Deck 30: Intermediate Procedures

Question 1

Which of these statements about the application of moist heat is TRUE?

A)It is the preferred treatment for open wounds.
B)It provides more immediate relief from pain or spasm than dry heat.
C)It increases overall body temperature.
D)It is effective only when adequate vasculature is present.

Answer 1

It is effective only when adequate vasculature is present.

Question 2

A nurse is preparing to administer a medication in tablet form to a client who has difficulty swallowing.Which of these actions should the nurse take?

A)Crush the tablet into a powder,and mix it with a small amount of applesauce.
B)Ensure the tablet is not enteric-coated or time-released before crushing it.
C)Administer the tablet with extra amounts of liquid.
D)Substitute a liquid form of the medication for the tablet.

Answer 2

Ensure the tablet is not enteric-coated or time-released before crushing it.

Question 3

When preparing a unit dose tablet for administration,the nurse should:

A)open the package and place it in the medicine cup
B)take the package to the client and have the client open it
C)place the tablet directly in the medicine cup without opening it
D)check the order with another nurse before placing it in the medicine cup

Answer 3

place the tablet directly in the medicine cup without opening it

Question 4

A client is to receive continuous bladder irrigation following prostate surgery.Which type of catheter will be used for this procedure?

A)straight catheter
B)indwelling catheter to straight drainage
C)three-way catheter
D)two-way catheter

Question 5

Prior to medication administration,the nurse would ensure safety by verifying the right client,the right medication,the right dose,and:

A)the right color,and the right manufacturer
B)the right generic substitute,and the right-size tablet or capsule
C)the right route,and the right time
D)the right name,and the right room

Question 6

As a nurse is pouring a solution into a container on a sterile field,which of these steps is correct?

A)Hold the bottle with the label facing the nurse,about 4 to 6 inches over the container,and pour slowly from the side of the field.
B)Hold the bottle with the label facing down,about 6 to 8 inches over the container,and pour slowly from in front of the field.
C)Hold the bottle with the label facing the nurse,about 8 to 10 inches over the container,and pour quickly from the side of the field.
D)Hold the bottle with the label facing down,about 2 to 4 inches over the container,and pour quickly from in front of the field.

Question 7

When a nurse is adding additional dressings to a sterile field,which of these steps is correct?

A)Grasp the bottom,use a sterile clamp to remove dressing,and drop it anywhere on the field.
B)Place the unopened package directly on the field.
C)Grasp top flaps,pull downward,and drop dressing in center of field.
D)Hold the sides,pull them outward,and drop dressing on the field.

Question 8

A nurse who is left-handed is applying sterile gloves for a procedure.What is the correct procedure for this nurse?

A)Glove the left hand first by grasping 2-inch cuff with thumb and the first two fingers of the right hand.
B)Glove right hand first by grasping 2-inch cuff with thumb and the first finger of the left hand.
C)Glove either hand first by grasping 2-inch cuff with thumb and the first two fingers of the right hand.
D)Glove the left hand first by grasping 2-inch cuff with thumb and the second finger of the right hand.

Question 9

A nurse is preparing to insert an indwelling urinary catheter prescribed for a client,and a sterile field is prepared.Which of these steps MUST the nurse take before the catheter is inserted?

A)Cleanse the catheter with a povidone-iodine solution.
B)Inflate and deflate the retention balloon.
C)Examine the perineal area for signs of irritation or infection.
D)Attach the urinary drainage bag to the catheter.

Question 10

While a nurse is pouring a cleansing solution into a container on a sterile field,some of the solution splashes over the side of the container.This field is now considered to be:

A)sterile
B)medically aseptic
C)surgically aseptic
D)contaminated

Question 11

What is the purpose of a sitz bath?

A)to provide warm,moist heat to the perineal area
B)to provide local application of cold to the rectum
C)to provide application of medication to the perineal area
D)to provide specialized cleansing to the vagina or rectum

Question 12

A nurse is preparing to change a client's colostomy pouch.After removing the pouch,which of these steps should the nurse take NEXT?

A)Prepare solution for cleansing the stoma.
B)Measure the stoma to fit the new pouch.
C)Remove gloves,cleanse hands,and apply clean gloves.
D)Place a gauze pad over the stoma while preparing to cleanse it and apply new pouch.

Question 13

A nurse is removing sterile gloves after a procedure is completed.Which of the following actions is necessary during this procedure?

A)Keep soiled gloves from touching the client.
B)Place soiled gloves in a recycling container.
C)Wash gloved hands before removal.
D)Remove gloves without coming into contact with soiled surfaces.

Question 14

When preparing a sterile field for a client dressing change,the nurse should open the outer wrapper on the sterile package by pulling the wrapper:

A)toward the nurse's body
B)away from the nurse's body
C)toward the client's body
D)away from the client's body

Question 15

Use of dry-heat treatment is contraindicated in clients who have:

A)diabetes mellitus
B)hypertension
C)hepatitis
D)pancreatitis

Question 16

What is the BEST evidence that a nurse has been successful when catheterizing a client?

A)The client does not complain of pain.
B)The client develops bladder spasms.
C)The sterile field has been maintained.
D)Urine drains from the catheter.

Question 17

How will the nurse document a bladder irrigation on the client's intake and output record?

A)by recording only the amount of irrigant instilled
B)by recording the amount of irrigant instilled and the amount of drainage measured
C)by recording only the amount of drainage
D)by measuring drainage before and after irrigation is completed

Question 18

A client has a prescription for an ice bag to be applied to a sprained ankle.The nurse would return to remove the ice bag in:

A)10 minutes
B)20 minutes
C)45 minutes
D)1 hour

Question 19

Cold therapy for a client is usually indicated when:

A)there is no other way to provide pain relief
B)vasoconstriction and increased blood viscosity are desired
C)heat therapy is ineffective
D)there are multiple open areas prone to infection

Question 20

A client who has an indwelling urinary catheter develops increased sediment in the drainage tubing,and a catheter irrigation is prescribed.Before the irrigating solution is introduced into the catheter,the nurse must FIRST do which of the following actions?

A)Insert the tip of the irrigating syringe into the catheter;then fill it with 60 cc of solution.
B)Disinfect the connection between the catheter and drainage tubing before separating them.
C)Separate the catheter and drainage tubing,and let the catheter drain to empty the bladder.
D)Remove the current catheter;then reinsert another catheter before starting the procedure.

Question 21

A nurse is administering tuberculin screening tests to people attending a health fair.When injecting the solution,the nurse should take which of these steps?

A)Insert the needle at a 10-degree angle,inject rapidly,note formation of a bleb,and withdraw needle.
B)Insert the needle at a 5- to 15-degree angle,inject slowly,note formation of a bleb,withdraw needle,and massage the site.
C)Insert the needle at a 5- to 15-degree angle,inject slowly,note formation of a bleb,and withdraw needle.
D)Insert the needle at a 10-degree angle,inject rapidly,note formation of a bleb,withdraw needle,and massage the site.

Question 22

The nurse is preparing to administer a liquid medication.After removing the container cap,which of these steps in preparation is correct?

A)Place cap facedown,hold bottle at waist level,and pour to desired level using edge of liquid as the scale.
B)Dispose of cap,hold bottle at chest level,and pour to desired level using base of the meniscus as the scale.
C)Place cap on the side,hold bottle at eye level,and pour to desired level using edge of liquid as the scale.
D)Place cap upside down,hold bottle at eye level,and pour to desired level using base of the meniscus as the scale.

Question 23

What is the maximum amount of medication that should be administered subcutaneously?

A)l mL
B)1.5 mL
C)2 mL
D)2.5 mL

Question 24

When a nurse is to administer a medication to a client using the Z-track method,which of these sites is preferred?

A)deltoid
B)quadriceps
C)dorsogluteal
D)ventrogluteal

Question 25

Before applying a new,dry dressing to a client's surgical incision,the nurse should remove and discard the current dressing with gloved hands and then:

A)cleanse the skin around the incision with hydrogen peroxide
B)remove soiled gloves and apply clean gloves before proceeding
C)notify the health care provider if any irritation is evident
D)apply a new dressing

Question 26

Before administering a capsule form of medication to a client via a nasogastric tube,the nurse must FIRST do which of the following actions?

A)Dissolve it in about 50 cc of cold water.
B)Check placement of the tube before instilling medication.
C)Dissolve it in about 100 cc of warm water.
D)See if a liquid equivalent form is available.

Question 27

A nurse is preparing to change a client's wet-to-moist dressing and notes the dressing is extremely dry.Which of these steps should the nurse take NEXT?

A)Check the client record as to the time of the last dressing change.
B)Ask another nurse to help remove the current dressing.
C)Moisten the dressing with a small amount of saline before removing it.
D)Supersaturate the new dressing and cover with dry 4 x 4 gauze pads.

Question 28

A nurse is to administer an intramuscular (IM)injection into the vastus lateralis muscle.How should the client be positioned before the injection?

A)lying on side or back with knee and hip slightly flexed
B)lying flat or supine with knee slightly flexed
C)lying flat with lower arm relaxed across abdomen
D)lying prone with feet turned inward

Question 29

After cleansing the top of a medication vial with an alcohol pad,the nurse must NEXT:

A)hold the vial at waist level and withdraw the desired dosage
B)inject air equal to the amount of medication to be withdrawn
C)shake the vial vigorously
D)place the vial on a stable surface to withdraw the desired dosage

Question 30

A nurse is to administer nitroglycerin ointment to a client.It is essential that the nurse FIRST:

A)squeeze the dosage on the medication measuring strip
B)take the client's apical pulse
C)remove the current strip and clean the site before applying new ointment in another site
D)ask the client about any episodes of angina before applying new ointment

Question 31

To insert a rectal suppository in an adult client,the nurse should position the client in the Sims' left position and insert the suppository:

A)into the anal canal
B)past the internal sphincter and against the rectal wall
C)approximately 8 inches
D)until the client experiences the urge to defecate

Question 32

A nurse should instruct a client who is to use a metered-dose nebulizer to follow which of these steps?

A)Exhale,place mouthpiece in mouth,press down on dispenser while simultaneously inhaling,and hold for 10 seconds before exhaling slowly.
B)Inhale and exhale several times,place mouthpiece in mouth,press down on dispenser,inhale,and hold for 20 seconds before exhaling slowly.
C)Place mouthpiece in mouth,press down on dispenser,take two deep breaths,and exhale rapidly.
D)Rest quietly for 5 minutes before placing mouthpiece in mouth,press down on dispenser,take two deep breaths,and exhale rapidly.

Question 33

To correctly administer nose drops,the nurse should:

A)insert dropper about 1/2 inch into the nostril and allow drops to remain at least 10 minutes
B)insert dropper about 3/8 inch into the nostril and have client inhale as drops are administered
C)have client blow nose and then insert dropper about 3/4 inch into the nostril
D)have client blow nose;then insert dropper about 1/2 inch into the nostril and allow drops to remain at least 10 minutes

Question 34

Which of these steps in administering eyedrops to a client is MOST important?

A)placing a tissue below the lower lid
B)pulling down on the cheek
C)having client close eyes after drops are instilled
D)holding the eyedropper at least 1/2 inch above the eyeball

Question 35

Which of these directions should the nurse give to a client who is to take a medication administered buccally?

A)Place the medication in the mouth against the cheek until it dissolves completely.
B)Place the medication under the tongue until it dissolves completely.
C)Chew the medication thoroughly before swallowing it.
D)Drink plenty of liquids after chewing the medication and swallowing it.

Question 36

After a client has self-administered a vaginal medication,the nurse should suggest the client:

A)perform perineal care
B)allow the medication to remain in place at least 30 minutes before voiding
C)apply a perineal pad to collect any discharge or drainage
D)remain in the dorsal recumbent position for at least 10 minutes

Question 37

To withdraw medication from an ampule,the nurse should open the ampule by:

A)placing a tissue around the neck and snapping the top off carefully
B)filing the neck and snapping the top while wearing gloves
C)wrapping a sterile gauze pad around the neck and snapping the top off away from oneself
D)placing the neck on a solid surface and tapping it gently with a sterile clamp

Question 38

When administering a medication to a client,which of these actions should the nurse take to correctly identify the client?

A)Read the name on the door of the room where the client is sitting.
B)Read the client's name bracelet.
C)Ask the client to repeat his or her name.
D)Read the client's name bracelet,and ask the client to repeat his or her name.

Question 39

One of the differences in using the Z-track method of IM medication administration and the usual IM injection is that the Z-track method:

A)takes more time
B)does not have the site rubbed or wiped after administration
C)is more painful
D)requires a larger needle and syringe

Question 40

A nurse is to administer eardrops to an adult client.In which direction should the nurse pull the pinna?

A)upward and outward
B)down and back
C)down and outward
D)upward and back

Question 41

A nurse is obtaining a capillary blood specimen from a client.After cleaning the site,which of these steps is correct?

A)Insert lancet about 3 cm,and then collect blood into the appropriate tube.
B)Squeeze the site,insert the lancet,and maintain pressure while collecting blood into the appropriate tube.
C)Stab quickly,wipe away first drop of blood,and then collect blood into the appropriate tube.
D)Stab slowly,squeeze the site,and maintain pressure while collecting blood into the appropriate tube.

Question 42

Which of these steps is essential when the nurse is preparing to suction a client's tracheostomy?

A)Administer oxygen or use an Ambu bag before beginning procedure.
B)Change the client's inner cannula.
C)Cover the tracheostomy ties with a clean towel.
D)Set up sterile hydrogen peroxide to use for rinsing the suction catheter.

Question 43

A nurse is preparing to teach a client how to walk with crutches.To ensure client safety and comfort,the crutch pad should fit approximately how many inches below the axilla?

A)1
B)1-1/2 to 2
C)2-1/2 to 3
D)4

Question 44

A client is receiving oxygen therapy via a Venturi mask.Which of these actions is essential when a nurse is caring for this client?

A)Check the flow rate at least every 2 hours.
B)Ensure that the mask ports are cleansed every 4 hours.
C)Begin to wean the client to a nasal cannula as soon as possible.
D)Assess client's face and ears for signs of pressure from the mask.

Question 45

Before a nurse administers an enteral feeding,it is essential to take which of the following actions?

A)Determine if the client has had a bowel movement in the past 24 hours.
B)Ask the client about any feeling of gastric fullness.
C)Weigh the client and compare with previous weight.
D)Auscultate for bowel sounds to determine gastric motility.

Question 46

Which of these exercises,if taught to a client prior to surgery,can BEST prevent development of postoperative respiratory complications?

A)turning
B)coughing
C)deep breathing and spirometry
D)splinting

Question 47

To improve venous blood return from the legs postoperatively,which of these exercises will be MOST beneficial to the client?

A)turning from side to side at regular intervals
B)splinting incision when coughing
C)deep breathing and making circles with the ankles
D)pushing toes toward the foot of the bed until calf muscles tighten,then relaxing and pulling toes toward chin until calf muscles tighten,then relaxing again

Question 48

After checking the health care provider's order for a client's wound irrigation,the nurse should:

A)prepare the sterile irrigation tray and dressing supplies and warm irrigating solution in a microwave
B)prepare the irrigating solution and flush from about 2 inches above the wound
C)prepare the sterile irrigation tray and dressing supplies and pour room-temperature solution into the sterile container
D)flush the wound with saline and then prepare to culture the wound before irrigating it

Question 49

One advantage of selecting continuous enteral feeding for a client who is unable to eat by mouth is that it:

A)is easier to administer and requires minimal equipment
B)keeps gastric volume small,reducing risk of aspiration
C)is less irritating than intermittent feedings
D)requires less effort for digestion to occur

Question 50

Which of these statements about oxygen therapy for a client is TRUE?

A)The client is started on the highest dose possible,and dose is reduced as the client improves.
B)Oxygen is a medication,requiring medication administration criteria as well as oxygen therapy administration criteria.
C)The prescription for oxygen therapy is determined by the respiratory therapist in consultation with the client's health care provider.
D)Oxygen therapy can be initiated by a nurse in any emergency situation.

Question 51

A nurse is preparing to culture a client's wound to determine if it is infected.Which of these steps should the nurse take?

A)Irrigate the wound with antiseptic,swab over granulation tissue,and replace swab in culture tube.
B)Irrigate the wound with saline,swab over granulation tissue,and replace swab in culture tube.
C)Irrigate the wound with antiseptic,swab over eschar,and replace swab in culture tube.
D)Swab over granulation tissue,replace swab in culture tube,and redress the wound.

Question 52

A nurse is preparing to suction an adult client's tracheostomy.At what pressure,in mm HG,should the nurse set the wall suction?

A)50 to 100
B)100 to 120
C)120 to 130
D)130 to 140

Question 53

A client requires nasopharyngeal suctioning.To ensure the suction catheter is properly placed,the nurse should do which of the following?

A)Ensure a sterile suction set is available at the client's bedside.
B)Check the function of the suction device before beginning the procedure.
C)Use the estimated distance from the tip of the client's nose to the earlobe,and grasp catheter at this point.
D)Advance the catheter gently until resistance is met,and continue rotating the catheter until secretions are obtained.

Question 54

When a nurse is replacing a client's tracheostomy ties,which of these steps is correct?

A)Hold the neck plate firmly with one hand while untying and removing soiled tapes.
B)Remove soiled tapes,cleanse the neck plate,and replace with clean tapes.
C)Suction the tracheostomy,perform tracheostomy cleaning,cut the soiled tapes,and replace with clean tapes.
D)Sedate the client,remove soiled tapes,perform tracheostomy cleaning,and apply clean tapes.

Question 55

A client who experienced respiratory distress had a tracheostomy performed 2 hours ago.The nurse must use which of these approaches when caring for the tracheostomy?

A)clean technique
B)sterile technique
C)clean technique to remove the cannula and sterile technique to suction it
D)client self-care technique

Question 56

What protective devices should a nurse wear when preparing to perform oropharyngeal suction on a client?

A)gown and gloves
B)gown,mask,and goggles
C)gloves only
D)gown and mask only

Question 57

A nurse is preparing to perform tracheostomy care.Which of these steps is correct?

A)Clean the neck plate with saline and rinse with hydrogen peroxide;then remove inner cannula.
B)Place the inner cannula in hydrogen peroxide solution;then clean the neck plate with peroxide and saline.
C)Clean the neck plate with hydrogen peroxide and rinse with saline;then remove inner cannula.
D)Place the inner cannula in saline solution;then clean the neck plate with hydrogen peroxide solution.

Question 58

Which of these sites is MOST commonly used when a capillary puncture is needed to obtain a small amount of blood from an adult?

A)heel
B)fingertip
C)earlobe
D)toe

Question 59

A client is receiving oxygen via nasal cannula.In addition to monitoring the client's vital signs,the nurse MUST:

A)adjust the cannula every 4 hours
B)assess the client's respiratory rate every 2 hours
C)assess the client's nostrils every 8 hours
D)check the flow rate every 6 hours

Question 60

A client has a percutaneous endoscopic gastrostomy (PEG)tube in place.Which of these actions must the nurse take when caring for this client?

A)Rotate the PEG tube daily.
B)Keep the PEG tube pinned to the client's gown at all times.
C)Minimize flushing of the PEG tube.
D)Cleanse the skin around the client's PEG tube with hydrogen peroxide.

Question 61

Which of these steps is correct when a nurse is instilling two medications into a client's enteral tube?

A)Clamp the tube,attach the syringe,add both medications,release the clamp,and flush with 30 cc water.
B)Attach the syringe,pour 30 cc of one medication,open the clamp,rinse with 5 cc water,pour remaining medication into the tube,and flush with 30 to 50 cc water.
C)Attach the syringe,pour both medications into the tube,open the clamp,and flush with 30 to 50 cc water.
D)Aspirate gastric contents,attach the syringe,pour each medication sequentially into the tube,and flush with 100 cc water

Question 62

The nurse is aware that the enteral tube feedings are contradicted in clients with which of the following? (Select all that apply. )

A)severe diarrhea
B)intestinal obstruction
C)peritonitis
D)severe pancreatitis
E)GI ischemia
F)paralytic ileus