Exam 2 (NUR 336) | Questions with Verified Answers

Exam 2 (NUR 336) | Questions with Verified Answers The doctor has just ordered a central line insertion on one of your clients. Which of the following tasks may be delegated to a NAP? (Select all that apply). a. Assist with positioning the patient during insertion and care. b. Reporting if the patient has a fever. c. Assessing the site for redness or irritation. d. Reporting to the nurse if the catheter line appears to have been pulled out further than its original insertion position. e. Inserting the central line using aseptic technique. f. Changing the central line dressing. (The NAP may assist with positioning the patient and making sure they are comfortable during the procedure. The NAP can also check for fever and if the catheter line as moved. They cannot insert the catheter or change the central line dressing or assess the site for infection.) Which statement might the nurse make to nursing assistive personnel (NAP) when caring for a patient with a dressed central venous access device (CVAD) site? A. "Assess the site frequently for signs of inflammation." B. "Be sure to change the transparent dressing on the site once every 7 days." C. "Let me know immediately if the patient's dressing becomes damp." D. "Make sure the patient knows to notify me if the site becomes painful or swollen." Which action would the nurse take to minimize the patient's risk for infection when changing the dressing on a CVAD? A. Use sterile technique throughout the process. B. Apply a stabilization device if the initial sutures are no longer intact. C. Apply a mask to the patient during the procedure. D. Change the transparent dressing every 48 hours. What is the most important way in which the nurse can reduce the risk for infection in a patient with a CVAD that has a gauze dressing? A. Change the dressing every 48 hours. B. Apply sterile gloves to remove the original dressing. C. Cleanse the catheter and insertion site with sterile saline. D. Label the dressing with the date and time of application and the nurse's initials. (A gauze dressing on a CVAD should be changed every 48 hours and as needed. Doing so will reduce the patient's risk for infection. It is not necessary to wear sterile gloves to remove the soiled dressing. Cleansing the site with sterile saline will not minimize the patient's risk for infection. Labeling the dressing will not minimize the patient's risk for infection.) What will the nurse do after removing the soiled dressing from a patient's CVAD device? A. Cleanse the site with soap and water. B. Use 2% chlorhexidine swabs to cleanse the site. C. Apply a skin protectant. D. Remove the catheter stabilization device, if present. How can the nurse minimize the risk of dislodging the catheter when removing a dressing? A. Lower the patient's head during the dressing change. B. Remove the transparent dressing or tape and gauze in the direction of catheter insertion. C. Apply skin protectant while the stabilization device is off. D. Cleanse the insertion site quickly and gently in concentric circles. B A female patient placed in the dorsal recumbent position for the insertion of an indwelling urinary catheter tells the nurse that she "doesn't feel comfortable in this position" and that her "back really hurts." What is the nurse's best response? A. Reassure the patient that the procedure will take only a few minutes. B. Promise to reposition the patient as soon as the catheter has been inserted. C. Reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip. D. Explain to the patient that the position will allow the catheter insertion to be more efficient. Which action(s) would minimize the patient's risk for injury during insertion of an indwelling urinary catheter? A. Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances B. Thoroughly cleansing the patient's perineal area with povidone-iodine solution before inserting the catheter C. Performing proper hand hygiene and applying gloves before inserting the catheter D. Terminating the insertion if the patient reports pain at any time during the procedure 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. Begin to establish a sterile field. B. Open and assemble the urine drainage bag. C. Remove soiled gloves, and perform hand hygiene. D. Center the drape over the patient's labia. 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? A. "Please direct the light to better illuminate the patient's perineal area." B. "You need to be comfortable inserting a catheter in a patient of her size." C. "See if a size 14-French catheter is big enough." D. "Find out if the patient has any allergies to latex or iodine." 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? A. Wear clean gloves when inserting the catheter. B. Inflate the balloon on the catheter before using it. C. Use the smallest-size catheter possible. D. Empty the urine by disconnecting the catheter from the collection bag. When educating a client about using an incentive spirometer, you should make which of the following statements? (Select all that apply). a. Use the incentive spirometer once every 1-2 hours. b. Use the incentive spirometer 10 times every 1-2 hours. c. Sit upright when using your incentive spirometer. d. When using the device, exhale slowly until the piston rises to your goal. e. After you complete the session, cough and deep breathe a few times to clear the mucus from your lungs. When mixing rapid or short acting insulins with intermediate acting insulins, you should: (Select all that apply). a. Roll the vial between your hands for suspension. b. Inject air into the longer-acting insulin first, without touching the medication to the needle. c. Draw up the short-acting insulin first. d. Verify that the correct dosage of insulin has been drawn up with a second nurse. e. Draw up the longer acting insulin first. f. Not push any insulin back into the longer acting insulin vial. The nurse is preparing to mix short- and intermediate-acting insulins to administer to a patient. Which action best preserves the insulin's effectiveness? A. Determining the patient's blood glucose level B. Refraining from injecting the intermediate-acting insulin into the short-acting vial C. Applying clean gloves when administering the medication D. Having another registered nurse verify the dose of both types of insulins (Refraining from injecting the intermediate-acting insulin into the short-acting vial will prevent the short-acting insulin vial from being contaminated with intermediate-acting insulin. Determining the patient's blood glucose level will not ensure the effectiveness of the insulin. Wearing clean gloves will not ensure the effectiveness of the insulin. Having another nurse verify the dose will not ensure the effectiveness of the insulin.) Which action would the nurse take when mixing intermediate- and long-acting insulins together in one syringe? A. Draw the intermediate-acting insulin into the syringe first. B. Draw the long-acting insulin into the syringe first. C. Prepare two injections. D. Draw either the intermediate- or the long-acting insulin into the syringe first. (You never mix long-acting insulin with any other insulins. You would need to prepare two injections because you never mix long-acting insulin with any other insulins.) 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? A. Insert air into the intermediate-acting insulin. B. Warm the vials to room temperature. C. Shake the vials to disperse the medication within the suspension. D. Withdraw the prescribed amount of short-acting insulin after the intermediate-acting insulin. (Air is injected into the intermediate-acting insulin before it is injected into the short-acting insulin. Warming the vials to room temperature will enhance patient comfort but will not ensure the effectiveness of the insulin injection. Shaking insulin is not recommended, as it may damage the protein molecules. Short-acting insulin must be drawn up before intermediate-acting insulin.) 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? A. Mix the insulins in one syringe for a single injection. B. Prepare the insulins in two syringes for separate injections. C. Roll each vial between the palms to disperse the medication within the suspension. D. Have another registered nurse verify the dose of the insulins. When preparing an injection of mixed insulin that includes 12 units of NPH and 5 units of regular insulin, how does the nurse initially confirm the proper dosage in the syringe? A. By noting when 5 units of clear insulin is visible in the syringe B. By noting when 12 units of cloudy insulin is visible in the syringe C. By having another registered nurse verify the presence of 17 units of insulin D. By verifying that the prescription confirms the medication administration record (MAR) (Because it is clear, regular insulin will be drawn into the syringe first, so it is the first thing the nurse will verify as she draws the proper dosage. NPH or cloudy insulin is not drawn into the syringe first. While this confirms the correct total insulin volume, it fails to confirm the first step of drawing the clear, regular insulin. Although this confirms the amount of insulin prescribed, which is important, it does not address the amount of insulin in the syringe.) What is the most important task to use when preventing the spread of infection? a. Performing hand hygiene. Which action would the nurse take to diminish tissue irritation when administering a subcutaneous injection to a patient of average size? A. Massage the site after administration. B. Make sure the volume of the medication is less than 2 mL. C. Administer the injection at a 45- to 90-degree angle. D. Wear clean gloves while administering the injection. What can the nurse do to ensure proper site selection for subcutaneous insulin injection? A. Insert the needle at a 30-degree angle. B. Select a different anatomical region for each injection. C. Ask the patient to relax before inserting the needle. D. Systematically rotate sites within the same anatomical location or area. (Systematic rotation within one anatomical location will allow consistent insulin absorption. The correct needle angle for a subcutaneous injection is 45 to 90 degrees. Administering the injection at a 30-degree angle will not deliver medication to the subcutaneous tissue. Furthermore, injection technique has no bearing on site selection. Changing anatomical regions for each insulin injection is not recommended. Asking the patient to relax will help decrease discomfort during the injection, but doing so will not ensure proper site selection.) When preparing to administer heparin or insulin subcutaneously, which site is preferred? A. Abdomen B. Scapula C. Deltoid muscle D. Back of the upper arm What can the nurse do to minimize the discomfort of a subcutaneous injection? A. Inject the medication rapidly. B. Massage the injection site. C. Cover the injection site with gauze pad after withdrawing the needle. D. Inject the medication without pinching the skin. (Covering the nonintact skin of a subcutaneous injection site with a gauze pad, rather than with an alcohol swab, will reduce discomfort. Rapid injection of medication will increase discomfort. Massaging the injection site can cause discomfort and tissue damage. Injecting the medication without pinching the skin will not reduce discomfort.) Which needle would be most appropriate for the nurse to use when giving a subcutaneous injection to a patient of average height and weight? A. 20-gauge, ½-inch B. 22-gauge, 1-inch C. 25-gauge, ⅜-inch D. 27-gauge, 1-inch Syringe size for SubQ 1-3 mL Needle size for SubQ 3/8-5/8 inch When preparing an intramuscular injection, what can the nurse do to reduce the patient's risk for infection? A. Wear clean gloves. B. Use a 3-mL syringe. C. Clean the injection site with an alcohol swab. D. Massage the injection site. Which action by the nurse helps to ensure that the medication is delivered into the muscle when administering an intramuscular injection? A. Using a 1-inch needle B. Inserting the needle at a 45- to 60-degree angle C. Withdrawing the needle immediately after delivering the medication D. Aspirating for blood return before injecting the medication What can the nurse do to minimize the patient's risk for injury when delivering an intramuscular injection? A. Instruct the patient to relax. B. Insert the needle at a 45-degree angle. C. Pull back on the plunger after inserting the needle. D. Pull the skin taut at the injection site when inserting the needle. (Pulling back on the plunger will allow the nurse to determine if the needle is in a blood vessel, rather than in muscle tissue. Encouraging the patient to relax may decrease discomfort, but will not reduce the patient's risk for injury. For an intramuscular injection, the needle must be inserted at a 90-degree angle. Pulling the skin taut when inserting the needle will not reduce the patient's risk for injury.) Which action by the nurse ensures patient safety when administering an intramuscular injection? A. Putting on clean gloves before administration B. Rotating injection sites C. Aspirating for blood return when administering a vaccine D. Injecting the medication quickly Which site is most commonly used for intramuscular injections? A. Ventrogluteal B. Abdominal C. Deltoid D. Dorsogluteal (The ventrogluteal site is the preferred IM injection site for adults and children, but not for infants and toddlers. The abdomen is used for subcutaneous injections. The deltoid site is an appropriate choice for small volumes, but it is not the preferred site for intramuscular injections. The dorsogluteal site is contraindicated for intramuscular injections.) Needle size for IM 1-1/2 inch (23-25 gauge) Site choices for IM injection (3) 1. Ventrogluteal 2. Vastus lateralis 3. Deltoid Site choices for SubQ injection (3) 1. Abdomen 2. Thigh 3. Back of the arm Site for allergy and TB tests (ID) Palm side of forearm about 2 to 4 inches below the elbow Site for ID flu vaccine Deltoid muscle Syringe size for ID 1 mL Needle size for ID 25-27 gauge (3/8-5/8 inch) Which statement might the nurse make to nursing assistive personnel (NAP) when caring for a patient who is prescribed an intradermal injection? A. "Be sure to wear clean gloves during the injection." B. "Tell him it's OK; the site should look like a mosquito bite." C. "Immediately report any patient complaints of itching or dyspnea." D. "Remind the patient to come back in 48 to 72 hours so we can evaluate the site." How can the nurse determine that the needle tip for an intradermal injection is in the dermis? A. A bleb the size of a mosquito bite will appear. B. The needle will enter at a 5- to 15-degree angle. C. The bulge of the needle tip will be visible through the skin. D. The needle will penetrate through the epidermis to a depth of about ⅛ inch. In which site would it be inappropriate to administer an intradermal injection? A. Lower abdomen of an obese patient B. Upper back of a patient who is on bed rest C. Right deltoid of a high school softball pitcher D. Left forearm of a patient with right-sided weakness (The deltoid area is not an acceptable intradermal injection site for any patient. If the forearm and back cannot be used, it is acceptable to use sites routinely used for subcutaneous injections. The upper back is an acceptable intradermal injection site for a patient on bed rest. The left forearm is an acceptable intradermal injection site.) When administering an intradermal injection, which outcome would require the nurse to withdraw the needle and begin again?