Skills Review Questions Test 3 Exam
Questions And Answers
/.An intravenous (IV) fluid is infusing slower than ordered. The infusion pump is set
correctly. Which factors could cause this slowing? (Select all that apply.)
1. Infiltration at vascular access device (VAD) site
2. Patient lying on tubing
3. Roller clamp wide open
4. Tubing kinked in bedrails
5. Circulatory overload
2. Patient lying on tubing
4. Tubing kinked in bedrails
/.The nurse assesses pain and redness at a vascular access device (VAD) site. Which
action is taken first?
1. Apply a warm, moist compress.
2. Aspirate the infusing fluid from the VAD.
3. Report the situation to the health care provider.
4. Discontinue the intravenous infusion.
/.When delegating input and output (I&O) measurement to assistive personnel, the
nurse instructs them to record what information for ice chips?
1. Two-thirds of the volume
2. One-half of the volume
3. One-quarter of the volume
4. Two times the volume
/.What assessments does a nurse make before hanging an intravenous (IV) fluid that
contains potassium? (Select all that apply.)
1. Urine output
2. Arterial blood gases
3. Fullness of neck veins
4. Serum potassium laboratory value in EHR
5. Level of consciousness
4. Serum potassium laboratory value in EHR
/.The health care provider's order is 500 mL 0.9% NaCl intravenously over 4 hours.
Which rate does the nurse program into the infusion pump?
1. 100 mL/hr
2. 125 mL/hr
3. 167 mL/hr
,4. 200 mL/hr
/.An older-adult patient is receiving intravenous (IV) 0.9% NaCl. The nurse detects new
onset of crackles in the lung bases. What is the priority action?
1. Notify a health care provider.
2. Decrease the IV flow rate.
3. Lower the head of the bed.
4. Discontinue the IV site.
/.Place the following steps for discontinuing intravenous (IV) access in the correct order:
1. Perform hand hygiene and apply gloves.
2. Explain procedure to patient.
3. Remove IV site dressing and tape.
4. Use two identifiers to ensure correct patient.
5. Stop the infusion and clamp the tubing.
6. Carefully check the health care provider's order.
7. Clean the site, withdraw the catheter, and apply pressure.
6. Carefully check the health care provider's order.
4. Use two identifiers to ensure correct patient.
2. Explain procedure to patient.
1. Perform hand hygiene and apply gloves.
5. Stop the infusion and clamp the tubing.
3. Remove IV site dressing and tape.
7. Clean the site, withdraw the catheter, and apply pressure.
/.A patient has hypokalemia with stable cardiac function. What are the priority nursing
interventions? (Select all that apply.)
1. Fall prevention interventions
2. Teaching regarding sodium restriction
3. Encouraging increased fluid intake
4. Monitoring for constipation
5. Explaining how to take daily weights
4. Monitoring for constipation
/.A patient is admitted to the hospital with severe dyspnea and wheezing. Arterial blood
gas levels on admission are pH 7.26; PaCO2, 55 mm Hg; PaO2, 68 mm Hg; and , 24.
How does the nurse interpret these laboratory values?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
/.Which assessment does the nurse use as a clinical marker of vascular volume in a
patient at high risk of extracellular fluid volume (ECV) deficit?
1. Dryness of mucous membranes
2. Skin turgor
, 3. Fullness of neck veins when supine
4. Fullness of neck veins when upright - Answer-✅3. Fullness of neck veins when
supine
/.The nurse is preparing to perform nasotracheal suctioning on a patient. Arrange the
steps in order.
1. Apply suction.
2. Assist patient to semi-Fowler's or high Fowler's position, if able.
3. Advance catheter through nares and into trachea.
4. Have patient take deep breaths.
5. Lubricate catheter with water-soluble lubricant.
6. Apply sterile gloves.
7. Perform hand hygiene.
8. Withdraw catheter. - Answer-✅7, 2, 6, 4, 5, 3, 1, 8
7. Perform hand hygiene.
2. Assist patient to semi-Fowler's or high Fowler's position, if able.
6. Apply sterile gloves.
4. Have patient take deep breaths.
5. Lubricate catheter with water-soluble lubricant.
3. Advance catheter through nares and into trachea.
1. Apply suction
8. Withdraw catheter.
/.Which skills can the nurse delegate to assistive personnel (AP)? (Select all that apply.)
1. Initiate oxygen therapy via nasal cannula.
2. Perform nasotracheal suctioning of a patient.
3. Educate the patient about the use of an incentive spirometer.
4. Assist with care of an established tracheostomy tube.
5. Reposition a patient with a chest tube. - Answer-✅4. Assist with care of an
established tracheostomy tube.
5. Reposition a patient with a chest tube.
/.The nurse is caring for a patient with pneumonia. On entering the room, the nurse
finds the patient lying in bed, coughing, and unable to clear secretions. What should the
nurse do first?
1. Start oxygen at 2 L/min via nasal cannula.
2. Elevate the head of the bed to 45 degrees.
3. Encourage the patient to use the incentive spirometer.
4. Notify the health care provider. - Answer-✅2. Elevate the head of the bed to 45
degrees.
/.The nurse is performing discharge teaching for a patient with chronic obstructive
pulmonary disease (COPD). What statement, made by the patient, indicates the need
for further teaching?
1. "Pursed-lip breathing is like exercise for my lungs and will help me strengthen my
breathing muscles."
Questions And Answers
/.An intravenous (IV) fluid is infusing slower than ordered. The infusion pump is set
correctly. Which factors could cause this slowing? (Select all that apply.)
1. Infiltration at vascular access device (VAD) site
2. Patient lying on tubing
3. Roller clamp wide open
4. Tubing kinked in bedrails
5. Circulatory overload
2. Patient lying on tubing
4. Tubing kinked in bedrails
/.The nurse assesses pain and redness at a vascular access device (VAD) site. Which
action is taken first?
1. Apply a warm, moist compress.
2. Aspirate the infusing fluid from the VAD.
3. Report the situation to the health care provider.
4. Discontinue the intravenous infusion.
/.When delegating input and output (I&O) measurement to assistive personnel, the
nurse instructs them to record what information for ice chips?
1. Two-thirds of the volume
2. One-half of the volume
3. One-quarter of the volume
4. Two times the volume
/.What assessments does a nurse make before hanging an intravenous (IV) fluid that
contains potassium? (Select all that apply.)
1. Urine output
2. Arterial blood gases
3. Fullness of neck veins
4. Serum potassium laboratory value in EHR
5. Level of consciousness
4. Serum potassium laboratory value in EHR
/.The health care provider's order is 500 mL 0.9% NaCl intravenously over 4 hours.
Which rate does the nurse program into the infusion pump?
1. 100 mL/hr
2. 125 mL/hr
3. 167 mL/hr
,4. 200 mL/hr
/.An older-adult patient is receiving intravenous (IV) 0.9% NaCl. The nurse detects new
onset of crackles in the lung bases. What is the priority action?
1. Notify a health care provider.
2. Decrease the IV flow rate.
3. Lower the head of the bed.
4. Discontinue the IV site.
/.Place the following steps for discontinuing intravenous (IV) access in the correct order:
1. Perform hand hygiene and apply gloves.
2. Explain procedure to patient.
3. Remove IV site dressing and tape.
4. Use two identifiers to ensure correct patient.
5. Stop the infusion and clamp the tubing.
6. Carefully check the health care provider's order.
7. Clean the site, withdraw the catheter, and apply pressure.
6. Carefully check the health care provider's order.
4. Use two identifiers to ensure correct patient.
2. Explain procedure to patient.
1. Perform hand hygiene and apply gloves.
5. Stop the infusion and clamp the tubing.
3. Remove IV site dressing and tape.
7. Clean the site, withdraw the catheter, and apply pressure.
/.A patient has hypokalemia with stable cardiac function. What are the priority nursing
interventions? (Select all that apply.)
1. Fall prevention interventions
2. Teaching regarding sodium restriction
3. Encouraging increased fluid intake
4. Monitoring for constipation
5. Explaining how to take daily weights
4. Monitoring for constipation
/.A patient is admitted to the hospital with severe dyspnea and wheezing. Arterial blood
gas levels on admission are pH 7.26; PaCO2, 55 mm Hg; PaO2, 68 mm Hg; and , 24.
How does the nurse interpret these laboratory values?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
/.Which assessment does the nurse use as a clinical marker of vascular volume in a
patient at high risk of extracellular fluid volume (ECV) deficit?
1. Dryness of mucous membranes
2. Skin turgor
, 3. Fullness of neck veins when supine
4. Fullness of neck veins when upright - Answer-✅3. Fullness of neck veins when
supine
/.The nurse is preparing to perform nasotracheal suctioning on a patient. Arrange the
steps in order.
1. Apply suction.
2. Assist patient to semi-Fowler's or high Fowler's position, if able.
3. Advance catheter through nares and into trachea.
4. Have patient take deep breaths.
5. Lubricate catheter with water-soluble lubricant.
6. Apply sterile gloves.
7. Perform hand hygiene.
8. Withdraw catheter. - Answer-✅7, 2, 6, 4, 5, 3, 1, 8
7. Perform hand hygiene.
2. Assist patient to semi-Fowler's or high Fowler's position, if able.
6. Apply sterile gloves.
4. Have patient take deep breaths.
5. Lubricate catheter with water-soluble lubricant.
3. Advance catheter through nares and into trachea.
1. Apply suction
8. Withdraw catheter.
/.Which skills can the nurse delegate to assistive personnel (AP)? (Select all that apply.)
1. Initiate oxygen therapy via nasal cannula.
2. Perform nasotracheal suctioning of a patient.
3. Educate the patient about the use of an incentive spirometer.
4. Assist with care of an established tracheostomy tube.
5. Reposition a patient with a chest tube. - Answer-✅4. Assist with care of an
established tracheostomy tube.
5. Reposition a patient with a chest tube.
/.The nurse is caring for a patient with pneumonia. On entering the room, the nurse
finds the patient lying in bed, coughing, and unable to clear secretions. What should the
nurse do first?
1. Start oxygen at 2 L/min via nasal cannula.
2. Elevate the head of the bed to 45 degrees.
3. Encourage the patient to use the incentive spirometer.
4. Notify the health care provider. - Answer-✅2. Elevate the head of the bed to 45
degrees.
/.The nurse is performing discharge teaching for a patient with chronic obstructive
pulmonary disease (COPD). What statement, made by the patient, indicates the need
for further teaching?
1. "Pursed-lip breathing is like exercise for my lungs and will help me strengthen my
breathing muscles."
