N3160 - EVOLVE Q'S And A’S WITH COMPLETE
SOLUTIONS
1. How can the nurse best minimize a patient's risk for infection
during tracheostomy care?
A. Adhere to sterile technique when appropriate.
B. Frequently assess for signs of local or systemic infection.
C. Monitor for indications that tracheostomy care is needed.
D. Instruct nursing assistive personnel (NAP) to report any
changes in color or odor of tracheal drainage. Correct Answers
A. Adhere to sterile technique when appropriate.
Rationale: Adherence to sterile technique is the most important
factor in minimizing the patient's risk for infection during
tracheostomy care. Proper assessment is important but will not
reduce the patient's risk for infection during tracheostomy care.
Monitoring the patient for indications that tracheostomy care is
needed will not reduce the patient's risk for infection. Although
the NAP would be instructed to report changes in tracheal
drainage, such notification will not minimize the patient's risk
for infection.
1. Why does the nurse elevate the head of the bed to 30 degrees
for a patient receiving an intermittent tube feeding?
A. Elevating the head of the bed reduces the risk for aspiration.
B. Proper elevation of the head of the bed promotes the patient's
digestion.
C. Acid reflux is reduced when the head of the bed is elevated at
least 30 degrees.
,D. Nutrients are absorbed more efficiently when the head of the
bed is elevated. Correct Answers A. Elevating the head of the
bed reduces the risk for aspiration.
Rationale: Elevating the head of the bed reduces the risk for
aspiration. Digestion is not affected when the head of the bed is
elevated. Reducing acid reflux is not the reason for elevating the
head of the bed. Nutrient absorption is unaffected by elevating
the head of the bed.
2. What is the proper response to the nurse's observation that the
patient's closed-system enteral feeding has 150 mL of formula
remaining and that the infusion order rate is for 50 mL/hr?
A. Recalculate the present drip factor for accuracy.
B. Terminate the fluid, and prepare to hang a new bag of
formula.
C. Plan to check the feeding for completion within the next 3
hours.
D. Check with the pharmacy to see if the formula has been
hanging too long. Correct Answers C. Plan to check the
feeding for completion within the next 3 hours.
Rationale: Because the ordered dose is 50 mL/hr, checking for
completion within 3 hours is the right choice. Recalculating the
present drip factor for accuracy does not address the issue of
time needed to infuse the feeding. The closed-system feeding
has a 24-hour delivery timeframe. Terminating delivery is
inappropriate because the tube feeding still has 3 hours to infuse.
Because the formula still has 3 hours to infuse, there is no need
to contact the pharmacy.
, A patient experiencing a blood transfusion reaction is prescribed
to receive epinephrine. What is the purpose of this medication
when given for this indication?
A. To relieve respiratory distress
B. To block histamine receptors
C. To reduce circulatory overload
D. To combat bacterial infection Correct Answers A. To
relieve respiratory distress
Rationale: The patient's vital signs should be monitored every 15
minutes. The patient's vital signs need not be monitored every 5
minutes in most cases. Monitoring every 30 minutes and every
hour are not often enough.
A patient for whom an intravenous antibiotic is prescribed has a
multilumen central line in place for central parenteral nutrition
(CPN). What should the nurse do?
A. Infuse the antibiotic through another lumen of the multilumen
central line.
B. Interrupt the CPN infusion only long enough to administer
the antibiotic.
C. Rearrange the antibiotic administration schedule so it does
not interfere with the CPN.
D. Ask the prescriber if the route of administration for the
antibiotic can be changed Correct Answers A. Infuse the
antibiotic through another lumen of the multilumen central line.
Rationale: IV medications and blood should be infused through
a different line or lumen than CPN. The parenteral nutrition
must not be interrupted for medication administration.
SOLUTIONS
1. How can the nurse best minimize a patient's risk for infection
during tracheostomy care?
A. Adhere to sterile technique when appropriate.
B. Frequently assess for signs of local or systemic infection.
C. Monitor for indications that tracheostomy care is needed.
D. Instruct nursing assistive personnel (NAP) to report any
changes in color or odor of tracheal drainage. Correct Answers
A. Adhere to sterile technique when appropriate.
Rationale: Adherence to sterile technique is the most important
factor in minimizing the patient's risk for infection during
tracheostomy care. Proper assessment is important but will not
reduce the patient's risk for infection during tracheostomy care.
Monitoring the patient for indications that tracheostomy care is
needed will not reduce the patient's risk for infection. Although
the NAP would be instructed to report changes in tracheal
drainage, such notification will not minimize the patient's risk
for infection.
1. Why does the nurse elevate the head of the bed to 30 degrees
for a patient receiving an intermittent tube feeding?
A. Elevating the head of the bed reduces the risk for aspiration.
B. Proper elevation of the head of the bed promotes the patient's
digestion.
C. Acid reflux is reduced when the head of the bed is elevated at
least 30 degrees.
,D. Nutrients are absorbed more efficiently when the head of the
bed is elevated. Correct Answers A. Elevating the head of the
bed reduces the risk for aspiration.
Rationale: Elevating the head of the bed reduces the risk for
aspiration. Digestion is not affected when the head of the bed is
elevated. Reducing acid reflux is not the reason for elevating the
head of the bed. Nutrient absorption is unaffected by elevating
the head of the bed.
2. What is the proper response to the nurse's observation that the
patient's closed-system enteral feeding has 150 mL of formula
remaining and that the infusion order rate is for 50 mL/hr?
A. Recalculate the present drip factor for accuracy.
B. Terminate the fluid, and prepare to hang a new bag of
formula.
C. Plan to check the feeding for completion within the next 3
hours.
D. Check with the pharmacy to see if the formula has been
hanging too long. Correct Answers C. Plan to check the
feeding for completion within the next 3 hours.
Rationale: Because the ordered dose is 50 mL/hr, checking for
completion within 3 hours is the right choice. Recalculating the
present drip factor for accuracy does not address the issue of
time needed to infuse the feeding. The closed-system feeding
has a 24-hour delivery timeframe. Terminating delivery is
inappropriate because the tube feeding still has 3 hours to infuse.
Because the formula still has 3 hours to infuse, there is no need
to contact the pharmacy.
, A patient experiencing a blood transfusion reaction is prescribed
to receive epinephrine. What is the purpose of this medication
when given for this indication?
A. To relieve respiratory distress
B. To block histamine receptors
C. To reduce circulatory overload
D. To combat bacterial infection Correct Answers A. To
relieve respiratory distress
Rationale: The patient's vital signs should be monitored every 15
minutes. The patient's vital signs need not be monitored every 5
minutes in most cases. Monitoring every 30 minutes and every
hour are not often enough.
A patient for whom an intravenous antibiotic is prescribed has a
multilumen central line in place for central parenteral nutrition
(CPN). What should the nurse do?
A. Infuse the antibiotic through another lumen of the multilumen
central line.
B. Interrupt the CPN infusion only long enough to administer
the antibiotic.
C. Rearrange the antibiotic administration schedule so it does
not interfere with the CPN.
D. Ask the prescriber if the route of administration for the
antibiotic can be changed Correct Answers A. Infuse the
antibiotic through another lumen of the multilumen central line.
Rationale: IV medications and blood should be infused through
a different line or lumen than CPN. The parenteral nutrition
must not be interrupted for medication administration.
