3620 Final Exam PDF

3620 Final Exam Study online at https://quizlet.com/_e9nqa0 Gown, gloves, mask, and eye protection Which personal protective equipment (PPE) will the nurse wear if there is a risk of a blood splash when caring for a patient? Perform hand hygiene What will the nurse do first when preparing to apply p...

3620 Final Exam Study online at https://quizlet.com/_e9nqa0 Gown, gloves, mask, and eye protection Which personal protective equipment (PPE) will the nurse wear if there is a risk of a blood splash when caring for a patient? Perform hand hygiene What will the nurse do first when preparing to apply personal protective equipment (PPE) before caring for a patient in isolation? "I really dislike wearing a mask, so it's the first thing I take off." The nurse is discussing the guidelines for proper use of PPE by nursing assistive personnel (NAP). Which statement made by the NAP requires follow-up by the nurse? To prevent touching contaminated material with unprotected hands When removing a gown worn as personal protective equipment (PPE) while caring for a patient in isolation, why does the nurse avoid touching the outside of the gown? Review the patient's need for a specific isolation precaution When delegating patient care that requires nursing assistive personnel (NAP) to use personal protective equipment (PPE), it is necessary for the nurse to do what first? To prevent the spread of infection What is the purpose of performing hand hygiene? If the hands are not visibly soiled When is it appropriate to use an alcohol-based hand rub to perform hand hygiene? Use plenty of lather and friction and wash for at least 15 to 20 seconds. When washing the hands with soap and water, which procedure should the nurse follow? About 1 teaspoon When using soap and water to perform hand hygiene, how much soap should the nursing assistant use? Use clean, dry paper towels. As part of performing hand hygiene, how should the nursing assistant dry the hands? Withhold the medication. As the nurse is at the bedside preparing to administer a new medication, the patient mentions that he is allergic to the drug. What will the nurse do first? As the nurse prepares to administer oral acetaminophen, the Explain that drugs often come in different physical forms, depend- patient refuses to accept the drug because it doesn't look like the ing on the manufacturer. Tylenol she takes at home. After verifying that the medication and dosage are correct, what is the nurse's best response? Work with the patient to find alternative nonpharmacologic means What is the nurse's first response when a patient requests another of pain management. dose of narcotic pain medication before it is time for the next dose? Check to see when the medication was given last, and make sure The patient has requested a PRN medication for nausea. Which the time interval is up. of the following should the nurse do first? Ask the patient the reason for his refusal. After requesting a narcotic pain medication, the patient refuses it after the nurse prepares the injection. What is the nurse's best initial response? A face shield A nurse preparing to infuse a hazardous medication and has donned a gown and two pairs of chemotherapy gloves. Which item of PPE is donned next? Ask the pharmacy if a liquid form of the HD is available. A patient with a feeding tube has been ordered a new HD in tablet form. The nurse sees that the patient has a feeding tube, and the HD would have to be crushed. What is the nurse's first action? The nurse is caring for a patient who is taking an HD and notices The nurse wears PPE to remove the linens and places the linens that the linens on the bed are soiled. What is the best course of in impervious laundry bags marked as hazardous waste. action for handing the soiled linens? A pregnant nurse reviews her assigned patients, sees that one of HDs carry a risk for reproductive abnormalities, low birth weight the patients is taking an HD and asks to be reassigned. Why is it and early pregnancy termination. important that this nurse be reassigned? Evacuate those not involved in the exposure area. What is the first action the nurse should take in the event of an HD spill? During a care transition point, such as transfer to another unit When is a patient at a higher risk for a medication administration error? 1 / 12 3620 Final Exam Study online at https://quizlet.com/_e9nqa0 As the nurse is giving a patient his medications, he remarks, "Don't take it. Let me double-check the doctor's order to make sure "I've never seen this blue pill before." What is the nurse's correct this is the correct medication for you." response? What is the best way for the nurse to ensure that the patient does not receive the wrong dose because of a calculation error? Ask another registered nurse (RN) to verify the calculation. Using an oral dosing syringe when administering oral liquid med- Which of the following nursing actions will reduce the risk of "wrong ication route" when administering a medication? Ask the pharmacy if it is appropriate to split the pill and if so, ask What is the most appropriate way for the nurse to split an unscored them to split and repackage it with the adjusted dose given on the tablet? label. A female nurse is preparing to administer a rectal suppository to "How about if I show you how to insert the suppository yourself?" a male patient. The patient says, "This is so embarrassing. Is this really necessary?" What is the most appropriate response? Instruct the patient to use the call light for assistance to the bathroom. The nurse is preparing to administer a rectal suppository to an elderly patient. Which step best protects the patient's safety? "Be sure to let me know if the patient has a bowel movement." Which statement made by a nurse best illustrates an understanding of the role of nursing assistive personnel (NAP) in administering a rectal suppository? Low platelet count After administering a rectal suppository for constipation, the nurse will monitor for all of the following responses except which one? Watery diarrhea The nurse should question a provider's order to insert a suppository into the rectum of a patient with which condition? Place the capsule in a spoonful of the patient's applesauce. How might the nurse safely administer an extended-release capsule to a patient with dysphagia? Establish whether the medications may be taken with orange juice. The nurse is preparing to administer several oral medications when the patient says he would like to take his pills with orange juice. What is the nurse's best response? Which statement or question best illustrates the nurse's underPlease make sure the patient has plenty of fresh water to take with standing of the role of nursing assistive personnel (NAP) in adher pills." ministering oral medications? The nurse has provided a patient with a PRN oral analgesic that may be repeated as needed every 6 to 8 hours. What is the most appropriate follow-up action to ensure appropriate pain management? Reassess the patient's pain in 30 to 40 minutes. A patient with a history of nighttime confusion is to receive several Ask the patient to open his mouth after swallowing each tablet. oral medications at bedtime. What is the best way for the nurse to ensure that the patient has swallowed the medication? Wear gloves during the entire application process. What is the best way for the nurse to minimize the risk of contaminating the patient's eye during the instillation of eye drops? Do not apply pressure directly to the eyeball when removing excess medication. Which instruction should be given to a patient to ensure safety when self-applying an antibiotic ointment? Which statement or question best illustrates the nurse's under"Her vision may be temporarily impaired, so please help her to the standing of the role of nursing assistive personnel (NAP) in the bathroom." instillation of eye medications? The patient's hand grasp, strength, coordination, and ability to manipulate the applicator After instructing a patient in the self-administration of antibiotic eye drops, what is the nurse's highest priority assessment? Lack of visibility of the disk as it is placed under the lower eyelid When placing an intraocular disk, the nurse recognizes that it is in the correct position by assessing what? Review the medication administration record (MAR). What is the nurse's first step in preparing to administer a prescribed medication using an automated medication dispensing system? Prepare medications for one patient at a time. Which precaution should the nurse observe to ensure patient safety when using an automated medication dispensing system? 2 / 12 3620 Final Exam Study online at https://quizlet.com/_e9nqa0 Which statement or question best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) in using automated medication dispensing systems? "Let me know if she complains of any nausea." Which action by the nurse is most important in protecting the Refusing to share his or her individual security log-in code for the safety of patients and staff when using an automated medication dispensing system dispensing system? While preparing a patient's oral medication dispensed from an automated medication dispensing system, the nurse realizes that Notify the pharmacy to determine if the accurate dose is available. the pill dispensed is twice the correct dose. What is the nurse's best action at this time? Warm the eardrops to room temperature before instillation. What is the best way to minimize discomfort caused by the instillation of ear medication? Remain in the lateral position (unaffected side) for a few minutes after instillation. Which instruction would help ensure the maximum therapeutic response when a patient self-administers ear medication? Which statement or question best illustrates the nurse's under"Be sure to keep the patient on her side for a few minutes, because standing of the role of nursing assistive personnel (NAP) in the I just administered her eardrops." instillation of ear medications? The patient's hand grasp, strength, coordination, and ability to manipulate the applicator After instructing a patient in the self-administration of antibiotic eardrops, what must come first in the nurse's assessment? Instill the medication after gently pulling the ear up and back. To ensure proper distribution of ear medication after instillation, what will the nurse instruct an adult patient to do? Assess the patient's respiratory status before administration. A nurse is preparing to help a patient administer a bronchodilator using a nebulizer. What will the nurse do first in order to evaluate the medication's effectiveness? Do not give the medication. What should the nurse do first if the patient or family express concerns about the accuracy of a nebulized medication? The nurse should use an aerosol facemask to administer the nebulized medication The nurse needs to administer a nebulized medication to an older adult who is too weak hold the nebulizer mouthpiece. Which intervention should the nurse implement? To release droplets that are clinging to the side of the cup Why should the nurse tap the nebulizer medication cup during and near the end of the treatment? The nurse discontinues the medication for 15 to 20 minutes and then restarts the treatment if bronchospasm resolves. Severe bronchospasm occurs during nebulizer treatment. What action should the nurse take? Assess the patient's respiratory status. The nurse is preparing to help a patient use a dry powder inhaler. What will the nurse do first in order to evaluate the medication's effectiveness? After inhaling the medication, hold your breath for at least 10 seconds before exhaling. To make sure the drug is delivered properly, what discharge instructions might the nurse give a patient who is being discharged with a dry powder inhaler (DPI)? "Be sure to let me know if the patient starts coughing again." Which statement best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) in the use of a dry powder inhaler (DPI)? Patient's ability to handle, manipulate, and activate the DPI Before discharge, the nurse shows a patient how to use a dry powder inhaler (DPI). What should the nurse now assess? It is important to read the manufacturer's instructions to determine When instructing a patient in the use of a dry powder inhaler (DPI), how quickly to inhale the medication. which statement is accurate? Including the location of an injection site on the MAR Which example reflects effective documentation of medication administration by a nurse? Compare the prescriber's order with the MAR before dispensing What is the best way for the nurse to ensure that a patient receives the medication. the correct dose of a medication? "Let me know if the patient says her nausea is getting worse." Which statement best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) in documenting medication administration? 3 / 12 3620 Final Exam Study online at https://quizlet.com/_e9nqa0 The patient refuses a scheduled dose of an antibiotic, saying that Notify the prescriber of the patient's reason for refusing the medthe medication makes him feel nauseated. What it the nurse's best ication. response? Immediately contact the prescriber to complete the order. While reviewing a new medication order, the nurse notes that the frequency of administration has been omitted. What is the nurse's best response? Wipe the rubber seal of the vial with an alcohol swab. A nurse is preparing to withdraw medication from an open multi-dose vial. After confirming that the vial contains the appropriate medication and checking the expiration date, what would the nurse do next? Position the tip of the needle in the vial's airspace, and tap the barrel of the syringe. What would the nurse do to remove air trapped in a syringe before withdrawing the syringe from the vial? Inject a volume of air into the vial equivalent to the volume of medication to be withdrawn. How can the nurse prevent negative pressure from building up in the vial when preparing an injection? Discard the vial and any remaining medication in the vial directly How can the nurse ensure that medication from a single-dose vial after use. is used appropriately? Label the vial with the date it was opened and your initials. What will the nurse do after opening a multi-dose vial and withdrawing a dose of medication from it? Use quick, light finger taps on the top of the ampule to move the When preparing an injection from an ampule, what will the nurse liquid. do if liquid is trapped in the neck of the ampule? Withdrawing glass particles into the syringe What is the greatest safety concern when withdrawing medication from an ampule? Preserving the sterility of the needle while preparing the medica- How does the nurse minimize the risk of patient infection when tion preparing medication from an ampule? Using a filter needle or straw to draw the medication from the ampule Which action minimizes the risk of introducing glass particles into the syringe when drawing medication from an ampule? Hold the ampule upside down while inserting the filter needle. Which action might the nurse take when drawing up medication from an ampule? The nurse is preparing to mix short- and intermediate-acting inRefraining from injecting the intermediate-acting insulin into the sulins to administer to a patient. Which action best preserves the short-acting vial insulin's effectiveness? Prepare the insulins in two syringes for separate injections. The patient is to receive both Lantus (insulin glargine) and regular insulin. To ensure the proper action of the insulins, what would the nurse do when preparing these two types of insulin for administration? Insert air into the intermediate-acting insulin. When preparing an injection that contains both short- and intermediate-acting insulins, what is the first step the nurse would take to ensure the effectiveness of the injection? When preparing an injection of mixed insulin that includes 12 units By verifying that the prescription confirms the medication adminof NPH and 5 units of regular insulin, how does the nurse initially istration record (MAR) confirm the proper dosage in the syringe? Prepare two injections. Which action would the nurse take when mixing intermediate- and long-acting insulins together in one syringe? Inability to feel resistance when injecting the medication When administering an intradermal injection, which outcome would require the nurse to withdraw the needle and begin again? Which statement might the nurse make to nursing assistive per"Immediately report any patient complaints of itching or dyspnea." sonnel (NAP) when caring for a patient who is prescribed an intradermal injection? A hard, raised area 15 mm or greater in diameter Which finding tells the nurse that a patient may have had a positive reaction to a tuberculin test? Right deltoid of a high school softball pitcher In which site would it be inappropriate to administer an intradermal injection? The bulge of the needle tip will be visible through the skin. How can the nurse determine that the needle tip for an intradermal injection is in the dermis? 4 / 12 3620 Final Exam Study online at https://quizlet.com/_e9nqa0 Make sure the volume of the medication is less than 2 mL. Which action would the nurse take to diminish tissue irritation when administering a subcutaneous injection to a patient of average size? 25-gauge, \-inch Which needle would be most appropriate for the nurse to use when giving a subcutaneous injection to a patient of average height and weight? Cover the injection site with gauze pad after withdrawing the needle. What can the nurse do to minimize the discomfort of a subcutaneous injection? Abdomen When preparing to administer heparin or insulin subcutaneously, which site is preferred? Systematically rotate sites within the same anatomical location or What can the nurse do to ensure proper site selection for subcuarea. taneous insulin injection? Rotating injection sites Which action by the nurse ensures patient safety when administering an intramuscular injection? Clean the injection site with an alcohol swab When preparing an intramuscular injection, what can the nurse do to reduce the patient's risk for infection? Pull back on the plunger after inserting the needle. What can the nurse do to minimize the patient's risk for injury when delivering an intramuscular injection? Ventrogluteal Which site is most commonly used for intramuscular injections? Aspirating for blood return before injecting the medication Which action by the nurse helps to ensure that the medication is delivered into the muscle when administering an intramuscular injection? Obtain the patient's current blood glucose level. How can the nurse best ensure the patient's safety when preparing insulin for administration? Roll the vial of insulin suspension between the palms prior to drawing up the medication. How would the nurse prepare insulin to ensure its efficacy? In 2 to 3 hours When will a patient's blood glucose levels be most affected by a short-acting insulin injection, such as Humulin-R? Vials of insulin must be inspected before each use for changes in Which of the following statements is accurate regarding insulin appearance. administration? 5 to 15 minutes To prevent hypoglycemia and enhance efficacy, it is appropriate to give rapid-acting insulin how many minutes before the next meal? Use the smallest-size catheter possible. Which action would the nurse take to reduce the risk for a catheter-associated urinary tract infection (CAUTI) in a patient with an indwelling urinary catheter? Assessing the patient for allergies related to latex, antiseptic, tape, Which action(s) would minimize the patient's risk for injury during and/or iodine-based substances insertion of an indwelling urinary catheter? "Please direct the light to better illuminate the patient's perineal area." Which statement best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) when inserting an indwelling urinary catheter in a female patient? Remove soiled gloves, and perform hand hygiene. The nurse has completed the initial inspection of the patient's perineum and is preparing to insert an indwelling urinary catheter. Which action would the nurse complete next? A female patient placed in the dorsal recumbent position for the Reposition the patient in a side-lying position, with her upper leg insertion of an indwelling urinary catheter tells the nurse that she flexed at the knee and hip. "doesn't feel comfortable in this position" and that her "back really hurts." What is the nurse's best response? To promote relaxation What is the best reason for the nurse to instruct a male patient to take slow, deep breaths during insertion of an indwelling urinary catheter? Lubricate the first 5 to 7 inches of the catheter. When preparing to insert an indwelling urinary catheter in a male patient, it is important for the nurse to do what? 5 / 12 3620 Final Exam Study online at https://quizlet.com/_e9nqa0 Which observation indicates that instruction given to nursing asThe excess catheter tubing has been coiled beside the patient's sistive personnel (NAP) in caring for a patient with an indwelling inner thigh. urinary catheter has been effective? Which action will the nurse implement to reduce the risk of catheter-associated urinary tract infection (CAUTI) in a male patient with an indwelling urinary catheter? Clean the urinary meatus daily. While setting up the sterile field in preparation for inserting an indwelling urinary catheter, a male patient is incontinent of urine Replace all contaminated supplies, and begin the process again. over most of the supplies. What action would the nurse take to reduce the patient's risk for infection? The wrapper of the sterile kit can be used as a sterile field. What is the best reason for a nurse to select a prepackaged sterile kit for a sterile procedure? Position the height of the table to be above waist level. Which action is the most important step the nurse can take to keep the field sterile when using an overbed table as the work surface for a sterile field? While opening a prepackaged sterile kit, a package of sterile 4 × "Please go to the clean utility room and get me a package of sterile 4-in gauze pads falls to the floor. What will the nurse ask ancillary 4 × 4-in gauze pads." staff to do to ensure the integrity of the sterile field the outermost flap can be opened away from the nurse's body. When preparing a sterile field using a prepackaged sterile kit, what will influence the nurse's placement of the kit on the overbed table? Before setting up a sterile field for a sterile procedure in a patient's Ensures that no unnecessary movement occurs that could controom, why would the nurse ask any visitors to please leave the aminate the sterile field patient's bedside? Urinary tract infection (UTI) When preparing to discharge a patient who had an indwelling urinary catheter removed 24 hours ago, the nurse would offer patient education regarding which common complication? The nurse or nursing assistive personnel (NAP) removing the catheter must employ clean technique. Which action would best minimize a patient's risk for infection during removal of an indwelling urinary catheter? "Tell me when and how much the patient first voids." Which statement might the nurse make to nursing assistive personnel (NAP) caring for a patient who has just had an indwelling urinary catheter removed? Checking the documentation for the volume of fluid used to inflate Which nursing action minimizes a patient's risk for injury during the balloon removal of an indwelling urinary catheter? Which is not an expected outcome on a first voiding after catheter removal? Fever and back pain Sterile technique ensures that microorganisms in the specimen Why does the nurse need to keep the urine sterile while obtaining are from the urine, and not the result of contamination a sample from an indwelling urinary catheter? Which action will ensure that a sterile urine specimen is handled properly in order to help obtain reliable results? Having someone take the specimen to the lab immediately Which statement might the nurse make to nursing assistive per"Let me know if the urine contains blood or sediment, or appears sonnel (NAP) before delegating the collection of a routine urine cloudy." sample from a patient with an indwelling urinary catheter? Firmly securing the lid of the urine specimen container Which measure may be taken to minimize the staff's risk for infection from a urine specimen? Clamping the catheter tubing for 15 minutes before collection When collecting a urine specimen from an indwelling urinary catheter, which action is most likely to ensure that sufficient urine is collected? Kinks are associated with the development of urinary tract infection (UTI). What is the primary reason the nurse ensures that a patient's indwelling urinary catheter drainage tubing is free of kinks? Redness noted on the external urethral meatus The nurse has delegated measurement of a patient's vital signs and catheter care to nursing assistive personnel (NAP). Which observation should the NAP report to the nurse immediately? Use of plain soap instead of an antiseptic cleanser for perineal hygiene All of the following factors are known to increase the risk of urinary tract infection (UTI) except which one? 6 / 12 3620 Final Exam Study online at https://quizlet.com/_e9nqa0 The labia have contaminated the area. While performing catheter care, the nurse moves her hand, allowing the patient's labia to close around the catheter. Why would the nurse repeat this part of the care? Cleanse from the meatus outward. What is the most effective way to prevent infection when providing catheter care for a patient? Keep the catheter in place, and begin again with a new sterile catheter. While performing an intermittent straight urinary catheterization of a female patient, the nurse inadvertently inserts the catheter into the patient's vagina. Which action would the nurse take next? While attempting to perform a straight catheterization for a male Continue to advance the catheter until 5 to 7 inches of the catheter patient, the nurse advances the catheter 3 to 4 inches into the tube has been introduced into the urethra. meatus but observes no urine flow. Which action would the nurse take at this time? "I'll help keep his legs away from the sterile field." The nurse instructs nursing assistive personnel (NAP) regarding proper technique for intermittent straight catheterization of a male patient. Which statement made by NAP indicates that the instruction was effective? To reduce the patient's risk of urinary tract infection Why does the nurse cleanse a female patient's perineum before inserting an intermittent urinary catheter? Measure and empty the urine. The nurse has completed an intermittent straight urinary catheterization of a female patient. Which action would the nurse delegate to nursing assistive personnel (NAP)? To collect urine for an incontinent man What is the purpose of a condom catheter? Roll the condom onto the penis, leaving 1 inch between the penis and the end of the catheter What is the correct method for applying a condom catheter? Once a day after perineal care How often should a condom catheter be changed? In a spiral pattern A person has a condom catheter that must be secured with elastic tape. How should you apply the tape? Coil and secure it on the bed After connecting the condom catheter to the drainage tubing, what should you do with the excess tubing? Examine the drainage tubing for clots, sediment, and kinks. During intermittent open bladder irrigation, a patient complains of pain. Which action would the nurse take first? Use slow, even pressure when injecting the irrigating fluid. Which action would the nurse take to minimize a patient's risk for injury during urinary catheter irrigation? "Measure and report the patient's temperature to me every 4 hours." Which instruction might the nurse give to nursing assistive personnel (NAP) helping to care for a patient receiving bladder irrigation? Cleaning the end of the drainage tubing with an antiseptic wipe before reconnecting it to the catheter Which action is most important in reducing the risk for infection in a patient receiving open intermittent irrigation of a urinary catheter? Increase the irrigation drip rate. Which action would the nurse take to manage continuous urinary catheter irrigation for a patient whose urine is bright red and contains clots? Apply a tourniquet to the selected arm 4 to 6 inches above the proposed site Which technique is most accurate in identifying an appropriate vein site for IV catheter insertion into the arm? Assess the patient's understanding of the placement of the device. When preparing to insert a venous access device, how can the nurse encourage patient compliance with the procedure? Checking for a radial pulse once the tourniquet has been applied Which action minimizes the patient's risk for injury when inserting a venous access device into the arm? Superficial dorsal vein The nurse is preparing to insert a venous access device into a newly admitted 75-year-old patient. Which vein is an inappropriate choice for IV insertion in this patient? The nurse is using chlorhexidine to prepare the site before inCleanse the area by first swabbing horizontally, then vertically with serting a venous access device into the median cubital vein of a the applicator for about 30 seconds. 60-year-old patient. Which action is correct? 7 / 12 3620 Final Exam Study online at https://quizlet.com/_e9nqa0 Why is it important to label the gauze dressing covering the site Informs the nurse and other staff when the next dressing change of an intravenous access device with the date, time, and nurse's is due initials? Use aseptic technique throughout the process. Which action will the nurse take to minimize a patient's risk for injury when applying a dressing to an infusion site? Assess the site. The nursing assistive personnel (NAP) reports to the nurse that a patient's intravenous access device dressing is wet. What would the nurse do first? When applying a dressing to an infusion site on a patient's left Apply the dressing proximal to the tubing and catheter hub conforearm, what will the nurse do to ensure proper maintenance of nector. the tubing? Which action will the nurse take to minimize a patient's risk for injury when applying a gauze dressing to an infusion site? Avoid encircling the arm with tape Which instruction to nursing assistive personnel (NAP) reflects the "Let me know when you notice that the IV bag contains less than nurse's correct understanding of the NAP's role in caring for a 100 mL." patient receiving intravenous (IV) fluids by gravity drip? The provider has ordered that a patient be 1000 mL of IV normal Calculate the hourly volume of normal saline the patient should saline to run over 12 hours. What is the first step in the calculation receive. of the rate of infusion? The provider orders that a patient be given 1000 mL of IV normal saline to run over 10 hours. The drop factor of the selected tubing is 15. What is the correct rate of infusion in drops per minute? 25 drops/minute The nurse receives an order to infuse 1000 mL of D5W at 125 mL Infusing D5W at a rate of 125 mL/hr until the health care provider continuously. Which of the following actions by the nurse indicates changes the order correct interpretation of this order? Using a volume-control device for the infusion Which action by the nurse helps to ensure patient safety when administering IV fluids by gravity to very young children? "I'll check the IV site and pump." Which response might the nurse give to nursing assistive personnel (NAP) who reports that the alarm is sounding on a patient's electronic infusion device (EID)? The flow of fluid would stop. How would the infusion of the IV fluids be affected if the tubing were unintentionally dislodged from the chamber of the control mechanism of the EID? 125 mL A patient is prescribed 1000 mL of intravenous (IV) normal saline to run over 8 hours. The initial fluid is hung at 0800. How many milliliters of fluid will have infused by 1200? First verify that the fluid is dripping, and then check the level of fluid remaining in the container every hour. The nurse calculates that the patient is to receive 125 mL of intravenous (IV) normal saline per hour. After programming the infusion pump to deliver at that rate, how would the nurse ensure accurate fluid administration? Patient's pulse and heart rate Which information is not necessary for the nurse to include when documenting the use of an EID for an intravenous infusion? Extending your arm over the sterile field to pour the liquid into the receptacle When adding a sterile liquid to a sterile field, which action will contaminate the field? Avoid splashing when pouring sterile liquids onto the sterile field. Which action is the most effective in minimizing the risk of contamination when using sterile liquids during a sterile procedure? "Would you please get me another bottle of sterile water?" What direction would the nurse provide to nursing assistive personnel (NAP) assisting with a sterile procedure in which sterile solutions are being used? Collect new supplies, and prepare another sterile field. What would the nurse do if a sterile solution splashed onto a sterile field and contaminated the field during a dressing change? The label may become illegible if it is splashed When pouring a sterile liquid into a container on a sterile field, why does the nurse hold the bottle with the label facing the palm of the hand? 8 / 12 3620 Final Exam Study online at https://quizlet.com/_e9nqa0 Adhere to sterile technique when appropriate. How can the nurse best minimize a patient's risk for infection during tracheostomy care? Keeping an obturator and a tracheostomy tube at the patient's bedside Which nursing action shows the most effective planning for emergency care of a patient with a tracheostomy? Cleaning and assessing the skin around the stoma Which intervention reduces the risk for skin breakdown in a patient with a new tracheostomy? Holding the tracheostomy tube while the nurse changes the neck ties Which action may be delegated to nursing assistive personnel (NAP) regarding the care of a patient with a tracheostomy? Ensure that two fingers fit snugly under the tie. Which technique would the nurse use to change a patient's tracheostomy ties? Return it to the blood bank until it can be administered. While checking a blood product prior to administration, the nurse is called away to assist with another procedure. What should the nurse do with the blood product? Return the blood to the blood bank. While checking a blood product prior to administration, the nurse notices that the birth date on the blood bag and requisition do not match the birth date on the patient's identification bracelet. Which is the correct action for the nurse to take? 18-gauge An adult patient is prescribed to receive a unit of packed red blood cells. Which size intravenous catheter does the patient need to safely receive this blood? Return the unit to the blood bank. The nurse is preparing to administer a unit of blood to a patient in the emergency department and discovers that he is not wearing an identification bracelet. What should the nurse do? Administer the blood. While checking a blood bag prior to infusion, the nurse notes that the patient's blood type is A+ and the donor's blood type is O+. Which action would the nurse take? Through another IV line A patient prescribed to receive two units of packed red blood cells is to receive a dose of intravenous medication between the two units. How would the nurse administer the medication? 0.9% normal saline The nurse is preparing equipment to administer a unit of blood to a patient. Which type of fluid would the nurse piggyback with the blood transfusion? 2 mL/min A patient is to receive one unit of packed red blood cells over 2 hours. Which rate is the usual flow rate for the first 15 minutes of a blood transfusion? Infuse 0.9% normal saline at the KVO rate. A patient is to receive 3 units of packed red blood cells over 8 hours. What will the nurse do to maintain the patency of the patient's IV access line after each of the first two units of blood has transfused? 625 mL A patient received two 300-mL units of packed red blood cells, and the line was flushed with 25 mL of solution between the units. What is the total amount of fluid the nurse will document having provided to the patient? Stop the transfusion. A patient receiving a unit of blood complains of feeling cold and begins to have shaking chills. What is the nurse's first action? Return both to the blood bank. A patient has a blood transfusion reaction, and the transfusion is stopped. What should the nurse do with the remaining blood and transfusion administration set? Every 15 minutes A patient receiving a unit of blood begins to show signs of a transfusion reaction. How frequently should the nurse monitor the patient's vital signs after stopping the transfusion? To relieve respiratory distress A patient experiencing a blood transfusion reaction is prescribed to receive epinephrine. What is the purpose of this medication when given for this indication? 9 / 12 3620 Final Exam Study online at https://quizlet.com/_e9nqa0 Blood bank and infection control department It is determined that a patient who received a blood transfusion received an infection from the blood. Whom should the nurse notify of this infection? Infuse the antibiotic through another lumen of the multilumen central line. A patient for whom an intravenous antibiotic is prescribed has a multilumen central line in place for central parenteral nutrition (CPN). What should the nurse do? A patient's central parenteral nutrition (CPN) order has been Hang an infusion of 10% dextrose in water at the same infusion changed to a different solution, and the present solution is to be rate as the CPN. discontinued immediately. What should the nurse do until the new solution is delivered by the pharmacy? Change the CPN infusion tubing at least once every 24 hours. Which action will best minimize a patient's risk for infection while receiving central parenteral nutrition (CPN)? Contact the pharmacy for a new infusion bag. When preparing to infuse a bag of parenteral nutrition through a patient's central line, the nurse notices that the solution has coalesced. What is his or her best response? Verify the physician's order for central parenteral nutrition (CPN) Which nursing action will best ensure the safety of a patient who and the flow rate. is about to receive an infusion of parenteral nutrition? Do not disrupt the dressing on the midline catheter A nurse is educating a patient with a new midline catheter. Which of the following teaching points should the nurse emphasize? A gauze dressing placed over catheter exit site A nurse is preparing for a midline dressing change with a patient who is extremely diaphoretic. Which of the following dressings is most appropriate for this patient? Notify the practitioner When changing a midline dressing, the nurse notices redness, swelling, and drainage at the catheter exit site. Which of the following actions should the nurse take next? After removing the syringe A nurse is flushing and locking a midline catheter through a positive displacement valve needleless access device. When should the nurse clamp the catheter? Central parenteral nutrition A nurse is teaching a new nurse about midline catheters. The new nurse is asked about which intravenous infusions can be administrated through a midline catheter. Which of the following responses would indicate the new nurse needs more teaching? Notify the physician that the attempts were unsuccessful. What would the nurse do if he or she were not able to insert a nasogastric tube in either of a patient's nares? Withdraw the tube to the nasopharynx. What would the nurse do if he or she encountered resistance when inserting a nasogastric tube? A 28-year-old patient who fractured a femur after heavy drinking. Which patient does not have a medical condition that contraindicates placement of a nasogastric tube? Examine each naris for patency and skin breakdown. What might the nurse do to reduce the patient's discomfort before inserting a nasogastric tube? Positioning the patient in a high-Fowler's position Which intervention might the nurse delegate to nursing assistive personnel (NAP) when inserting a nasogastric tube? Notify the health care provider. What would the nurse do if material aspirated from a patient's nasogastric tube resembled coffee grounds in color and texture? Purified water What would the nurse use to irrigate a patient's nasogastric tube after providing medications? "Tell me if you see any vomit in the patient's mouth during oral care." Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a nasogastric (NG) tube? Check NG tube placement. What would the nurse do before providing the patient with a scheduled intermittent feeding through a nasogastric (NG) tube? Anticipate a chest x-ray When checking gastric aspirate from an NG tube, the nurse assesses a pH of 7. What would the nurse do next? 10 / 12 3620 Final Exam Study online at https://quizlet.com/_e9nqa0 Provide reassurance of what will happen during the procedure and talk the patient through the process. How might the nurse minimize the patient's anxiety when removing a nasogastric tube? Wearing treatment gloves What would minimize the nurse's risk for contamination during the removal of a nasogastric tube? A health care provider's order What will the nurse need before removing a patient's nasogastric tube? Providing the patient with mouth care What patient care might the nurse delegate to nursing assistive personnel (NAP) when a patient's nasogastric tube is removed? To keep any fluid from flowing out Why does the nurse clamp the nasogastric tube before removing it from a patient? Elevating the head of the bed reduces the risk for aspiration. Why does the nurse elevate the head of the bed to 30 degrees for a patient receiving an intermittent tube feeding? What is the proper response to the nurse's observation that the Plan to check the feeding for completion within the next 3 hours. patient's closed-system enteral feeding has 150 mL of formula remaining and that the infusion order rate is for 50 mL/hr? Obtain a product designed to unclog NG tubes. After unsuccessfully attempting to flush a nasogastric (NG) tube with water, what is the most appropriate action for the nurse to take? Check the gastric residual volume. How could the nurse assess the patency of a nasogastric (NG) tube being used for enteral nutrition? Return it to the stomach via the feeding tube. Which nursing action is appropriate when feeding gastric residual is 50 mL? Applying clean gloves What is the nurse's initial action when preparing to change a patient's colostomy pouching system? Protecting the skin from irritation caused by fecal drainage When pouching a patient's colostomy, which action reduces the patient's risk for injury? Avoiding unnecessary changes of the pouching system When changing the pouching system, which routine step best minimizes irritation of the skin surrounding the stoma? Giving the patient a handheld mirror to watch the nurse provide care Which initial nursing action would best help the patient learn self-care of a colostomy pouching system? Which instruction might the nurse give to nursing assistive person"Alert me immediately if you see any blood in the fecal matter in nel (NAP) regarding the care of a patient with a newly established the pouch." colostomy? Clean the skin with warm water and pat dry. What will the nurse do to protect the peristomal skin of a patient with a urostomy? Notify the health care provider. Which action would be the nurse's priority when caring for a patient with a urostomy who had no urine output for 4 hours? Which statement might a nurse make to nursing assistive person"Let me know immediately if the patient complains of pain at the nel (NAP) when caring for a patient prescribed an intravenous (IV) insertion site." bolus of analgesic medication? Determining that the medication is compatible with the IV solution Which patient safety issue is specific to administration of medication by IV bolus? Injecting the medication at the prescribed rate What is the most important action the nurse can take to protect the patient when administering a narcotic analgesic by IV bolus? Follow aseptic technique during the entire process. How can the nurse best minimize the patient's risk for infection when administering an IV bolus of an analgesic? If the nurse does not see blood return when aspirating the saline Assess the site for swelling or coolness while flushing the saline lock in preparation for an IV bolus medication, what is the next lock with normal saline. step? Which instruction reflects the nurse's correct understanding of the "Let me know immediately if the patient complains of pain at the role of nursing assistive personnel (NAP) in caring for a patient IV site." receiving an intravenous (IV) antibiotic medication by piggyback? 11 / 12 3620 Final Exam Study online at https://quizlet.com/_e9nqa0 Hang the piggyback medication higher than the primary fluid. When administering an IV piggyback medication to infuse by gravity, how can the nurse ensure that the medication will flow properly? Assess the IV site before initiating the IV piggyback medication. What is the best way to protect a patient from an IV site injury when giving an antibiotic medication by piggyback? Leave both the piggyback tubing and the bag attached to the primary line Y-site port until the next scheduled dose. What is the best way to prevent infection and conserve resources when terminating an IV piggyback medication infusion in a patient who also has a primary fluid infusion? 12 / 12