Deck 31: Advanced Procedures

Question 1

A nurse has successfully initiated an IV infusion as ordered for a client.After securing the IV catheter and tubing,which of these actions should the nurse take next?

A)Document the IV insertion in the nurse's notes.
B)Start an IV flow sheet.
C)Prepare the next bag of solution for infusion,and leave it at the client's bedside.
D)Place a label with the date and time of insertion and the size and gauge of catheter on the dressing.

Answer 1

Place a label with the date and time of insertion and the size and gauge of catheter on the dressing.

Question 2

Before a nurse initiates a venipuncture,it is essential for the nurse to know:

A)what tests are ordered and any special conditions related to collection or handling
B)the client's blood type
C)the client's previous experiences with the procedure
D)how many times other health care providers have drawn blood in the past 24 hours

Answer 2

what tests are ordered and any special conditions related to collection or handling

Question 3

To prepare a time tape for a bag of IV solution,the nurse must note:

A)the infusion rate and approximate infusion intervals
B)date and time infusion was started
C)initials of person preparing time tape
D)the name of the solution,manufacturer,infusion rate,and expected time of completion

Answer 3

the infusion rate and approximate infusion intervals

Question 4

To estimate the length of the nasogastric (NG)tube that should be inserted to reach the client's stomach,the nurse should use the NG tube to measure the distance from the:

A)client's earlobe to the sternum after placing the client in a sitting position
B)base of the client's nose to the umbilicus after placing the client in a supine position
C)mouth to the earlobe and then to the xiphoid process after placing the client in a supine position
D)tip of the client's nose to the earlobe and then to the xiphoid process after placing the client in a sitting position

Question 5

The nurse is preparing for placement of a nasogastric tube in a client and will use which type of technique for this procedure?

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

Question 6

The nurse is preparing for placement of a nasogastric tube in a client.Before inserting a nasogastric tube,which position will the nurse place the client?

A)high Fowler's
B)Sims' left
C)supine
D)Sims' right

Question 7

A nurse is collecting equipment to start an intravenous (IV)infusion in an adult client.Which gauge IV catheter should the nurse select?

A)18 to 19
B)20 to 22
C)23 to 24
D)25 to 26

Question 8

To set the flow rate for a client's IV infusion,the nurse must FIRST determine:

A)the drops/mL that the specific infusion set delivers
B)the client's age and health status
C)the length of time over which the IV is to infuse
D)the type of IV solution to be administered

Question 9

As a nasogastric (NG)tube is being inserted,the nurse should tell the client to:

A)tip the head forward when the tube reaches the nasopharynx,to minimize gagging
B)tip the head backward when the tube reaches the nasopharynx,to minimize gagging
C)keep the head straight to aid in visualizing the nasal passage
D)take deep breaths while the tube is being advanced,to ease insertion

Question 10

According to Centers for Disease Control and Prevention (CDC)guidelines,IV solutions must be changed every 24 hours and IV catheters must be changed every:

A)12 hours
B)24 hours
C)48 to 72 hours
D)3 days

Question 11

What is the BEST way for a nurse to identify the best site for a venipuncture?

A)auscultation
B)percussion
C)inspection
D)palpation

Question 12

Which of these signs would indicate to the nurse that a client's nasogastric (NG)tube has become blocked?

A)The client begins to gag.
B)The client becomes restless.
C)The client becomes irritable.
D)The client begins to vomit.

Question 13

After a client's nasogastric (NG)tube is inserted,what is the BEST way for the nurse to confirm the tube is correctly placed?

A)Inject air and auscultate for a "whoosh."
B)Aspirate for gastric contents and measure pH.
C)Ask the client if the tube can be felt in the stomach.
D)Ask the health care provider to check the placement.

Question 14

According to the CDC guidelines,IV tubing must be changed every:

A)12 hours
B)24 hours
C)48 hours
D)3 days

Question 15

To prepare a bag of IV solution for administration,the nurse must first:

A)label the bag with date,time,and initials
B)cleanse the bag with an alcohol wipe and then check the expiration date
C)insert the IV tubing,cleanse the bag with saline,and prepare the label
D)inspect the fluid for clarity,particulate matter,and color,and check the expiration date

Question 16

A nurse is preparing to draw blood from a client.Where should the tourniquet be applied?

A)2 inches above the venipuncture site
B)3 to 4 inches above the venipuncture site
C)5 inches above the venipuncture site
D)6 to 7 inches above the venipuncture site

Question 17

Which of these steps describes the correct way for a nurse to cleanse the site selected for a client's venipuncture?

A)Cleanse the site back and forth using a povidone-iodine swab.
B)Use a crisscross motion at the site and extending 4 inches beyond.
C)Cleanse the site back and forth using an alcohol pad.
D)Use a circular motion at the site and extending 2 inches beyond.

Question 18

Which of these statements about selecting a vein for venipuncture to start an IV infusion is TRUE?

A)Choose a vein near a bony prominence.
B)The wrist or hand is the preferred initial site.
C)Use the most distal part of the vein first.
D)Choose an extremity where the client has decreased sensation.

Question 19

What is the MOST common method of obtaining blood specimens from a client?

A)skin puncture
B)arterial stick
C)venipuncture
D)intravascular catheter

Question 20

A nurse is to start an IV solution for a client.After cleansing the site selected,the nurse applies a tourniquet and inserts the IV catheter needle,but there is no blood return in the flashback chamber.Which of these actions should the nurse take?

A)Remove the catheter needle,and attempt reinsertion at another site within the cleansed area.
B)Remove the catheter needle,discard the catheter,select another site,and use a new IV catheter.
C)Move the catheter needle around in the selected vein until blood appears in the chamber.
D)Remove the catheter needle,bandage the area,and let the client rest for at least 30 minutes;then attempt reinsertion.

Question 21

A nurse is to remove an interrupted suture from an incision site.After the site has been cleansed,which of these steps is correct?

A)Use forceps to grasp the middle of the suture,cut it,and pull either end.
B)Use forceps to grasp the suture near the knot,place the curved edge of the scissors under the suture and cut close to the skin,and pull the long end to remove.
C)Use forceps to grasp every other suture,cut each with the curved edge of the scissors down,and pull the short end to remove.
D)Grasp the knot of the suture,cut with the scissors in a position of comfort,and pull either end.

Question 22

When changing a central venous dressing,the nurse would include which of the following actions? (Select all that apply. )

A)explaining the procedure to the client
B)applying gauze dressing
C)putting on a mask
D)using sterile gloves for removing dressing
E)cleansing the exit site in a circular manner
F)labelling with date and time of dressing change

Question 23

A client is to receive 1,000 mL of 5% dextrose in water over a 12-hour period.What is the hourly flow rate?

A)50 mL/hr
B)83 mL/hr
C)100 mL/hr
D)166 mL/hr

Question 24

Which of these observations of a client's IV infusion site would indicate to the nurse that no complications have developed?

A)The site is clean and dry.
B)The site is warm and slightly swollen.
C)The site is cool and dry.
D)The site is red and slightly painful.

Question 25

A client has an order for an IV medication to be administered via secondary administration set (piggyback).Before hanging the secondary administration set (piggyback)medication,the nurse must:

A)check the client's drug allergies,check the compatibility of the solutions,and assess the infusion site
B)discuss the purpose of the medication with the client
C)ask the client's family about any history of allergies,and determine the flow rate
D)apply clean gloves,discuss the purpose of the medication with the client,and hang the piggyback bag

Question 26

At what level should a nurse attach a secondary administration set (piggyback)medication bag to a primary bag of IV solution?

A)at the same level
B)below the level
C)above the level
D)It makes no difference as long as the piggyback drips without problem.

Question 27

To calculate the minute rate of a client's IV infusion,the nurse follows which of these steps?

A)Multiply the infusion time in minutes by the drop factor.
B)Divide the infusion time in minutes by the hourly rate.
C)Divide the hourly infusion rate by number of minutes.
D)Multiply the hourly infusion rate by the drop factor,and divide by the infusion time in minutes.

Question 28

A client who is receiving IV therapy has decreased urine output,has poor skin turgor,and is becoming confused.The nurse should suspect that the client is becoming:

A)overhydrated
B)dehydrated
C)septicemic
D)edematous

Question 29

When changing a central venous dressing,the nurse understands that the rationale to prevent complications such as infection include:

A)explaining the procedure to the client
B)the use of aseptic dressing changes
C)the use of medical asepsis for dressing changes
D)the development of systemic infection

Question 30

To calculate the desired hourly flow rate of an IV infusion,the nurse follows which of these steps?

A)Multiply the volume of fluid by the total infusion hours.
B)Divide total volume by total infusion hours.
C)Multiply drops per mL by the total infusion hours.
D)Divide drops per mL by the total infusion hours.

Question 31

A client is to receive 3,000 mL of 5% dextrose in normal saline over a 24-hour period.The infusion set delivers 15 drops per mL.What is the flow rate in drops per minute?

A)15
B)31
C)45
D)62