UAB Nursing 321L Skills Final Exam Graded A

The nurse has delegated administration of tube feeding to a specially trained UAP. Before the UAP administers the tube feeding, what action should be taken by the nurse in regard to this delegation? A) check tube for pl ...

The nurse has delegated administration of tube feeding to a specially trained UAP. Before the UAP administers the tube feeding, what action should be taken by the nurse in regard to this delegation? A) check tube for placement B) orders the equipment to give the feeding C) regulate the rate of feeding D) set up the equipment and mix the feeding - ANSWER A) check tube for placement Which of the following is true regarding traction? A) traction force enables the distal bone to remain in alignment with the proximal end B) traction pressure is used to keep bone fragments slightly apart C) patients with traction devices should be kept immobile D) patients with traction devices have decreased sensation and pulses in the limb distal to the fracture - ANSWER A) traction force enables the distal bone to remain in alignment with the proximal end A patient with a large infected wound needs negative-pressure wound therapy and asks the nurse how the technique works. Which statement by the nurse is most accurate? - ANSWER A measured foam pad is placed over the open area along with an occlusive dressing. Negative pressure removes drainage and contracts the wound bed. The nurse notes that a tube-fed client has shallow breathing and dusky color. The continuous feeding is running at the prescribed rate. What is the nurse's priority action? A) Assess the client's lung sounds B) Place the client in high Fowler's position C) Turn off the tube feeding D) Assess the client's bowel sounds - ANSWER C) Turn off the tube feeding The nurse has inserted a nasogastric tube for gastric suction. What is the most reliable test for confirming tube placement? - ANSWER Aspirate stomach contents and check the acidity using a pH test strip. As the nasogastric tube is passed into the oropharynx, the client begins to gag. What is the correct nursing action? A) Remove the tube and attempt reinsertion. B) Give the client a few sips of water. C) Use firm pressure to pass the tube through the glottis. D) Have the client tilt the head back to open the passage. - ANSWER B) Give the client a few sips of water. Identify the correct technique for cleaning a surgical wound with a drain. - ANSWER Clean any drainage tube sites using a full circle; beginning at the drain insertion site and moving in a circle outward from the drain The priority nursing action for a patient with a traction device is which of the following? A) Provide psycho-social support to prevent depression and isolation B) Provide pain medication frequently to prevent distress C) Monitor circulation of the limb distal to the fractures D) Clean pin sites every four hours with hydrogen peroxide - ANSWER C) Monitor circulation of the limb distal to the fracture Negative wound pressure therapy is used for: - ANSWER chronic open wounds such as pressure ulcers Your patient has pin sites to secure Halo Traction in her skull. Choose the correct nursing action for care of these pin sites. A) Adjust Halo traction for comfort by loosening the pins and arranging insertion sites B) Document observation of scant serous drainage at pin sites C) Vigorously clean pin sites every two hours with hydrogen peroxide - ANSWER B) Document observation of scant serous drainage at pin sites The client who has a nasogastric tube in place has been restless and pulling at the tube. How would the nurse assess if the tube is still in place? A) Assess the client's bowel sounds B) Advance the tube C) Auscultate the bilateral breath sounds D) Obtain an order for a CXR - ANSWER D) Obtain an order for a CXR The nursing student is completing I/O for the shift with the nurse. The student is emptying the Hemovac drain. Which action by the student requires intervention by the nurse? A) The student replaces the drainage plug with one hand and reestablishes vacuum pressure with the other hand. B) The student avoids touching the drainage port. C) The student empties the drainage into the trash can D) The student wears gloves for the procedure - ANSWER C) The student empties the drainage into the trash can The nurse has orders to remove the patient's sutures. Which action demonstrates appropriate technique? A) The nurse uses bandage scissors to remove sutures B) The nurse sedates the patient prior to removal of sutures C) The nurse removes every other suture D) The nurse does not wear gloves when removing the sutures - ANSWER C) The nurse removes every other suture Heparin infusions are titrated using which lab values? - ANSWER PTT and anti-Xa The nurse is reviewing lab data for a client who is receiving total parental nutrition. Which lab value should be immediately brought to the physician's attention? A) Potassium of 3.5 B) Serum glucose of 401 C) Prealbumin of 15 D) BUN of 45 - ANSWER B) Serum glucose of 401 A patient has been ordered to begin an insulin infusion. Other than glucose, what lab factor should the nurse pay particular attention to? - ANSWER Potassium Level Which of the following is MOST IMPORTANT when administering an IV Push medication in order to prevent crystallization in the IV tubing? A) Scrubbing the hub prior to inject B) Explaining the purpose of the medication to the patient C) Y site compatibility D) Patient privacy - ANSWER C) Y site compatibility The nurse is to administer 75 mL of an antibiotic solution by IV over the next 30 minutes. The tubing has a drop factor of 20. What rate should the nurse set the control device to deliver? - ANSWER 50 gtt/min The client complains of burning along the vein in which a medicated IV is infusing. The site is slightly reddened, but not warmer than the surrounding skin, and without swelling. What action should be taken? - ANSWER Discontinue the IV and place a warm pack on the area 50 mL of an IV solution to infuse over the next 20 minutes. What rate should the nurse set the electronic controller to deliver? - ANSWER 150 mL/hr The nurse is collecting equipment to administer a unit of packed rbcs. Which IV fluid should be used to initiate for this transfusion? A) 100 mL of 5% dextrose and 1/2 normal saline B) 500 mL of 5% dextrose and water C) 250 mL of normal saline - ANSWER C) 250 mL of normal saline A nurse is preparing to administer a unit of packed RBCs to a patient. The transfusion begins on Tuesday at 2015. The infusion should be completed by what time? - ANSWER Wednesday at 0015 A nurse needs to administer medications to a client through an IV port. How should the nurse ascertain that the IV catheter is in the vein? - ANSWER Aspirate and observe the tubing near the insertion device A patient is receiving IV therapy and the nurse notices swelling and coolness at the site along with an absent blood return. What would the nurse suspect? - ANSWER Infiltration Which part of the administration set would the nurse use to manually regulate the infusion rate? - ANSWER Roller clamp Ten minutes after the transfusion of a unit of packed RBCs was initiated, the client complains of a headache. The nurse asses the client has slight shortness of breath and feels warm to the touch. What action is priority? A) Discontinue the transfusion B) Notify the client's physician C) Prepare to resuscitate the client D) Slow the rate of transfusion - ANSWER A) Discontinue the transfusion The nurse has completed a closed irrigation of a clients retention catheter. What specific information should the nurse document about this procedure? A) Technique used B) Location of bag C) Number of mL used to inflate balloon D) Abnormal drainage, such as blood clots, pus, or mucous - ANSWER D) Abnormal drainage, such as blood clots, pus, or mucous A nurse is caring for an elderly client at his home. The client his had a condom catheter applied. Which of he following describes a condom catheter? A) A bag attached by adhesive backing the skin around the genitalia B) A urine drainage tube that is left in place over a period of time C) A flexible sheath that is rolled around the penis D) A urine drainage tube inserted but not left in place - ANSWER C) A flexible sheath that is rolled around the penis A student nurse is performing urinary catheterization for the first time and inadvertently contaminates the catheter by touching the bed linens. What should the nurse do to maintain surgical asepsis? A) Complete the procedure and report what happened B) Gather new sterile supplies and start over C) Nothing, because the client is on antibiotics D) Apologize to the client and complete the procedure - ANSWER B) Gather new sterile supplies and start over A nurse is preparing to catharize a female client What ill the nurse consider when comparing the anatomy of the female urethra with that of the male urethra? A) Shorter length B) Has different innervation C) Longer in length D) No connection to bladder - ANSWER A) Shorter length A nurse is carrying out an order to remove an indwelling catheter What is the first step of this skill? A) Ask the client to take several deep breathes. B) Wash hands and put on gloves C) Tell the client burning may initially occur D) Deflate the balloon by aspirating the fluid - ANSWER B) Wash hands and put on gloves The nurse has been closely monitoring a patient who has recently had her indwelling catheter removed. In the six hours since the catheter has been removed, he patient has yet to void How should the nurse first respond to this assessment finding? A) Obtain an order for an oral diuretic and administer this drug to the patients B) Inform the physician and request blood work to assess the patient's renal function C) Reinsert the patient's urinary catheter D) Assess the patient's bladder by palpation and bedside ultrasound - ANSWER D) Assess the patient's bladder by palpation and bedside ultrasound A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. Which of the following is an accurate guideline for using this technique? A) Open sterile packages so that the first edge of the wrapper is directed towards you B) Consider the outside of the sterile package to be sterile C) Hold sterile objects above waist level to prevent accidental contamination D) Consider the outer 3-inch edge of a sterile field to be contaminated - ANSWER C) Hold sterile objects above waist level to prevent accidental contamination A client with urine retention related to a complete prostatic obstruction requires a urinary catheter to drain the bladder. Which type of catheter is most appropriate for an obstructed urethra? A) Indwelling urinary catheter B) Suprapubic catheter C) Straight catheter D) Intermittent urethral catheter - ANSWER B) Suprapubic catheter In order to administer enema or medication to a patient who has a bowel management system, the nurse must: A) Flush the irrigation lumen with 20 ml of cold water B) Inflate the stop-flow balloon with 25 ml of air C) Inflate the stop-flow balloon with 25 ml of water D) Connect the IV pump to the clear connector to administer the medication at an even rate - ANSWER B) Inflate the stop-flow balloon with 25 ml of air Which of the following oxygen delivery systems is most used because it does not impede eating or speaking? A) Oxygen Mask B) Oxygen Tent C) Nasal Cannula D) Oxygen Hood - ANSWER C) Nasal Cannula You are observing your patient's use of an Incentive Spirometer to evaluate his understanding of teaching related to the use of this device. Which of the following behaviors indicate the need for further teaching? A) Patient weighing 250 lbs is able to move the indicator on the device to 700 mls B) Patient insists the device be clean between uses with water C) Patient inhales deeply then briskly blows into the device with lips sealed around the mouth piece. D) Patient relaxes between uses and takes several normal deep breathes - ANSWER C) Patient inhales deeply then briskly blows into the device with lips sealed around the mouth piece. Select the oxygen delivery device with the most precise measurement of oxygen (FlO2 - Fraction inspired oxygen) A) Nasal cannula at 6 liters oxygen per minute B) Ambu-bag (Bag-valve-mask) with Room Air (21%) C) Non-rebreather mask with 15 liters oxygen per minute D) Venturi Mask with 50% oxygen - ANSWER D) Venturi Mask with 50% oxygen In setting up a sterile field, which of the following actions would require intervention? A) The first flap of the sterile package is opened towards the nurse B) The sterile drape is allowed to unfold above the waist C) The bottle of solution is poured with the label facing up D) The glove for the dominant hand is pulled on first - ANSWER A) The first flap of the sterile package is opened towards the nurse When opening a sterile pack, which action compromises the sterility of the contents? A) Opening the pack just before the procedure B) Allowing movement around the sterile field that does not touch near the sterile field C) Keeping the contents of the pack away from the table edge D) Holding or moving the object below the waist - ANSWER D) Holding or moving the object below the waist