Adult Care 2 Final Exam Test Bank New Latest Version Updated 2023-2024 with All Questions, Exams of Nursing

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Adult Care 2 Final Exam Test Bank New Latest

Version Updated 2023-2024 with All Questions

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The student nurse is preparing to document a suspicious area over a bony prominence. Which description would be most appropriate? A. Reddened area on left hip B. Reddened, nonblanching area approximately 1 cm x 1 cm C. Suspicious area over left trochanter D. Nonblanching area over left trochanter 0.8 cm x 1.2 cm --------- Correct Answer ------- Nonblanching area over left trochanter 0.8 cm x 1.2 cm *The area should be described as to location, appearance, and exact measurement A patient who had TURP reports increasing bladder spasms. Which is the appropriate initial nursing action? A. Medicate with B&O suppository B. Check the urinary catheter tubing for kinks and obstruction C. Teach relaxation exercises D. Encourage use of patient-controlled analgesia --------- Correct Answer ------- Check the urinary catheter tubing for kinks and obstruction *Before giving medication, the nurse checks the tubing to ensure that it is not kinked and the catheter is draining well, as obstruction can cause bladder spasm. (1) This is not an initial action. Abdominal distention may be a sign of catheter obstruction as well. (3) Relaxation is not effective to eliminate spasms. (4) The patient who has had a radical procedure may have a patient-controlled analgesia pump to control pain. Which male patient has the condition with the highest priority for attention? A. The patient with a testicular torsion B. The patient with urinary retention secondary to BPH C. The patient with orchitis D. The patient with Klinefelter's syndrome --------- Correct Answer ------- The patient with a testicular torsion When discussing prostate cancer with a patient who has a strong family history of the disorder and BPH, the nurse tells him that which medication is used to help prevent prostate cancer?

A. Finasteride B. Doxazosin C. Terazosin D. Tamsulosin --------- Correct Answer ------- Finasteride When considering complementary and alternative therapy for prostate cancer, which is true? A. Plant extracts should not be taken if receiving hormone therapy B. It is best to train the body to hold urine for an increasingly longer duration C. Research has proven that saw palmetto helps relieve symptoms D. Surgery is the only way to improve symptoms --------- Correct Answer ------- Plant extracts should not be taken if receiving hormone therapy A patient asks the nurse for information about prostate cancer and how it develops. The nurse answers: A. "It is a quick-growing cancer and the nodule is small." B. "Prostate cancer is a very slow-growing cancer." C. "It is a cancer that is related to sexually transmitted viruses." D. "This type of cancer is embryonic and continues to grow slowly after birth." --------- Correct Answer ------- "Prostate cancer is a very slow-growing cancer." After a transurethral resection of the prostate (TRUP), a priority nursing problem in the immediate post-operative period is A. Altered activity tolerance due to required bedrest B. Pain due to bladder spasms C. Potential for bleeding due to surgery D. Anxiety due to sexual function after surgery --------- Correct Answer ------- Potential for bleeding due to surgery Which diagnostic test would most likely be performed on an elderly patient who has a PSA result of 7.2? A. Another blood sample for PSA B. CT scan of the pelvis C. Voiding urethrogram D. Prostate needle biopsy --------- Correct Answer ------- Prostate needle biopsy The nurse anticipates that the malnourished postoperative 70-year-old patient will receive an intravenous (IV) infusion of 5% dextrose in 0.45% saline, because it is: a. isotonic. b. hypotonic.

c. hypertonic. d. total parenteral nutrition --------- Correct Answer ------- hypertonic *5% Dextrose in 0.45% saline is a hypertonic or high molecular solution and is a frequent choice for postoperative maintenance fluid. The nurse is planning for the initiation of a blood transfusion. The type of tubing the nurse will prepare is a: a. piggyback set. b. primary infusion set. c. controlled volume set. d. Y administration set --------- Correct Answer ------- Y administration set. *A Y administration set is used to place the blood on one side and normal saline on the other. This is necessary so that the blood can be discontinued but the vein can remain open with the saline in the case of a transfusion reaction or other medically necessary situation. The nurse is aware that as a safety precaution against over hydration, the tubing drip factor set appropriate for a 6-month-old infant is: a. 60 gtt/mL. b. 20 gtt/mL. c. 15 gtt/mL. d. 10 gtt/mL. --------- Correct Answer ------- 60 gtt/mL. *A microdrip infusion set, which delivers 60 gtt/mL, is used for infants and children. The nurse evaluating a piggyback IV setup finds an error in the construction of the fluids. Which situation would the nurse correct? a. Secondary bag is hung higher than the primary bag. b. Primary line clamp is closed. c. Slide clamp near the insertion site is open. d. Secondary line clamp is open. --------- Correct Answer ------- Primary line clamp is closed *When a medication is given via piggyback setup, the secondary bag is hung slightly higher than the primary line and, when the secondary infusion finishes, the primary one takes over again; therefore, all clamps (roller and slide) must be open for the setup to work properly.

The nurse assisting in the initiation of a blood transfusion is aware that the only appropriate solution to infuse through a parallel infusion set before and after the transfusion is: a. 5% dextrose in water. b. 10% dextrose in water. c. lactated Ringer's solution. d. normal saline. --------- Correct Answer ------- normal saline. *Normal saline is the only solution used in conjunction with infusion of a blood product. To facilitate the administration of an IV antibiotic every 6 hours to a patient who is ambulatory, well hydrated, and on a regular diet, the nurse would insert a(n): a. primary IV line. b. secondary IV line. c. intermittent infusion device. d. central venous line --------- Correct Answer ------- intermittent infusion device. *Patients who do not require large amounts of fluid but receive intermittent IV medications benefit from an intermittent infusion device. A patient is receiving IV fluids through an infusion pump. How often should the nurse check the functioning of the pump? a. Every 15 to 30 minutes b. Every 1 to 2 hours c. Every 2 to 4 hours d. Once during the shift --------- Correct Answer ------- Every 1 to 2 hours *An IV infusion pump should be checked every 1 to 2 hours to ensure that it is functioning properly. When a patient receiving IV medication exhibits light headedness, tightness in the chest, flushed face, and irregular pulse, the nurse suspects: a. speed shock. b. drug allergy. c. fluid overload. d. air embolus. --------- Correct Answer ------- speed shock *Light headedness, tightness in the chest, flushed face, and irregular pulse are all signs of speed shock. Speed shock is when a foreign substance is infused into the body rapidly. The infusion should be stopped, the primary care provider notified, and the patient monitored.

A patient is admitted with a peripherally inserted central catheter (PICC). As part of standard care for this patient, the nurse should: a. obtain the patient's temperature every 2 hours. b. prepare to infuse fluids at high volumes. c. avoid taking blood pressures on the arm with the PICC line. d. have the catheter withdrawn while the patient is hospitalized. --------- Correct Answer ------- avoid taking blood pressures on the arm with the PICC line *PICC lines are inserted by physicians or specially trained nurses, and they are used for long-term therapy; blood pressures are not taken in the arm that has the PICC line to avoid interfering with the function or the life of the catheter. Many times this catheter is used in home care. A patient has just undergone placement of a central venous catheter through the subclavian vein. When the placement is complete, the nurse should: a. hang the prescribed fluid at a rate of 1 mL/min. b. assess the quality of the breath sounds. c. note the length of the tubing. d. wait for the results of the chest radiograph before beginning fluids. --------- Correct Answer ------- wait for the results of the chest radiograph before beginning fluids. *Correct placement of subclavian catheters must be verified by radiographic studies before any fluid is infused through them. The nurse observes that the insertion site of an IV catheter looks pale and puffy and the area feels cool to the touch. The initial action for the nurse should be to: a. discontinue the infusion and start a new IV site. b. apply warm compresses to the site. c. monitor the patient's temperature every 4 hours. d. call the primary care provider and report these findings. --------- Correct Answer ------- discontinue the infusion and start a new IV site *Infiltration is the most common complication of IV therapy, and it occurs when fluid or medication leaks out of the vein and into the tissue. The infusion should be discontinued immediately and a new insertion site initiated. Signs are pale, cool skin that is edematous (puffy).

A patient rings the call bell and states that the IV insertion site is painful. The site is reddened, warm, and swollen. The nurse assesses that the patient is most likely experiencing: a. bloodstream infection. b. catheter embolus. c. infiltration of the line. d. phlebitis. --------- Correct Answer ------- phlebitis. *Phlebitis is caused by irritation of the vessel by the needle, cannula, medications, or additives to IV solution. Typical signs are erythema, warmth, swelling, and tenderness. A patient receiving TPN fluid therapy experiences an air embolus in the central line. The nurse should immediately turn the patient onto the: a. right side and raise the head of the bed. b. right side and lower the head of the bed. c. left side and raise the head of the bed. d. left side and lower the head of the bed. --------- Correct Answer ------- left side and lower the head of the bed *To anatomically minimize the risk of the air embolus reaching the lungs, the nurse should turn the patient onto the left side and lower the head of the bed. The primary care provider is notified immediately. The nurse takes into consideration that according to The Joint Commission, the first IV antibiotics order for a community acquired pneumonia must be administered within: a. 1 to 2 hours b. 2 to 4 hours c. 6 to 8 hours d. 24 hours --------- Correct Answer ------- 6 to 8 *The Joint Commission suggests that the first IV antibiotic administered for community acquired pneumonia be administered in the first 6 to 8 hours after admission. A nurse is monitoring the status of an older adult patient who is receiving IV therapy. Indicator of fluid volume overload is suspected when the nurse assesses: a. crackles in the lung fields. b. pulse rate of 64 beats/min, irregular. c. respirations of 16 breaths/min, regular. d. slight edema to the feet. --------- Correct Answer ------- crackles in the lung fields

*Fluid overload is signaled by crackles in the lung fields, increasing pulse rate, and shortness of breath. A nurse accessing the injection port of the IV tubing will "scrub the hub" for: a. 5 seconds. b. 10 seconds. c. 15 seconds. d. 30 seconds --------- Correct Answer ------- 15 seconds *The hub of the injection port on a piggyback setup should be scrubbed for 15 seconds. A patient is to have an IV insertion site changed. The current line is in the lower right forearm. Which location is contraindicated for the new site? a. Right upper forearm b. Right hand c. Left upper forearm d. Left hand --------- Correct Answer ------- Right hand *A new IV site should not be placed distal to an old site; the right hand is distal to the right forearm, so it should not be used. The nurse would plan to get another nurse to try to obtain a successful venipuncture if the first nurse was not successful in: a. five attempts. b. three attempts. c. two attempts. d. one attempt. --------- Correct Answer ------- two attempts *If the nurse cannot initiate a patent IV in two attempts, it is good judgment to ask another nurse to perform the task. A nurse is aware that for a patient with a continuous IV infusion running, the IV bag should be changed when only ______ mL of solution remains in the bag. a. 10 mL b. 25 mL c. 50 mL d. 100 mL --------- Correct Answer ------- 50 mL *When the container has only 50 mL of solution left, the next ordered solution is added to the setup and the flow begun to prevent air from entering the line.

A patient who requires an immediate transfusion of blood has previously signed a consent form to receive it. The nurse confirms that the consent was signed within the last: a. 8 hours. b. 12 hours. c. 24 hours. d. 48 to 72 hours. --------- Correct Answer ------- 48 to 72 hours. *A consent to receive blood must be signed by the patient, usually no more than 48 to 72 hours before receiving the blood product. A patient complains of chills, back pain, and shortness of breath a few minutes after the blood infusion is started. The first thing the nurse should do is: a. slow down the blood infusion. b. stop the blood infusion and start the saline. c. monitor vital signs and call the primary care provider. d. start low flow oxygen as per facility protocol. --------- Correct Answer ------- stop the blood infusion and start the saline. *If a transfusion reaction occurs, such as chills, back pain, and shortness of breath or itching, the nurse should stop the infusion and start the saline to keep the line open The LVN/LPN is told by the RN to discontinue an IV line to the patient. The best nursing action is to: a. check the primary care provider's order. b. stop the IV flow by clamping the tubing securely. c. wash hands and don gloves. d. quickly withdraw the cannula and apply pressure. --------- Correct Answer ------- check the primary care provider's order. *Checking the primary care provider's order will prevent inadvertently discontinuing the IV and having to restart it. The nurse caring for a patient with an intermittent IV device should: a. attach continuous fluid infusion to the device. b. infuse saline or heparin solution to maintain patency. c. discontinue when the IV medication is finished. d. reduce patient activity to prevent dislodgement. --------- Correct Answer ------- infuse saline or heparin solution to maintain patency. *The intermittent IV device should be flushed periodically with saline or heparin, depending on

facility policy, to maintain patency, which allows more freedom of movement for the patient. The nurse instills diluted medication in the portion of the controlled volume IV setup, which is called the ___________. --------- Correct Answer ------- burette *The burette is the tube-like chamber that holds only about 150 mL of fluid with diluted medication. After the blood infusion has started, the nurse should let the blood flow at 2 mL/min for the first ___________ minutes. --------- Correct Answer ------- 15 *The initial rate of blood infusion is 2 mL/min for the first 15 minutes. If the patient tolerates this rate, it can be gradually increased. Your patient is to receive intravenous therapy for several weeks. A PICC line is placed. Where would the nurse expect it to be inserted? A. the antecubital space B. the plantar aspect of the lower arm C. the basilic or cephalic vein of the upper arm D. above the wrist and below the elbow --------- Correct Answer ------- the basilic or cephalic vein of the upper arm The order for the patient reads "D5W 1000 mL to follow the container that is hanging presently." There are 75 mL left in the container hanging. The nurse should A. hang the new container before the old one runs dry B. wait until another 25 mL have infused before hanging the new container C. hang the new container when the remaining fluid has infused D. hang the new container when there are 10 mL left in the container --------- Correct Answer ------- wait until another 25 mL have infused before hanging the new container The patient complains that the IV site is stinging. It is not reddened or warm to the touch. He has been up and about and the flow rate has increased from where it was set. You should FIRST A. stop the infusion B. take the vital signs C. reset the drip rate D. change the IV site --------- Correct Answer ------- reset the drip rate The patient will need intravenous therapy for at least a week. The nurse would change the IV site every A. 24 hours

B. 48-72 hours C. 12 hours D. 72- 96 --------- Correct Answer ------- 72 - 96 hours After the piggyback infusion is finished, the nurse would FIRST A. flush the cannula with normal saline B. attach the next piggyback medication tubing C. disconnect the piggyback tubing D. cleanse the port on the prn device with alcohol --------- Correct Answer ------- disconnect the piggyback tubing A patient is receiving total parenteral nutrition (TPN) through a central line. His TPN solution is behind schedule when the nurse comes on duty. The nurse would A. increase the flow rate to "catch up" B. leave the flow rate alone C. notify the primary care provider that the solution is behind schedule D. adjust the flow rate to that which is ordered --------- Correct Answer ------- adjust the flow rate to that which is ordered During the first several days of TPN administration, it is especially important to check the patient's ________________. --------- Correct Answer ------- blood glucose level Because of a communication error, the pharmacy says that there is a long delay for a replacement of TPN to be mixed and delivered to the unit for the patient. While awaiting the replacement bag of TPN, the nurse recognizes that a medical order is needed for which type of IV fluid? A. 0.45% Saline B. 5% Dextrose in water C. 10% Dextrose in water D. Lactated Ringer --------- Correct Answer ------- 10% Dextrose in water *If TPN is suddenly discontinued, a patient can experience hypoglycemia. (1) 0.45% saline is a common solution ordered for maintenance replacement of fluids. (2) 5% dextrose is most commonly used as a vehicle for piggyback medications. (4) Lactated Ringer is an isotonic solution that is used for cases of excessive fluid loss, such as trauma or major burns. What is the nurse's primary responsibility in the daily care of a patient with a central line? A. Use sterile technique during insertion B. Flush the line according to agency policy C. Verify catheter placement with an x-ray examination

D. Rotate the insertion site every 72 hours --------- Correct Answer ------- Flush the line according to agency policy. *Nurses are responsible for the maintenance of central lines, which would include flushing to ensure patency. (1) Sterile technique is used during the insertion; however, central lines are usually inserted by physicians or advanced practice nurses who have undergone specialized training. (3) The catheter placement should be verified with a radiograph; however, this is the responsibility of the person doing the insertion. The nurse should not use the catheter for infusion until after placement has been verified. (4) The site is not usually changed so frequently. One of the advantages of central line placement over peripheral sites is longevity. A nurse is adding a secondary piggyback to the patient's existing IV. To use the gravity system, the nurse should hang A. The piggyback bag higher than the maintenance IV bag B. The maintenance IV bag at the same height as the piggyback bag C. The piggyback bag and the maintenance IV bag using Y tubing D. The maintenance IV bag after the piggyback bag is completed --------- Correct Answer ------- The piggyback bag higher than the maintenance IV bag *If the piggyback bag is higher than the maintenance bag, the fluid from the piggyback will flow in first. As soon as the piggyback is empty, fluid from the maintenance bag will begin. Recall that the fluid level in the piggyback bag must be higher throughout the entire infusion. (2) If the maintenance bag and the piggyback bag are at the same height, the fluid from the maintenance bag can flow up into the piggyback (if there is no backflow valve within the tubing). The bag that has the greater volume will flow first. As the volume of the greater bag depletes, the less the bag will begin to flow. Eventually both would infuse, but the two bags of fluid would be competing for flow. (3) Y-tubing is generally reserved for blood product infusion. It would be an inappropriate waste of a more expensive tubing (which has a special filter). (4) You can manually hang or restart the maintenance IV after the piggyback is completed. In fact, if fluid overload is an issue and you do not have an infusion pump, you may choose to do this; however, this completely eliminates the advantage of having a piggyback setup. In which circumstance would the use of a burette be advised as a safety device? A. A trauma patient needs several units of packed red blood cells B. The patient needs IV fluids, but no infusion pump is available C. An infant is at risk for IV fluid volume overload D. A confused patient keeps trying to unplug the infusion pump --------- Correct Answer - ------ An infant is at risk for IV fluid volume overload *The burette provides a way to measure the exact amount of IV fluid that could flow into the infant. (1) The burette would not be used in the case of a trauma patient. (2) You could use a burette for a patient who needs IV fluids, but remember that the burette will

hold a limited amount of fluid and you will have to refill the burette frequently, so it may cause more work. (4) If a patient unplugs an infusion pump, the pump is likely to continue on a battery. When the battery runs low, an alarm will begin to sound. If the battery depletes, the IV will not infuse. Use of a burette in this case serves no purpose. The patient is receiving a blood transfusion and develops a fever, shortness of breath, and a diffuse rash within 10 minutes after the start of the transfusion. What is the priority action? A. Take vital signs and call the primary care provider B. Place the patient in a supine position and start oxygen C. Stop the blood and change the IV tubing D. Slow the blood and check the vital signs --------- Correct Answer ------- Stop the blood and change the IV tubing. *First stop the blood and change the IV tubing so that the patient does not receive the blood that is within the tubing. (1, 2, 3) Taking the vital signs, starting oxygen, and calling the primary care provider are appropriate actions. The high Fowler position is better initially for oxygenation; if the patient's vital signs suggest shock, the supine position is used. Slowing the blood is not an adequate measure if a transfusion reaction is in progress. A patient returns from physical therapy, and her IV has a very sluggish flow, but it was functioning well before going to physical therapy. What is the primary nursing action? A. Call the physical therapist and ask if anything happened to the IV during the treatment session B. Discontinue the IV and restart the IV at a new site C. Assess the IV insertion site and tubing and try repositioning the extremity D. Use a heparin flush to clear the line --------- Correct Answer ------- Assess the IV insertion site and tubing and try repositioning the extremity *Assess the site and try to troubleshoot; repositioning the extremity is one solution. Also, try to aspirate for a small blood clot. (See Table 36-3 for other troubleshooting tips.) (1) PT should have called you if something happened to the patient that created a potential danger. It is unlikely that you will gain any useful information by calling, but you could if you suspect an unusual circumstance. (2) Discontinue and restart, if you have tried to reestablish flow without success. (4) Use of a heparin flush requires a medical order. The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item? A. vital signs B. skin color C. Oxygen saturation

D. Latest hematocrit level --------- Correct Answer ------- vital signs *A change in the vital signs may indicate that a transfusion reaction is occurring. The nurse assesses the client's vital signs before the procedure to obtain a baseline every 15 minutes for the first half hour after beginning the transfusion and every half hour thereafter. Skin color, oxygen saturation, and most recent hematocrit may be checked but are not the most important A client who is receiving a blood transfusion pushes the call light for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How should the nurse correctly interpret these findings? A. Bacteremia B. Fluid overload C. Hypovolemic shock D. Transfusion reaction --------- Correct Answer ------- Transfusion reaction *The signs and symptoms exhibited by the client are consistent with a transfusion reaction. A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area? A. The pharmacy B. The laboratory C. The blood bank D. The risk-management department --------- Correct Answer ------- The blood bank *The nurse prepares to return the blood transfusion bag containing any remaining blood to the blood bank. This allows the blood bank to complete any follow-up testing procedures that are needed after a transfusion reaction has been documented A nurse takes a client's temperature before giving a blood transfusion. The temperature is 100 degrees F orally. The nurse reports the finding to the RN and anticipates that which of the following actions will take place? A. The transfusion will begin as prescribed B. The blood will be held and the physician will be notified C. The transfusion will begin after the administration of an antihistamine D. The transfusion will begin after the administration of 600 mg of acetaminophen --------

• Correct Answer ------- the blood will be held and the physician will be notified *If the client has a temperature of 100F or more, the unit of blood should be held until the PCP is notified and has the opportunity to give further prescriptions

A client has a prescription to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing? A. Uncaps the distal end of the tubing B. Uncaps the spike portion of the tubing C. Opens the roller clamp on the IV tubing D. Closes the roller clamp on the IV tubing --------- Correct Answer ------- Closes the roller clamp on the IV tubing *The nurse should first clamp the tubing to prevent the solution from running freely through the tubing after it is attached to the IV bag. The nurse should next uncap the proximal (spike) portion of the tubing and attach it ti the IV bag. The IV bag is elevated, and the roller clamp is then opened slowly, and the fluid is allowed to flow through the tubing in a controlled fashion to prevent air from remaining in parts of the tubing The nurse is diong a routine assessment of a clients's peripheral intravenous (IV) site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which has probably occurred? A. Phlebitis B. Infection C. Infiltration D. Thrombosis --------- Correct Answer ------- Infiltration *An infiltrated IV is one that has dislodged fromthe vein and is lying in subcutaneous tissue. The pallow, coolness, and swelling are the result of IV fluid being deposited into the subcutaneous tissue. When the pressure in the tissue exceeds the pressure in the tubing, the flow of the IV solution will stop. The other options identify complications that are likely to be accompanied by warmth at the site rather than coolness The nurse is doing a routine assessment of a client's peripheral intravenous (IV) infusion. The nurse is providing hygiene care to the client and should avoid which while changing the client's hospital gown? A. Using a hospital gown with snaps at the sleeves B. Disconnecting the IV tubing from the catheter in the vein C. Checking the IV flow rate immediately after changing the hospital gown D. Putting the bag and tubing through the sleeve, followed by the client's arm --------- Correct Answer ------- Disconnecting the IV tubing from the catheter in the vein *The tubing should not be removed from the IV catheter. With each break in the system, there is an increased chance of introducing bacteria into the system, which can lead to an infection. Using gowns with snaps and inserting the IV bag and tubing throught the sleeve of the gown first are appropritate. The flow rate should be checked immediately

after changing the hospital gown, because the position of the roller clamp may have been affected furing the change The nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the intravenous (IV) of an assigned client who is receiving fluid replacement therapy how frequently? A. Every hour B. Every 2 hours C. Every 3 hours D. Every 4 hours --------- Correct Answer ------- Every hour *Safe nursing practice includes monitoring an IV infusion at least once every hour for an adult client. The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of which? A. Phlebitis of the vein B. Infiltration of the IV line C. Hypersensitivity to the IV solution D. An allergice reaction to the IV catheter material --------- Correct Answer ------- Phlebitis of the vein *Phlebitis at an IV site results in discomfort and redness, warmth, and swelling proximal to the IV catheter. The IV catheter should be removed, and a new IV should be inserted at a different site. The nurse has been instructed to remove an intravenous (IV) line. The nurse removes the catheter while applying pressure to the site with which item? A. Band-Aid B. Alcohol swab C. Betadine swab D. Sterile 2x2 gauze --------- Correct Answer ------- Sterile 2x2 gauze *A dry, sterile dressing such as sterile 2x2 gauze is used to apply pressure to the site while the cathter is discontinued and removed. This material is absorbent, sterile, and nonirritating to the site. A Band-Aid may be used to cover the site after hemostasis as occurred. An alcohol swab or Betadine would irritate the opened puncture site and would not stop the blood flow

The nurse is preparing an intravenous (IV) solution and tubing for a client who requires IV fluids. While preparing to prime the tubing, the tubing drops and hits the top of the medication cart. The nurse should plan to take which action? A. Change the IV tubing B. Wipe the tubing with Betadine C. Scrub the tubing with an alcohol swab D. Scrub the tubing before attaching it to the IV bag --------- Correct Answer ------- Change the IV tubing *The nurse should change the IV tubing. The tubing has become contaminated, and, if used, it could result in a systemic infection in the client. Wiping or scrubbing the tubing is insufficient to prevent systemic infection A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started? A. 5 minutes B. 15 minutes C. 30 minutes D. 45 minutes --------- Correct Answer ------- 15 minutes *The nurse must remain with the client for the first 15 minutes of a transfusion, which is the most likely time that a tranfusion reaction will occur. This enables the nurse to detect a reaction and intervene quickly. THe nurse engages in safe nursing practice by obtaining coverage for the other clients during this time. A client is assisting with caring for a client who is receiving a unit of packed red blood cells (PRBCs). The nurse should tell the client that it is most important to report which sign(s) immediately? A. Sore throat or earache B. Chills, itching, or rash C. Unusual sleepiness or fatigue D. Mild discomfort at the catheter site --------- Correct Answer ------- Chills, itching, or rash *The client is told to report chills, itching, or rash immediately because these could be signs of a possible transfusion reaction. The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which finding? A. An increased hematocrit level

B. An increased hemoglobin level C. A decline of the temperature to normal D. A decrease in oozing from puncture sites and gums --------- Correct Answer ------- A decrease in oozing from puncture sites and gums *Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or the oozing of blood from puncture sites, wounds, and mucous membranes. A nurse is demonstrating how to insert an IV catheter. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure? A. "I will thread the needle all the way into the vein until the hub rests against the insertion site after I see a flashback of blood." B. "I will insert the needle into the client's skin at an angle of 10 to 30 degrees with the bevel up." C. "I will apply pressure approximately 1.2 inches below the insertion site prior to removing the needle." D. "I will choose a vein inthe antecuvital fossa for IV insertion due to its size and easily accessible device." --------- Correct Answer ------- "I will insert the needle into the client's skin at an angle of 10 to 30 degrees with the bevel up." *Use a smooth, steady motion to insert the catheter through the skin at an angle of 10 to 30 degrees with the bevel up. This is the optimal angle for preventing the puncture of the posterior wall of the vein A urse is collecting data from a client who is receiving IV therapy and reports pain in the arm, chills, and "not feeling well." The nurse notes warmth, edema, induration, and red streaking on the client's arm close to the IV insertion site. Which of the following actions should the nurse plan to take first? A. Obtain a specimen for culture B. Apply a warm compress C. Administer analgesics D. Discontinue the infusion --------- Correct Answer ------- Discontinue the infusion *The greatest risk to this client is further injury to the irritated vein. the first action is to stop the infusion and remove the cathter to prevent further harm During new employee orientation, a nurse is explaining how to prevent IV infections. Which of the following statements by an orientee indicates understanding of the preventative strategies? A. "I will leave the IV catheter in place after the client completes the course of IV antibiotics."

B. "As long as I am working with the same client, I can use the same IV catheter for my second insertion attempt." C. "If my client needs to use the rest room, it would be safer to disconnect their IV infustion as long as I clean the injection port thoroughly with an antiseptic swab." D. "I will replace any IV catheter when I suspect contamination during insertion." --------- Correct Answer ------- "I will replace any IV catheter when I suspect contamination during insertion." *Replace IV catheters when suspecting any break in surgical aseptic technique (in emergency insertions) Which drug route would you expect to be the most rapidly absorbed? a. Subcutaneous injection b. Intravenous injection c. Rectal suppository d. Sublingual tablet --------- Correct Answer ------- Intravenous injection A 62-year old male patient with liver disease asks you why he is receiving a drug intravenously rather than by mouth. What is your best response? a. "Many oral drugs are inactivated as you get older." b. "Your liver disease impairs the transformation of a drug into its active form." c. "Intravenous drugs reduce toxicity to the liver through first-pass metabolism." d. "Individuals with liver disease have a genetic impairment that prevents drug activation." --------- Correct Answer ------- "Your liver disease impairs the transformation of a drug into its active form." *Many drugs must be activated by enzymes before they can be used in the body. This biotransformation happens in the liver. Liver disease impairs this process A patient who was given intravenous penicillin for a severe infection develops hives, itching, and facial swelling immediately after the infusion. What type of drug reaction is this patient experiencing? a. An adverse reaction b. A paradoxical reaction c. An anaphylactic reaction d. A hypersensitivity reaction --------- Correct Answer ------- A hypersensitivity reaction *Some drugs (sulfa products, aspirin, and penicillin) can produce allergic (hypersensitivity) reactions that usually occur when an individual has taken the drug and the body has developed antibodies to it. Which statement is true regarding giving drugs by the IV route?

a. Intravenous drugs must go through first-pass metabolism to be absorbed. b. Intravenous drugs are deposited directly into the blood stream. c. Intravenous drugs have lower rates of adverse events. d. Intravenous drugs are less effective than oral drugs. --------- Correct Answer ------- Intravenous drugs are deposited directly into the blood stream. *Drugs administered by the intravenous route are deposited directly into the bloodstream and have a higher incidence of chance for adverse events. When a patient is experiencing a life-threatening emergency, you may be given an order to give drug via which route? a. IV route b. IM route c. Rectal route d. Subcutaneous route --------- Correct Answer ------- IV route What physical assessment findings would you observe when an IV becomes infiltrated? a. Pallor and pain b. Pallor, warmth c. Pain, warmth, and burning d. Pain, swelling, and redness --------- Correct Answer ------- Pain, swelling, and redness *Infiltration produces pain, swelling of the area, and redness. Pain with warmth and burning are signs of infection. What solution can you not give to a child? --------- Correct Answer ------- hypotonic Which foundational behavior is necessary for effective critical thinking? A. Unshakeable beliefs and values B. An open-minded attitude C. An ability to disregard evidence inconsistent with set goals D. An ability to recognize the perfect solution --------- Correct Answer ------- An open- minded attitude The nurse is assessing a new patient who complains of his chest feeling tight. The patient displays a temperature of 100F and an oxygen saturation of 89% and exportorates frothy mucus. Which finding is an example of subjective data? A. Temperature B. Oxygen saturation C. Frothy mucus D. Chest tightness --------- Correct Answer ------- Chest tightnes

The nurse is caring for a newly admitted patient who is describing his recent symptoms to the nurse. This scenario is an example of which type of source? A. Primary B. Objective C. Secondary D. Complete --------- Correct Answer ------- Primary The nurse is performing an intake interview on a new resident to the long-term care facility. The nurse detects the odor of acetone from the patient's breath. Which term accurately describes this assessment? A. Inspection B. Observation C. Auscultation D. Olfaction --------- Correct Answer ------- Olfaction During a morning assessment, the nurse observes that the patient displays significant edema of both feet and ankles. Which statement best documents these findings? A. Pitting edema present in both feet and ankles B. Edema in both feet and ankles approximately 4 mm deep C. 4 mm pitting edema quickly resolving D. Bilateral pitting edema in feet and ankles, 4 mm deep, resolving in 3 seconds --------- Correct Answer ------- Bilateral pitting edema in feet and ankles, 4 mm deep, resolving in 3 seconds Which technique should the nurse employ to best assess skin turgor? A. Examine mucous membranes of the mouth B. Compare limbs for similar color C. Pinch a skinfold on chest to assess for tenting D. Palpate the ankles for evidence of pitting edema --------- Correct Answer ------- Pinch a skinfold on chest to assess for tenting Which example shows that the nursing student demonstrates compliance with the Health Insurance Portability and Accountability Act (HIPAA)? A. The student uses the patient's full name only on clinical assignments submitted to the instructor B. The student uses the facility printer to copy laboratory reposts on an assigned patient C. The student shreds any documents that contain identifying patient information before leaving the clinical facility D. The student asks the patient for permission to copy laboratory and diagnostic reports for educational purposes --------- Correct Answer ------- The student shreds any documents that contain identifying patient information before leaving the clinical facility

The nurse is caring for a patient with the problem statement/nursing diagnosis of Risk for Impaired Skin Integrity Related to Immobility. Which goal/outcome statement best correlates with this diagnosis? A. The patient will sit in a chair at bedside for 15 minutes after each meal B. The nurse will assist the patient to chair every shift C. The nurse will assess skin and record condition every shift D. The patient will change positions frequently --------- Correct Answer ------- The patient will sit in chair at bedside for 15 minutes after each meal The nurse who has recently moved from Lousiana to Texas is uncertain about the LPN/LVN's role in applying the nursing process. Which source is the most appropritate source for the nurse to consult? A. Hospital policies B. The Texas State Board of Nursing C. Rules and regulations of the Louisiana Nurse Practice Act D. The National Association of Practical Nurse Education and Service --------- Correct Answer ------- The Texas State Board of Nursing The nurse adds a nursing order to the care plan related to a patient with a problem statement/nursing diagnosis of altered nutrition/Nutrition: Less Than Body Requirements Related to Nausea and Vomiting. Which nursing order should the nurse include in the plan of care? A. Medicate with an antiemetic before each meal B. Offer crackers and iced drink before each meal C. Change diet to clear liquids D. Give nothing by mouth until nausea subsides --------- Correct Answer ------- Offer crackers and iced drink before each meal After evaluating the nursing care plan, the nurse finds lack of progress toward the goal. What action should the nurse take? A. Create a more accessible goal B. Revise the nursing interventions C. Change the problem statement/nursing diagnosis D. Use a new evaluation plan --------- Correct Answer ------- Revise the nursing interventions During an intake interview, the nurse observes the patient grimacing and holding his hand over his stomach. The patient previously denied having any pain. What action should the nurse take next? A. Examine the history closely for etiology of pain

B. Ask the patient if he is experiencing abdominal pain C. Record that patient seems to be having abdominal discomfort D. Physically examine the patient's abdomen --------- Correct Answer ------- Ask the patient if he is experiencing abdominal pain While conducting an admission interview, the nurse questions the patient about pain. The patient responds, "No. I'm pretty wobbly." Which action should the nurse take next? A. Repeat the question about pain B. Ask the patient to clarify his meaning C. Record that the patient denied pain D. Record that the patient stated he was wobbly --------- Correct Answer ------- Ask the patient to clarify his meaning The nurse is caring for a patient with a goal/outcome statement of Patient will sleep for 5 h uninterrupted each night. Which nursing intervention should the nurse include? A. Medicate with sedative each night B. Offer warm fluids frequently C. Arrange for a large meal at supper D. Discourage daytime napping --------- Correct Answer ------- Discourage daytime napping The nursing team is prioritizing the problem statement/nursing diagnoses of an overnight hospital patient. Which problem statement/nursing diagnosis would be most important for this patient? A. Risk for dehydration related to vomiting B. Activity intolerance related to shortness of breath C. Knowledge deficit related to weight reduction diet D. Altered self-image related to excessive weight --------- Correct Answer ------- Activity intolerance related to shortness of breath The nurse is explaining the components of a complete problem statement/nursing diagnosis. In addition to the NANDA stem and etiology, which other component should the diagnosis include? A. A time reference for meeting the need B. A designation of what the patient should do C. Signs and symptoms of the problem assessed D. A specifically worded medical diagnosis --------- Correct Answer ------- Signs and symptoms of the problem assessed Which statement explains the reason for the inclusion of potential problems in the nursing care plan?

A. To alert nursing staff to prevent potential complication B. To remind the family of potential problems C. To broaden the assessment of the caregiver D. To educate the patient of aspects of her health --------- Correct Answer ------- To alert nursing staff to prevent potential complication The nurse is completing the medication reconciliation form for a patient. Which information is most important for the nurse to include? A. The patient reports taking Ginkgo biloba daily for the last 6 months B. The patient reports having high hematocrit levels during his last hospital stay C. The patient reports he has been diabetic for 10 years D. The patient reports having a recent infection --------- Correct Answer ------- The patient reports taking Ginkgo biloba daily for the last 6 months The nurse is caring for a patient with pneumonia who complains of shortness of breath. Further assessment reveals an oxygen saturation of 89% on room air, 28 respirations/min with bilateral crackles in lung bases, blood pressure of 160/94, and a pulse rate of 102 beats per minute. Which nursing diagnosis is priority for this patient? A. Activity intolerance B. Impaired gas exchange C. Ineffective cardiopulmonary tissue perfusion D. Self-care deficit: bathing and hygiene --------- Correct Answer ------- Impaired gas exchange The nursing student demonstrates knowledge of the proper use of the following when determining that it is safe to administer meperidine (Demerol) and promethazine (Phenergan) together? A. Medication reconciliation form B. Polypharmacy C. EHR D. Medications --------- Correct Answer ------- Medication reconciliation form Which critical thinking skill is important to apply when formulating a nursing care plan? A. Having the nursing assistant help with assessment B. Reading the history and physical in the chart C. Analyzing the data to determine appropriate nursing diagnoses D. Including the patient in formulating the care plan --------- Correct Answer ------- Analyzing the data to determine appropriate nursing diagnoses *Analyzing the data from all areas of the assessment is use of critical thinking. (1) Using the nursing assistant is part of delegation. (2) Reading the history and physical in the

chart is appropriate but not a use of critical thinking. (4) Including the patient in care planning is appropriate but not a use of critical thinking. Critical thinking is important in the nursing process because it A. Can provide a better outcome for the patient B. Simplifies the planning process for the nurse C. Allows the patient to have input on the plan D. Directly communicates the plan to others --------- Correct Answer ------- Can provide a better outcome for the patient *Critical thinking can help create a better care plan and provide a better outcome for the patient. (2) It does not simplify the planning process for the nurse. (3) The patient should have input on the plan with or without the use of critical thinking. (4) Writing out the plan communicates it to others, not critical thinking. The assessment technique of percussion is used by the nurse to A. Determine whether lung sounds are normal B. Assess for air in the intestine C. Check for abdominal rigidity D. Assess the degree of abdominal pain --------- Correct Answer ------- Assess for air in the intestine *Percussion assists in determining if there is air in the intestine. (1) Auscultation is used to determine if lung sounds are normal. (3) Palpation is used to determine abdominal rigidity. (4) The patient must verbalize the degree or amount of abdominal pain. When caring for an older woman who developed a 5-cm pressure ulcer on her sacrum because of being immobilized and incontinent, an appropriate expected outcome for the problem of altered skin integrity would be A. "Patient will be able to ambulate to the bathroom with minimal assistance." B. "Turning and repositioning schedules will be provided for the staff." C. "Patient will demonstrate a decrease in size of the ulcer within 1 week." D. "Family will be able to provide protein-rich foods during the hospital stay." --------- Correct Answer ------- "Patient will demonstrate a decrease in size of the ulcer within 1 week." *Patient will demonstrate a decrease in size of the ulcer within 1 week is an appropriate expected outcome. (1) The ability to ambulate to the bathroom will help prevent further ulceration but will not directly decrease the impaired skin integrity. (2) A turning and repositioning schedule for the staff should be on the chart, but it is not an appropriate expected outcome. (4) It is desirable for the family to bring in protein-rich food for the patient to help the ulcer heal, but that is not an expected outcome.

The nurse is collecting data from an older patient with a history of fractures who has just had gallbladder surgery. Along with a focused assessment, the nurse should include: A. determining orientation to person, place, and time. B. auscultating for a heart murmur. C. checking pulse oximetry. D. testing passive and active range of motion --------- Correct Answer ------- determining orientation to person, place, and time. *Determining orientation to person, place, and time in order to plan safe care for the patient is important since surgery in an older adult may cause electrolyte shifts that lead to more confusion and disorientation, which could cause a fall and another fracture. (2) Auscultating for a heart murmur is not pertinent to postoperative care by the LPN/LVN, as a health care provider would detect this before surgery. (3) Checking peripheral pulses is standard to the care of a postoperative patient and not pertinent to the potential risk for fracture in this patient at this time. (4) Testing active and passive range of motion is not pertinent to postoperative care after gallbladder surgery. When evaluating patient understanding regarding the use of an incentive spirometer, which statement confirms a need for more teaching? A. "I will inhale as deeply as possible each time I use the spirometer." B. "I need to tilt the incentive spirometer slightly to reduce effort." C. "To monitor progress, I will record the top volume achieved." D. "I need to seal my lips around the mouthpiece." --------- Correct Answer ------- "I need to tilt the incentive spirometer slightly to reduce effort." *Tilting the incentive spirometer is not a correct use of the device and indicates a need for further teaching. (1) Inhaling deeply with each use of the spirometer is correct. (3) Recording the top volume achieved helps record progress in lung reexpansion. (4) Sealing the lips around the mouthpiece is correct technique for the spirometer. When approaching a clinical problem, an important characteristic of a critical thinker is to A. rely on one's own family values in considering a problem B. Consider only data given in report C. Recognize one's own biases and limitations D. Read chart documentation and draw a conclusion --------- Correct Answer ------- Recognize one's own biases and limitations The focus of the planning step of the nursing process is A. implementing nursing interventions B. Collecting data to determine appropriate nursing diagnoses C. determining goals and identifying expected outcomes