Question 1

The unit educator is performing skill validations with unit staff. Which of the following actions by the staff nurses demonstrate a correct understanding of parenteral medication administration? Select all that apply.

Accepted Answer

11ecbb05_cb46_10e4_b433_83e5d13de3c2_MD0009_00 Parenteral medications are administered via injection into body tissues using aseptic technique (eg, intradermal, intramuscular, subcutaneous, IV). Intradermal Administer injections at a 5- to 15-degree angle to reduce risk of injection into subcutaneous tissue (Option B). Apply firm pressure to the injection site to reduce bleeding. Massaging the site introduces medication into deeper tissues and should be avoided (Option C). Subcutaneous Administer injections at 90 degrees if 2 in (5 cm) of subcutaneous tissue can be grasped or at 45 degrees if only 1 in (2.5 cm) can be grasped (Option A). Intramuscular Acceptable sites include the deltoid, vastus lateralis, and ventrogluteal. The ventrogluteal is preferred as fewer large blood vessels and nerves are present. Position the client supine, prone, or side-lying with the knee and hip flexed when administering ventrogluteal injections. Flexing the knee and hip reduces muscle tension, improves access, and promotes client comfort (Option D) (Option E) A filter needle must be used when withdrawing medication from a glass ampule to prevent aspiration and injection of glass shards. After the medication is withdrawn, the filter needle is discarded and an injection needle (eg, 20-gauge, 1-in [2.5-cm] needle) is attached to the syringe. Educational objective: Use filter needles to withdraw medications from ampules to prevent aspiration and injection of glass shards. Perform intradermal injections at 5- to 15-degree angles and avoid massaging injection sites to prevent accidental subcutaneous administration. Administer subcutaneous injections at 45 or 90 degrees, depending on the volume of subcutaneous tissue.

Question 2

A nurse is reviewing the most recent laboratory results of a client on the telemetry floor. The client is currently asymptomatic, and the telemetry monitor indicates sinus rhythm. Which of the following critical values is mostlikely due to laboratory error?

Accepted Answer

With the exception of clients in end-stage renal disease, a serum potassium value >6.5 mEq/L (6.5 mmol/L) in any client who is walking and talking should raise the suspicion of an erroneously elevated serum potassium (pseudohyperkalemia) from poor hematology technique, hemolysis, or clotting. A serum potassium level of 7.0 mEq/L (7.0 mmol/L) would normally constitute a life-threatening electrolyte imbalance that would cause severe weakness or paralysis, unstable arrhythmias, and eventual cardiac arrest. An assessment would focus on evaluating cardiac symptoms and muscle strength and be reported to the health care provider (HCP). In this case, it is likely that a repeat blood draw would be prescribed. Pseudohyperkalemia can be avoided on the repeat blood draw by using heparin-impregnated hematology vials to prevent clotting, minimal use of a tourniquet and fist clenching, and use of a larger gauge needle for the sample. (Option A) This blood urea nitrogen (BUN) value is elevated (normal 6-20 mg/dL [2.1-7.1 mmol/L]) and could be related to kidney damage or dehydration. Therefore, it is not the most likely erroneous result. (Option B) Similar to the BUN level, this creatinine value is significantly elevated (normal 0.6-1.3 mg/dL [53-115 µmol/L]). Further nursing assessment is indicated, with documentation and involvement of the HCP in evaluating the impact of this kidney damage on the client's health. (Option D) This sodium value is high (normal 135-145 mEq/L [135-145 mmol/L]) and requires further exploration. The nursing assessment should be documented and reported to the HCP. Educational objective: High serum potassium levels could be due to hemolysis or clotting during the blood draw. If a clinical assessment does not correlate with the laboratory values, repeat testing is needed.

Question 3

The nurse is educating a client recently diagnosed with anaphylactic allergy to latex.  Which statement made by the client indicates that the client understood the condition correctly?

Accepted Answer

Anaphylactic shock is a medical emergency and the most severe form of an allergic reaction. Hives, itching, or a skin rash may or may not appear before rapid swelling of the mouth and throat (angioedema) makes breathing difficult or impossible within a span of minutes. Quick application of an epinephrine auto-injector (Epi-pen) into the thighis the only acceptable option for treating anaphylactic shock. The intramuscular adrenaline injection immediately counteracts the life-threatening swelling, hypotension, and vasodilation that characterize anaphylaxis. Diphenhydramine (Benadryl) is also given to treat any associated rash or itching (hives, wheals, urticaria) but is not sufficient as a monotherapy. (Option A) Latex products are everywhere. Clients and staff members should be educated and reminded about exposure to plastic products, condoms, and all other medical products containing latex. (Option B) Numerous products may contain trace amounts of latex; this crucial information may be omitted on the labels. (Option D) Bananas, avocados, chestnuts, and kiwifruit have been classified as having high-risk potential for cross-reaction allergy development. Clients should be advised to watch for potential allergic reactions due to a cross-allergen. Educational objective: Anaphylaxis is a medical emergency, and any client with a history of severe allergic reaction (sudden blotchy skin rash or swelling of the lips and mouth) should always carry an EpiPen. Epinephrine injection is the only option for treating anaphylaxis.

Question 4

A nurse is preparing to administer 2 continuous IV medications concurrently via a 20-gauge IV. What is the nurse's priority action?

Accepted Answer

The priority when administering 2 IV medications concurrently is to determine drug compatibility. Incompatible drugs given through the same IV line will deteriorate or form a precipitate. This change is visualized through either a color change, a clouding of the solution, or the presence of particles. If 2 or more drugs are not compatible, the nurse may consider inserting a second IV or consulting the pharmacist and the health care provider to determine the safest and most beneficial plan for the client. (Option A) Assessing the IV site for complications (eg, infiltration, phlebitis) should always be performed before giving any IV medication. This will be completed after determining drug compatibility. (Option B) Verification using 2 client identifiers pertains to the "right client" in the "6 rights" of medication administration. Drug compatibility should be determined prior to entering the client's room and verifying identity. (Option D) Hand hygiene is a standard precaution taken before any type of client interaction to prevent contamination and infection; hand washing will be completed after checking for drug compatibility. Educational objective: Checking for drug compatibility is a priority before administering 2 IV medications concurrently in the same IV site. Incompatible drugs will deteriorate or form a precipitate that is visible as a color change, cloudiness, or particulates.

Question 5

A nurse is caring for 4 clients.  Which prescription by the health care provider would the nurse question and seek further clarification before administering?

Accepted Answer

The nurse should question the administration of a hypotonic IV solution (ie, 0.45% sodium chloride) to replace gastrointestinal tract fluid losses as this would create a concentration gradient and shift fluid out of the intravascular compartment into the interstitial tissue and cells, worsening the client's fluid volume deficit. Isotonic IV solutions (eg, 0.9% sodium chloride, lactated Ringer's) have the same osmolality as plasma and are administered to expand intravascular fluid volume. These solutions replace fluid losses commonly associated with vomiting and diarrhea, burns, and traumatic injury. (Option B) Anaphylaxis causes increased capillary permeability, leaking intravascular fluid into free spaces; this places the client at risk for hypotension. Therefore, isotonic solutions should be given to such clients. (Option C) Extreme hyperglycemia in a client with diabetic ketoacidosis results in osmotic diuresis and dehydration. The immediate initial treatment is IV fluid resuscitation with isotonic 0.9% sodium chloride to replace fluid losses, stabilize vital signs, reestablish urine output, and dilute the serum glucose concentration before initiating insulin therapy. (Option D) A client with head trauma is at risk for increased intracranial pressure due to inflammation and cerebral edema. IV mannitol is an osmotic diuretic that reduces cerebral edema by pulling water from the cerebral cells into the vasculature. Educational objective: Isotonic IV solutions, which have the same osmolality as plasma, are administered to expand intravascular fluid volume and replace the fluid losses commonly associated with vomiting and diarrhea, burns, and traumatic injury.

Question 6

It is 0700 and the nurse is caring for an 84-year-old client with dementia and a fractured hip. The client has been disoriented to time, place, and person since admission. The client moans frequently and grimaces when moving. He is prescribed morphine IV every 2 hours as needed for pain and was last medicated at 0530. He is scheduled for surgery at 1000 to repair the hip fracture, but the consent has not yet been signed. The client's spouse and child are to arrive at 0900. Which intervention should the nurse carry out first?

Accepted Answer

The morning shift assessment should be completed first to collect baseline assessment data (eg, vital signs, lung sounds, level of consciousness), assess pain, and collect necessary information for the preoperative checklist. (Option A) Pain medicine is not due until 0730 and can be administered after the initial assessment if necessary. (Option B) The nurse should call the health care provider after the initial assessment (by 0730) and arrange for a meeting with family members at 0900 to obtain informed consent as the client is not capable of giving it. (Option C) The preoperative checklist can be completed after consent is obtained. Educational objective: Before surgery, the nurse makes sure informed consent is obtained, performs a complete physical assessment to collect baseline data and determine the client's physiologic and psychologic status, and completes the preoperative checklist.

Question 7

The nurse working in an intensive care unit cares for a client with a left triple lumen subclavian central venous catheter (CVC).  The nurse should call the primary health care provider (HCP) for clarification prior to implementation when recognizing that which prescription is an error?

Accepted Answer

11ecbb05_cb4a_2f9a_b433_ebcd7c16ea17_MD0009_00 Most CVC lumens require anticoagulation in the form of a heparin flush to maintain patency and prevent clotting when not in use. The nurse should check the institution's protocol and the HCP prescription to determine the correct dose. Doses of 2-3 mL containing 10 units/mL-100 units/mL are the standard of care for flushing a CVC. Doses of 1000-10,000 units are given for cases of venous thromboembolism; therefore, this prescription is an error and should be clarified by the nurse. The Centers for Disease Control and Prevention (CDC) recommend that a single-dose vial or prefilled syringe be used to reduce infection risk. Heparin is a high-alert medication (at high risk for causing significant harm to the client if given in error). (Option A) TPN should be administered through a CVC. Because of its viscosity and high glucose, lipids, electrolytes, vitamins and minerals, it is safest when administered through a CVC or peripherally inserted central catheter. (Option B) According to the CDC, an occlusive dressing should be changed every 7 days. The nurse should check the institution's protocol for frequency of dressing changes. (Option D) The distal port of a triple lumen CVC is the largest lumen (tube) and should be used for CVP (right atrium pressure) monitoring. The distal end of the CVC is in reverse as regards the client; therefore, the distal end is at the tip of the catheter in the superior vena cava vein, closest to the right atrium of the heart. Educational objective: Most CVCs require intravenous heparin flushes to maintain patency and prevent clotting. Single-dose vials of 2-3 mL of 10 units/mL or 100 units/mL are the standard of care. A dose of 1000-10,000 units is given for cases of thromboembolism.

Question 8

The nurse is caring for a client with active pulmonary tuberculosis. Which elements of infectious disease precautions are mandatory for the nurse when providing routine care? Select all that apply.

Accepted Answer

11ecbb05_cb48_81e7_b433_07bf95eb9f80_MD0009_00 Isolation is mandatory for clients with conditions that involve airborne transmission, and rooms must use both negative air pressurization and high-efficiency particulate air (HEPA) filters to avoid contamination. A class N95 or higher particulate respirator must be worn during client care. All clients with symptoms consistent with a suspected airborne illness should be given a surgical mask to wear as soon as they are assessed during triage. Good hand hygiene is always the first and last element of infection control in any client care setting. (Options A and B) Wearing a gown and face shield would be necessary only if the nurse suspected splash of body fluids from procedural client care, not from routine care such as assessment or medication administration. Contact precautions may also be necessary if the tuberculosis is extrapulmonary with draining lesions (eg, cutaneous tuberculosis). (Option E) For client care involving airborne precautions, a class N95 or higher respirator must be used in lieu of a surgical mask to avoid potential exposure to aerosolized particles. Surgical masks are rated for barrier protection for droplet splashing and filtration of large respiratory particles only. Clients should be given surgical masks during their transportation. Educational objective: Tuberculosis requires airborne precautions. Clients suspected of having tuberculosis should be given a surgical mask to wear on entering any health care setting. Clients are placed in negative-pressure isolation rooms. Nurses must use a class N95 or higher particulate respirator.

Question 9

The nurse is caring for a client with Clostridium difficile colitis. Which of the following infection control measures by the nurse are appropriate? Select all that apply.

Accepted Answer

11ecbb05_cb48_f718_b433_9be19dd11216_MD0009_00 Clostridium difficile is a highly infectious bacteria causing severe colitis in infected clients. When caring for a client with C difficile, it is critical that the nurse implement contact isolation precautions to prevent transmission of microorganisms between clients, including: Placing the client in a single-client room, if possible, or in a cohort with other clients infected with C difficile (Option C) Wearing a single-use, disposable gown and clean gloves during all client care and discarding the equipment before leaving the room (Option E) Performing hand hygiene before and immediately after client care with soap and water Using dedicated medical equipment (eg, stethoscope, blood pressure cuff) that is not shared between clients and always remains in the client's room (Option A) Clean, rather than sterile, gloves are required during care of a client with C difficile to prevent transmission of infection to other individuals. (Option B) Surgical masks are required when caring for a client prescribed droplet isolation precautions but are needed only in clients with contact isolation precautions if performing activities with the possibility of body fluid splashing (eg, suctioning, wound care). (Option D) When caring for clients with C difficile, it is critical to perform hand hygiene with soap and water, rather than alcohol-based sanitizers. Alcohol-based sanitizers are unable to effectively kill spore-forming bacteria (eg, C difficile, anthrax). Educational objective: Clostridium difficile is a highly infectious bacteria requiring contact isolation precautions, including a single-client room assignment if available, disposable gowns and clean gloves, and hand hygiene with soap and water. Surgical masks are not necessary unless performing client care with the possibility of body fluid splashing.

Question 10

The nurse is caring for a client with bacterial meningitis, identified as Neisseria meningitidis who has a stage 4 pressure injury. What personal protective equipment is most appropriate for the nurse to wear when performing a dressing change? Select all that apply.

Accepted Answer

11ecbb05_cb49_6c49_b433_55dd3268c740_MD0009_00 Bacterial meningitis (eg, Neisseria meningitidis) and many respiratory illnesses (eg, influenza) are transmitted through large droplets of secretions spread into the air by coughing, sneezing, or talking. These droplets can land on surfaces up to 6 feet (1.8 meters) away from the client. Droplet precautions for routine care (eg, medication administration) require the use of a surgical mask, as the highest risk of transmission is through inhalation of droplets (Option E). Wearing a face shield, gown, and gloves is required if there is a risk of splash or contact with body fluids from procedural client care (eg, suctioning, wound care) (Options A, B, and C). Dedicated medical equipment (eg, stethoscope, blood pressure cuff) should remain in the room to limit spread of infection. (Option D) For client care involving airborne precautions, a class N95 or higher respirator must be used instead of a surgical mask to avoid potential exposure to aerosolized particles. Surgical masks are rated only for barrier protection from droplet splashing and for filtration of large respiratory particles. Educational objective: When caring for clients on droplet precautions, a surgical mask is needed for routine care, such as assessment or medication administration. If there is risk of contact with body fluids during procedures (eg, wound care, suctioning), gloves, gown, and face shield are used.

Question 11

The nurse observes an ambulating client begin to experience a tonic-clonic seizure. Which nursing actions should be implemented immediately? Select all that apply.

Accepted Answer

11ecbb05_cb48_5ad6_b433_3786b07eb83e_MD0009_00 Protecting the ambulating client from injury is the immediate priority. The nurse assists the client to the floor, cradles the head, and places the client in the left lateral position. Left lateral position is preferred to avoid the risk of aspiration. Hard or sharp objects should be removed from the client's environment to prevent injury. The nurse remains with the client until the seizure is over to assess seizure activity and postictal symptoms and to minimize injury. (Option B) No objects should be placed in a client's mouth during a seizure. Following the seizure, the client may require assessment and maintenance of the airway, suctioning, and oxygen administration. (Option D) Attempting to restrain a client during a seizure may cause injury to the client. Educational objective: Safety measures implemented during a seizure include positioning the client to protect from injury, maintaining a patent airway, and observing the seizure activity. During the seizure, the nurse does not restrain the client or place objects in the client's mouth.

Question 12

A client who was placed in restraints appears in the hallway an hour later and states, "I'm Houdini.… I can get out of anything. There could be trouble now." Which of the following is the best response to this client?

Accepted Answer

In this situation, the priority nursing action is to quickly and calmly assess this client's present risk for violence before implementing an intervention. This client's statement, "There could be trouble now," has multiple possible meanings (eg, Is the nurse "in trouble" as the restraints may not have been applied properly? Are the other clients in the unit "in trouble" as this client is out of restraints? Is this client "in trouble" due to thoughts of self-harm?). Seeking clarification of this client's statement is a therapeutic communication technique that will help the nurse determine the next steps in providing care. Mechanical restraints may be necessary only as a last resort for a client at high risk for violence, self-directed or other-directed. Clients placed in restraints must be observed and monitored frequently for: Assisting with hydration, elimination, and positioning Ensuring that circulation is not compromised Determining readiness for removal of restraints (Option A) It is important to ask this client about current feelings. However, in this situation, the priority is to clarify this client's statement. (Option B) This statement is immaterial; it is important to assess this client's current status. (Option C) Assistance from another staff member may be necessary if this client is still at high risk for violence; this client needs to be assessed first. Educational objective: A client at high risk for violence, self-directed or other-directed, may need to be placed in restraints as a last resort. Frequent monitoring and assessment through observation and use of therapeutic communication techniques will help determine if a client is ready to have restraints removed.

Question 13

A client is receiving normal saline 75 mL/hr and morphine sulfate via patient-controlled analgesia (PCA) bolus doses. The PCA and normal saline tubing are connected at the "Y" site. The nurse reviews a prescription from the health care provider to discontinue the normal saline. What is the most appropriate nursing action?

Accepted Answer

11ecbb05_cb43_03a2_b433_cf56e0a8aff8_MD0009_00 Patient-controlled analgesia (PCA) delivers a set amount of IV analgesic each time the client presses the administration button. With many PCA pumps, a continuous IV solution (eg, normal saline) is required to keep the vein open and flush the PCA medication through the line so that the boluses reach the client. Many facilities have a policy regarding IV fluid for use with PCA; however, a prescription may be required. To ensure uninterrupted delivery of this client's PCA, the nurse should contact the health care provider to clarify the prescription to discontinue the normal saline. (Option A) A "keep-vein-open" rate (eg, 5-20 mL/hr) may be appropriate; however, a prescription is necessary before the nurse can implement this. (Option C) This client is still receiving PCA, so it is inappropriate to convert the IV to a saline lock. In addition, this does not address the need to flush the PCA medication through the line. (Option D) Continuous IV fluids may be required to deliver the PCA boluses; before discontinuing the normal saline, the nurse should receive clarification from the health care provider. Educational objective: Continuous IV fluids are often necessary with use of a patient-controlled analgesia (PCA) pump; the fluids maintain an open vein and provide a vehicle for PCA delivery.

Question 14

The nurse caring for a client diagnosed with HIV uses which infection prevention and control measures? Select all that apply.

Accepted Answer

Hand hygiene is performed before and after providing client care. HIV is a blood-borne virus, and standard precautions are sufficient protection against viral transmission. The nurse wears gloves when anticipating exposure to blood or body fluids. Isolation gowns are applied if the nurse anticipates splashing of body fluids on clothing. A face shield and goggles are applied if splashing in the eyes is a possibility. The nurse should always don gloves when starting an intravenous line. (Option C) This would be an acceptable level of protective equipment if the client undergoes a non-sterile procedure with significant splash risk, such as vaginal delivery. (Option E) Face shields are used when splashing on the face or in the eyes is anticipated. A N95 respirator mask is used when caring for a client with airborne isolation precautions. Educational objective: The Centers for Disease Control and Prevention recommend the use of standard precautions for preventing transmission of HIV.

Question 15

Which of the following drug administrations should be reported as a practice error? Select all that apply.

Accepted Answer

Warfarin (Coumadin) is generally contraindicated in pregnancy. Warfarin is a teratogen and exposure during early pregnancy can result in fetal malformations (warfarin embryopathy). It crosses the placenta, resulting in fetal anticoagulation; dangerous fetal bleeding, including intracranial hemorrhage, can occur. As a result, a client on warfarin is taught to use effective contraception (Option E). For children age <7 months, the site for immunizations is the anterolateral thigh (vastus lateralis). The gluteus medius muscle (muscle injected with a ventrogluteal injection) is developed through crawling and walking. The muscles are not developed enough at this age to be used as an acceptable site (Option C). History of penicillin hypersensitivity should be determined prior to administration. Clients who are truly allergic to penicillins (eg, anaphylaxis) have an increased risk of allergy to other beta-lactam antibiotics. The incidence of cross-reactivity is 1%-4% (Option A). (Option B) Pruritus (itching) is a known side effect of narcotic administration, particularly if the client is opioid naïve. It does not represent true allergy and is often treated with an antihistamine. Nausea is also quite common when opioid therapy is initiated, but clients quickly develop tolerance. (Option D) Niacin (nicotinic acid or B₃) is used in large doses for lipid-lowering properties. In large doses, it may produce cutaneous vessel vasodilation. The resulting warm sensation within the first 2 hours after oral ingestion is uncomfortable but harmless. It may last for several hours. Effects usually subside as therapy continues. Educational objective: Do not administer warfarin if the client is pregnant. Intramuscular injections are given in the vastus lateralis to children age <7 months. Penicillins and cephalosporins can have a cross-sensitivity response. Narcotic-induced pruritus is not a true allergy.

Question 16

The nurse is reconstituting methylprednisolone sodium succinate for IM injection. Place in order the steps that the nurse should perform to appropriately prepare the medication. All options must be used.

Accepted Answer

When reconstituting a powdered medication for parenteral administration, the nurse should: Perform hand hygiene and don clean gloves prior to handling medication (Option C). This is a universal practice for aseptic handling of any medication. Cleanse the vial top with alcohol and let it dry to prevent possible microbial contamination. Withdraw an amount of air from the vial equal to the prescribed amount of diluent to create negative pressure that will be equalized when the diluent is injected into the vial. The medication manufacturer will specify the needed amount and type of diluent (Option E). Inject the appropriate diluent (eg, sterile saline, sterile water) into the vial. The diluent reconstitutes the medication by dissolving the powder (Option A). Roll the vial between the palms of the hands to gently mix the solution. Avoid shaking the vial as bubbles may develop, making withdrawal of the reconstituted medication difficult (Option D). Withdraw the reconstituted medication from the vial into a sterile syringe for administration (Option F). Verify the dosage by checking the prepared medication against the medication administration record and medication label. Label the syringe with the medication name and dosage to prevent medication errors at the bedside (Option B). Educational objective: To reconstitute powdered medication from a vial, the nurse should perform hand hygiene and don gloves; withdraw air; inject the prescribed amount/type of diluent; mix by rolling the vial between the palms of the hands; withdraw the reconstituted medication into a syringe; and label the syringe with the medication name and dosage.

Question 17

The nurse is preparing an injection of IM haloperidol from a glass ampule. Which of the following actions by the nurse are appropriate? Select all that apply.

Accepted Answer

11ecbb05_cb46_fb45_b433_75957ca24494_MD0009_00 A glass ampule is a single-dose medication container with a scored area on the neck that must be broken to withdraw the medication. When preparing medication from a glass ampule, the nurse ensures safety and prevents contamination during medication administration by: Flicking the upper stem of the ampule with a fingernail several times to ensure removal of medication from the ampule neck Using sterile gauze to break the ampule neck away from the nurse's body to prevent injury from glass shards (Option B) Setting the ampule on a flat surface or inverting it to withdraw the medication Disposing of the ampule in a sharps container (Option C) (Option A) Glass shards may be present in the medication after an ampule is opened. To prevent the accidental administration of glass shards, the nurse must use a filter needle, rather than an injection needle, when withdrawing medication. filter needle (Option D) Unlike when withdrawing medication from a vial, air should not be injected into a glass ampule; this causes the contents to spill from the container. (Option E) Ensure that the filter needle does not touch the glass edges, which are not sterile, as this can introduce bacteria. Educational objective: When preparing medication from a glass ampule, the nurse breaks the ampule away from the body and discards it in the sharps container. The nurse withdraws medication using a filter needle to prevent the injection of glass shards, avoids touching the needle to contaminated ampule edges, and avoids injecting air to prevent spillage.

Question 18

The nurse is preparing to administer an IM immunization to a 6-month-old infant. Which needle length and injection site would be the most appropriate to minimize a local reaction to the vaccine components?

Accepted Answer

11ecbb05_cb43_51c3_b433_1795ce1c13b9_MD0009_00 The needle length and injection site for IM injections are dependent on a client's age and muscle mass. The vastus lateralis muscle in the anterolateral middle portion of the thigh is the preferred IM injection site for newborns (age <1 month) and infants (age 1-12 months). Selection of the most appropriate needle length is an important factor in ensuring immunization success and minimizing local reactions to vaccine components. If the needle is too short, the IM vaccine is injected into subcutaneous fat, resulting in vaccine failure due to poor mobilization of the antigen within adipose tissue. Infants typically require a 1-in (25-mm) needle for IM injections (Option C). (Option A) A 3⁄8-in (9-mm) needle is too short to penetrate the deep vastus lateralis muscle of the thigh. (Options B and D) The ventrogluteal area in an infant does not have enough muscle mass for use and is not recommended until at least age 3. A 5⁄8-in (16-mm) needle is too short and does not penetrate the deep muscle. A 1½-in (38 mm) length is too long and is normally used on older children and adults with sufficient muscle mass. Educational objective: Appropriate needle length and injection site are essential for proper administration of IM immunizations. For infants, use of a 1-in (25-mm) needle to administer medication in the vastus lateralis muscle is recommended to reach the IM tissue and minimize local reactions.

Question 19

The nurse caring for a client with tuberculosis (TB) transports the client to the radiology department for a chest x-ray.  The nurse ensures that the client uses which personal protective equipment when out of the negative-pressure room?

Accepted Answer

Clients with airborne infections such as TB, measles, or chickenpox (varicella) are confined to a negative-pressure room except when traveling to various departments for essential diagnostic procedures or surgery. While being transported through the health care facility, the client on airborne transmission-based precautions wears a surgical mask to protect health care workers (HCWs) and other clients from respiratory secretions. (Options A and B) The client on airborne transmission-based precautions must wear a surgical mask to contain exhaled respiratory secretions. The other personal protective equipment is not necessary. (Option C) The Centers for Disease Control and Prevention recommends that HCWs who transport clients wear N95 respirator masks as protection against exposure to airborne droplets. N95 respirator masks protect HCWs by removing particles from inhaled air. The client is already infectious and does not require protection from inhaled air. Educational objective: While away from the negative-pressure isolation room, all clients on airborne transmission-based precautions must wear a surgical mask to contain exhaled respiratory secretions.

Question 20

A client with a tracheostomy is alert and oriented and able to tolerate oral intake.  Which action would be appropriate to reduce the client's risk of aspiration pneumonia?

Accepted Answer

11ecbb05_cb4a_a4cb_b433_1dad1dd34cb2_MD0009_00 A tracheostomy tube with inflated cuff is used in clients who are at risk for aspiration (eg, who are unconscious or on mechanical ventilation). However, an inflated cuff is uncomfortable for clients who are awake because it is difficult to swallow or talk. The cuff is deflated when the client is improving, is determined not to be at risk of aspiration, and is awake. Before the cuff is deflated, the client is asked to cough (if possible) to expectorate the oropharyngeal secretions that have built up above the inflated cuff. In addition, suction is applied through the tracheostomy tube and then the mouth; the cuff is then deflated. Additional interventions to decrease the risk of aspiration include the following: Having the client sit upright with the chin flexed slightly toward the chest Monitoring for a wet or garbled-sounding voice Monitoring for signs of fever (Option A) Inflating the cuff makes it difficult for a client who is awake to swallow and talk. In addition, more secretions can accumulate above the inflated cuff due to difficulty swallowing. The inflated cuff may not provide a 100% seal and the accumulated secretions can slide through it, causing aspiration. For these reasons, the deflated cuff is beneficial in awake clients with no risk of aspiration. (Option B) Having the client sit upright will help reduce the risk of aspiration. However, the chin should be flexed toward the chest; hyperextension of the neck increases the risk of aspiration. (Option D) There is no reason to give pureed foods just because the client has a tracheostomy. The client's diet should be determined by a swallowing evaluation. Educational objective: The risk of aspiration in a conscious, alert, and oriented client with a tracheostomy can be reduced by partially or fully deflating the tracheostomy cuff, having the client in an upright position, monitoring for a wet cough or voice quality, and monitoring vital signs.

Exam 4: Fundamentals

The unit educator is performing skill validations with unit staff. Which of the following actions by the staff nurses demonstrate a correct understanding of parenteral medication administration? Select all that apply.

A nurse is reviewing the most recent laboratory results of a client on the telemetry floor. The client is currently asymptomatic, and the telemetry monitor indicates sinus rhythm. Which of the following critical values is mostlikely due to laboratory error?

The nurse is educating a client recently diagnosed with anaphylactic allergy to latex. Which statement made by the client indicates that the client understood the condition correctly?

A nurse is preparing to administer 2 continuous IV medications concurrently via a 20-gauge IV. What is the nurse's priority action?

A nurse is caring for 4 clients. Which prescription by the health care provider would the nurse question and seek further clarification before administering?

The nurse working in an intensive care unit cares for a client with a left triple lumen subclavian central venous catheter (CVC) . The nurse should call the primary health care provider (HCP) for clarification prior to implementation when recognizing that which prescription is an error?

The nurse is caring for a client with active pulmonary tuberculosis. Which elements of infectious disease precautions are mandatory for the nurse when providing routine care? Select all that apply.

The nurse is caring for a client with Clostridium difficile colitis. Which of the following infection control measures by the nurse are appropriate? Select all that apply.

The nurse is caring for a client with bacterial meningitis, identified as Neisseria meningitidis who has a stage 4 pressure injury. What personal protective equipment is most appropriate for the nurse to wear when performing a dressing change? Select all that apply.

The nurse observes an ambulating client begin to experience a tonic-clonic seizure. Which nursing actions should be implemented immediately? Select all that apply.

A client who was placed in restraints appears in the hallway an hour later and states, "I'm Houdini.… I can get out of anything. There could be trouble now." Which of the following is the best response to this client?

The nurse caring for a client diagnosed with HIV uses which infection prevention and control measures? Select all that apply.

Which of the following drug administrations should be reported as a practice error? Select all that apply.

The nurse is reconstituting methylprednisolone sodium succinate for IM injection. Place in order the steps that the nurse should perform to appropriately prepare the medication. All options must be used.

The nurse is preparing an injection of IM haloperidol from a glass ampule. Which of the following actions by the nurse are appropriate? Select all that apply.

The nurse is preparing to administer an IM immunization to a 6-month-old infant. Which needle length and injection site would be the most appropriate to minimize a local reaction to the vaccine components?

The nurse caring for a client with tuberculosis (TB) transports the client to the radiology department for a chest x-ray. The nurse ensures that the client uses which personal protective equipment when out of the negative-pressure room?

A client with a tracheostomy is alert and oriented and able to tolerate oral intake. Which action would be appropriate to reduce the client's risk of aspiration pneumonia?