the hospital against medical advice. Educational objective: To de-escalate a violent situation involving a client with irrational thinking (eg, from substance use), the nurse should ensure the safety of the client and others and use calm, clear, nonthreatening communication focusing on mutual goals. The nurse should avoid attempting to reason with the client or providing false reassurance.

Question 10

A client is seen in the clinic for the third time for a nonhealing, infected diabetic foot ulcer. The client is able to verbalize the correct procedure for wound care but reports not adhering to the ordered routine at home. What intervention does the nurse prioritize to promote proper self care? A)Assess the client's feelings about placement at a skilled nursing facility for care B)Educate the client on the risks of tissue death if not properly cared for at home C)Explore the client's abilities and motivation to perform care at home D)Provide the client with the supplies needed to change dressings as recommended

Accepted Answer

Self care is a critical component of health. However, barriers to self care are multifactorial, and include: Knowledge (lack of experience, cognitive abilities) Skills/supplies (lack of dexterity, experience, financial barriers) Motivation (lack of assumed threat to health, denial, hopelessness) The nurse must assess for adequate knowledge and ability to perform self-care activities and the desire to complete such activities (Option C). Once the barriers have been identified, the nurse can work with the client to create an individualized plan to meet health care needs. (Option A) Without understanding the barriers to self care, the nurse cannot identify proper resources to assist the client in meeting needs. Placement for skilled nursing may be excessive for a client who lives independently. (Option B) Education on tissue death may be perceived as threatening and not therapeutic. (Option D) Financial resources or supplies may not be the barrier; therefore, this intervention may not effectively assist the client in performing self care successfully. Educational objective: The nurse must assess a client's knowledge, skills, and motivation to identify barriers to self care. Through this identification, the nurse can help develop an individualized plan to meet health care needs.

Question 11

While preparing to insert a peripheral IV line, the nurse notices scarring near the client's left axilla. The client confirms a history of left breast cancer and modified radical mastectomy. Which actions should the nurse take? Select all that apply. A)Advance the entire stylet into the vein upon venipuncture B)Insert the IV line into the most distal site of the right arm C)Place an appropriate precaution sign above the bed D)Review the medical record for history of mastectomy E)Teach the client to keep the left arm in a dependent position

Accepted Answer

A modified radical mastectomy includes removal of axillary lymph nodes that are involved in lymphatic drainage of the arm. Any trauma (eg, IV extravasation) to the arm on the operative side can result in lymphedema, characterized by painful and lengthy swelling, as normal lymphatic circulation is impaired by scarring. Therefore, starting an IV line in this arm is contraindicated. The nurse should insert the IV line into the most distal site of the unaffected side (Option B). For client safety, it is also important to ensure documentation of the mastectomy history, place a restricted extremity armband on the affected arm, and place a sign above the client's bed notifying hospital staff of necessary mastectomy precautions (eg, no blood pressure measurements, venipuncture, or IV lines) (Options C and D). In general, venipuncture is contraindicated in upper extremities affected by: Weakness Paralysis Infection Arteriovenous fistula or graft (used for hemodialysis) Impaired lymphatic drainage (prior mastectomy) (Option A) The stylet should be advanced until blood return is seen (approximately ¼ inch). If advanced fully, the stylet may penetrate the posterior wall of the vein and cause a hematoma. (Option E) Keeping the affected arm in a dependent position for a long time can increase lymphedema. The client should be reminded that raising the limb helps drainage. Educational objective: IV line insertion is contraindicated on the operative side of clients with a prior mastectomy. Additional contraindications for IV line insertion include weakness, paralysis, or infection of the arm; or presence of an arteriovenous fistula.

Question 12

The nurse plans to start an IV line to infuse 2 units of packed red blood cells for a stable 42-year-old client with a gastrointestinal bleed. Which IV catheter size is best? A)14-gauge B)18-gauge C)20-gauge D)22-gauge

Accepted Answer

When selecting catheter size, the need for rapid fluid administration and the type of fluid administered versus client discomfort should be assessed. A lower IV catheter gauge number corresponds to a larger bore IV catheter. A 14-gauge (large-bore) catheter may be used for administering fluids and drugs in an emergency or prehospital setting, or for hypovolemic shock (Option A).In somewhat stable adult clients who require large amounts of fluids or blood, an 18-gauge catheter is preferred. A 14-gauge (large-bore) catheter may be used for administering fluids and drugs in an emergency or prehospital setting, or for hypovolemic shock (Option A). In somewhat stable adult clients who require large amounts of fluids or blood, an 18-gauge catheter is preferred. (Options C and D) A 20-22-gauge catheter is sufficient for administering general IV fluids and medications to adult clients; a 20-gauge is acceptable for blood transfusion. However, 20-22-gauge is not preferred for blood administration. A 24-gauge catheter is recommended for children and some older adults with small, fragile veins. Educational objective: A 14-gauge (large-bore) catheter is used to administer fluids and drugs in a prehospital or emergency setting, or for hypovolemic shock. An 18-gauge catheter is typically indicated for infusing blood or large amounts of fluid in adults.

Question 13

The nurse is assigned to care for a hospitalized confused client with an indwelling urinary catheter. On entering the client's room, the nurse notes the client pulling at the catheter and grimacing in pain. Blood is trickling from the client's meatus and the urine in the drainage bag is pink. Which action should the nurse take first? A)Collect a urine specimen and send to the lab B)Deflate the balloon on the urinary catheter C)Remove the catheter by gently pulling from the urethra D)Use a sterile 4x4 pad to absorb the blood around the meatus

Accepted Answer

Because signs of traumatic injury are present, the nurse should follow steps to remove the catheter before further complications such as obstruction occur. Steps for removing an indwelling catheter include the following: Perform hand hygieneEnsure privacy and explain the procedure to the clientApply clean glovesPlace a waterproof pad underneath the clientRemove any adhesive tape or device anchoring the catheterFollow specific manufacturer instructions for balloon deflationLoosen the syringe plunger and connect the empty syringe hub into the inflation portDeflate the balloon by allowing water to flow back into the syringe naturally, removing all 10 mL, or applicable amount (note the size of the balloon labeled on the balloon port). If water does not flow back naturally, use only gentle aspiration.Remove the catheter gently and slowly; inspect to make sure it is intact and fragments were not left in the client.If any resistance is met, stop the removal procedure and consult with the urologist for removalEmpty and measure urine before discarding the catheter and drainage bag in the biohazard bin or according to hospital policyRemove gloves and perform hand hygiene Perform hand hygiene Ensure privacy and explain the procedure to the client Apply clean gloves Place a waterproof pad underneath the client Remove any adhesive tape or device anchoring the catheter Follow specific manufacturer instructions for balloon deflation Loosen the syringe plunger and connect the empty syringe hub into the inflation port Deflate the balloon by allowing water to flow back into the syringe naturally, removing all 10 mL, or applicable amount (note the size of the balloon labeled on the balloon port). If water does not flow back naturally, use only gentle aspiration. Remove the catheter gently and slowly; inspect to make sure it is intact and fragments were not left in the client. If any resistance is met, stop the removal procedure and consult with the urologist for removal Empty and measure urine before discarding the catheter and drainage bag in the biohazard bin or according to hospital policy Remove gloves and perform hand hygiene (Option A) A urine specimen can be collected after the balloon is deflated or after the catheter is removed if needed. (Option D) The meatus should be cleaned after balloon deflation. Educational objective: When the urinary catheter balloon occludes the urethra, it should be deflated immediately to prevent further injury or complication. After balloon deflation, gently and slowly remove the catheter. If there is resistance, notify the urologist.

Question 14

The nurse is assessing the abdomen of a client experiencing gastrointestinal distress. Place the answer choices in the correct order of assessment. All options must be used. A)Auscultation B)Inspection C)Palpation D)Percussion E)Placement of client in supine position

Accepted Answer

Nursing assessments are generally performed in order of least to most invasive. To perform an abdominal assessment, the nurse places the client in the supine position to promote relaxation of the abdominal muscles. Standing on the right side of the client, the nurse makes a visual inspection of the abdomen before touching the client. After inspection, the nurse auscultates the abdomen. Auscultation is performed next because percussion and palpation may increase peristalsis, potentially leading the nurse to make an erroneous interpretation of bowel sounds. The nurse should lightly place the diaphragm of the stethoscope in the right lower quadrant because high-pitched bowel sounds are normally present in this region. After auscultation, the nurse proceeds to percussion. Palpation is performed last because it may induce pain, resulting in abdominal rigidity, guarding, and a change in respirations. This rigidity may affect the tone heard on percussion. Percussion is also intended to identify borders of organs that move with respiration (eg, liver, spleen). A client in pain from abdominal tenderness will likely take quick, shallow breaths, which will change how far organs are displaced and make it more difficult for the examiner to identify true borders of organs. Educational objective: Abdominal examination is performed with the client in the supine position using the following sequence: inspection, auscultation, percussion, and palpation.

Question 15

The nurse is caring for an older adult client who is confused and has a high risk for falls. The client is incontinent of urine and frequently attempts to get out of bed unassisted to use the restroom. Which nursing interventions are appropriate when caring for this client? Select all that apply. A)Ensuring bed alarm remains activated B)Initiating an hourly rounding schedule C)Inserting an indwelling urinary catheter D)Moving client to a room close to the nurses' station E)Raising all side rails of the client's bed

Accepted Answer

11ecbb05_cb69_777f_b433_d9092c57b41f_MD0009_00 Falls can occur with any client; however, advanced age, incontinence, confusion, and presence of lines, tubes, and drains increase the risk for falls and injury. Interventions to reduce falls in high-risk clients include: Hourly rounding (eg, assessing pain, offering toileting and nutrition) (Option B) Moving the client to a room close to the nurses' station (Option D) Activating bed alarms to alert staff if the client gets out of bed unassisted (Option A) Asking family members or visitors to stay at the bedside with the client (Option C) Lines, tubes, and drains (eg, indwelling urinary catheter, IV tubing) tether (ie, tie) the client to the bed or equipment and limit mobility, increasing fall risk. In addition, indwelling urinary catheters increase risk for infection and should be used only when clinically indicated (eg, strict hourly output, critical illness), not for the nurse's convenience (eg, clients requiring frequent toileting or incontinence care). The nurse can reduce urinary urgency and incontinence episodes by offering clients toileting with hourly rounding. (Option E) Raising all side rails is considered a physical restraint and is associated with more severe fall injuries from clients attempting to climb over the side rails. Educational objective: Interventions to reduce falls in high-risk clients include hourly rounding, moving the client to a room close to the nurses' station, and using bed alarms. Lines, tubes, drains (eg, indwelling urinary catheters), and restraints (eg, all side rails raised) increase fall risk and should be used only when clinically indicated.

Question 16

A client is receiving a blood transfusion. Fifteen minutes after the transfusion starts, the nurse notes a drop in blood pressure from 110/70 to 84/50 mm Hg. The client reports "feeling a little cold." Based on this assessment, in what order should the nurse complete the following actions? All options must be used. A)Administer prescribed vasopressor B)Collect urine specimen C)Document the occurrence D)Stop the blood transfusion E)Using new tubing, infuse normal saline into the vein

Accepted Answer

It is important for the nurse to remain with the client for 15 minutes after starting a blood transfusion to monitor for signs of a reaction. These signs include fever, chills, nausea, vomiting, pruritus, hypotension, decreased urine output, back pain, and dyspnea. The client may report a variety of symptoms ranging from none to a feeling of impending doom. If signs of a transfusion reaction occur, the nurse should: Stop the transfusion immediately (Option D). Using new tubing, infuse normal saline to keep the vein open (Option E). Continue to monitor hemodynamic status and notify the health care provider and blood bank. Administer any emergency or prescribed medications to treat the reaction; these may include vasopressors, antihistamines, steroids, or IV fluids (Option A). Collect a urine specimen to be assessed for a hemolytic reaction (Option B). Document the occurrence and send the remaining blood and tubing set back to the blood bank for analysis (Option C). Educational objective: If signs or symptoms of a blood transfusion reaction occur, the nurse should stop the infusion immediately and use new tubing to keep the vein open with normal saline. The nurse should continue to monitor the client's hemodynamic status, and administer prescribed drugs. The nurse should also collect a urine specimen to be assessed for a hemolytic reaction.

Question 17

The primary health care provider prescribes a 24-hour urine collection for a client with suspected Cushing syndrome. Which instructions should the nurse give the client regarding this test? Select all that apply. A)"A continuous urinary catheter must be inserted for this test and the urine will collect in an attached bag." B)"Keep the urine collection container in the refrigerator or a cooled ice chest when it is not in use." C)"Only daytime urine should be collected in the container as cortisol levels are higher in the morning." D)"Record the time the urine collection is started and then empty the bladder into the toilet so that the start time coincides with an empty bladder." E)"You will be given a dark plastic jug containing a powder that absorbs into the urine that you will collect in the jug."

Accepted Answer

A 24-hour urine is collected to evaluate Cushing syndrome (a condition that results from chronic increased corticosteroids). The urine is tested for free cortisol, and results >80-120 mcg/24 hr (220-330 nmol/day) indicate that Cushing syndrome is present. Instructions for collecting a 24-hour urine are as follows: Use a dark jug containing a special powder (obtained from the lab) to protect the urine from light during collection. The powder helps preserve the urine and adjusts its acidity (Options A and E). Collection of the 24-hour urine should span over exactly 24 hours. It is important to first record the time and empty the bladder into the toilet so that the start time coincides with an empty bladder. At that exact time the next day, the bladder should be emptied for a final time and collected into the jug. All urine between the start time and end time should be collected into the container. The time for each urination between start and end does not need to be recorded (Options C and D). Keep the urine in a refrigerator or a cooled ice chest with the lid tightly screwed on for preservation (Option B). Educational objective: A 24-hour urine is collected to test for increased cortisol levels when evaluating for Cushing syndrome. The client should be taught to collect the urine in a dark jug issued by the lab, start time and then empty the bladder and discard the 1st urine, and collect all the urine for 24 hours; it is kept in the refrigerator or ice chest with a secure lid. Exactly 24 hours after start time, empty bladder once more into the collection container.

Question 18

The nurse prepares to exit the room of a client on airborne and contact isolation precautions. Place the following nursing actions in the correct order. All options must be used. A)Discard the gown and gloves and perform hand hygiene B)Exit the negative-pressure room and close the door C)Place the call light within the client's reach D)Remove the gown and gloves without contaminating hands E)Remove the N95 respirator mask and perform hand hygiene

Accepted Answer

11ecbb05_cb6a_b001_b433_a77d5f8af90f_MD0009_00 The order of removal for personal protective equipment (PPE) should be from most to least contaminated, because this reduces the risk of contaminating the nurse's skin and clothes. When exiting the room of a client on both contact and airborne precautions, the nurse should perform the following actions in order: Place the call light within the client's reach and ensure that the client's bed is locked and in the lowest position. Place the call light within the client's reach and ensure that the client's bed is locked and in the lowest position. Remove the gown and gloves (ie, contact isolation PPE) in order of most to least contaminated. The nurse can remove gloves and then gown, or alternately, can remove gown and gloves together. Remove the gown and gloves (ie, contact isolation PPE) in order of most to least contaminated. The nurse can remove gloves and then gown, or alternately, can remove gown and gloves together. Discard the gown and gloves and then perform hand hygiene. Discard the gown and gloves and then perform hand hygiene. Exit the negative pressure room and immediately close the door to prevent infectious airborne microorganisms from escaping into the hallway or isolation anteroom. Exit the negative pressure room and immediately close the door to prevent infectious airborne microorganisms from escaping into the hallway or isolation anteroom. Remove and discard the N95 respirator mask and then perform final hand hygiene. Remove and discard the N95 respirator mask and then perform final hand hygiene. Negative pressure rooms continuously filter air out of the room, creating a lower pressure gradient that prevents airborne microorganisms from escaping through the doorway. To prevent exposure to infectious airborne microorganisms, nurses should remove N95 respirator masks only after exiting the room. Educational objective: Personal protective equipment should be removed in order from most to least contaminated. The gown and gloves may be removed together. For clients on airborne precautions, the nurse should exit the negative pressure room and close the door before removing the N95 respirator mask. Removing the mask in the room risks exposure to infectious airborne microorganisms.

Question 19

The nurse is performing a central line tubing change when the client suddenly begins gasping for air and writhing. Order the interventions by priority. All options must be used. A)Administer oxygen as needed B)Clamp the catheter tubing C)Notify the health care provider (HCP) D)Place the client in Trendelenburg position on the left side E)Stay with the client and provide reassurance

Accepted Answer

Leakage of more than 500 mL of air into a central venous catheter is potentially fatal. An air embolism in the small pulmonary capillaries obstructs blood circulation. A central venous catheter leaks air rapidly at 100 mL/sec. This client requires immediate intervention to prevent further complications (eg, cardiac arrest, death). The nurse should not delay emergency treatment, not even to stop and contact the HCP or the rapid response team (RRT). Priority interventions for active or suspected air embolism are as follows: Clamp the catheter to prevent more air from embolizing into the venous circulation.Place the client in Trendelenburg position on the left side, causing any existing air to rise and become trapped in the right atrium.Administer oxygen if necessary to relieve dyspnea.Notify the HCP or call an RRT to provide further resuscitation measures.Stay with the client to provide reassurance and monitoring as the air trapped in the right atrium is slowly absorbed into the bloodstream over the course of a few hours. Clamp the catheter to prevent more air from embolizing into the venous circulation. Place the client in Trendelenburg position on the left side, causing any existing air to rise and become trapped in the right atrium. Administer oxygen if necessary to relieve dyspnea. Notify the HCP or call an RRT to provide further resuscitation measures. Stay with the client to provide reassurance and monitoring as the air trapped in the right atrium is slowly absorbed into the bloodstream over the course of a few hours. Educational objective: Any delay in treatment of an air embolism could prove fatal. There is no time to call the HCP. Seal off the source of the leak, and ensure stabilization of the air bubble via left lateral positioning.

Question 20

The nurse plans to start an IV line on a female client hospitalized with pneumonia. The nurse reviews the electronic medical record for relevant information and learns that the client is right-handed and has a history of a left-sided mastectomy with lymph node removal. Which site is best for the nurse to select for the client's IV line? A)Basilic vein of the left forearm B)Cephalic vein in the right antecubital space C)Median vein of the right forearm D)Radial vein of the left wrist

Accepted Answer

11ecbb05_cb6d_6f22_b433_49ea7b466360_MD0009_00 The client's medical history should be reviewed prior to starting an IV line so that the nurse can identify any contraindications to specific anatomical sites. Lymph node removal during a mastectomy may affect lymphatic fluid drainage on the affected side and cause lymphedema or other complications such as infection, venous thromboembolism, or trauma to the affected arm. The nurse must avoid any needlesticks, IV insertions, or blood pressure measurements in the affected arm (Options A and D). The nondominant side is preferred when no medical contraindications exist. However, in this case, the right forearm is best because the client had a left-sided mastectomy (Option C). Other considerations when selecting IV sites include avoidance of areas that have obstructed blood flow, dialysis sites, areas distal to old puncture sites, bruised areas, painful areas, or areas with skin conditions or signs of infection. (Option B) The antecubital space should be avoided when possible (except for emergency insertion) as it inhibits mobility and may be positional. Educational objective: The nurse should review the client's medical record and assess for contraindications to IV sites, including impaired lymphatic drainage (prior mastectomy), arteriovenous fistula or graft (used for hemodialysis), and areas distal to old puncture sites.

Exam 4: Fundamentals

An experienced nurse precepts a graduate nurse in the intensive care unit while caring for a client with a right subclavian triple-lumen central venous catheter (CVC) . Which statement by the graduate nurse indicates understanding of the CVC?

The nurse performs nasogastric (NG) tube insertion using a large-bore NG tube on a hospitalized client with a gastrointestinal bleed. During insertion, after the tube passes the nasopharynx, the client begins to cough and gag. Which action should the nurse take first?

The nurse performs tracheostomy care for a client with a disposable inner cannula and tracheostomy dressing. Place the steps in the correct order. All options must be used.

The caregiver of a toddler calls the clinic because the child has accidentally ingested one capsule of amitriptyline found in the medicine cabinet. The caregiver states that the child appears to be acting normally. Which response by the nurse is appropriate?

The nurse helps the health care provider perform a thoracentesis at the bedside. In which position does the nurse place the client to facilitate needle insertion and promote comfort?

The nurse prepares to insert an indwelling urinary catheter in a client who is disoriented to time, place, and person and cannot follow directions or commands. Which intervention is most important when inserting the urinary catheter?

A female client is admitted to the emergency department after a motor vehicle collision. The client is unresponsive and on a mechanical ventilator. Which actions should the nurse perform? Select all that apply.

The nurse is caring for a pregnant client with a positive urine drug screen. When questioned about substance abuse, the client begins to throw objects at the nurse and yells, "I'm leaving this hospital right now before you call the police on me!" What is the best response by the nurse?

A client is seen in the clinic for the third time for a nonhealing, infected diabetic foot ulcer. The client is able to verbalize the correct procedure for wound care but reports not adhering to the ordered routine at home. What intervention does the nurse prioritize to promote proper self care?

While preparing to insert a peripheral IV line, the nurse notices scarring near the client's left axilla. The client confirms a history of left breast cancer and modified radical mastectomy. Which actions should the nurse take? Select all that apply.

The nurse plans to start an IV line to infuse 2 units of packed red blood cells for a stable 42-year-old client with a gastrointestinal bleed. Which IV catheter size is best?

The nurse is assessing the abdomen of a client experiencing gastrointestinal distress. Place the answer choices in the correct order of assessment. All options must be used.

The nurse is caring for an older adult client who is confused and has a high risk for falls. The client is incontinent of urine and frequently attempts to get out of bed unassisted to use the restroom. Which nursing interventions are appropriate when caring for this client? Select all that apply.

The primary health care provider prescribes a 24-hour urine collection for a client with suspected Cushing syndrome. Which instructions should the nurse give the client regarding this test? Select all that apply.

The nurse prepares to exit the room of a client on airborne and contact isolation precautions. Place the following nursing actions in the correct order. All options must be used.

The nurse is performing a central line tubing change when the client suddenly begins gasping for air and writhing. Order the interventions by priority. All options must be used.