NUR 213: final exam. Skill presentation questions.
1. The nurse is making initial, rounds on the nursing unit to assess the condition of
assigned clients. The nurse notes that a client's IV site is cool, pale swollen, and the
solution is not infusing. The nurse concludes that which of the following complications has
occurred?
A. Infection
B. Phlebitis
C. Infiltration
D. Thrombosis: Infiltration
Rational:
IÏnfection would be indicated if the site was redness, swollen near IV line with possible oozing fluid, blood or pus with crusting or scabbing.
ÏPhlebitis would be indicated if the site was reddened, warm, painful, and slightly edematous IÏnfiltration is
indicated with the site being cool, pale, and swollen with the IV fluids not infusing ÏThrombosis would be
indicated if the site was swollen and painful, remove IV immediately
2. The nurse is inserting an IV line into a client's vein. After the initial stick, the nurse
continues to advance the catheter if:
A. The catheter advances easily.
B. The vein is distended under the needle
C. The client does not complain of discomfort.
,D. Blood return shows in the backflash chamber of the catheter.: D. Blood flow shoes in the backflash
chamber of the catheter.
Rational:
ÏWhen you get blood return in the chamber that means that you are in the vein, and it is ok to advance the catheter. Once you pop the
tourniquet and flush the IV you will know for sure that it is in the vein when there isn't any swelling.
3. The nurse is preparing a continuous IV infusion at the medication cart. As the nurse
goes to attach the distal end of the IV tubing to a needleless device, the exposed tubing
drops and hits the floor. Which of the following is the appropriate action by the nurse?
A. Obtain new I.V tubing
B. Attach a new needleless device
C. Wipe the distal end of the tubing with betadine.
D. Scrub the needleless device with an alcohol swab.: A. obtain new I.V. tubing
Rational:
ÏAn IV site is an opening into the skin, so it is important to maintain aseptic technique to prevent contamination and infection.
4. Which of the following rhythms would indicate that defibrillation is needed?
A. V-tach with a pulse
B. Pulseless v-tach
C. A-fib
D. 3rd degree heart block: B. Pulseless v-tach
, Rational:
Pulseless ventricular tachycardia requires immediate/ emergent intervention such as defibrilation in order to increase a patients survival
rate.
5. A patient comes in with complaint of chest pain, which diagnostic test will be obtained
first?
A. Chest x-ray
B. 12- lead electrocardiogram (ECG)
C. CT- scan
D. Heart Catheterization.: B. 12 lead ECG
Rationalization: You want to obtain an ECG first so that you can determine if the patient is having an emergency cardiac situation such as a
STEMI and interventions can be put in place immediately.
6. A patient is undergoing preoperative teaching before his cardiac surgery and the nurse
is aware that a temporary pacemaker will be placed later that day. What is the nurse's
responsibility in the care of the patient's pacemaker?
A. Monitoring for pacemaker malfunction or battery failure?
B. Determining when it is appropriate to remove the pacemaker?
C. Making necessary changes to the pacemaker settings?
D. Selecting alternatives to future pacemaker use: A. Monitoring for pacemaker malfunction or battery
failure.
1. The nurse is making initial, rounds on the nursing unit to assess the condition of
assigned clients. The nurse notes that a client's IV site is cool, pale swollen, and the
solution is not infusing. The nurse concludes that which of the following complications has
occurred?
A. Infection
B. Phlebitis
C. Infiltration
D. Thrombosis: Infiltration
Rational:
IÏnfection would be indicated if the site was redness, swollen near IV line with possible oozing fluid, blood or pus with crusting or scabbing.
ÏPhlebitis would be indicated if the site was reddened, warm, painful, and slightly edematous IÏnfiltration is
indicated with the site being cool, pale, and swollen with the IV fluids not infusing ÏThrombosis would be
indicated if the site was swollen and painful, remove IV immediately
2. The nurse is inserting an IV line into a client's vein. After the initial stick, the nurse
continues to advance the catheter if:
A. The catheter advances easily.
B. The vein is distended under the needle
C. The client does not complain of discomfort.
,D. Blood return shows in the backflash chamber of the catheter.: D. Blood flow shoes in the backflash
chamber of the catheter.
Rational:
ÏWhen you get blood return in the chamber that means that you are in the vein, and it is ok to advance the catheter. Once you pop the
tourniquet and flush the IV you will know for sure that it is in the vein when there isn't any swelling.
3. The nurse is preparing a continuous IV infusion at the medication cart. As the nurse
goes to attach the distal end of the IV tubing to a needleless device, the exposed tubing
drops and hits the floor. Which of the following is the appropriate action by the nurse?
A. Obtain new I.V tubing
B. Attach a new needleless device
C. Wipe the distal end of the tubing with betadine.
D. Scrub the needleless device with an alcohol swab.: A. obtain new I.V. tubing
Rational:
ÏAn IV site is an opening into the skin, so it is important to maintain aseptic technique to prevent contamination and infection.
4. Which of the following rhythms would indicate that defibrillation is needed?
A. V-tach with a pulse
B. Pulseless v-tach
C. A-fib
D. 3rd degree heart block: B. Pulseless v-tach
, Rational:
Pulseless ventricular tachycardia requires immediate/ emergent intervention such as defibrilation in order to increase a patients survival
rate.
5. A patient comes in with complaint of chest pain, which diagnostic test will be obtained
first?
A. Chest x-ray
B. 12- lead electrocardiogram (ECG)
C. CT- scan
D. Heart Catheterization.: B. 12 lead ECG
Rationalization: You want to obtain an ECG first so that you can determine if the patient is having an emergency cardiac situation such as a
STEMI and interventions can be put in place immediately.
6. A patient is undergoing preoperative teaching before his cardiac surgery and the nurse
is aware that a temporary pacemaker will be placed later that day. What is the nurse's
responsibility in the care of the patient's pacemaker?
A. Monitoring for pacemaker malfunction or battery failure?
B. Determining when it is appropriate to remove the pacemaker?
C. Making necessary changes to the pacemaker settings?
D. Selecting alternatives to future pacemaker use: A. Monitoring for pacemaker malfunction or battery
failure.
