Nursing Medication Administration Practices, Exams of Nursing

Download Nursing Medication Administration Practices and more Exams Nursing in PDF only on Docsity! ATI Skills 3.1EXAM | ACCURATE QUESTIONS AND DETAILED ANSWERS | GUARANTEED PASS | GRADED A | LATEST UPDATE 2024-2025 A nurse is preparing to obtain a blood sample from a client who has a triple-lumen central catheter in place. Which of the following actions should the nurse take? - ANSWER Turn off the distal infusion for 1 to 5 min before obtaining the blood sample. This ensures that the lab results will not be altered by the solution infusing through the central access device. A nurse in the ED is caring for a client who was in a motor-vehicle crash. The provider determines that the client needs immediate central venous access for fluid and blood replacement. Which of the following central venous access devices should the nurse anticipate being inserted. - ANSWER A non-tunneled percutaneous central catheter. A nurse is caring for a client who requires long-term central venous access and is an avid swimmer. Which of the following central venous access devices is the best choice for this client? - ANSWER An implanted port This entire device lies beneath the skin and the client can be immersed in water when the device is not in use without any increased risk for infection. A nurse is caring for a client who has an implanted port that needs to be accessed for an infusion. Which of the following action should the nurse take? - ANSWER Cover the device and the needle with a sterile transparent dressing. A nurse is caring for a client who has a central venous catheter and suddenly develops dyspena, tachycardia, and dizziness. The nurse suspects an air ebmolism and clamps the catheter immediately. The nurse should reposition the client into which of the Following positions - ANSWER On their left side in Trendelenburg position This helps trap air in the apex of the right atruim rather than allowing it to enter the right ventricle. A nurse is caring for a client who has a central venous catheter. When flushing the catheter, the nurse should use a 10-mL syringe to prevent which of the following complication associated with central vascular access devices? - ANSWER Catheter rupture A nurse is caring for a client who has a central venous catheter. Which of the following routine interventions should the nurse use to prevent lumen occlusion? - ANSWER Clamp the tubing before a syringe from the positive pressure end cap. This action maintains the positive pressure of the cap and prevents air from entering the line. The needle must be supported and anchored Mnemonic devices can help with memorization. - ANSWER True Which of the following multiple intelligences best describes an artist? - ANSWER Visual intelligence Kolb's model categorizeds learners based on how they take in and process information. - ANSWER True Which of the following hands-on strategies are most appropriate for an intuitive learner? - ANSWER Checking your work When a client is rising with two crutches, how does she stand? - ANSWER Client should place both crutches on the unaffected side while the other hand is on the bed rail to push up. Next, place a crutch under each arm. Then move the crutches 6 inches to the side and 6 inches forward to create crutch stance. Basically client repeats these steps when sitting such as moving the crutches to unaffected side and holding onto bed rail. Also remember crutches should never put pressure on axillae and elbows should be bent to 30 degrees. 4 Point gait (partial weight bearing): Think all four points touch the floor. Think all 4 points line up. – ANSWER 1. Move right crutch forward (6-10 inches) 2. Move left foot forward to meet left crutch 3. Move right foot forward to meet right crutch 4. Move right crutch forward 5. Repeat cycle **Numbers are different 6-12 inches in front or 6-10 inches but remember around this range. 3 point gait: (Pt cannot bear wt on one leg): 3 points on the ground - ANSWER 1. Move both crutches forward with weight on unaffected leg 2. Move unaffected leg forward shifting weight to the crutches 3. Repeat cycle 2 point gait: (partial wt bearing on both legs but needs less support than the 4 point gait). Think like 2 different points. - ANSWER 1. Move leg foot and right crutch at same time 2. Move right crutch and left foot at same time 3. Repeat cycle Swing to gait (bear wt on both legs = stability and arm strength) - ANSWER 1. Move both crutches forward 2. Lift both legs and swing forward next to crutches 3. Repeat cycle Swing-Through gait (bear wt on both legs w/good arm and shoulder strength) - ANSWER 1. Move crutches forward 2. Lift feet and wing through crutches w/feet in front of crutches 3. Repeat cycle When ambulating the client which side does the nurse stand on? - ANSWER Affected side Client rises by placing a hand on the bed rail and the other on the bed.. True or false: After grasping the walker, client moves unaffected leg with the walker. - ANSWER False: Client moves the affected leg with the walker Then she advances the unaffected leg to meet walker and opposite leg. Mechanical lift - ANSWER - HOB flat/client supine - Sling under client from shoulder to knees - Then raise HOB w/Pt's arm crossed and connect straps to lift As you're transferring a client from a bed to a chair, how should you position the chair in relation to the HOB? - ANSWER 45 degree angle When transferring a client from the bed to the chair, how should the client's feet be placed? - ANSWER Stronger side should be place in front of the weaker side. True or false: As you lower a client into a chair, your hips and knees should be flexed. - ANSWER True = lowers center of gravity in r/t object. Which movement would indicated full ROM of the shoulder? - ANSWER Flexing the shoulder by raising the arm from a side position to a 180 degree angle. A client who has a fractured lower extremity, body cast, or leg cast should use a regular bed pan or a fracture bed pan? - ANSWER Fracture bed pan because they are unable to lift their hips Therapeutic uses for an enema. - ANSWER Constipation, expel flatus, empty bowels prior to surgery, instill a medication, or initiate bowel training program. Types of enemas - ANSWER Return-flow (large- volume): container w/bag and a rectal tube attached. Admin. 100-200mL of fluid into rectum for peristalsis stimulation. After instillation, lower container for solution to flow back into the container. Repeat until flatus is expelled and abdominal distention subsides. Oil-retention (Small- volume) prepackaged container w/prefilled solution and rectal tip When administering an enema, "until clear means"? - ANSWER Repeat enema until fluid passes that is clear of fecal matter. Do NOT admin more than 3 times. Use normal saline as the solution When instilling a Return flow enema, the nurse administers 100 mL of fluid and then instructs the client to ____? - ANSWER Lower the container to allow the solution to flow back out. During the administration of a return-flow enema, how much fluid can be instilled into and out of the rectum? - ANSWER 100-200 mL When administering a retention enema the nurse should compress or release the container upon removal? - ANSWER Compress- prevents return of administered solution into the container. True or False: For a retention enema the client should hold the fluid for 15 minutes. - ANSWER False: For as long as the client can hold the fluid. Return-flow enema fluid should be flowed back into the container by ______. - ANSWER Holding the container below the level of the rectum Return-flow enemas can have instillation and return repeated up to ______ times or as prescribed by the HCP. - ANSWER 5-6 times Hypertoninc (fleet) enema should be retained for how long? - ANSWER Until she feels the urge to defecate in 2-5 min Tubes for enemas should be administered about _____ inches into the rectum. What direction should you point the tube? - ANSWER 3-4 inches (7.5- 10cm) and towards the umbilicus.. Remember have the patient only take a deep breath to feel more relaxed. Known as the patient's physiological response to the medication decreases after repeated administration. An increased dose of the med is required to achieve therapeutic benefit - ANSWER Drug Tolerance Known as includes intense feelings of craving for a substance, can be a factor in development of addiction. - ANSWER Drug Dependence Known as characterized by a psychological inability to stop taking the substance despite serious problems, such as loss of relationships and other important parts of a person's life - ANSWER Addiction Known as develops when a patient actually needs a drug physiologically to function - ANSWER Physical dependence Known as the s its noncommercial name of a drug. It only has one name used by all manufacturers. Until a patent expires this name and form cannot be manufactured and made for available use. It is more cost efficient. Also, is the same s its nonproprietary (noncommerical) name for e.g. acetaminophen is N- acetyl-para-aminophenol - ANSWER Generic name Known as the name its manufacturer gives the drug, thus one drug might have several names assigned by a different manufacturer. The name in which the drug is marketed. for e.g. Tylenol- trade, Acetaminophen- generic - ANSWER Trade or Brand name Med Error Define - ANSWER results in a patient receiving inappropriate medication therapy or failing to receive it as prescribed or intended. How long should it be before an incident, variance, or quality-assurance report be completed of a med a error? - ANSWER 24 hours True or false: The med error that is completed as an incident report, is documented into the client's record. - ANSWER False because it is to protect the nurse and the facility What are the components of a medication order? - ANSWER 1. Client's name 2. Date/Time 3. Drug name 4. Dose 5. Route 6. Frequency 7. Signature of HCP * Also, any special instructions. When taking a verbal order and transcribing it into the computer, the doctor has to sign it in what time frame? - ANSWER 24hrs As-needed orders, called PRN orders, are for medications administered only when needed or requested - ANSWER The prn order tells how frequently the medication may be given. standing or routine orders are given on a ______ basis. - ANSWER regular Single, one-time orders - ANSWER given prior to a procedure Means that you must give the prescribed drug immediately. - ANSWER STAT Less urgent that STAT orders and should be given within a 90-minute time frame or by the time frame mandated by specific facility policy - ANSWER Now orders List the six rights of medication administration - ANSWER 1. Right medication 2. Right dose 3. Right patient Have another nurse check the dose you will give. Teach the patient about possible adverse effects. Identify the patient by two acceptable methods. Confirm that the patient can swallow adequately. - ANSWER Identify the patient by two acceptable methods. ______ effect is an uncommon, unexpected, or individual drug response thought to result from a genetic predisposition. - ANSWER idiosyncratic effect Known as an adverse drug reaction caused by an excessive dose of a particular medication. - ANSWER Toxic effect Known as a result of the action of two medications combined, either to potentiate, block, or alter the effects of either or both drugs when used separately. These interactions are typically predictable and sometimes beneficial. - ANSWER synergistic effect Oral medication what do you do if a client refuses a medication? of course document reason why, but what about the med? - ANSWER Unopened package, return it to the storage area Wrapper removed, then discard med per hospital protocal A client should breath in or out as the Metered-dose inhaler is depressed? - ANSWER Inhale What is an important educational lesson after administering corticosteroids through a MDI? - ANSWER Rinse mouth out with warm water to prevent thrush Nasal drops admin - ANSWER 1. blow nose 2. lay supine and extend head backwards 3. Instill drops towards ethmoid bone 4. Instruct Pt to breath out of mouth during administration 5. Remain in a supine position for 5 min without blowing nose or sneezing. Nasal spray - ANSWER 1. Client sits upright and head is slightly hyperextended 2. Client will inhale via the nose while spraying * Do not use for prolonged periods or can lead to mucosal swelling and nasal congestion. NG Med admin forms. - ANSWER If a medication is not available in liquid form, you must first crush it or open the capsule and empty the powder or granules and then dissolve the medication in sterile water. In general, do not administer sustained-release, chewable, long-acting, or enteric-coated tablets and capsules through an NG or enteral tube NG Med admin steps (don't forget there is a separate module for NG insertion) - ANSWER Place client in high fowler's position Verify placement tube in stomach by checking gastric pH or *(Remember gold standard is X-ray)* Check gastric residual: use a 60-mL syringe, to the end of the nasogastric or enteral tube, aspirate contents. Return gastric contents to the stomach. If the aspirate is greater than 100 mL, follow the agency policy about returning contents to the stomach and administering medications. Flush with 15 mL of sterile water. Receiving a continuous feeding, do not mix the medications in the enteral feeding solution. Instead, stop the feeding for 30 minutes, give the medications, flush the tube with 15 to 30 mL (5 to 10 mL for pediatric patients) of sterile water and then resume the feeding after at least 30 minutes. After you administer medications, keep the head of the patient's bed elevated for at least 1 hour Keep a patent tube by flushing flush it with at least 15 to 30 mL (5 to 10 mL for pediatric patients) of sterile water before/after administering each medication and 15 to 30 mL (5 to 10 mL for pediatric patients) after you have given all the patient's medications. True or false: When instilling eye medications, place drops, ointments, and intraocular disks in the cornea. - ANSWER False: conjunctival sac (think the space of btwn lower lid and eye ball). Opthalmic med administration - ANSWER Supine or Fowler's position with neck slightly hyperextended Wipe away any drainage or discharge along eyelid margin or inner canthus. use a cotten ball to gently pull down the lower lid to expose conjunctival sac. Ask client to look upward. Move from inner canthus to outer canthus. Medicine tube should be 1/2 inch-3/4 inch (1-2cm) from the eye. Eye Ointment: Client should blink multiple times to help with absorption or massage eyelid in a circular motion.. Ointment may cause blurred vision for a short time Eye Drop: Close eyes after administration and wipe excess away If the medication has the potential to produce systemic effects, apply gentle pressure to the nasolacrimal duct for 30 to 60 seconds. Buccal - ANSWER Cheek Sublingual - ANSWER Under the tongue Rectal or vaginal suppositories should be refrigerated. - ANSWER When inserted into the rectum or vagina it melts as a result of the patient's body temperature and is thus distributed to rectal tissue. Administration of rectal suppository - ANSWER Position client in left lateral or left sim's position and needs to remain in this position for 5 min afterward to help ensure absorption Is this procedure aseptic or sterile?? You tell me!! Instill the medication by placing it past the internal anal sphincter and against the rectal mucosa, avoiding insertion into feces Client should relax and take deep breaths.. Do not bare down as could cause pressure on the anal sphincter True or False: Inserting an enema is aseptic technique - ANSWER True After a vaginal suppositories insertion, client should remain in supine position for _____ minutes - ANSWER 10 minutes When instilling a suppository in the vagina is the technique clean or sterile? - ANSWER Clean When a girl is menstruating, should she continue to apply the vaginal medication? - ANSWER Yes, advise them to continue using the medication even if they are actively menstruating Patients taking vaingal antifungal medications to abstain from _______ until they have completed the entire medication course and the infection has resolved. - ANSWER sexual intercourse Place the following steps in the order that reflects the proper use of a metered-dose inhaler (MDI). 1. Hold breath for 10 seconds. 2. Exhale slowly through pursed lips. 3. Place lips firmly around the mouthpiece. 4. Inhale deeply and then exhale completely. 5. Wait 30 to 60 seconds between each puff. 6. Breathe in slowly over 2 to 3 seconds while pushing down on the canister. - ANSWER 436125 Which of the following indicates the daughter of the older adult understood the teaching about instilling eye drops? "I will have my mother look down while dropping the medication into her eye." "I will instruct my mother to tightly close her eye for 30 to 60 seconds after the medication has been given. "I will instruct my mother to tightly close her eye for 30 to 60 seconds after the medication has been given. "I will pull down her lower eyelid and drop the medication inside." - ANSWER "I will pull down her lower eyelid and drop the medication inside." *remember client should gently close her eye* NG tube administration you raise or lower the syringe? - ANSWER Raise- facilitate instillation, raise the syringe up to 18 inches from the insertion site. How do you admin NG tube meds? - ANSWER infusing each medication by gravity and flushing with water before and after instillation. *Remember tube feedings have to stop 30 min prior to med admin. Pt refuses to take his med because it makes him nauseated. What is the correct way to indicate the refusal? Choose the correct answer below. A. document the reason for refusal along with the date and time in the patient's medical record. B. notify the primary care provider that the patient refused to take the medication. - ANSWER A. document the reason for refusal along with the date and time in the patient's medical record. With NG tube placement assessment which of the following is NOT an accurate method? A. Correct tube placement by inserting air into tube while auscultating at gastric fundus B. Amount of residual volume left in stomach - ANSWER A. Correct tube placement by inserting air into tube while auscultating at gastric fundus More medication is delivered to the lungs when you use a spacer." because it acts like a propellent. - ANSWER A spacer slows down and breaks up the medication, allowing the patient to better control the flow of medication. This, in turn, decreases the amount of medication deposited in the oropharynx. DPI is is important to assess? - ANSWER Client's ability to inhale deeply because there is no spacer which is the propellent. Insert the needle at a point two to three finger widths (1 to 2 inches) below the acromion process, above the axillary line in the lateral aspect of the arm. ATI says ____ mL per 10 seconds for Im injection. - ANSWER 1mL Intradermal Injection sites - ANSWER Appropriate sites are the inner forearm and the upper back. For skin testing, examine the site to ensure that it is free of lesions and hair, as these might interfere with accuracy when reading the results. tuberculin or other small syringe (1 mL or smaller) with a ½- to ⅝-inch, 25- to 27-gauge needle for _______ injection. - ANSWER Intradermal What is the angle for intradermal injection? - ANSWER Pull the patient's skin so that it is taut and insert the needle at a 5º to 15º angle, almost parallel to the patient's skin and with the bevel facing up. Administering an intradermal injection. - ANSWER at a 5-15 degree angle and parallel to the client's skin. The needle will be visible under the skin; insert it about 1/8 inch. Give the injection slowly while observing the site for blanching and for the appearance of a wheal. After you have injected all of the medication, withdraw the needle slowly and gently apply dry gauze. Do not massage the site. Bleeding or no wheal formation at the injection site indicates that the injection was given incorrectly. True or false: Subcutaneous injections are absorbed slower. - ANSWER True: Subcutaneous tissue is less vascular than muscle is, so medication deposited in subcutaneous tissue is absorbed somewhat slower. Subcutaneous injection sites - ANSWER Most commonly selected are the upper outer aspect of the arm, the abdomen (at least 2 inches from the umbilicus), and the anterior thighs. The scapular area and the upper ventrodorsal gluteal area can also be used. Administering a subcutaneous injection. - ANSWER Do not administer more than 1.5 mL with a single subcutaneous injection. Use a 25- to 31-gauge, ⅝-inch needle if inserting at a 45- degree angle or ½-inch needle if inserting at a 90-degree angle. Rotate sites with each injection.you can pinch 2 inches (5 cm) of skin, insert the needle at a 90-degree angle. If you can pinch 1 inch (2.5 cm) of skin, insert the needle at a 45-degree angle. ventrogluteal muscle site - ANSWER Greater trochanter with heel of hand on it, thumb towards abdomen, index finger up towards anterior, superior iliac spine, and spread other fingers among iliac crest. Your patient asks why insulin is injected subcutaneously. Which of the following is an appropriate response? - ANSWER Medication absorption is slower from subcutaneous tissue, an important factor in the effectiveness of insulin therapy. The subcutaneous layer has a relatively poor vascular system. It is the abundance of the vascular supply that is the primary factor in the speed with which medication enters into the bloodstream (the absorption rate). You discuss that insulin requires the use of a specific syringe called an insulin syringe - ANSWER while a 1-mL syringe called a tuberculin syringe may be used for other medications given subcutaneously The term intradermal means that the fluid must be injected - ANSWER into the skin where the blood supply is minimal. When disposing of a syringe - ANSWER Never recap a needle that has been in contact with a patient, but when you recap a needle after drawing medication into the syringe, use a one- hand scoop technique to get the cap back onto the needle. Deltoid injection volume per ati guidelines - ANSWER The deltoid can handle medication volumes of 3 mL or less. Limited movement is contraindicated for ___ injection. - ANSWER IM injection. You should avoid the deltoid muscle when a patient is not capable of unrestricted movement because immobility will negatively affect the rate of absorption and possibly result in unnecessary pain at the site. Which method is appropriate for IM injection - ANSWER Z track method Measure a handbreadth above the knee and a handbreadth below the greater trochanter is locating which landmark? - ANSWER Vastus lateralis Measure two fingerbreadths below the acromion process is locating which landmark? - ANSWER The deltoid muscle Ventrogluteal muscle injection - ANSWER Use a 11/2-inch needle for most adults when giving an intramuscular injection in the ventrogluteal area Parenteral means - ANSWER medication is given by injection. True or False: Administer no more than 2 mL per injection. - ANSWER False: No more than 1 mL should be administered with a single subcutaneous injection. Types of Enteral feeding tubes - ANSWER Tube feedings are usually administered through a soft, small-caliber nasogastric or nasointestinal tube for short-term therapy (less than 4 weeks) or a gastrostomy or jejunostomy tube for longer-term therapy. Occasionally, an orogastric tube, placed from the mouth to the stomach, is used for premature infants, mechanically ventilated patients, and those with a history of craniofacial surgery or trauma. Sizes of small-bore nasogastric feeding tubes are 6 to 12 French (Fr) for adults. patient is undergoing a surgical procedure known to present challenges to nutritional intake, such as head and neck surgery, the feeding tube may be inserted in the surgical suite. Which types of feeding tubes may be inserted? - ANSWER Gastrostomy and jejunostomy tube placement Do not advance an NG tube during _____ or _____ because it will enter _____. - ANSWER *Inhalation or coughing because it will enter the respiratory tract* Do not force the tube. If patient starts to cough or has a drop in oxygen saturation or an increased CO2, withdraw tube into the posterior nasopharynx until normal breathing resumes. You want to advance the tube each time the client swallows. During insertion of NG tube, if the tubing becomes coiled, then what is the appropriate action? - ANSWER You pull back on the tube until it becomes taunt and then reinsert it. Formula should be at room temperature to prevent ___? - ANSWER Gastric cramping Question the HCP about ___ mL or more of residual before beginning the tube feeding. - ANSWER Plan to withhold feedings for residual volumes of greater than 500 mL or when two consecutive measurements (taken 1 hour apart) each exceed 250 mL. You explain to the patient that her physician has prescribed a small-bore nasogastric tube because - ANSWER t is best suited for short-term enteral feeding therapy. This is the primary reason for selection, since a small-bore nasogastric tube is appropriate for therapy lasting less than 4 weeks. With NG tube placement, you explain to the client and her parents that she will be recieving which type of feeding? - ANSWER Polymeric formula- This formula provides whole nutrients to this patient who has an intact and functioning gastrointestinal tract. After reviewing the physician orders, you hang the feeding bag and tubing on the pole. You know that prior to initiating the feeding you should.. fill the bag with only enough formula to last over a 4-hour period. keep the formula in the refrigerator until just before feeding begins. notify the physician if bowel sound are decreased prior to starting tube feeding. - ANSWER fill the bag with only enough formula to last over a 4-hour period. You begin the continuous feeding using a feeding pump. You know that management of continuous enteral feeding includes changing the feeding bag every 72 hours. flushing the tube with 30 mL of water every 4 hours to prevent clogging. checking residual volumes every 12 hours. - ANSWER flushing the tube with 30 mL of water every 4 hours to prevent clogging. The tube should be flushed at least every 4 hours during continuous feeding. This can be done manually, or many pumps can be programmed to flush the tube. residual volumesshouold be checked every 4 to 6 hours during continuous feeding. The bag should be changed every 24 hours to prevent bacterial contamination. To facilitate the insertion of the NG tube, you should___. instruct the patient to swallow during tube insertion. have the patient extend head after the tube has passed through nasopharynx. apply gentle force when meeting resistance. - ANSWER instruct the patient to swallow during tube insertion. You have selected the correct response. Swallowing, especially by sipping water, closes the epiglottis over the trachea and thus helps direct the tube to the esophagus rather than to the airways. To determine the length of tube that will achieve the proper insertion depth, you - ANSWER use the tube to measure the distance from the patient's naris to his ear lobe to the tip of his xiphoid process. To minimize the risk of trauma and discomfort for the patient when removing the NG tube, you... slowly rotate the tube 180 degrees while pulling back on it. using the pull-pause method to remove the tubing gradually. fold the tube onto itself while quickly pulling back on it. - ANSWER fold the tube onto itself while quickly pulling back on it. You have selected the correct response. Folding the tube prevents tube contents from draining into the patient's oropharynx. Quick removal minimizes discomfort. d. Sterile state is questionable (e.g., when you find a tear or break in the covering of a sterile object). Discard it regardless of whether the object itself appears untouched. 2. Only sterile objects may be placed on a sterile field. All items are properly sterilized before use. Sterile objects are kept in clean, dry storage areas. The package or container holding a sterile object must be intact and dry. A package that is torn, punctured, wet, or open is considered unsterile. 3. A sterile object or field out of the range of vision or an object held below a person's waist is contaminated. Nurses never turn their back on a sterile field or tray or leave it unattended. Contamination can occur accidentally by a dangling piece of clothing or an unknowing patient touching a sterile object. Any object held below waist level is considered contaminated 468because it cannot be viewed at all times. Keep sterile objects in front with the hands as close together as possible. 4. A sterile object or field becomes contaminated by prolonged exposure to air. Avoid activities that create air currents such as excessive movements or rearranging linen after a sterile object or field becomes exposed. When you open sterile pac Pouring Sterile Solutions - ANSWER A bottle containing a sterile solution is sterile on the inside and contaminated on the outside; the neck of the bottle is also contaminated, but the inside of the bottle cap is considered sterile. After you remove the cap or lid, you hold it in your hand or place its sterile side (inside) up on a clean surface. This means that you are able to see the inside of the lid as it rests on the table surface. Never rest a bottle cap or lid on a sterile surface, even though the inside of the cap is sterile. The outer edge of the cap is unsterile and contaminates the surface. Placing a sterile cap down on an unsterile surface increases the chances of the inside of the cap becoming contaminated. Hold the bottle with its label in the palm of the hand to prevent the possibility of the solution wetting and fading the label. Before pouring the solution into the container, pour a small amount (1 to 2 mL) into a disposable cap or plastic-lined waste receptacle. Donning PPE - ANSWER 1. gown 2. mask 3. goggles 4. gloves Doffing PPE - ANSWER 1. gloves 2. goggles 3. gown 4. mask After completing a procedure that required donning PPE of a gown, N95 respirator, face shield, and gloves which of the following should the nurse remove first when removing PPE safely? - ANSWER Gloves Irrigating an open wound... besides gloves, which other PPE must you wear? A. sterile gown B. goggles C. N95 respirator D. face shield - ANSWER A face shield protects the face, mouth, nose, and eyes from any potential splashes of blood or other body fluids. Irrigating a wound certainly has the potential for splashing irrigating fluid containing blood, body fluids, and tissue particles onto your face. Pt Dx with mycoplasma pneumonia. Droplet precautions have been instituted, so you must ____. A. Wear a respirator B. Protect your eyes C. Use an air filter D. Wear shoe covers - ANSWER Protect your eyes. Droplet transmission involves contact of infectious, large-particle droplets with the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person. Droplets are generated by the patient during coughing, sneezing, or talking, and during procedures such as suctioning and bronchoscopy. Contact precautions would be mandated for a client Dx with? A. Hep B B. Measles C. Meningitis D. Infectious diarrhea - ANSWER Infectious diarrhea Measles transmission - ANSWER Airborne Meningitis transmission - ANSWER Droplet Hepatitis B transmission - ANSWER Standard precautions which of the following is an advantage of using alcohol-based gel? - ANSWER Its use takes less time than washing with soap and water does How many inches of above the site do you place a tourniquet? - ANSWER Place the tourniquet above the antecubital fossa or approximately 4 to 6 inches (10 to 15 centimeters) above the anticipated site. Do you use heat (warm) or cold when it is hard to find a well-dilated vein for IV insertion? - ANSWER Heat (warm) place a warm blanket or towel on the extremity for a couple of minutes. extension IV tubing - ANSWER a short piece of IV tubing that has a male adapter at one end and a female adapter at the other (used to extend length of primary tubing; may have features such as stopcock, ports etc...) Primary Tubing - ANSWER primary tubing, this long piece of tubing has several components attached: the spike, the drip chamber, the roller clamp, the syringe tip and locking collar, and medication ports IV Circulatory overload - ANSWER causes excess fluid in the circulatory system. The characteristics of circulatory overload include dyspnea, elevated blood pressure, edema in dependent areas, and moist breath sounds when auscultating the lungs. Removing an IV cather always make sure you do which step for safety reasons? - ANSWER Once you have removed the catheter, inspect the catheter's tip to be sure that it is intact. If it is not intact, notify the provider immediately. A catheter that broke off in the vein has the potential to cause an embolus. To limit the movement of the embolus, apply a tourniquet high on the extremity where the IV line was located and follow your facility's policy for further intervention. Also, you may need to assess for infection. IV cathether insertion is at which angle? - ANSWER 10-30 angle When you get a back flash of blood, you know the IV catheter is in the vein.. What is the next step? - ANSWER Lower the IV catheter until it is flush with the skin and advance it a 1/4 (0.25) of an inch more. Which of the following criteria should you use to determine the type of vascular access device to use for this patient? - ANSWER Type of fluid ordered and length of expected IV therapy You determine that you will need IV access for this patient for 1 to 3 days and that the fluid to be infused is neither caustic nor viscous. Which of the following devices should you prepare to insert? - ANSWER A short peripheral catheter You determine that you will need IV access for this patient for 1 to 3 days and that the fluid to be infused is neither caustic nor viscous. Which of the following devices should you prepare to insert? True or false: IV insertion is a sterile procedure - ANSWER False If 1,000 ml of IV fluid starts infusing at 100 mL per hour at 1200 (12:00 noon), you must be prepared to hang the next liter (1,000 mL) of fluid at approximately what time? A.1800 B.2000 C.2200 - ANSWER C. 2200 IV: You tell the patient that you will assess her infusion often. But, because she is alert and competent, you also ask her to notify staff immediately if the site dressing becomes - ANSWER Damp This indicates that the hub is loose or has become detached from the tubing or that the site itself is leaking IV solution. These situations require immediate attention. To monitor the patient for fluid overload postoperatively, you assess the patient frequently for - ANSWER abnormal breath sounds and difficulty breathing. A pale, cool IV insertion site that is both tender and edematous most likely indicates that the patient has developed - ANSWER infiltration. After finding the patient's IV insertion site pale and cool, your first step is to - ANSWER Disontinue the infusion- You must stop the infusion to prevent any additional fluid from entering into the tissue surrounding the site. When discontinuing an IV infusion, you should minimize the patient's risk for infection by - ANSWER covering the venipuncture site with a sterile dressing