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PN 4006 FINAL STUDY QUIZZES
The nurse is preparing to assist with a sterile procedure in the surgical suite. Which of the following is an appropriate technique that the nurse includes in the surgical scrub? Select one: a. Keeping the hands below the elbows throughout the scrub b. Using a brush on the palms and dorsal surface of the hands c. Maintaining a scrub for two to six minutes d. Washing well around all artificial nails - Answers :c. Maintaining a scrub for two to six minutes Which one of the following indicates that the nurse is using surgical aseptic technique? Select one: a. Inserting an intravenous catheter b. Placing soiled linen in moisture-resistant bags c. Disposing of syringes in puncture-proof containers d. Washing hands before changing a dressing - Answers :a. Inserting an intravenous catheter Droplet precautions will be instituted for the client admitted to the infectious disease unit with which of the following conditions? Select one: a. Influenza b. C. difficile c. Pulmonary tuberculosis d. Measles - Answers :a. Influenza A client with active tuberculosis is admitted to the medical center. The nurse recognizes that which of the following types of precautions will be required upon admission of this client? Select one: a. Airborne precautions b. Droplet precautions c. Contact precautions d. Reverse isolation - Answers :a. Airborne precautions The parent of a preschool child asks the nurse how chickenpox (caused by the varicella-zoster virus) is transmitted. The nurse explains which of the following about the virus? Select one:
a. It is carried by a vector organism. b. It is carried though the air in droplets after sneezing or coughing. c. It is transmitted through person-to-person contact. d. It is acquired through contact with contaminated objects. - Answers :b. It is carried though the air in droplets after sneezing or coughing. The nurse recognizes the appropriate procedures for sterile asepsis. Of the following, which action is consistent with sterile asepsis? Select one: a. Clean forceps may be used to move items on the sterile field. b. Sterile fields may be prepared well in advance of the procedures. c. The first small amount of sterile solution should be poured and discarded. d. Wrapped sterile packages should be opened starting with the flap closest to the nurse. - Answers :c. The first small amount of sterile solution should be poured and discarded. The nursing assistant is learning how to use protective equipment when caring for a client in isolation. The nursing assistant is instructed in the correct sequence for putting on the protective equipment. Which of the following describes the correct sequence? Select one: a. Wash her hands, apply the mask and eyewear, put on the gown, and then apply gloves. b. Apply the mask and eyewear, put on the gown, wash her hands, and then apply gloves. c. Wash her hands, put on the gown, apply gloves, and then put on mask and eyewear. d. Put on the gown, apply the mask and eyewear, wash her hands, and then apply gloves. - Answers :a. Wash her hands, apply the mask and eyewear, put on the gown, and then apply gloves. The nurse is aware that it is important to break the chain of infection. Which of the following is an example of a nursing intervention implemented to reduce a reservoir of infection for a client? Select one: a. Covering the mouth and nose when sneezing b. Wearing disposable gloves c. Isolating the client's articles d. Changing soiled dressings - Answers :d. Changing soiled dressings The client requires a sterile dressing change. Which of the following is an appropriate intervention for the nurse to implement in maintaining sterile asepsis? Select one: a. Put sterile gloves on before opening sterile packages.
Which of the following is an unexpected value that the nurse, in reviewing the results of the client's blood work, should report to the physician? Select one: a. Calcium, 1.9 mmol/L b. Sodium, 140 mmol/L c. Potassium, 3.5 mmol/L d. Magnesium, 1.8 mmol/L - Answers :a. Calcium, 1.9 mmol/L A client has intravenous (IV) therapy for the administration of antibiotics and is stating that the IV site "hurts and is swollen." Which of the following information assessed on the client indicates the presence of phlebitis, as opposed to infiltration? Select one: a. Intensity of the pain b. Warmth of integument surrounding the IV site c. Amount of subcutaneous edema d. Skin discoloration of a bruised nature - Answers :b. Warmth of integument surrounding the IV site Which of the following is the most common electrolyte imbalance? Select one: a. Hypokalemia b. Hyperkalemia c. Hyponatremia d. Hypernatremia - Answers :a. Hypokalemia The nurse will be starting a new intravenous (IV) infusion and needs to select the site for the insertion. In selecting a site, the nurse should do which of the following? Select one: a. Start with the most distal site. b. Look for hard, cord-like veins. c. Use the dominant arm. d. Vigorously rub and tap the chosen vein. - Answers :a. Start with the most distal site. The client is receiving an epidural opioid infusion for pain relief. Which one of the following is a priority nursing intervention when caring for this client? Select one: a. Use aseptic technique. b. Label the port as an IV catheter. c. Monitor vital signs every 15 minutes.
d. Prepare the client for discomfort he or she may encounter. - Answers :c. Monitor vital signs every 15 minutes. A 17-year-old postoperative client is laughing with friends. Soon after they leave, he tells the nurse he is experiencing pain and asks for something for pain. What does the nurse understand about this situation? Select one: a. Teenagers will try to obtain narcotics by faking pain. b. Distraction reduces pain awareness. c. Postoperative pain comes on suddenly. d. Clients who are able to laugh are not really experiencing pain. - Answers :b. Distraction reduces pain awareness. Upon entering the client's room, the nurse discovers that the client is experiencing acute pain. Which of the following is an expected assessment finding for this client? Select one: a. Bradycardia b. Bradypnea c. Diaphoresis d. Decreased muscle tension - Answers :c. Diaphoresis A terminally ill client with liver cancer is experiencing great discomfort. Which of the following is a realistic goal in caring for this client? Select one: a. Increasingly administer narcotics to oversedate the client and thereby decrease the pain. b. Continue to change the analgesics until the right narcotic is found that completely alleviates the pain. c. Adapt the analgesics as the nursing assessment reveals changes in client condition and pain. d. Withhold analgesics as they are not being effective in relieving discomfort. - Answers :c. Adapt the analgesics as the nursing assessment reveals changes in client condition and pain. The nurse consults with the primary physician of a client who is experiencing continuous, severe pain. In planning for the client's treatment, the nurse is aware of the principles of pain management. Which of the following is it appropriate for the nurse to expect treatment to include? Select one: a. Focusing on intramuscular administration of analgesics b. Waiting for pain to become more intense before administering opioids c. Administering opioid with non-opioid analgesics for severe pain experiences
In determining the client's urinary status, which of the following does the nurse anticipate the urinary output for an average adult should be? Select one: a. 800 to 1000 mL per day b. 1000 to 1200 mL per day c. 1500 to 1600 mL per day d. 2000 to 2300 mL per day - Answers :c. 1500 to 1600 mL per day A timed urine specimen collection is ordered. The test will need to be restarted if which one of the following occurs? Select one: a. The client voids in the toilet. b. The urine specimen is kept cold. c. The first voided urine is discarded. d. The preservative is placed in the collection container. - Answers :a. The client voids in the toilet. The client has an indwelling catheter. How should the nurse obtain a sterile urine specimen? Select one: a. Disconnect the catheter from the drainage tubing. b. Withdraw urine from a urinometer. c. Open the drainage bag and remove urine. d. Use a needle to withdraw urine from the catheter port. - Answers :d. Use a needle to withdraw urine from the catheter port. The client is going to have a cystoscopy. Which of the following statements or questions reflects the correct information that should be taught or obtained before the procedure? Select one: a. "Are you allergic to iodine?" b. "There will be no need to have a special consent form." c. "You will need to have fluids restricted the evening before the cystoscopy." d. "You will probably be given sedatives before the procedure." - Answers :d. "You will probably be given sedatives before the procedure." A condom catheter is to be used for an adult male client in the extended care facility. Which of the following techniques is appropriate for the nurse to use in applying the condom catheter? Select one: a. Using sterile gloves
b. Wrapping the adhesive tape securely around the base of the penis c. Leaving a 2.5- to 5-cm space between the tip of the penis and the end of the catheter d. Taping the tubing tightly to the thigh and attaching the drainage bag to the bed frame
- Answers :c. Leaving a 2.5- to 5-cm space between the tip of the penis and the end of the catheter A client in the hospital has an indwelling urinary catheter, and the nurse is instructing the nursing student in the appropriate care to provide. Which one of the following does the nurse teach the student to do? Select one: a. Empty the drainage bag at least q8h. b. Cleanse up the length of the catheter to the perineum. c. Use sterile technique to obtain a specimen for culture and sensitivity. d. Place the drainage bag on the client's lap while transporting the client to testing. - Answers :a. Empty the drainage bag at least q8h. An order is written for the client's indwelling urinary catheterization to be discontinued. While observing the new staff nurse providing care to this client and implementing the prescriber's order, the unit manager determines that further instruction about catheter removal is required for the new nurse if he or she does which one of the following? Select one: a. Drapes the female client between the thighs b. Obtains a specimen before removal c. Cuts the catheter to deflate the balloon d. Checks the client's output for 24 hours after removal - Answers :c. Cuts the catheter to deflate the balloon Which one of the following measures should be included in a bladder-retraining program for a client in an extended care facility? Select one: a. Providing negative reinforcement when the client is incontinent b. Having the client wear adult diapers as a preventive measure c. Initiating a voiding schedule d. Promoting the intake of caffeine to stimulate voiding - Answers :c. Initiating a voiding schedule The nurse is caring for clients on a postoperative unit in the medical centre. The nurse is alert to the possibility that for 24 to 48 hours of the postoperative period, clients may experience which of the following symptoms as a result of the anesthetic used during the surgery? Select one: a. Colitis
When turning a client, the nurse notices a reddened area on the coccyx. Which of the following skin care interventions should the nurse use on this area? Select one: a. Clean the area, dry it, and add a protective moisturizer. b. Apply a diluted hydrogen peroxide and water mixture, and use a heat lamp on the area. c. Soak the area in normal saline solution. d. Wash the area with an astringent and paint it with povidone-iodine (Betadine). - Answers :a. Clean the area, dry it, and add a protective moisturizer. Which of the following information about how smoking influences healing does the nurse include when planning a program on wound healing? Select one: a. Smoking suppresses protein synthesis. b. Smoking creates increased tissue fragility. c. Smoking depresses bone marrow function. d. Smoking reduces the amount of functional hemoglobin in the blood. - Answers :d. Smoking reduces the amount of functional hemoglobin in the blood. The client is scheduled for a dressing change. When removing the adhesive tape used to secure the dressing, the nurse should lift the edge and hold the tape in which manner? Select one: a. At a 45-degree angle to the skin surface while pulling away from the dressing b. At a right angle to the skin surface while pulling toward the dressing c. At a right angle to the skin surface while pulling away from the dressing d. Parallel to the skin surface while pulling toward the dressing - Answers :d. Parallel to the skin surface while pulling toward the dressing The client tells the nurse, "Blowing into this tube thing (incentive spirometer) is a ridiculous waste of time." Which one of the following does the nurse tell the client is the specific purpose of using an incentive spirometer? Select one: a. It directly removes excess secretions from the lungs. b. It increases pulmonary circulation. c. It promotes optimal lung expansion. d. It stimulates the cough reflex. - Answers :c. It promotes optimal lung expansion. The nurse is completing the preoperative checklist for an adult female client who is scheduled for an operative procedure later in the morning. Which preoperative assessment finding for this client indicates a need to contact the surgeon?
Select one: a. Hgb, 90 g/L b. Creatinine 50 μmol/L c. BUN 3.0 mmol/L d. Platelets 200 × 10 - Answers :a. Hgb, 90 g/L The client will have an incision in the lower left abdomen. Which of the following measures by the nurse will help decrease discomfort in the incisional area when the client coughs postoperatively? Select one: a. Applying a splint directly over the lower abdomen b. Keeping the client flat with feet flexed c. Turning the client onto the right side d. Applying pressure above and below the incision - Answers :a. Applying a splint directly over the lower abdomen The nurse is completing the preoperative checklist for an adult client who is scheduled for an operative procedure later in the morning. Which preoperative assessment finding for this client indicates a need to contact the anesthesiologist? Select one: a. Temperature, 39ºC b. Pulse, 90 beats per minute c. Respiration, 20 breaths per minute d. Blood pressure, 130/74 - Answers :a. Temperature, 39ºC The nurse is working in a postoperative care unit in an ambulatory surgery center. Of the following clients that have come to have surgery, which one is at the greatest risk during surgery? Select one: a. A 78-year-old taking an analgesic agent b. A 43-year-old taking corticosteroids c. A 27-year-old taking an anticoagulant agent d. A 10-year-old taking an antibiotic agent - Answers :c. A 27-year-old taking an anticoagulant agent After discharge from the PACU, the client returned to the surgical nursing unit at 10: A.M. It is now 11:30 A.M. and the client is not experiencing any complications or difficulties. How often should the nurse plan to measure the client's vital signs? Select one: a. Every 15 minutes b. Every 30 minutes
Select one: a. 15 degrees b. 30 degrees c. 45 degrees d. 90 degrees - Answers :a. 15 degrees The nurse is administering an injection at the ventrogluteal site. Upon aspiration, the nurse notices that there is blood in the syringe. Which of the following actions should the nurse take? Select one: a. Inject the medication. b. Pull the needle back slightly and inject the medication. c. Move the skin to the side and inject the medication slowly. d. Discontinue the injection and prepare the medication again. - Answers :d. Discontinue the injection and prepare the medication again. A medication is prescribed for the client and is to be administered by intravenous (IV) bolus injection. Which of the following is a priority for the nurse before administering the medication via this route? Select one: a. Set the rate of the IV infusion. b. Check the client's mental alertness. c. Confirm placement of the IV line. d. Determine the amount of IV fluid to be administered. - Answers :c. Confirm placement of the IV line. Which of the following actions must the nurse take in preparing two different medications from two vials? Select one: a. Inject fluid from one vial into the other. b. Uncap the syringe and wipe the needle with an alcohol preparation before inserting into either vial. c. Discard the medication from vial number two if medication from vial number one is pushed into it. d. Insert air into the first vial, but not the second vial. - Answers :c. Discard the medication from vial number two if medication from vial number one is pushed into it. The nurse administers the intramuscular medication of iron by the Z-track method. Why was this method used? Select one: a. To provide faster absorption of the medication b. To reduce discomfort from the needle
c. To provide a more even absorption of the drug d. To prevent the drug from irritating sensitive tissue - Answers :d. To prevent the drug from irritating sensitive tissue A client on the medical unit receives regular insulin at 7:00 A.M. The nurse is alert to a possible hypoglycemic reaction by which time? Select one: a. 7:30 A.M. b. 10:00 A.M. c. 4:00 P.M. d. 8:00 P.M. - Answers :b. 10:00 A.M. Which of the following is the most effective way in the acute care environment to determine the client's identity before administering medications? Select one: a. Ask the client's name. b. Check the name on the chart. c. Ask the other caregivers. d. Check the client's name band. - Answers :d. Check the client's name band. The nurse completes preparation of the sterile field to change a patient's dressing when the patient's dinner tray arrives. Which action should the nurse take? Select one: a. Use the sterile field on another patient in another room. b. Change the dressing using clean technique to save time. c. Set the tray aside and proceed with the dressing change. d. Cover the setup with a sterile drape and let the patient eat. - Answers :c. Set the tray aside and proceed with the dressing change. The nurse is getting ready to provide a sterile dressing change. Which nursing action is consistent with principles used to prepare a sterile field? Select one: a. Identify that items below waist height are contaminated. b. Use opened packages of dressing supplies within the same shift. c. Identify that sterile drapes have a 5.08 cm 2-inch contaminated border. d. Replace bottle caps if the inside of the cap is not touched. - Answers :a. Identify that items below waist height are contaminated. The nurse helps the health care provider get supplies and monitor the patient during an emergency insertion of a femoral line at the patient's bedside. Which nursing behavior helps to maintain the sterile environment?
The nurse teaches the patient handwashing before discharge and asks for a return demonstration. Which hand hygiene technique indicates that patient teaching by the nurse is effective? Select one: a. The patient washes hands with running water. b. Soap, water, and friction are used by the patient. c. The patient washes hands with very hot water. d. A basin with warm soapy water is used. - Answers :b. Soap, water, and friction are used by the patient. The nurse is performing a neurological assessment. Which patient behaviors demonstrate a level of consciousness within normal limits? Select one: a. States name, age, and date but not location b. Is lethargic; responds logically to questions c. Responds verbally, but words are unintelligible d. Opens eyes spontaneously; is alert and oriented - Answers :d. Opens eyes spontaneously; is alert and oriented A female patient needs to provide a midstream-voided urine specimen for examination. What teaching by the nurse would provide a valid specimen? Select one: a. Use a clean specimen cup for testing. b. Collect at least 125 to 150 mL of urine. c. Wash the perineal area with soap and water. d. Void some urine and then collect the sample. - Answers :d. Void some urine and then collect the sample. A patient is unable to void on demand for a clean-voided specimen. What is the appropriate action by the nurse? Select one: a. Notify the provider that the patient has anuria. b. Palpate the suprapubic area for retained urine. c. Catheterize the patient to obtain the urine specimen. d. Offer fluids, if allowed, and wait about 30 minutes. - Answers :d. Offer fluids, if allowed, and wait about 30 minutes. The patient notices that the newly formed ileostomy stoma is pinkish red and slightly puffy. Which information should the nurse include during patient teaching? Select one: a. This is what a new healthy stoma looks like.
b. Any bleeding indicates that a problem is present. c. Healthy stomas are usually pale pink and flat. d. There should be very little drainage from the stoma. - Answers :a. This is what a new healthy stoma looks like. The home health nurse pouches an enterostomy for a patient with serious financial constraints. What should the nurse recommend to the patient about his ostomy care? Select one: a. Use soap and warm water for peristomal cleansing. b. Leave the pouch in place for 3 to 7 days. c. Place several pin holes in the pouch for flatus to escape. d. Use a firm pouching system on a round, hard abdomen. - Answers :b. Leave the pouch in place for 3 to 7 days. The nurse evaluates the effluent from the patient's new ileostomy. What does the nurse expect the effluent to look like immediately after surgery? Select one: a. Formed stool b. Stool that is like thick liquid c. Watery stool d. Semiformed stool - Answers :c. Watery stool A patient with an ascending colostomy made as a result of abdominal trauma 4 days ago closes his eyes during stoma care. What patient outcome is most important for the nurse to help the patient achieve? Select one: a. The patient needs no assistance to perform this procedure within a few days. b. The patient will ask questions about what clothing he can wear before discharge. c. The patient touches the stoma while looking at it within the next 2 days. d. The patient's family learns how to pouch his stoma within 1 week. - Answers :c. The patient touches the stoma while looking at it within the next 2 days. A patient is hesitant to look at his stoma 2 days after colostomy surgery. Which is the best response by the nurse to the patient? Select one: a. "I see that you don't want to look at the stoma, but it looks good for a new colostomy." b. "I'll teach stoma care to each family member before you leave the hospital." c. "I'll explain everything I do in great detail in case you want to know." d. "You know you must look at it eventually; so let's look together now." - Answers :a. "I see that you don't want to look at the stoma, but it looks good for a new colostomy."
c. Aspirate before injecting to ensure that the needle is not in a vessel. d. Instruct the patient to use an insulin syringe with a 1-inch needle. - Answers :a. Insert the needle into abdominal tissue at 90-degree angle. The nurse instructs a patient's partner to administer subcutaneous regular Humulin insulin. What information should the nurse include in the partner's teaching? Select one: a. Select a 25-gauge, 5/8-inch needle. b. Massage the site after the injection. c. Always insert the needle at a 90-degree angle. d. Use a different injection site each time. - Answers :a. Select a 25-gauge, 5/8-inch needle. The nurse prepares an insulin injection for the patient who has diabetes mellitus. Which does the nurse implement for correct insulin administration? Select one: a. Gives regular insulin within 15 to 30 minutes of meals b. Injects insulin just removed from the refrigerator c. Examines vials of NPH insulin for abnormal cloudiness d. Administers NPH insulin for sliding-scale insulin dosing - Answers :a. Gives regular insulin within 15 to 30 minutes of meals The nurse prepares to administer 2.2 mL of an oil-based medication intramuscularly to a male patient who is 5 feet 10 inches tall and weighs 165 pounds. Which needle and syringe combination should the nurse choose to administer the injection? Select one: a. 20-gauge, 1 1/2-inch needle on a 3-mL syringe b. 21-gauge, 1 1/2-inch needle on a 5-mL syringe c. 23-gauge, 1-inch needle on a 3-mL syringe d. 25-gauge, 1-inch needle on a 5-mL syringe - Answers :a. 20-gauge, 1 1/2-inch needle on a 3-mL syringe The nurse is preparing to administer the anticoagulant enoxaparin (Lovenox) subcutaneously. Which injection site is most appropriate for the nurse to use? Select one: a. Thighs b. Deltoid area c. Sides of abdomen d. Ventrogluteal area - Answers :c. Sides of abdomen The patient wants to receive insulin by continuous subcutaneous injection (CSCI). Which injection site does the nurse suggest for the patient?
Select one: a. The upper arm b. The upper chest c. The lower abdomen d. The thigh - Answers :c. The lower abdomen The nurse is preparing to give an injection in the ventrogluteal injection site. Which pair of anatomical landmarks does the nurse use for this site? Select one: a. Greater trochanter and knee b. Acromion process and axilla c. Anterior superior iliac spine and iliac crest d. Posterior superior iliac spine and iliac crest - Answers :c. Anterior superior iliac spine and iliac crest The nurse prepares to remove the patient's sutures and staples. Which step should the nurse implement before proceeding with the removal? Select one: a. Assess the type of suture material used. b. Snip off both ends of the suture material. c. Cleanse crusting with hydrogen peroxide. d. Plan staple removal for postoperative day 5. - Answers :a. Assess the type of suture material used. The nurse teaches a patient about self-care of two Jackson-Pratt drains after breast surgery. What does the nurse include in patient teaching? Select one: a. Empty the drain every 2 hours and measure the contents. b. Maintain a small, steady amount of tension on the drain tubing. c. Record the amount removed from each drain separately. d. Keep the collection end of the drain lower than the patient's waist. - Answers :c. Record the amount removed from each drain separately. The nurse evaluates the surgical incision before removing the patient's staples. What assessment finding would suggest staple removal is contraindicated for now? Select one: a. The area could have an increased risk of visible scarring. b. There is a small open area along the incision. c. The site is without drainage or erythema. d. The patient is quite anxious about the staple removal. - Answers :b. There is a small open area along the incision.
