Exam 3 - Questions Flashcards
1
Q
A nurse is assessing a patient with COPD who is experiencing dyspnea. What action will the nurse take first?
Place the patient in Fowler position.
Encourage diaphragmatic breathing.
Ask the patient to cough.
Initiate oral suctioning of secretions.
A
Place the patient in Fowler position
2
Q
A nurse is maintaining airway patency in an unconscious patient by providing frequent nasopharyngeal suction. When would the nurse anticipate inserting a nasopharyngeal airway (nasal trumpet)?
Vomiting during suctioning occurs.
Secretions appear to contain stomach contents.
The suction catheter touches an unsterile surface.
Epistaxis is noted with continued suctioning.
A
Epistaxis is noted with continued suctioning.
3
Q
A nurse in the PACU is performing oral suctioning for a patient with an oropharyngeal airway, when the patient begins to vomit. What is the nurse’s priority nursing action at this time?
Removing the suction catheter and elevating the head of the bed
Notifying the primary health care provider
Confirming the size of the oral airway is correct
Placing the patient in the supine position
A
Removing the suction catheter and elevating the head of the bed
4
Q
A nurse plans to suction a patient’s endotracheal tube using the open suction technique. Which intervention is appropriate for this technique?
Using a suction catheter that is the diameter of the endotracheal tube
Maintaining the patient in the supine position
Administering oxygen prior to suctioning
Changing the inline suction device every 24 hours
A
Administering oxygen prior to suctioning
5
Q
A nurse is caring for a patient admitted for an acute asthma exacerbation. The patient reports extreme dyspnea, stating, “Turn up the oxygen, I’m not getting enough air.” Which actions would the nurse take first?
Suction the airway.
Assess the pulse oximetry reading.
Obtain a peak flow meter reading.
Assess for cyanosis of the lips.
A
Assess the pulse oximetry reading.
6
Q
A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient?
Assisting with all bathing and hygiene
Telling the patient to avoid speaking during hygiene
Teaching the patient to take short shallow breaths during activity
Taking rest periods between activities
A
Taking rest periods between activities
7
Q
A nurse working in the pulmonary clinic is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? [Select all that apply]
Avoid exercise.
Take steps to manage or reduce anxiety.
Eat meals 1 to 2 hours prior to breathing treatments.
Eat a high-protein/high-calorie diet.
Maintain a high-Fowler position when possible.
Drink 2 to 3 pints of clear fluids daily.
A
Take steps to manage or reduce anxiety.
Eat a high-protein/high-calorie diet.
Maintain a high-Fowler position when possible.
8
Q
A nurse is teaching a patient how to use a metered-dose inhaler for asthma. Which comments from the patient assure the nurse that the teaching has been effective? [Select all that apply]
“I’ll be careful not to shake the canister before using it.”
“It’s important to hold the canister upside down when using it.”
“I have to remember to inhale the medication through my nose.”
“I will continue to inhale when the cold propellant is in my throat.”
“I won’t inhale more than one spray with one breath.”
“I will activate the device while continuing to inhale.”
A
“I will continue to inhale when the cold propellant is in my throat.”
“I won’t inhale more than one spray with one breath.”
“I will activate the device while continuing to inhale.”
9
Q
A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly? [Select all that apply]
Making sure the oxygen is flowing into the prongs
Maintaining oxygen saturation between 94% and 98%
Encouraging the patient to breathe through their nose with their mouth closed
Initiating the oxygen flow rate at 6 L/min or more
Protecting the patient’s skin from irritation by the oxygen tubing
A
Making sure the oxygen is flowing into the prongs
Encouraging the patient to breathe through their nose with their mouth closed
Protecting the patient’s skin from irritation by the oxygen tubing
10
Q
A nurse is securing a patient’s endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident?
Instructing the assistant to notify the health care team
Assessing the patient’s vital signs
Removing the tape, adjusting the depth to the ordered depth, and retaping securely
Taking no action, as the depth will adjust automatically
A
Removing the tape, adjusting the depth to the ordered depth, and retaping securely
11
Q
A nurse is providing teaching for a patient who will undergo surgery and return to the intensive care unit with an endotracheal tube. What education is most important for the nurse to provide?
“The endotracheal tube will drain out excess secretions from the surgical site.”
“This tube is used to facilitate breathing; you will not be able to speak while it is in place.”
“This is a surgically placed tube in your neck; we will suction it frequently to remove mucus.”
“Your oxygenation will be monitored frequently using pulse oximetry.”
A
“This tube is used to facilitate breathing; you will not be able to speak while it is in place.”
12
Q
A nurse is caring for a patient who has a pleural chest tube attached to a disposable chest drainage system. Which nursing actions are indicated for this patient? [Select all that apply]
Avoiding turning the patient to prevent disconnections in the tubing
Maintaining an occlusive dressing on the site
Assessing the patient for signs of respiratory distress
Keeping the chest drainage device at the level of the patient’s thorax
Ensuring there are no dependent loops or kinks in the tubing
Observing for bubbles indicating air leak in the water seal chamber
A
Maintaining an occlusive dressing on the site
Assessing the patient for signs of respiratory distress
Ensuring there are no dependent loops or kinks in the tubing
Observing for bubbles indicating air leak in the water seal chamber
13
Q
A nurse in the emergency department is caring for a patient who was brought in by fire rescue due to a heroin overdose. The nurse notes the patient is not breathing. What action will the nurse take immediately? [Select all that apply]
Tilt the patient’s head forward.
Begin ventilation using a manual resuscitation bag (Ambu bag).
Place the mask tightly over the patient’s nose and mouth.
Pull the patient’s jaw backward.
Compress the bag twice the normal respiratory rate for the patient.
Recommend that a sputum culture for cytology is obtained.
A
Begin ventilation using a manual resuscitation bag (Ambu bag).
Place the mask tightly over the patient’s nose and mouth.
14
Q
Which assessments and interventions should the nurse consider when performing tracheal suctioning? [Select all that apply]
Closely assessing the patient before, during, and after the procedure
Hyperoxygenating the patient before and after suctioning
Limiting the application of suction to 20 to 30 seconds
Monitoring the pulse to detect effects of hypoxia and stimulation of the vagus nerve
Using an appropriate suction pressure (80 to 150 mm Hg)
Inserting the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube
A
Closely assessing the patient before, during, and after the procedure
Hyperoxygenating the patient before and after suctioning
Monitoring the pulse to detect effects of hypoxia and stimulation of the vagus nerve
Using an appropriate suction pressure (80 to 150 mm Hg)
Inserting the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube
15
Q
A nurse is monitoring a patient with a pleural effusion after a thoracentesis removing 1,400 mL of dark yellow liquid. What is the expected outcome of this procedure?
Tachycardia
Hypotension
Reduced dyspnea
Pulse oximetry of 88%
A
Reduced dyspnea
16
Q
A nursing student attending clinical on a medical-surgical unit receives report from the off-going nurse stating the patient has adventitious breath sounds that clear after expectorating sputum. Which adventitious breath sound will the student expect to auscultate?
Bronchial
Bronchovesicular
Vesicular
Wheezing
A
Wheezing
17
Q
A nurse in the emergency department is caring for a patient who had eaten shellfish and is now wheezing. The nurse explains to the patient that the health care provider has prescribed a bronchodilator, which will have what action?
Helping the patient cough up thick mucus
Opening narrowed airways and relieving wheezing
Acting as a cough suppressant
Blocking the effects of histamine
A
Opening narrowed airways and relieving wheezing
18
Q
A nurse is planning to suction a patient’s tracheostomy tube the day after its placement. Which action by the nurse is absolutely essential?
Assessing the need to premedicate with an analgesic
Placing the patient in low Fowler position
Inserting the obturator into the outer cannula
Maintaining aseptic technique
A
Maintaining aseptic technique
19
Q
A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which findings are early indications that should alert the nurse that the client is developing hypoxia? [Select all that apply]
Restlessness
Tachypnea
Bradycardia
Confusion
Hypertension
A
Restlessness
Tachypnea
Confusion
Hypertension
Monitor for: restlessness, tachypnea, confusion, and hypertension → early manifestations of hypoxia ALONG WITH: tachycardia, elevated BP, use of accessory muscles, nasal flaring, tracheal tugging, adventitious lung sounds
20
Q
A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which instructions? [Select all that apply]
Apply petroleum jelly around and inside the nares
Remove the nasal cannula during mealtimes
Check the position of the cannula frequently
Report any nausea or difficulty breathing
Post “No Smoking” signs in prominent locations
A
Check the position of the cannula frequently
Report any nausea or difficulty breathing
Post “No Smoking” signs in prominent locations
21
Q
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which intervention is the nurse’s priority?
Increase the oxygen flow
Assist the client to Fowler’s position
Promote removal of pulmonary secretions
Obtain a specimen for arterial blood gases
A
Assist the client to Fowler’s position
- Use the ABC approach to relieve dyspnea. Fowler’s position facilitates maximal lung expansion → optimizes breathing*
22
Q
A nurse is preparing to perform endotracheal suctioning for a client. Place the following actions in proper order:
Remove the bag or ventilator from the tracheostomy or endotracheal tube and insert the catheter into the lumen of the airway. Advance the catheter until resistance is met. The catheter should reach the level of the carina [location of bifurcation into the mainstem bronchi]
Don the required PPE
Reattach the BVM or ventilator and administer 100% oxygen
Assist the client to high-Fowler’s or Fowler’s position for suctioning if possible
Pull the catheter back 1cm [0.4in] prior to applying suction
Apply suction intermittently by covering and releasing the suction port with the thumb for 10-15 seconds
Rinse catheter and suction tubing with sterile saline until clear
Encourage the client to breathe deeply and cough in an attempt to clear the secretions without artificial suction
Obtain baseline breath sounds and vital signs, including SaO2 by pulse oximeter. Can monitor SaO2 continually during the procedure
A
- Don the required PPE
- Assist the client to high-Fowler’s or Fowler’s position for suctioning if possible
- Encourage the client to breathe deeply and cough in an attempt to clear the secretions without artificial suction
- Obtain baseline breath sounds and vital signs, including SaO2 by pulse oximeter. Can monitor SaO2 continually during the procedure
- Remove the bag or ventilator from the tracheostomy or endotracheal tube and insert the catheter into the lumen of the airway. Advance the catheter until resistance is met. The catheter should reach the level of the carina [location of bifurcation into the mainstem bronchi]
- Pull the catheter back 1cm [0.4in] prior to applying suction
- Apply suction intermittently by covering and releasing the suction port with the thumb for 10-15 seconds
- Reattach the BVM or ventilator and administer 100% oxygen
- Rinse catheter and suction tubing with sterile saline until clear
23
Q
A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? [Select all that apply]
Apply the oxygen source loosely of the SpO2 decreases during the procedure
Use surgical asepsis to remove and clean the inner cannula
Clean the outer cannula surfaces in a circular motion from the stoma site outward
Replace the tracheostomy ties with new ties
Cut a slit in gauze squares to place beneath the tube holder
A
Apply the oxygen source loosely of the SpO2 decreases during the procedure
Use surgical asepsis to remove and clean the inner cannula
Clean the outer cannula surfaces in a circular motion from the stoma site outward
24
Q
A nurse is preparing to suction a client’s tracheostomy. Which of the following actions should the nurse take?
Suction for 30 seconds with each pass.
Allow 2 min in between suctioning to reoxygenate the lungs.
Use a rotating motion when inserting the catheter from the tracheostomy.
Set the suction pressure to 180 mm Hg
A
Allow 2 min in between suctioning to reoxygenate the lungs.
25
A nurse is suctioning a client's airway using in-line suctioning. Which of the following actions should the nurse plan to take?
Hyperoxygenate the client before disconnecting the ventilator.
Apply suction pressure while advancing the catheter.
Wear a face shield during the procedure.
Reuse the catheter repeatedly.
Reuse the catheter repeatedly.
26
A nurse is caring for a client who has a tracheostomy tube in place. During tracheostomy care, which of the following should the nurse place underneath the flange of the outer cannula?
Commercially prepared transparent dressing
Cotton-filled gauze square
Commerically prepared fenestrated dressing
Twill tape
Commerically prepared fenestrated dressing
27
A nurse is caring for a client who has a cuffed endotracheal [ET] tube in place. Which of the following actions should the nurse plan to take?
Repositioning the ET tube in the client’s mouth every 12 hr
Providing oral care every 24 hr
Applying the securing tape over the client’s ears
Maintaining a cuff pressure of 35 mm Hg
Repositioning the ET tube in the client’s mouth every 12 hr
28
A nurse is preparing to suction a client’s oral airway. Which of the following devices or methods should the nurse take?
In-line suctioning
Yankauer catheter
Bulb syringe
Open suctioning
Yankauer catheter
29
A nurse is caring for a client who sustained trauma to their head and neck and will require long-term airway support. Which of the following pieces of equipment will be required for home health care for this client?
Nasopharyngeal airway device
Oropharyngeal airway device
Endotracheal tube
Tracheostomy tube
Tracheostomy tube
30
A nurse is performing chest physiotherapy for a client who needs help mobilizing and expectortating thick pulmonary secretions. To increase the turbulence of the air the client exhales, the nurse should use which of the following techniques?
Vibration
Percussion
Nebulization
Postural drainage
Vibration
31
Postural drainage
A nurse is caring for a client who has a tracheostomy tube with an inner cannula in place. Which of the following supplies should the nurse use to dry the inner cannula of the client’s tracheostomy tube after cleaning it?
Paper towels
Cotton-tipped applicators
Folded pipe cleaners
Facial tissues
Folded pipe cleaners
32
Oxygen therapy is prescribed for a client who is brought to an emergency department in the early stages of hypoxia. When assessing this client, a nurse should expect which of the following findings?
Elevated blood pressure
Decreased respiratory rate
Cyanosis
Peripheral edema
Elevated BP
33
Administering oxygen therapy with a nonrebreather mask has which of the following advantages?
Offers the highest oxygen concentration of the low-flow systems
Provides oxygen concentrations of 40% to 60%
Incorporates a design that requires minimal monitoring of the client
Is designed for safety once the mask's valves and flaps are sealed
Offers the highest oxygen concentration of the low-flow systems
34
A nurse should recognize that which of the following findings is an indication for oxygen therapy?
Respiratory rate 32/min
PaO₂ 90 mm Hg
Fraction of inspired oxygen (FiO₂) 65% for 4 days
Oxygen saturation (SaO₂) 90%
Oxygen saturation (SaO₂) 90%
35
A nurse is caring for a critically ill client who has COPD and requires delivery of a precise concentration of oxygen. Which of the following types of oxygen-delivery devices is indicated for this client?
Simple face mask
Nasal cannula
Venturi mask
Face tent
Venturi mask
36
A home health nurse is teaching a client who has just started receiving oxygen therapy via mask. The nurse should emphasize that the client must
Clean the mask with soapy water once every other day.
Reposition the elastic band frequently.
Apply petroleum jelly around and inside the nares.
Make sure there is adequate condensation in the tubing.
Reposition the elastic band frequently.
37
A nurse is caring for a client who has a tracheostomy. Which of the following pieces of equipment should the nurse use when administering oxygen to this client?
Distilled water for humidification
A tracheostomy collar
A nasal cannula
An aerosol mask
A tracheostomy collar
38
A nurse is providing discharge teaching with a client who is going home on continuous liquid oxygen therapy. Which of the following instructions should the nurse include?
"Place the oxygen tank in a clutter-free environment."
"Keep the oxygen tank at least 6 feet away from a heat source."
"Ensure you are close to electricity to use your oxygen tank."
"Turn the valve on the oxygen tank until an alarm sounds."
"Place the oxygen tank in a clutter-free environment."
39
A nurse is caring for a client who was admitted with community-acquired pneumonia and has been receiving oxygen therapy for several days. Which of the following findings indicates an adverse effect of oxygen therapy?
Poor skin turgor
Copious respiratory secretions
Cracks in the oral mucosa
Elevated heart rate
Cracks in the oral mucosa
40
A nurse is caring for a client who has been receiving oxygen via nasal cannula for 4 hr. Which of the following assessment findings helps indicate that oxygen therapy has been effective?
Respiratory rate 14/min
SaO 90%
Cardiac output 5.6 L/min
PaCO 68 mm Hg
Respiratory rate 14/min
41
A nurse is providing discharge teaching to a client who will continue oxygen therapy at home. The nurse should instruct the client that turning the knob on the oxygen flow meter all the way to the right…
starts the flow of oxygen.
provides the maximal oxygen flow.
provides a minimal oxygen flow.
stops the flow of oxygen.
stops the flow of oxygen.
42
A nurse is caring for a client who has dyspnea, slight cyanosis, and a respiratory rate of 28/min. During which of the following phases of the nursing process will the nurse determine that the client has impaired gas exchange?
Assessment
Diagnosis
Planning
Evaluation
Diagnosis
43
How far should you insert the catheter when suctioning a client’s airway?
1. Insert the suction catheter until you meet resistance at the carina OR until the client coughs
2, Then pull it back 1 cm [0c5cm] and slowly withdraw it while applying intermittent suction and using a rotating motion
44
My client tends to develop respiratory distress during suctioning. What should I do when this happens?
Immediately withdraw the suction catheter. Administer oxygen and breaths from a manual resuscitation bag as needed. In an emergency, you can deliver oxygen directly through the catheter by disconnecting the suction and attaching oxygen at the prescribed flow rate.
45
Just before suctioning the client’s airway, which action should you perform?
Hyperoxygenate the client
Adjust the suction pressure to 160 mmHg
Inspect the lumen of the tracheostomy
Hyperoxygenate the client
46
As you advance the catheter, you meet resistance and the client begins to cough. Which of the following is the appropriate nursing action?
Withdraw the entire catheter immediately
Pull the catheter back about 1-2 cm (0.5-1in)
Use a rotating motion to advance the catheter further
Pull the catheter back about 1-2 cm (0.5-1in)
47
Which of the following lengths of time should you apply suction during this suction pass?
10 seconds
20 seconds
30 seconds
10 seconds
48
Which of the following interventions should be added to the client's nursing care plan to help thin secretions?
Perform chest physiotherapy
Instill sterile 0.9% sodium chloride solution into the airway
Increase fluid intake
Increase fluid intake
49
Is a prescription required to administer oxygen therapy?
Yes - because the administration of oxygen can have potent effects on the ient. Treat oxygen therapy as you would a medication, applying the rights of medication administration. Check the provider's orders to verify that the client is receiving the correct dosage or concentration of oxygen and note any parameters for adjustment.
50
What assessment findings would indicate that the oxygen therapy is effective?
Objective measures of the effectiveness of oxygen therapy include vital signs including pulse oximetry, arterial blood gas analysis, pulmonary function tests, ECG tracings, physical examination findings, and functional status. For some conditions, such as COPD, oxygen therapy might do little to improve exercise tolerance.
On the other hand, oxygen therapy used during exercise for cystic fibrosis may increase exercise duration and peak performance.
Any evaluation should consider the client's specific condition, health status, progress, expected outcome, and perceptions.
Assessment of dyspnea, fatigue, comfort level, mood, level of alertness, and quality of life may indicate that the client is deriving some benefits from oxygen therapy.
And in palliative care, oxygen is often prescribed to improve the client's comfort level.
51
How do I know that the client is experiencing oxygen toxicity?
Signs and symptoms of oxygen toxicity result from its effects on the central nervous system (CNS) and pulmonary system.
CNS manifestations of oxygen toxicity include:
pallor, sweating, nausea, vomiting, seizures, muscle twitching, vertigo, tinnitus, hallucinations, visual changes, anxiety, respiratory changes, and decreased levels of consciousness.
Pulmonary signs and symptoms of oxygen toxicity include:
substernal chest pain, shortness of breath, dry cough, and pulmonary edema or fibrosis.
52
After several days, the client is nearing discharge from the hospital and is able to ambulate in the hall. Immediately after he ambulates, the nurse finds the client lying in bed. He states, "I'm having trouble catching my breath." Which of the following actions is the priority at this time?
Administer supplemental oxygen as prescribed.
Assess vital signs, including oxygen saturation.
Raise the head of the bed to a semi-Fowler's position.
Raise the head of the bed to a semi-Fowler's position.
53
Which of the following observations is the best indicator that the client does not have an acute need for oxygen therapy after ambulation?
His pulse oximetry reading was 95% after returning to bed.
He states, "It really felt good to walk a little."
His respiratory rate is the same both before and after ambulation.
His pulse oximetry reading was 95% after returning to bed.
54
Which of the following client actions best indicates that he will be able to effectively manage his compromised respiratory status?
Walks around the unit without experiencing any dyspnea
Identifies the early signs and symptoms of hypoxemia
Verbalizes the importance of keeping his scheduled appointments with his provider
Identifies the early signs and symptoms of hypoxemia
55
Which of the following situations should the family be able to identify as dangerous when supplemental oxygen is in use? (Select all that apply.)
The client wearing woolen socks to keep his feet warm
The client driving the family's vehicle
The client's wife smoking while the family eats dinner
The client's wife removing nail polish while the couple watches television
The client wearing cotton pajamas while relaxing at home
The client wearing woolen socks to keep his feet warm
The client's wife smoking while the family eats dinner
The client's wife removing nail polish while the couple watches television
56
A nurse administers a dose of an oral medication for hypertension to a patient who immediately vomits after swallowing the pill. What action will the nurse take first?
Readminister the medication and notify the health care provider.
Obtain the pill in a liquid form for administration.
Assess the emesis, looking for the pill.
Notify the primary care provider.
Assess the emesis, looking for the pill.
57
A nurse caring for a group of patients uses measures to reduce discomfort for the patients during injections. Which technique is recommended?
Selecting a needle of the largest gauge that is appropriate for the site and solution to be injected
Injecting the medication into contracted muscles to reduce pressure and discomfort at the site
Using the Z-track technique for intramuscular injections to prevent leakage of medication into the needle track
Applying vigorous pressure in a circular motion after the injection to distribute the medication to the intended site
Using the Z-track technique for intramuscular injections to prevent leakage of medication into the needle track
58
A nurse is preparing medications for patients in the ICU. The nurse is aware that patient variables may affect the absorption of these medications. Which statements accurately describe these variables the nurse will use as a basis for practice? [Select all that apply]
Patients in certain ethnic groups obtain therapeutic responses at lower doses or higher doses than those usually prescribed.
Some people experience the same response with a placebo as with the active drug used in studies.
People with liver disease metabolize drugs more quickly than people with normal liver functioning.
A patient who receives a pain medication in a noisy environment may not receive full benefit from the medication’s effects.
Oral medications should not be given with food as the food may delay the absorption of the medications.
Circadian rhythms and cycles may influence drug action.
Patients in certain ethnic groups obtain therapeutic responses at lower doses or higher doses than those usually prescribed.
Some people experience the same response with a placebo as with the active drug used in studies.
A patient who receives a pain medication in a noisy environment may not receive full benefit from the medication’s effects.
Circadian rhythms and cycles may influence drug action.
59
A nurse is administering a pain medication to a patient. In addition to checking the identification bracelet, which active identification strategy reflects best practice?
Asking the patient their name and birthdate
Reading the patient’s name on the sign over the bed
Asking the patient’s roommate to verify the patient’s name
Asking, “Are you Mr. Brown?”
Asking the patient their name and birthdate
60
A nurse is administering a medication to a patient via an enteral feeding tube. Which are accurate guidelines related to this procedure? [Select all that apply]
Crushing the enteric-coated pill and mix it in a liquid
Initially flushing the tube with 60 mL of very warm water
Using the recommended policy to check tube placement in the stomach or intestine
Giving each medication separately and flush with water between each drug
Lowering the head of the bed to prevent reflux
Adjusting the amount of water used if patient’s fluid intake is restricted
Using the recommended policy to check tube placement in the stomach or intestine
Giving each medication separately and flush with water between each drug
Adjusting the amount of water used if patient’s fluid intake is restricted
61
A nurse discovers that a medication error occurred. What is the nurse’s priority?
Recording the error on the medication sheet
Notifying the physician regarding course of action
Assessing the patient for adverse effects of the error
Completing an event report, explaining how the mistake was made
Assessing the patient for adverse effects of the error
62
A nurse is teaching a patient how to use a meter-dosed inhaler to control asthma. What are appropriate guidelines for this procedure? [Select all that apply]
Shake the inhaler well and remove the mouthpiece covers from the MDI and spacer.
Take shallow breaths when breathing through the spacer.
Depress the canister releasing one puff into the spacer and inhale slowly and deeply.
After inhaling, exhale quickly through pursed lips.
Wait 1 to 5 minutes as prescribed before administering the next puff.
Gargle and rinse with salt water after using the MDI.
Shake the inhaler well and remove the mouthpiece covers from the MDI and spacer.
Depress the canister releasing one puff into the spacer and inhale slowly and deeply.
Wait 1 to 5 minutes as prescribed before administering the next puff.
63
A nurse is preparing to administer medications to a patient transferred from the intensive care unit just as lunch is served. Prior to administering medications to the patient, the nurse takes which action?
Performing medication reconciliation
morning care has been administered
Ordering the patient a meal
Taking a report from the nurse sending the patient
Performing medication reconciliation
64
A nurse is administering medications to an older adult with dysphagia. After crushing the pills, which action is most appropriate?
Mixing the crushed medications with 120 mL of water before administering
Mixing the medications into the patient’s bowl of pudding
Crushing each pill separately and administering each in a teaspoon of applesauce
Asking the patient to chew the pills and providing juice after swallowing
Crushing each pill separately and administering each in a teaspoon of applesauce
65
A patient experiencing chest pain asks the nurse why a nitroglycerin tablet must be placed under their tongue instead of swallowed. Which answer by the nurse is appropriate?
“We could put the tablet between the cheek and gum, instead.”
“The area is rich in superficial blood vessels, and helps with absorption.”
“Swallowing interferes with quick systemic effects.”
“This is an enteric-coated tablet, designed for absorption outside the stomach.”
“The area is rich in superficial blood vessels, and helps with absorption.”
66
At 8 AM, a nurse receives a prescription for an analgesic to be administered every 4 hours PRN. The nurse plans to administer this medication at what times?
0800, 1200, 1600, 2000, 0000, 0400 hours
Around the clock on even hours
Six times daily
Upon patient request, within prescribed time intervals
Upon patient request, within prescribed time intervals
67
A nurse is teaching a client how to self-administer ear drops. Which statement by the client indicates an understanding of the teaching?
I will pull my ear down and back before I insert the drops
I will gently apply pressure with my finger to the front part of my ear after putting in the drops
I will chill my ear drops before I use them
I will place a cotton ball into my inner ear canal after the drops are in
I will gently apply pressure with my finger to the front part of my ear after putting in the drops
68
# ATI Book
A nurse is teaching a newly licensed nurse who is caring for a client who is receiving enteral feedings, how to administer medications through a jejunostomy tube. Which instruction should the nurse include?
a. Flush the tube before and after each medication
b. Mix the medications with the enteral feeding
c. Use a parenteral syringe to administer the medications
d. Combine multiple medications together to administer at the same time
a. Flush the tube before and after each medication
69
# ATI Book
A nurse is preparing to inject heparin subcutaneously for a client who is postoperative. Which action should the nurse plan to take?
a. Use a 22 guage needle
b. Select a site on the client’s abdomen
c. Use the z-track method to displace the skin on the injection site
d. Observe for bleb formation to confirm proper placement
b. Select a site on the client’s abdomen
70
# ATI Book
The nurse is reviewing the client’s medical administration record and notes a prescription for docusate 100 mg PO once every day. The nurse should identify this as which of the following types of prescription?
a. Single
b. Stat
c. Routine
d. Now
c. Routine
71
# ATI Book
The nurse administers the wrong medication to the client. Which of the following actions should the nurse take first?
a. Report the error to the facilities risk manager
b. Notify the provider
c. Complete an incident report
d. Check the client’s vital signs
d. Check the client’s vital signs
72
# ATI Book
The nurse is teaching the newly licensed nurse how to insert an IV catheter into the client. Which of the following statements by the newly licensed nurse indicates understanding of the procedure?
a. I will cleanse the area of the insertion site in a circular motion from the outside to the middle
b. I will insert the needle into the client’s skin at an angle of 10-30 degrees with the bevel up
c. I will apply pressure 1 inch below the insertion site prior to removing the needle
d. I will choose a vein in the antecubital fossa for IV insertion
b. I will insert the needle into the client’s skin at an angle of 10-30 degrees with the bevel up
73
# ATI Book
The nurse is assessint the client. Which of the following findings are a manifestation of fluid overload?[Select all that apply]
a. Respiratory rate
b. Blood pressure
c. Heart rate
d. Pedal pulses
e. Neurological status
a. Respiratory rate
b. Blood pressure
c. Heart rate
74
# ATI Book
Client reports not feeling well and is having chills and pain at the IV site. Peripheral IV in left arm is warm to touch. Edema and hardness above the insertion site. Red streaking noted on the client’s arm close to the IV insertion site. The nurse is caring for a client who is receiving IV therapy. Which action should the nurse plan to take first?
a. Obtain a specimen for culture
b. Apply a warm compress
c. Administer analgesics
d. Discontinue the infusion
d. Discontinue the infusion
75
# ATI Book
A nurse is preparing to administer diazepam to a client. Prior to administering the medication, which of the following actions is the nurse’s priority?
a. Teach the client about the purpose of the medication
b. Give the medication at the prescribed administration time
c. Identify the client’s medication allergies
d. Document the client’s anxiety levels
c. Identify the client’s medication allergies
76
# ATI
A nurse is reviewing a group of prescriptions. What should the nurse identify as an example of a complete prescription?
a. Aspirin PO 1 tablet daily
b. Ferrous sulfate 624 mg PO
c. Hydrocodone/acetaminophen 5/325 mg PRN
d. Digoxin 1.25 mg PO daily
d. Digoxin 1.25 mg PO daily
77
# ATI
A nurse is caring for a client who is receiving a medication that typically causes drowsiness. While assessing the client, the nurse notes that the medication has caused the client to become hyperactive. Which of the following terms describes the client's unexpected response to the medication?
a. Idiosyncratic effect
b. Allergic response
c. Toxic effect
d. Synergistic effect
a. Idiosyncratic effect
## Footnote
***An idiosyncratic effect is an uncommon, unexpected, or individual medication response thought to result from a genetic predisposition. An allergic response is an immune response. Usually, a client has been previously exposed to the offending allergen. Re-exposure to the medication causes a predictable reaction that can range in intensity from mild itching to anaphylaxis, a life-threatening response. Toxicity is an adverse medication reaction caused by an excessive dose of a particular medication. A synergistic effect is a result of the action of two medications combined, either to potentiate, block, or alter the effects of either or both medications when used separately. These interactions are typically predictable and sometimes beneficial.
78
# ATI
Which one below represents the correct administration of the prescribed medication?
a. Acetaminophen 650 mg PO prescribed; 5 tsp of 325 mg/10 mL liquid given
b. Levothyroxine 100 mcg PO prescribed; three 0.025 mg tablets given
c. Amoxicillin 1 g PO prescribed; two 500 mg tablets given
d. Diphenhydramine 40 mg IM prescribed; 1.25 mL of 50 mg/mL for injection given
c. Amoxicillin 1 g PO prescribed; two 500 mg tablets given
79
# ATI
Which of the following actions demonstrates correct use of one of the Ten Rights of Medication Administration?
a. Administering a client's medication by the route the provider has prescribed
b. Adhering as closely as possible to the medication schedule the client follows at home
c. Gathering a medication history from the client before administering any medications
d. Insisting that the client take all medications prescribed
a. Administering a client's medication by the route the provider has prescribed
80
# ATI
Which route of medication administration has no barriers to absorption?
a. Intravenous
b. Intramuscular
c. Subcutaneous
d. Oral
a. Intravenous
81
# ATI
A nurse has a handwritten prescription that is difficult to read. Which of the following actions should the nurse take to avoid an error in medication administration?
a. Ask another nurse to decipher the prescription.
b. Call the provider for clarification of the prescription.
c. Rely on their knowledge of the client to get the prescription right.
d. Inquire at the facility pharmacy about the prescription.
b. Call the provider for clarification of the prescription.
82
# ATI
A nurse is preparing to administer several PO medications to a client. The client states they can only take one pill at a time. Which of the following actions should the nurse take?
a. Ask the pharmacy to change the formulation of each medication.
b. Crush the pills and mix them in applesauce.
c. Remain at the bedside until the client has taken all of the medications.
d. Leave the pills at the bedside for the client to take.
c. Remain at the bedside until the client has taken all of the medications.
83
# ATI
Which one describes a medication’s generic name?
a. It’s the chemical name for a medication
b. It’s the same as its nonproprietary name
c. It’s the name under which a medication is marketed
d. It’s the formal name of a particular medication
b. It’s the same as its nonproprietary name
84
# ATI
A nurse is preparing to administer an oral medication to a client. Which of the following actions is the nurse's priority?
a. Have another nurse check the dose to be administered.
b. Teach the client about possible adverse effects.
c. Confirm the client's identity using two methods.
d. Confirm that the client can swallow adequately.
c. Confirm the client's identity using two methods.
85
# ATI
Which client is exhibiting medication tolerance?
a. A client who continues to take a medication despite harmful effects
b. A client who requires an increased dose of a medication to achieve continued therapeutic benefit
c. A client who exhibits signs of withdrawal when a medication is discontinued
d. A client who develops an intense craving for a medication
b. A client who requires an increased dose of a medication to achieve
86
# ATI
A nurse is documenting a client's response to a pain medication. Which of the following is an example of correct documentation regarding the client's response to pain?
a. The client states, "I feel better 10 minutes after medication administration."
b. The client is sleeping 1 hr after medication administration.
c. The client is up and walking in the hall 2 hr after medication administration.
d. The client reports pain decreased 30 min after medication administration to 3 on a scale of 0 to 10
d. The client reports pain decreased 30 min after medication administration to 3 on a scale of 0 to 10
87
# ATI
A client drinks 8 oz of water. Which is a correct conversion of the client’s intake?
a. 1 pint
b. 4 Tbsp
c. 2 cups
d. 240 mL
d. 240 mL
88
# ATI
A nurse is teaching the adult child of a client about instilling eye drops in the client's right eye. Which of the following statements by the client's adult child indicates an understanding of the teaching?
a. "I will have my mother look down while dropping the medication into her eye."
b. "I will instruct my mother to tightly close her eye for 30 to 60 seconds after the medication has been given."
c. “I should apply the medication using a thin stream from the inner canthus to the outer canthus.”
d. “I will pull down her lower eyelid and drop the medication inside.”
d. “I will pull down her lower eyelid and drop the medication inside.”
89
# ATI
A nurse is caring for a client who has a prescription for a fluticasone propionate inhaler with a spacer. The client asks the nurse why a spacer is needed with the inhaler. Which of the following responses should the nurse make?
a. "By using a spacer, you can take the medication correctly without any spills."
b. "You can inhale five or more puffs in 1 minute when using a spacer."
c. "By using a spacer, you eliminate the need for mouth rinsing after administration."
d. "More medication is delivered to the lungs when you use a spacer."
d. "More medication is delivered to the lungs when you use a spacer."
90
# ATI
A nurse is administering aspirin 81 mg PO daily to a client who has a history of myocardial infarction. The medication is scheduled for 0800. Which of the following scenarios demonstrates proper use of one of the Ten Rights of Medication Administration?
a. The nurse performs the first check of the correct dosage at the client's bedside.
b. The nurse identifies the client by stating the client's name as written on the medication administration record.
c. The nurse documents that the aspirin was given at 0825.
d. The nurse opens the 81 mg aspirin unit dose package prior to entering the client's room.
c. The nurse documents that the aspirin was given at 0825.
91
# ATI
A nurse is caring for a client who has COPD. For which of the following inhalation medication delivery methods should the nurse assess the client's ability to inhale deeply?
a. Dry powder inhaler [DPI]
b. Nasal spray
c. Metered dose inhaler [MDI] with attached spacer
d. Use of a nebulizer via a mask
a. Dry powder inhaler [DPI]
92
# ATI
A nurse is preparing to administer a client's medication. The client states the medication makes them feel nauseated and refuses to take it. Which of the following actions should the nurse take?
a. Document the reason for refusal along with the date and time in the client's medical record.
b. Tell the client that if they don't take the medication that they will not get any better.
c. Place the medication on the client's bedside so they can take it when they are no longer nauseated.
d. Notify the pharmacist that the client refuses to take the medication.
a. Document the reason for refusal along with the date and time in the client's medical record.
93
# ATI
A nurse is preparing to administer medications for a client who has a nasogastric tube. Which of the following actions should the nurse take prior to administering the medications?
a. Check tube placement by inserting air into the tube while auscultating at the gastric fundus.
b. Percuss the client's abdomen to assess for areas of tympany and dullness.
c. Observe the amount of residual volume left in the stomach.
d. Determine the client's ability to cooperate with instructions.
c. Observe the amount of residual volume left in the stomach.
94
# ATI
A nurse is preparing to administer several medications to a client who is receiving enteral feedings through a small bore nasogastric tube. Which of the following actions should the nurse take to ensure the medications are administered correctly?
a. Add crushed medications to the enteral tube feedings and infuse via an electronic pump.
b. Infuse each medication by gravity and flush with water before and after instillation.
c. Administer medications through a 5-mL syringe.
d. Lower the syringe to facilitate instillation of the medication.
b. Infuse each medication by gravity and flush with water before and after instillation.
95
# ATI
A nurse is preparing to instill antibiotic ear drops into the ear of a 2-year-old child. Which of the following techniques should the nurse use when administering ear drops to this client?
a. Have the client maintain a side-lying position for 30 min after administration of the ear drops.
b. Pull the client's auricle down and back to open the canal when administering the ear drops.
c. Don sterile gloves prior to administration of the ear drops.
d. Insert the tip of the dropper into the ear canal when administering the ear drops.
b. Pull the client's auricle down and back to open the canal when administering the ear drops.
96
# ATI
A nurse is preparing to give an intramuscular injection into the left ventrogluteal muscle. Which of the following actions should the nurse take to locate the site of injection?
a. Measure two fingerbreadths below the acromion process.
b. Measure a handbreadth above the knee and a handbreadth below the greater trochanter.
c. Place the heel of the hand on the greater trochanter and the index finger on the anterior superior iliac crest.
d. Locate the upper, outer quadrant of the buttocks.
c. Place the heel of the hand on the greater trochanter and the index finger on the anterior superior iliac crest.
97
# ATI
Which term indicates that a medication is given via an injection?
a. Enteral
b. Sublingual
c. Transdermal
d. Parenteral
d. Parenteral
98
# ATI
A nurse is preparing to administer an intradermal injection. Which of the following actions should the nurse take to ensure proper technique?
a. Rub the injection site after withdrawing the needle.
b. Pinch 1/2 inch of skin and administer the injection at a 45° angle.
c. Use a tuberculin syringe with a ⅝ , 25 gauge needle
d. Choose a site that is at least 1 inch from the umbilicus
c. Use a tuberculin syringe with a ⅝ , 25 gauge needle
99
# ATI
A nurse is preparing to administer an intramuscular injection at the ventrogluteal site. Which of the following needle lengths should the nurse select for an adult of average size?
a. ½ inch
b. 1 inch
c. 1 ½ inch
d. 2 inches
c. 1 ½ inch
100
# ATI
A nurse is preparing to administer a subcutaneous injection to a client. Which of the following should the nurse assess first?
a. The client’s level of knowledge about the medication
b. If the client has allergies to the medication
c. Where the most appropriate injection site is
d. The reason the client is receiving the medication
b. If the client has allergies to the medication
101
# ATI
A nurse is preparing to administer an insulin injection to a client. Which of the following actions should the nurse take?
a. Rotate the injection sites.
b. Administer no more than 2 mL of insulin per injection.
c. Displace the skin and subcutaneous tissue at the site about 1 to 1 1/2 inches.
d. Inject the medication after aspirating the syringe.
a. Rotate the injection sites.
102
# ATI
A nurse is assessing a client who is receiving 0.9% sodium chloride IV at 125 mL/hr. Which of the following should the nurse recognize as a possible complication related to the IV therapy?
a. Petechiae is present over the IV site.
b. The skin is cool over the IV site.
c. Client reports coughing and shortness of breath.
d. Client's blood pressure is lower than normal.
c. Client reports coughing and shortness of breath.
103
# ATI
A nurse is caring for a client who is receiving dextrose in 5% water with 20 mEq of potassium chloride at 75 mL/hr. The provider has prescribed 1 g ceftriaxone IV. When preparing to administer this medication by intermittent IV bolus, which of the following actions should the nurse take first?
a. Obtain the client's vital signs.
b. Determine the client's level of consciousness.
c. Verify the medication's compatibility with the primary IV solution.
d. Check the amount of IV solution in the primary bag.
c. Verify the medication's compatibility with the primary IV solution.
104
# ATI
A nurse is caring for a client who is receiving 0.9% sodium chloride IV at 75 mL/hr through a triple lumen central venous access device. The V pump alarm sounds, indicating that there is an occlusion. Which of the following actions should the nurse take first?
a. Call the provider who inserted the catheter.
b. Flush the line with a 10-mL syringe of heparin.
c. Check the line at or above the hub for kinked tubing that is creating a resistance to flow.
d. Reposition the client.
c. Check the line at or above the hub for kinked tubing that is creating a resistance to flow.
105
# ATI
A nurse is preparing to administer an IV medication to a client. The nurse lould identify that which of the following is a disadvantage of administering IV medications?
a. IV medications are irreversible.
b. IV medications have a slow onset.
c. IV medications bypass the liver.
d. IV medications have less bioavailability.
a. IV medications are irreversible.
106
# ATI
A nurse is caring for a client who has a peripherally inserted central catheter (PICC) line. The nurse should identify that which of the following information is true about this type of IV route?
a. A PICC line is a midline catheter used to administer blood.
b. A PICC line is a catheter that allows for infusion of IV fluids without an infusion pump.
c. A PICC line is a long catheter inserted through the veins of the antecubital fossa.
d. A PICC line is a catheter that is used for emergent or trauma situations.
c. A PICC line is a long catheter inserted through the veins of the antecubital fossa.
107
# ATI
A nurse administers the first dose of a client's prescribed antibiotic via intermittent IV bolus. During the first 10 to 15 min of administration, which of the following assessments is the nurse's priority?
a. Assess the IV site for redness or swelling.
b. Assess the client for a systemic allergic reaction.
c. Assess the IV dressing for signs of leakage.
d. Assess the client's limb for signs of discomfort
b. Assess the client for a systemic allergic reaction.
108
# ATI
A nurse is caring for a client who was admitted to the hospital for same day surgery and has a new prescription for continuous IV therapy. Which of the following actions should the nurse take when administering the IV therapy?
a. Place a cold compress over the vein.
b. Inspect the IV solution for fluid color, clarity, and expiration date.
c. Apply a tourniquet 1 to 2 inches above the selected insertion site.
d. Secure an armboard to the client's extremity.
b. Inspect the IV solution for fluid color, clarity, and expiration date.
109
# ATI Skills
To minimize the risk of a medication error, you must do which of the following?
a. Call the provider to double-check the prescription.
b. Check the client's chart for medication allergies.
c. Observe the rights of medication administration.
c. Observe the rights of medication administration.
110
# ATI Skills
You prepare to administer the first dose of the prescribed pain medication. While some providers used to abbreviate morphine sulfate as MS, your institution's policy does not recognize it as an accepted abbreviation for the medication. Which of the following actions should you take?
a. Call the nursing supervisor to confirm the medication intended in the prescription.
b. Ask the hospital's pharmacist to confirm the medication intended in the prescription.
c. Call the prescribing provider to confirm the medication intended in the prescription.
c. Call the prescribing provider to confirm the medication intended in the prescription.
111
# ATI Skills
To minimize drainage of the medication through the client's tear duct, you ask the client to do which of the following?
a. Lie in a supine position with the head turned towards the left shoulder
b. Sit upright with the head tilted slightly backward
c. Lie on the right side with the affected eye downward
b. Sit upright with the head tilted slightly backward
112
# ATI Skills
To ensure proper introduction of the medication into the eye, you drop the medication from a distance of ½ to ¾ inch onto which of the following locations?
a. Center of the right eye's cornea
b. Outer third of the conjunctival sac
c. Nasolacrimal duct of the right eye
b. Outer third of the conjunctival sac
113
# ATI Skills
The medication is distributed more evenly after instillation if the client does which of the following?
a. Closes their eyes gently
b. Presses gently on the inner canthus
c. Blinks repeatedly
a. Closes their eyes gently
114
# ATI Skills
To ensure proper administration of the otic (ear) medication, you should instruct the client to do which of the following? (Select all that apply.)
a. Tilt their head with the affected ear upward to facilitate self-administration.
b. Straighten the ear canal by gently pulling downward on the ear's auricle.
c. Place a cotton ball inside the external ear canal to keep the medication inside.
d. Keep their head tilted for 2 to 3 minutes after instillation to prevent drainage out into the pinna.
e. Massage the tragus of the ear gently to help the medication move down the ear canal.
a. Tilt their head with the affected ear upward to facilitate self-administration.
d. Keep their head tilted for 2 to 3 minutes after instillation to prevent drainage out into the pinna.
e. Massage the tragus of the ear gently to help the medication move down the ear canal.
115
# ATI Skills
To minimize your client's risk of aspiration, you should initially do which of the following?
a. Position the client on their left side.
b. Assess the client's level of consciousness.
c. Elevate the head of the bed to at least 30°
c. Elevate the head of the bed to at least 30°
116
# ATI Skills
To best ensure that the NG tube is correctly placed prior to instilling the client's medications, you should do which of the following? (Select all that apply.)
a. Irrigate the NG tube with 30 mL of sterile water.
b. Arrange for a portable abdominal x-ray to verify the position of the NG tube.
c. Aspirate 5 to 10 mL of fluid from the NG tube to check for appropriate pH.
d. Examine the outside of the NG tube for movement of the ink mark away from the naris.
e. Use your stethoscope to monitor for swooshing over the epigastric region as you inject 30 mL of air into the tube.
c. Aspirate 5 to 10 mL of fluid from the NG tube to check for appropriate pH.
d. Examine the outside of the NG tube for movement of the ink mark away from the naris.
117
# ATI Skills
To facilitate the administration of levothyroxine, you should do which of the following?
a. Introduce it whole since it is a small, smooth pill.
b. Crush and dissolve it in 15 to 30 mL of warm water.
c. Mix the medication with a soft-textured food to promote its passage.
b. Crush and dissolve it in 15 to 30 mL of warm water.
118
# ATI Skills
Between administering the various medications, you should do which of the following?
a. Recheck the placement of the NG tube.
b. Flush the NG tube with 15 to 30 mL of water.
c. Clamp the NG tube for 5 minutes.
b. Flush the NG tube with 15 to 30 mL of water.
119
# ATI Skills
Since clients are typically placed in a dorsal recumbent position (supine with legs flexed at the knees) for the insertion of this form of medication, which of the following nursing actions is the highest priority for this client's safety?
a. Insert the suppository prior to administering the medication via NG tube.
b. Thoroughly explain the procedure to the client to ensure physical cooperation.
c. Elevate the head of the bed to 45° after you insert the suppository.
a. Insert the suppository prior to administering the medication via NG tube.
120
# ATI Skills
To facilitate the delivery of the medication from the canister, which of the following should be done to the canister and inhaler?
a. Hold upright and shake five to six times.
b. Cleanse with warm after each dose.
c. Check daily to determine the number of remaining doses.
a. Hold upright and shake five to six times.
121
# ATI Skills
To prevent medication toxicity, the client should initiate the application of the daily patch by doing which of the following?
a. Applying the patch immediately after opening it
b. Washing and drying the skin at the site of the new application
c. Removing and disposing of the used patch
c. Removing and disposing of the used patch
122
# ATI Skills
Which of the following actions has the greatest impact on preserving skin integrity while using the transdermal patch?
a. Rotating application sites with each patch change
b. Cutting the patch in half if skin irritation develops
c. Assessing the application site thoroughly for redness
a. Rotating application sites with each patch change
123
# ATI Skills
You are teaching the client about self-administration of insulin. Which of the following injection sites should you suggest for self-administration of insulin?
a. Posterior thigh
b. Upper back
c. Lower abdomen
c. Lower abdomen
124
# ATI Skills
The client asks why insulin is injected subcutaneously. Which of the following is information should you provide to the client?
a. Subcutaneous tissue has few sensory nerves, so the insulin injection is less painful than it would be if given by another route.
b. Medication absorption is slower from subcutaneous tissue, an important factor in the effectiveness of insulin therapy.
c. Subcutaneous injections are technically the easiest form of parenteral injection, making the route well suited for frequent insulin injections.
b. Medication absorption is slower from subcutaneous tissue, an important factor in the effectiveness of insulin therapy.
125
# ATI Skills
When instructing the client about self-administration of insulin, which of the following information should you include?
a. Hold the syringe like a dart.
b. Use the Z-track method for administration.
c. Aspirate gently before injecting.
a. Hold the syringe like a dart.
126
# ATI Skills
You explain to the client that which of the following areas are the best sites for a subcutaneous injection? (Select all that apply.)
a. On the anterior aspects of the thighs
b. On the inner aspect of the forearms
c. 2 inches below acromion process
d. On the outer posterior aspect of upper arms
e. On the abdomen from below the umbilicus to the iliac crests
a. On the anterior aspects of the thighs
d. On the outer posterior aspect of upper arms
e. On the abdomen from below the umbilicus to the iliac crests
127
# ATI Skills
The term intradermal means that the fluid must be injected into which of the following sites?
a. Vascular area for rapid absorption
b. Skin where the blood supply is minimal
c. Readily accessible site for easy follow-up
b. Skin where the blood supply is minimal
128
# ATI Skills
The inner aspect of the forearm is usually an ideal location for an intradermal injection provided that it is which of the following?
a. Not the client's dominant arm or it will restrict function
b. Free of any skin lesion that might impede evaluation
c. Easily moved by the client to facilitate absorption
b. Free of any skin lesion that might impede evaluation
129
# ATI Skills
To make sure that you deposit the serum into the dermal layer, you select which of the following needle sizes?
a. 5/8-inch long and 25- to 27-gauge
b. ½-inch long and 18-gauge
c. Determined by the client's weight
a. 5/8-inch long and 25- to 27-gauge
130
# ATI Skills
To administer the serum into the dermis, you insert the needle at which of the following angles?
a. 5° to 15° to produce a small bleb
b. 45° to prevent introduction into the subcutaneous tissue.
c. 90° to ensure introduction into the dermis.
a. 5° to 15° to produce a small bleb
131
# ATI Skills
Which of the following actions is one of the 10 rights of medication administration?
a. Assess the client's vital signs.
b. Review the client's medication list.
c. Check the client's identification band.
b. Review the client's medication list.
132
# ATI Skills
Which of the following is most important to reduce the risk of injury to the client prior to the administration of the tetanus booster?
a. Review the risk of potential adverse reactions.
b. Assess the client's allergy history.
c. Confirm the date of the last tetanus booster.
b. Assess the client's allergy history.
133
# ATI Skills
Since an IM injection delivers medication into the muscle, you best determine the appropriate needle length by assessing which of the following?
a. Preferred site for injection
b. Client's muscle mass and weight
c. Viscosity of the medication
b. Client's muscle mass and weight
134
# ATI Skills
You assess the client to determine the location for the injection. Which of the following is the correct method to locate the site to administer an injection into the deltoid muscle?
a. One hand width above the humerus epicondyle
b. Two finger widths lateral to the scapula
c. 2 inches below the acromion process
c. 2 inches below the acromion process
135
# ATI Skills
The client prefers that you administer the injection in his arm. The deltoid is an acceptable site for an intramuscular injection because of which of the following?
a. The deltoid can readily accept the prescribed volume of medication.
b. The client is of average or above average adult weight.
c. The client is capable of unrestricted movement in that arm.
a. The deltoid can readily accept the prescribed volume of medication.
136
# ATI Skills
The appropriate technique for administering an IM injection includes which of the following? (Select all that apply.)
a. Inserting the needle at a 90° angle
b. Donning gloves after washing your hands
c. Using the Z-track method to administer the medication
d. Applying pressure over the injection site after withdrawing the needle
e. Recapping the needle before disposing of it in a biohazard sharps container
a. Inserting the needle at a 90° angle
b. Donning gloves after washing your hands
c. Using the Z-track method to administer the medication
d. Applying pressure over the injection site after withdrawing the needle
137
# ATI Skills
Which of the following is the most effective way to make sure you are administering the right medication (fluid) to the right client?
a. Ask the client to state her full name and birth date while confirming this with the information on her medication band.
b. Compare the information on the client's identification bracelet with data from the client's medical record.
c. Address the client by name and observe for signs of recognition, such as nodding her head or verbally agreeing.
b. Compare the information on the client's identification bracelet with data from the client's medical record.
138
# ATI Skills
To be sure that you administer the correct fluid (right medication), verify the prescription and then do which of the following?
a. Start the infusion immediately after making the appropriate fluid selection.
b. Perform three checks of the right medication with the medication administration record.
c. Ask another staff RN to confirm that you have selected the prescribed fluid.
b. Perform three checks of the right medication with the medication administration record.
139
# ATI Skills
To ensure that the infusion continues appropriately and safely, which of the following should you do?
a. Assess the client and the infusion at least hourly.
b. Instruct ancillary staff to report the client's comments.
c. Educate the client about the possible unexpected outcomes of IV therapy.
a. Assess the client and the infusion at least hourly.
140
# ATI Skills
To prevent backflow into the line that could cause clotting, you should do which of the following? (Select all that apply.)
a. Maintain pressure on the plunger while withdrawing it from the port.
b. Clamp off the tubing before removing the syringe from the port.
c. Withdraw the flush syringe slowly from the tubing port.
a. Maintain pressure on the plunger while withdrawing it from the port.
b. Clamp off the tubing before removing the syringe from the port.
141
# ATI Skills
To ensure that the client's IV site provides the appropriate vascular access, you first ask the client if they are experiencing any pain or tenderness at the site. You then inspect the site for which of the following? (Select all that apply.)
a. Erythema
b. Edema
c. Dark blood
d. Temperature variations
a. Erythema
b. Edema
d. Temperature variations
142
# ATI Skills
You assess the client and observe a fine, red rash without pustles on the client’s neck and on both sides of his anterior and posterior thorax.
Your immediate priority at this time is to do which of the following?
a. Stop the intermittent IV bolus infusion of the medication
b. Check the client’s vital signs and report them to the provider
c. Ask the client if they have ever taken the medication before
a. Stop the intermittent IV bolus infusion of the medication
143
# Quiz
A nurse is preparing to administer medications for a patient and has just checked the patients ID wristband. What is the next best action to confirm patient identity?
a. Compare the bracelet information to the patient chart
b. Ask the patient to state their name and DOB
c. Ask the client ‘Are you John Doe?”
d. Compare that to the patient’s room #
b. Ask the patient to state their name and DOB
144
# Quiz
A nurse is preparing to administer subcutaneous insulin for a patient. How should the nurse administer this injection?
a. Aspirate prior to administration
b. Aspirate before and massage after injection
c. Gently massage the injection site after administration
d. Do not aspirate before or massage after injection
d. Do not aspirate before or massage after injection
145
# Quiz
A nurse is preparing to administer pantoprazole 80 mg IV push now. Which of the following actions indicates understanding of safe administration of IV push medications?
a. Push 0.25 mL each 15 seconds
b. Checking the amount of time the medication should be pushed over and follow manufacturing or pharmacy guidelines
c. Push the medication over 1 minute
d. As long as the medication is pushed slowly, that is fine
b. Checking the amount of time the medication should be pushed over and follow manufacturing or pharmacy guidelines
146
# Quiz
A nurse has gathered supplies to establish a continuous IV infusion of 0.9% Normal Saline at 63 mL/hr. Before starting this infusion, what is the nurse's priority action?
a. Obtain an IV pump
b. Assist the client to the restroom
c. Assess the IV site and patency
d. Warm the IV fluids
c. Assess the IV site and patency
147
# Quiz
A nurse is educating a patient about performing at home subcutaneous Insulin injections. Which of the following statements indicates understanding regarding subcutaneous medication administration?
a. I will be sure to rotate injection sites like my lower abdomen, anterior thigh, or the back of my arm
b. I will only use one side of my abdomen to inject this medication to decrease tissue damage
c. Since I will inject myself, I do not have to clean the injection site prior to administration
d. I can use the same needle tip a few times to save on supplies
a. I will be sure to rotate injection sites like my lower abdomen, anterior thigh, or the back of my arm
148
# Quiz
A nurse is caring for a client who is receiving a continuous IV infusion of Heparin of 7.4 mL/hr with concurrent a concurrent Potassium rider at 20 mEq/hr. The patient uses the call bell to call the nurse and states "My IV is really starting to hurt. I think my arm is swelling up a little bit and there is some clear fluid leaking from the IV dressing." What is the nursing priority action?
a. Establish a new IV site on the other arm
b. Stop the infusion
c. Call the provider
d. Slow down the infusion
b. Stop the infusion
149
# Quiz
A nurse is planning care for a patient with a new tracheostomy. Which of the following should be included in this patient's plan of care?
a. Trach care at least q shift and PRN
b. Hyperoxygenate the patient for 10 seconds prior to trach suctioning
c. Cleaning the disposable inner cannula q shift
d. Clean the stoma with antiseptic spray q shift
a. Trach care at least q shift and PRN
150
# Quiz
A new grad nurse is preparing to perform trach care and suctioning for a patient. Which of the following actions indicates understanding of these procedures? Select all that apply
a. Hyperoxygenate the client for 30 seconds prior to suctioning
b. Assisting the client to a semi-Fowler’s position
c. Apply suction when inserting the suction catheter
d. Assess lung sounds before and after
e. Apply water based lubrication to the tip of the suction catheter before insertion
f. Don sterile gloves prior to perform suctioning with an open catheter
a. Hyperoxygenate the client for 30 seconds prior to suctioning
b. Assisting the client to a semi-Fowler’s position
d. Assess lung sounds before and after
f. Don sterile gloves prior to perform suctioning with an open catheter
151
# Quiz
Nasal cannula 1-3 L
nasal prongs to deliver O2, 24-32% does not need humidification
152
# Quiz
Nasal cannula 4-6 L
nasal prongs to deliver O2 36-44, needs humidification
153
# Quiz
High flow nasal cannula
large nasal prongs deliver high flow O2 up to 100%, has own generator, air flow, humidication, and air warmer
154
# Quiz
Venturi mask
face mask with multiple port attachments, delivers precise rates of high flow O2
155
# Quiz
Non-rebreather mask
can deliver high concentration O2, has a reservoir bag, and one way valves to prevent inhalation of expired CO2…must be at least 10 L
156
# Quiz
Trach collar
oxygen delivered into a cylindrical shape collar which can sit over trach
157
# Quiz
CPAP
non-invasive ventilation system providing continuous positive pressure to airways
158
# Quiz
BiPAP
non-invasive ventilation support which provides positive pressure to airways, but has two settings for inspiration and expiration
159
# Quiz
Mechanical ventilator
machine which provides support or completely controls ventilation
160
# Quiz
Which of the following are abnormal findings during a respiratory assessment? Select all that apply
a. Clubbing
b. SpO2 95%, no COPD
c. Circumoral cyanosis
d. RR 24/min
e. SpO2 89% for pt with COPD
f. RR 11/min
g. Barrel Chest
h. Clear vesicular lung sounds
a. Clubbing
c. Circumoral cyanosis
d. RR 24/min
f. RR 11/min
g. Barrel Chest
161
# Quiz
A nurse is educating a client with COPD who is being discharged home. The client is concerned about times after activity when feeling SOB and would like to discuss breathing exercises to help recover. The nurse suggests pursed-lip breathing. Which of the following statements by the client indicates an understanding of proper technique when performing pursed-lip breathing?
a. I should take a long inhale through my nose and let the air out as fast as possible through my mouth
b. I will place one hand on my chest and one on my belly to ensure I am getting air deep into my lungs during an inhale
c. I should breathe in through my nose and slowly exhale from my mouth as if I am blowing through a straw
d. I should take a deep inhale through my nose and exhale while gently performing huff coughs
c. I should breathe in through my nose and slowly exhale from my mouth as if I am blowing through a straw
162
# Quiz
A nurse is orienting to the thoracic surgery unit and is performing trach care for a patient. For which of the following actions by the nurse should the charge nurse intervene?
a. The nurse gently cleans the peristomal skin with cotton swabs and normal saline
b. The nurse changes the disposable inner cannula during care
c. The nurse removes the old trach ties completely to perform trach care, and then applies a new trach tie
d. The nurse gently cleans the faceplate with cotton swabs and normal saline
c. The nurse removes the old trach ties completely to perform trach care, and then applies a new trach tie
163
# Quiz
A nurse is discharging a patient with a prescription for home oxygen. Which of the following statements by the client indicates understanding of home oxygen safety? Select all that apply
a. Smoking is ok so long as I am outside in open air
b. I will keep oxygen tanks at least 6 feet from heating or flame sources like my oven
c. I will store oxygen tanks upright and in a stable holder
d. I will alert my local FD and ensure that smoke detectors are functional in my house
b. I will keep oxygen tanks at least 6 feet from heating or flame sources like my oven
c. I will store oxygen tanks upright and in a stable holder
d. I will alert my local FD and ensure that smoke detectors are functional in my house
164
# Quiz
Which of the following medication orders is complete?
a. Lisinopril 20mg tablet PO q day
b. Aspirin, EC tablet PO 0800
c. Metformin 500 PO 1000 daily
d. Heparin 20 units BID
a. Lisinopril 20mg tablet PO q day
165
# Quiz
Which of the following scenarios would require an incident report regarding a medication error?
a. Humalog insulin 2 unit subq ACHS, administered to L deltoid
b. Albuterol INH 2 puffs PRN shortness of breath q 4 hr, administered 0834 and 1240
c. Ceftriaxone 2mg IVPB daily 0900 administered at 0945
d. Oxycodone 5mg PO tablet PRN for moderate pain 4-6 q 6hr, administered 1000 for pain at 6/10. Repeat pain assessment 1100 pain 5/10
a. Humalog insulin 2 unit subq ACHS, administered to L deltoid
