NR226 FINAL EXAM WITH
CORRECT ANSWERS
When delegating 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
2
What assessments does a nurse make before hanging an IV fluid that
contains potassium? (Select all that apply.)
1. Urine output
2. ABGs
3. Fullness of neck veins
4. Serum potassium laboratory value in EHR
5. Level of consciousness
1
4
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
2
Which of the following steps are necessary when inserting a short-peripheral
IV? (Select all that apply.)
1. Apply tourniquet to arm 10 to 15 cm (4-6 inches) above the intended
insertion site.
2. Cleanse skin using an approved antiseptic agent such as alcohol-based 2%
chlorhexidine and allow to dry thoroughly.
3. Stabilize the vein by placing the thumb proximal to the insertion site,
stretching the skin in the direction of insertion.
4. Use the smallest-gauge, shortest catheter available and insert with the
bevel up at a 10- to 15-degree angle.
5. Observe for blood in the flashback chamber of the catheter and advance
the catheter off the needle into the vein.
6. Release the tourniquet once the catheter has been secured and the
dressing has been applied.
1
2
4
5
Place the following steps for discontinuing 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, 4, 2, 1, 5, 3, 7
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
1
4
A patient is admitted to the hospital with severe dyspnea and wheezing. ABG
levels on admission are pH 7.26; PaO2, 68 mm Hg; PaCO2, 55 mm Hg; and
HCO3−, 24. How does the nurse interpret these laboratory values?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
3
, Which assessment does the nurse use as a clinical marker of vascular
volume in a patient at high risk of ECV deficit?
1. Dryness of mucous membranes
2. Skin turgor
3. Fullness of neck veins when supine
4. Fullness of neck veins when upright
3
A nurse is demonstrating how to insert an IV catheter. Which of the following
statements by a nurse viewing the demonstration indicates understanding of
the procedure?
A. "I will thread the needle all the way into the vein until the hub rests
against the insertion site after I see a flashback of blood."
B. "I will insert the needle into the client's skin at an angle of 10 to 30
degrees with the bevel up."
C."I will apply pressure approximately 1.2 inches below the insertion site
prior to removing the needle."
D."I will choose a vein in the antecubital fossa for IV insertion due to its size
and easily accessible location."
B
. A nurse is collecting data from a client who is receiving IV therapy and
reports pain in his arm, chills, and "not feeling well." The nurse notes
warmth, edema, induration, and red streaking on the client's arm close to the
IV insertion site. Which of the following actions should the nurse plan to take
first?
A. Obtain a specimen for culture.
B. Apply a warm compress.
CORRECT ANSWERS
When delegating 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
2
What assessments does a nurse make before hanging an IV fluid that
contains potassium? (Select all that apply.)
1. Urine output
2. ABGs
3. Fullness of neck veins
4. Serum potassium laboratory value in EHR
5. Level of consciousness
1
4
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
2
Which of the following steps are necessary when inserting a short-peripheral
IV? (Select all that apply.)
1. Apply tourniquet to arm 10 to 15 cm (4-6 inches) above the intended
insertion site.
2. Cleanse skin using an approved antiseptic agent such as alcohol-based 2%
chlorhexidine and allow to dry thoroughly.
3. Stabilize the vein by placing the thumb proximal to the insertion site,
stretching the skin in the direction of insertion.
4. Use the smallest-gauge, shortest catheter available and insert with the
bevel up at a 10- to 15-degree angle.
5. Observe for blood in the flashback chamber of the catheter and advance
the catheter off the needle into the vein.
6. Release the tourniquet once the catheter has been secured and the
dressing has been applied.
1
2
4
5
Place the following steps for discontinuing 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, 4, 2, 1, 5, 3, 7
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
1
4
A patient is admitted to the hospital with severe dyspnea and wheezing. ABG
levels on admission are pH 7.26; PaO2, 68 mm Hg; PaCO2, 55 mm Hg; and
HCO3−, 24. How does the nurse interpret these laboratory values?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
3
, Which assessment does the nurse use as a clinical marker of vascular
volume in a patient at high risk of ECV deficit?
1. Dryness of mucous membranes
2. Skin turgor
3. Fullness of neck veins when supine
4. Fullness of neck veins when upright
3
A nurse is demonstrating how to insert an IV catheter. Which of the following
statements by a nurse viewing the demonstration indicates understanding of
the procedure?
A. "I will thread the needle all the way into the vein until the hub rests
against the insertion site after I see a flashback of blood."
B. "I will insert the needle into the client's skin at an angle of 10 to 30
degrees with the bevel up."
C."I will apply pressure approximately 1.2 inches below the insertion site
prior to removing the needle."
D."I will choose a vein in the antecubital fossa for IV insertion due to its size
and easily accessible location."
B
. A nurse is collecting data from a client who is receiving IV therapy and
reports pain in his arm, chills, and "not feeling well." The nurse notes
warmth, edema, induration, and red streaking on the client's arm close to the
IV insertion site. Which of the following actions should the nurse plan to take
first?
A. Obtain a specimen for culture.
B. Apply a warm compress.
