Advanced Nursing Skills: Exam 1
Questions With Correct Answers.
*What is the order for mixing rapid acting/long acting insulin from two vials? - ANSWER-
Cloudy-clear-clear-cloudy
*Where should the nurse administer a subcutaneous insulin injection? - ANSWER-
Abdomen
*What site best absorbs insulin? - ANSWER- Abdomen (followed by arm, thighs, and
buttocks.
*Chest tube insertion for hemothorax is between the ___ and ___ ICS - ANSWER- 4-6
*Chest tube insertion for pneumothorax goes into the ____or ___ICS - ANSWER- 2nd
or 3rd
*Empynema - ANSWER- pus from an infection (pneumonia)
*It is important for the nurse to obtain informed consent from the patient before
______________. - ANSWER- administering pain medication (Opioids)
*If needing to take longer to set up a new chest tube system the nurse
should______________. - ANSWER- Place the end of the chest tube in sterile water.
*In the instance that the chest tube becomes disconnected the nurse knows to: -
ANSWER- Quickly cover insertion site with occlusive vaseline gauze during the PEAK
of INSPIRATION.
*The nurse know to ______________ if she notices changes in drainage greater than
________mL/hr. - ANSWER- Notify MD of changes >100 mL/hr
*The nurse knows to encourage the patient to ______________, and ______________
as the chest tube is being pulled out. - ANSWER- Take a deep breath and hold, and
tape on three sides (when the chest tube___________________)
*True/False The nurse should always be sure to take the velcro ties off before she puts
the new one on. - ANSWER- FALSE she only does this if there is an assistant present
to hold tracheostomy tube in place until new ties are firmly tied down.
*True/False: If the nurse notices a change in the patient with a chest tube's condition
she should notify the MD. - ANSWER- True
, *Correct incision site is made between ____________________ and the tube is
inserted directly into the trachea- just below the larynx. - ANSWER- second and third
tracheal rings
*You must take no longer than _______ when cleaning a trach - ANSWER- 15 sec
*No fluctuations in water-seal chamber indicates: - ANSWER- Lung re-expansion; kink
or clot in tubing indicates:
*True/False The nurse knows not to recap any needle - ANSWER- True Box 31-23
*True/False The nurse should maintain a sharps injury log that includes: type and brand
of device involved in the incident; location of the incident; description of the incident;
and privacy of the employees who have had sharps injuries to prevent needlestick injury
- ANSWER- True
*The nurse knows to ______________ in order to allow the patient to speak. -
ANSWER- place a speaking valve in the patient's trach and DEFLATE the cuff
*The nurse knows that when she completes trach care, she must always have the
patient in ________________ position. - ANSWER- Semi-fowlers
*A tracheostomy allows for comfort and mobility over a/an___________. - ANSWER-
Endotracheal tube
*The nurse knows that if a tracheostomy tube becomes dislodged she needs
to__________. - ANSWER- Attempt to replace it (Deb)
*An endotracheal tube or tracheostomy tube is connected by ______________ to the
ventilator. - ANSWER- oxygen tubing
*The nurse must ______________ BEFORE initiating ventilation. - ANSWER- ensure
that the healthcare team is aware of the patient's advance directives and consult with
family members
*The nurse knows that an oropharyngeal airway should be used in
_________________ patients - ANSWER- Unconscious (because they are likely to
trigger gagging, vomiting, or laryngospasms in responsive patient with airway intact
reflexes.)
*The nurse knows that oropharyngeal airways are likely to trigger
_________,________, or ____________ in responsive patient's with intact reflexes. -
ANSWER- gagging, vomiting, or laryngospasms
*Oropharyngeal airways - ANSWER- C-shaped, hard plastic devices available in infant,
pediatric, and adult sizes
Questions With Correct Answers.
*What is the order for mixing rapid acting/long acting insulin from two vials? - ANSWER-
Cloudy-clear-clear-cloudy
*Where should the nurse administer a subcutaneous insulin injection? - ANSWER-
Abdomen
*What site best absorbs insulin? - ANSWER- Abdomen (followed by arm, thighs, and
buttocks.
*Chest tube insertion for hemothorax is between the ___ and ___ ICS - ANSWER- 4-6
*Chest tube insertion for pneumothorax goes into the ____or ___ICS - ANSWER- 2nd
or 3rd
*Empynema - ANSWER- pus from an infection (pneumonia)
*It is important for the nurse to obtain informed consent from the patient before
______________. - ANSWER- administering pain medication (Opioids)
*If needing to take longer to set up a new chest tube system the nurse
should______________. - ANSWER- Place the end of the chest tube in sterile water.
*In the instance that the chest tube becomes disconnected the nurse knows to: -
ANSWER- Quickly cover insertion site with occlusive vaseline gauze during the PEAK
of INSPIRATION.
*The nurse know to ______________ if she notices changes in drainage greater than
________mL/hr. - ANSWER- Notify MD of changes >100 mL/hr
*The nurse knows to encourage the patient to ______________, and ______________
as the chest tube is being pulled out. - ANSWER- Take a deep breath and hold, and
tape on three sides (when the chest tube___________________)
*True/False The nurse should always be sure to take the velcro ties off before she puts
the new one on. - ANSWER- FALSE she only does this if there is an assistant present
to hold tracheostomy tube in place until new ties are firmly tied down.
*True/False: If the nurse notices a change in the patient with a chest tube's condition
she should notify the MD. - ANSWER- True
, *Correct incision site is made between ____________________ and the tube is
inserted directly into the trachea- just below the larynx. - ANSWER- second and third
tracheal rings
*You must take no longer than _______ when cleaning a trach - ANSWER- 15 sec
*No fluctuations in water-seal chamber indicates: - ANSWER- Lung re-expansion; kink
or clot in tubing indicates:
*True/False The nurse knows not to recap any needle - ANSWER- True Box 31-23
*True/False The nurse should maintain a sharps injury log that includes: type and brand
of device involved in the incident; location of the incident; description of the incident;
and privacy of the employees who have had sharps injuries to prevent needlestick injury
- ANSWER- True
*The nurse knows to ______________ in order to allow the patient to speak. -
ANSWER- place a speaking valve in the patient's trach and DEFLATE the cuff
*The nurse knows that when she completes trach care, she must always have the
patient in ________________ position. - ANSWER- Semi-fowlers
*A tracheostomy allows for comfort and mobility over a/an___________. - ANSWER-
Endotracheal tube
*The nurse knows that if a tracheostomy tube becomes dislodged she needs
to__________. - ANSWER- Attempt to replace it (Deb)
*An endotracheal tube or tracheostomy tube is connected by ______________ to the
ventilator. - ANSWER- oxygen tubing
*The nurse must ______________ BEFORE initiating ventilation. - ANSWER- ensure
that the healthcare team is aware of the patient's advance directives and consult with
family members
*The nurse knows that an oropharyngeal airway should be used in
_________________ patients - ANSWER- Unconscious (because they are likely to
trigger gagging, vomiting, or laryngospasms in responsive patient with airway intact
reflexes.)
*The nurse knows that oropharyngeal airways are likely to trigger
_________,________, or ____________ in responsive patient's with intact reflexes. -
ANSWER- gagging, vomiting, or laryngospasms
*Oropharyngeal airways - ANSWER- C-shaped, hard plastic devices available in infant,
pediatric, and adult sizes
