1-N QA
pt with trach. how to reduce risk of aspiration pneumonia - (correct answer)partially or
fully deflate the cuff, have pt sit upright- chin should be flexed toward chest,
(hyperextension increases risk of aspiration) , monitor for a wet cough or voice quality,
monitor vital signs
amoxicillin administration for otitis media in infant - (correct answer)can be given with or
without food. give medicine when baby is hungry makes it more likely for baby to
swallow it
-give full course of antibiotics as prescribed
-stroking infant cheek will open the infants mouth allowing for administration of medicine
The nurse inserts a urinary catheter into a female client who has not voided for 6 hours.
No urine is returned. What action should the nurse take next? - (correct answer)Leave
the catheter in place and insert a new catheter higher up in the perineal area.
Urine output would be expected as this client has not voided for 6 hours (obligatory
amount is at least 30 mL x 6 = 180 mL). The most common explanation is that the
catheter was unintentionally inserted into the vagina. The nurse should leave that
catheter as a landmark and insert a new sterile catheter into the urethra which is located
above the vagina.
An experienced nurse precepts a graduate nurse caring for a hospitalized client who
has a prescription for a transfusion of packed red blood cells (RBCs) to be hung over 3
hours. Which statement by the graduate nurse indicates the correct rationale for asking
the client to void prior to starting the transfusion? - (correct answer)"If a transfusion
reaction occurs, it will be important to collect a fresh urine specimen to check for
hemolyzed RBCs."
The nurse should ask the client to void or empty the urinary catheter and discard urine
prior to starting a blood transfusion. In the event of an acute hemolytic transfusion
reaction, a fresh urine specimen should be collected and sent to the laboratory to
analyze for hemolyzed RBCs. An acute hemolytic transfusion reaction is a life-
threatening reaction in which the host's antibodies rapidly destroy the transfused RBCs
,and is generally related to incompatibility. Early signs of a hemolytic reaction include red
urine, fever, and hypotension; late signs include disseminated intravascular coagulation
and hypovolemic shock. The transfusion should be stopped immediately if any sign of
transfusion reaction occurs.
Starting the transfusion with an empty bladder will help ensure that any urine specimen
collected after a reaction is reflective of the body's physiological processes after the
blood transfusion has started (Option 4).
The nurse is caring for a client who performs frequent self-urinary catheterizations.
Which client assessments would indicate a potential for a latex allergy? - (correct
answer)The greatest risk factor for latex allergy is long-term multiple exposures to latex
products. Powdered latex gloves were banned in the 1990s, and the incidence of latex
allergy is decreasing. It is estimated that 73% of clients with spina bifida have a
sensitivity to latex. This can be a result of frequent exposure to latex during their lifelong
care.
A classic screening question is whether the lips swell when blowing up balloons (which
have latex in them). Another is if your hands itch and/or burn after wearing rubber
gloves (Option 5).
Some proteins in rubber are similar to plant-derived food proteins. Therefore, certain
foods may cause a latex-food syndrome in clients with an allergy to latex. Common
foods include bananas, avocados, tomatoes, chestnuts, kiwis, potatoes, peaches,
grapes, and apricots (Option 3).
A nurse administers an intramuscular (IM) injection using the Z-track technique. Place
the steps in chronological order. - (correct answer)The Z-track technique prevents
tracking (leakage) of the medication into the subcutaneous tissue and is universally
recommended for the administration of IM injections. Displacing the skin while injecting
the medication, and then releasing the skin back to its normal position after removing
the needle creates a zigzag track. The procedure for administering an IM injection using
the Z-track technique includes these steps:
,Pull the skin 1-1 ½" (2.5-3.5 cm) laterally away from the injection site (Option 4).
Hold the skin taut with the nondominant hand, and insert the needle at a 90-degree
angle - taut skin facilitates entry of the needle and this angle ensures that the needle will
reach the muscle (Option 3).
Inject the medication slowly into the muscle while maintaining traction - slow injection
promotes comfort and allows time for tissue expansion to facilitate absorption of the
medication (Option 2).
Wait 10 seconds after injecting the medication and withdraw the needle while
maintaining traction on the skin; this allows the medication to diffuse before needle
removal and helps to prevent tracking (Option 6).
Release the hold on the skin - this allows the tissue layers to slide back to their original
position, sealing off the needle track (Option 5).
Apply gentle pressure at the injection site, but do not massage as this can cause the
medication to seep back up to the skin surface and cause local tissue irritation (Option
1).
The nurse is providing hospice care to a terminally ill client who is reporting dyspnea.
Which interventions should the nurse implement at this time? - (correct
answer)Dyspnea (air hunger) is a common symptom in terminally ill clients. Dyspnea is
subjective, and management depends on the client's clinical condition and reported
symptoms. Initial interventions focus on decreasing respiratory effort and the perception
of dyspnea, as well as relieving anxiety. Interventions for hospice clients include:
Administering opioids (eg, morphine, fentanyl), which are prescribed to relieve dyspnea
(Option 2)
Providing low-flow oxygen by nasal cannula, which may improve psychological comfort
and ease feelings of apprehension
Allowing frequent periods of rest to minimize exhaustion and dyspnea
Administering anxiolytics (eg, lorazepam) for anxiety associated with dyspnea
Assisting with relaxation strategies (eg, music, guided imagery) (Option 5)
Placing a fan in the room to improve airflow near the client, which decreases the
perception of dyspnea (Option 4)
, A nurse is reviewing the most recent laboratory results of a client on the telemetry floor.
The client is currently asymptomatic, and the telemetry monitor indicates sinus rhythm.
Which of the following critical values is most likely due to laboratory error? - (correct
answer)With the exception of clients in end-stage renal disease, a serum potassium
value >6.5 mEq/L (6.5 mmol/L) in any client who is walking and talking should raise the
suspicion of an erroneously elevated serum potassium (pseudohyperkalemia) from poor
hematology technique, hemolysis, or clotting. A serum potassium level of 7.0 mEq/L (7.0
mmol/L) would normally constitute a life-threatening electrolyte imbalance that would
cause severe weakness or paralysis, unstable arrhythmias, and eventual cardiac arrest.
An assessment would focus on evaluating cardiac symptoms and muscle strength and
be reported to the health care provider (HCP). In this case, it is likely that a repeat blood
draw would be prescribed.
Pseudohyperkalemia can be avoided on the repeat blood draw by using heparin-
impregnated hematology vials to prevent clotting, minimal use of a tourniquet and fist
clenching, and use of a larger gauge needle for the sample.
(Option 1) This blood urea nitrogen (BUN) value is elevated (normal 6-20 mg/dL [2.1-7.1
mmol/L]) and could be related to kidney damage or dehydration. Therefore, it is not the
most likely erroneous result.
(Option 2) Similar to the BUN level, this creatinine value is significantly elevated (normal
0.6-1.3 mg/dL [53-115 µmol/L]). Further nursing assessment is indicated, with
documentation and involvement of the HCP in evaluating the impact of this kidney
damage on the client's health.
(Option 4) This sodium value is high (normal 135-145 mEq/L [135-145 mmol/L]) and
requires further exploration. The nursing assessment should be documented and
reported to the HCP.
While preparing to insert a peripheral IV line, the nurse notices scarring near the client's
left axilla. The client confirms a history of left breast cancer and modified radical
mastectomy. Which actions should the nurse take? - (correct answer)A modified radical
pt with trach. how to reduce risk of aspiration pneumonia - (correct answer)partially or
fully deflate the cuff, have pt sit upright- chin should be flexed toward chest,
(hyperextension increases risk of aspiration) , monitor for a wet cough or voice quality,
monitor vital signs
amoxicillin administration for otitis media in infant - (correct answer)can be given with or
without food. give medicine when baby is hungry makes it more likely for baby to
swallow it
-give full course of antibiotics as prescribed
-stroking infant cheek will open the infants mouth allowing for administration of medicine
The nurse inserts a urinary catheter into a female client who has not voided for 6 hours.
No urine is returned. What action should the nurse take next? - (correct answer)Leave
the catheter in place and insert a new catheter higher up in the perineal area.
Urine output would be expected as this client has not voided for 6 hours (obligatory
amount is at least 30 mL x 6 = 180 mL). The most common explanation is that the
catheter was unintentionally inserted into the vagina. The nurse should leave that
catheter as a landmark and insert a new sterile catheter into the urethra which is located
above the vagina.
An experienced nurse precepts a graduate nurse caring for a hospitalized client who
has a prescription for a transfusion of packed red blood cells (RBCs) to be hung over 3
hours. Which statement by the graduate nurse indicates the correct rationale for asking
the client to void prior to starting the transfusion? - (correct answer)"If a transfusion
reaction occurs, it will be important to collect a fresh urine specimen to check for
hemolyzed RBCs."
The nurse should ask the client to void or empty the urinary catheter and discard urine
prior to starting a blood transfusion. In the event of an acute hemolytic transfusion
reaction, a fresh urine specimen should be collected and sent to the laboratory to
analyze for hemolyzed RBCs. An acute hemolytic transfusion reaction is a life-
threatening reaction in which the host's antibodies rapidly destroy the transfused RBCs
,and is generally related to incompatibility. Early signs of a hemolytic reaction include red
urine, fever, and hypotension; late signs include disseminated intravascular coagulation
and hypovolemic shock. The transfusion should be stopped immediately if any sign of
transfusion reaction occurs.
Starting the transfusion with an empty bladder will help ensure that any urine specimen
collected after a reaction is reflective of the body's physiological processes after the
blood transfusion has started (Option 4).
The nurse is caring for a client who performs frequent self-urinary catheterizations.
Which client assessments would indicate a potential for a latex allergy? - (correct
answer)The greatest risk factor for latex allergy is long-term multiple exposures to latex
products. Powdered latex gloves were banned in the 1990s, and the incidence of latex
allergy is decreasing. It is estimated that 73% of clients with spina bifida have a
sensitivity to latex. This can be a result of frequent exposure to latex during their lifelong
care.
A classic screening question is whether the lips swell when blowing up balloons (which
have latex in them). Another is if your hands itch and/or burn after wearing rubber
gloves (Option 5).
Some proteins in rubber are similar to plant-derived food proteins. Therefore, certain
foods may cause a latex-food syndrome in clients with an allergy to latex. Common
foods include bananas, avocados, tomatoes, chestnuts, kiwis, potatoes, peaches,
grapes, and apricots (Option 3).
A nurse administers an intramuscular (IM) injection using the Z-track technique. Place
the steps in chronological order. - (correct answer)The Z-track technique prevents
tracking (leakage) of the medication into the subcutaneous tissue and is universally
recommended for the administration of IM injections. Displacing the skin while injecting
the medication, and then releasing the skin back to its normal position after removing
the needle creates a zigzag track. The procedure for administering an IM injection using
the Z-track technique includes these steps:
,Pull the skin 1-1 ½" (2.5-3.5 cm) laterally away from the injection site (Option 4).
Hold the skin taut with the nondominant hand, and insert the needle at a 90-degree
angle - taut skin facilitates entry of the needle and this angle ensures that the needle will
reach the muscle (Option 3).
Inject the medication slowly into the muscle while maintaining traction - slow injection
promotes comfort and allows time for tissue expansion to facilitate absorption of the
medication (Option 2).
Wait 10 seconds after injecting the medication and withdraw the needle while
maintaining traction on the skin; this allows the medication to diffuse before needle
removal and helps to prevent tracking (Option 6).
Release the hold on the skin - this allows the tissue layers to slide back to their original
position, sealing off the needle track (Option 5).
Apply gentle pressure at the injection site, but do not massage as this can cause the
medication to seep back up to the skin surface and cause local tissue irritation (Option
1).
The nurse is providing hospice care to a terminally ill client who is reporting dyspnea.
Which interventions should the nurse implement at this time? - (correct
answer)Dyspnea (air hunger) is a common symptom in terminally ill clients. Dyspnea is
subjective, and management depends on the client's clinical condition and reported
symptoms. Initial interventions focus on decreasing respiratory effort and the perception
of dyspnea, as well as relieving anxiety. Interventions for hospice clients include:
Administering opioids (eg, morphine, fentanyl), which are prescribed to relieve dyspnea
(Option 2)
Providing low-flow oxygen by nasal cannula, which may improve psychological comfort
and ease feelings of apprehension
Allowing frequent periods of rest to minimize exhaustion and dyspnea
Administering anxiolytics (eg, lorazepam) for anxiety associated with dyspnea
Assisting with relaxation strategies (eg, music, guided imagery) (Option 5)
Placing a fan in the room to improve airflow near the client, which decreases the
perception of dyspnea (Option 4)
, A nurse is reviewing the most recent laboratory results of a client on the telemetry floor.
The client is currently asymptomatic, and the telemetry monitor indicates sinus rhythm.
Which of the following critical values is most likely due to laboratory error? - (correct
answer)With the exception of clients in end-stage renal disease, a serum potassium
value >6.5 mEq/L (6.5 mmol/L) in any client who is walking and talking should raise the
suspicion of an erroneously elevated serum potassium (pseudohyperkalemia) from poor
hematology technique, hemolysis, or clotting. A serum potassium level of 7.0 mEq/L (7.0
mmol/L) would normally constitute a life-threatening electrolyte imbalance that would
cause severe weakness or paralysis, unstable arrhythmias, and eventual cardiac arrest.
An assessment would focus on evaluating cardiac symptoms and muscle strength and
be reported to the health care provider (HCP). In this case, it is likely that a repeat blood
draw would be prescribed.
Pseudohyperkalemia can be avoided on the repeat blood draw by using heparin-
impregnated hematology vials to prevent clotting, minimal use of a tourniquet and fist
clenching, and use of a larger gauge needle for the sample.
(Option 1) This blood urea nitrogen (BUN) value is elevated (normal 6-20 mg/dL [2.1-7.1
mmol/L]) and could be related to kidney damage or dehydration. Therefore, it is not the
most likely erroneous result.
(Option 2) Similar to the BUN level, this creatinine value is significantly elevated (normal
0.6-1.3 mg/dL [53-115 µmol/L]). Further nursing assessment is indicated, with
documentation and involvement of the HCP in evaluating the impact of this kidney
damage on the client's health.
(Option 4) This sodium value is high (normal 135-145 mEq/L [135-145 mmol/L]) and
requires further exploration. The nursing assessment should be documented and
reported to the HCP.
While preparing to insert a peripheral IV line, the nurse notices scarring near the client's
left axilla. The client confirms a history of left breast cancer and modified radical
mastectomy. Which actions should the nurse take? - (correct answer)A modified radical
