NURS 3080 - Advanced Fundamentals Final Exam - Complete Solutions (Answered)

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NURS 3080 - Advanced Fundamentals Final Exam - Complete Solutions (Answered) The nurse is caring for a patient with a peripheral IV who tells the nurse that the IV site is painful and puffy. What is... the nurse's best action? a. Discontinue the IV and start another line in the other arm. b. Aspirate to check for blood return and flush the IV with sterile saline. c. Clean the IV site with chlorhexidine and apply a new sterile dressing. d. Change the IV tubing and administer prescribed pain medication. The nurse is caring for a patient who has a central venous catheter (CVC). Which nursing intervention is the most important for the nurse to include in the patient's plan of care? a. Carefully document all assessments of the catheter site. b. Use strict sterile procedure when performing dressing changes. c. Label each new dressing with the date, time, and nurse's initials. d. Ensure that the CVC is discontinued as soon as possible. The nurse is caring for a patient who is to receive intermittent bolus doses of phenytoin (Dilantin) through the IV line. Which intervention has the highest priority when administering this medication? a. Check for blood return and compatibility prior to administration. b. Use a new IV tubing set each time the medication is administered. c. Document the date, time, and nurse's initials after each dose is administered. d. Use sterile gloves when drawing up and administering the medication. The nurse is caring for a patient who is to receive a transfusion of packed red blood cells. The patient has a 22-gauge IV in his arm with 0.9% normal saline infusing. What intervention will the nurse perform before obtaining the packed red blood cells from the blood bank? a. Identify the blood group, type, and expiration date with another nurse. b. Insert an 18- or 20-gauge angiocatheter into the patient's other arm. c. Program the IV infusion pump so that the transfusion will complete within 4 hours. d. Obtain a new microdrip tubing and extension tubing from the clean utility room. The nurse is caring for a patient who is receiving a blood transfusion. One hour into the transfusion, the patient's blood pressure decreases significantly and the patient complains of a severe headache. What is the priority action of the nurse? a. Check the patient's temperature and administer acetaminophen (Tylenol) if higher than 101° F. b. Recheck the patient's blood pressure in 15 minutes after administering pain medication. c. Stop the blood transfusion and administer 0.9% normal saline through new IV tubing. d. Double-check that the transfusion blood type is an exact match to the patient. The nurse is caring for a patient who has B-positive blood. The patient is severely anemic and requires a blood transfusion. Which types of blood can the patient receive? (Select all that apply.) a. AB positive b. AB negative c. B negative d. B positive e. O positive f. O negative The nurse is assessing the intravenous (IV) site in the right forearm and notices the area around it is cool, swollen, firm, and tender to touch. Which complication is most likely occurring? a. Infection b. Speed shock c. Infiltration d. Phlebitis Which activity is important to include in the plan of care for a client with a peripherally inserted central catheter (PICC)? a. Use sterile technique when changing the PICC dressing. b. Change the IV tubing every 72 hours. c. Take blood pressure in the arm with the PICC line. d. Use only macrodrip tubing with IV infusions through the PICC line. The nurse has begun an infusion of fresh frozen plasma (FFP). Which symptom indicates an allergic reaction to the FFP? a. Respirations: 30/min b. Urine output: 50 mL/hr c. Heart rate: 62 beats/min d. Temperature: 39° C (102.2° F) The nurse is preparing to insert an IV catheter with an intermittent infusion device (IID) into an elderly woman for medication administration. Which of the following considerations would be incorrect? A. Insert the IV catheter into nondominant hand/arm. B. Use a 16- or 18-gauge over-the-needle catheter. C. Release the tourniquet before attaching the IID. D. Flush the IID with 2 to 3 mL normal saline after insertion. Which of the following would the nurse expect to be included in the plan of care for a patient receiving total parenteral nutrition (TPN)? A. Blood sugar levels are checked on a routine basis B. Maintaining NPO status C. Hourly urine output D. Vital signs every 4 hours Which of the following statements would be considered incorrect when transfusing packed red blood cells (RBCs)? (Select all that apply.) A. Adjust the infusion rate to ensure unit is infused within 6 hours. B. Begin an infusion of D5W prior to the packed RBCs. C. Obtain baseline vital signs, including temperature and pulse oximetry. D. Verify the patient ID and blood unit number with another nurse prior to administration. Which of the following IV solutions is considered hypertonic? A. Lactated Ringers B. D5W C. D5 0.45% NS D. 0.9% normal saline At 0900, the nurse hangs an IV of 1000 mL D5LR to infuse at 125 mL/hr. What time will the nurse need to hang a new bag of IV fluid? Provide your answer in military time: _____ hours. 1700 The nurse is caring for a patient who has a 1200 mL daily fluid restriction. The patient has consumed 250 mL with each of her three meals and had another 150 mL with her medications. The patient has received 150 mL of IV fluids during the day. How many mL of fluid may the patient still consume in order to stay within the prescribed fluid restriction? a. 100 mL b. 150 mL c. 250 mL d. 300 mL Which patient has a higher risk of impaired skin integrity using the Braden Scale? a. 6 b. 23 c. 1 d. 14 When should the braden scale be assessed on a patient? a. When they are receiving a bed change and a bath b. When they are sleeping c. When they are at physical therapy d. When they are getting their morning medications A fall risk assessment using the Morse Scale is done at least every ___________ hours. A. 6 B. 24 C. 12 D. 72 Which increases the patient's risk of falling? Select All That Apply: a. Has fallen within the last 6 months b. Walks freely with no assistance c. Alter cognition d. Takes their daily medications e. Has a broken femur f. Is in a room with clutter on the floor How can infectious waste pathogens be transmitted? (select all that apply) A. Puncture/abrasion in the skin B. Mucous membranes. C. Inhalation D. Ingestion T/F Nurses should wash hands with soap and water for at least 15 seconds. False Order of donning PPE A. Mask, gown, goggles, gloves B. Gown, mask, goggle, gloves C. Gloves, gown, mask, goggles D. Gown, goggles, mask, gloves Order of removing PPE A. Gloves, goggles, gown, mask B. Goggles, gloves, gown, mask, wash hands C. Gloves, goggles, gown, mask, wash hands D. Gown, gloves, goggles, mask, wash hands What is the single best way to avoid spreading infection? A. Avoid crowded areas B. Wear gloves C. Handwashing D. Vaccine T/F When disposing of syringes you should always hold it with the needle facing towards you so you can see the bevel False Which of the following are considered infectious waste? A. blood B. body fluids C. skin/tissues D. All the above All of the following are required following a needle stick except: A. wash infected site B. alert supervisor C. identify source patient D. ask the patient if they have a disease Which of the following will be disposed in the sharps container: A. IV tubing B. staples C. blood products D. needle caps What is the single best way to prevent needle sticks? A. keep needle capped B. wear gloves C. proper disposal D. Moving carefully [Show More]

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