Mod 1 Prep Quiz
1)The nurse has placed her sterile gloved hands below her waist. Her hands are now considered:
a sterile.
.
b non-sterile.
.
c free of disease-causing
.
organisms.
d aseptic.
.
ANS: B
Once the hands have been placed below the waist, they can longer be considered sterile or free
from organisms. Asepsis refers to freedom from disease-causing contamination.
2)The nurse is educating the patient about the signs and symptoms of a wound infection.
Which statement indicates a need for further education?
a “The wound will be red.”
.
b “The wound will be warm.”
.
c “The wound will have pus.”
.
d “The wound will need to be
. treated.”
ANS: C
An infected wound shows clinical signs of infection, including redness, warmth, and increased
drainage that may or may not be purulent (contain pus), and has a bacterial count in the tissue of
at least 105 per gram of tissue sampled when cultured. The wound will need to be treated for the
infection.
3)A home care nurse prepares to administer intravenous medication to a client. The nurse
assesses the site and reviews the client’s chart prior to administering the medication:
Client: Thomas Jackson
DOB: 5/3/1936
Gender: Male
January 23 (Today): Right upper extremity PICC is intact, patent, and has a good
blood return. Site clean and free from manifestations of infiltration, irritation, and
infection. –Sue Franks, RN
January 20: Purulent drainage from sacral wound. Wound cleansed and dressing
changed. Dr. Smith notified and updated on client status. New orders received for
intravenous antibiotics. –Sue Franks, RN
January 13: Client alert and oriented. Sacral wound dressing changed. –Sue Franks,
RN
January 6: Right upper extremity PICC inserted. No complications. Discharged with
home health care. –Dr. Smith
Based on the information provided, which action should the nurse take?
a Switch the medication to the oral
,. route.
b Discontinue the PICC.
.
c Administer the prescribed
.
medication.
d Notify the health care provider.
.
ANS: C
A PICC that is functioning well without inflammation or infection may remain in place for months
or even years. Because the line shows no signs of complications, it is permissible to administer
the IV antibiotic. There is no need to call the physician to have the IV route changed to an oral
route.
4)A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action
should the nurse take to protect the client’s skin during this procedure?
a Place a washcloth between the skin and
.
tourniquet.
b Apply warm compresses to the extremity.
.
c Lower the extremity below the level of the
.
heart.
d Tap the skin lightly and avoid slapping.
.
ANS: A
To protect the client's skin, the nurse should place a washcloth or the client's gown between the
skin and tourniquet. The other interventions are methods to distend the vein but will not protect
the client's skin.
5)A nurse assesses a client’s peripheral IV site, and notices edema and tenderness above the site.
Which action should the nurse take next?
a Elevate the extremity on a
.
pillow.
b Stop the infusion of intravenous
.
fluids.
c Flush the catheter with normal
.
saline.
d Apply cold compresses to the IV
.
site.
ANS: B
Infiltration occurs when the needle dislodges partially or completely from the vein. Signs of
infiltration include edema and tenderness above the site. The nurse should stop the infusion and
remove the catheter. Cold compresses and elevation of the extremity can be done after the
catheter is discontinued to increase client comfort. Alternatively, warm compresses may be
prescribed per institutional policy and may help speed circulation to the area.
,6)The nurse is caring for a client 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 Document the date, time, and nurse’s initials after each dose is
.
administered.
c Use sterile gloves when drawing up and administering the
.
medication.
d Use a new IV tubing set each time the medication is
.
administered.
ANS: A
Phenytoin (Dilantin) can cause significant irritation to blood vessels and tissues when
administered via IV. For this reason, the nurse must ensure that the IV catheter is located
correctly in the vein by checking for a blood return prior to administration. Dilantin may not be
given with IV fluids that contain dextrose as precipitation and crystallization, so the nurse must
also check compatibility with the patient's prescribed IV fluids.
7)A nurse responds to an IV pump alarm related to increased pressure. Which action should the
nurse take first?
a Flush the catheter with a thrombolytic
.
enzyme.
b Check for kinking of the catheter.
.
c Remove the IV catheter.
.
d Get a new infusion pump.
.
ANS: B
Fluid flow through the infusion system requires that pressure on the external side be greater than
pressure at the catheter tip. Fluid flow can be slowed for many reasons. A common reason, and
one that is easy to correct, is a kinked catheter. If this is not the cause of the pressure alarm, the
nurse may have to ascertain whether a clot has formed inside the catheter lumen, or if the pump
is no longer functional. Removal of the IV catheter and placement of a new IV catheter should be
completed when no other option has
8)The nurse knows the layer that delivers the blood supply to the dermis, provides
insulation, and has a cushioning effect is:
a stratum
. germinativum.
b epidermis.
.
c subcutaneous
. layer.
d stratum corneum.
.
, ANS: C
The subcutaneous layer delivers the blood supply to the dermis, provides insulation, and has a
cushioning effect. The stratum germinativum constantly produces new cells that are pushed
upward through the other layers of the epidermis toward the stratum corneum, where they
flatten, die, and are eventually sloughed off and replaced by new cells. The epidermis is the
outermost layer of the skin and the thinnest of the layers. The stratum corneum is made up of
flattened dead cells.
9)The nurse knows that a hydrocolloid dressing is appropriate for the following type of
wound:
a A wound with a large amount of
. drainage
b A wound that is tunneling
.
c A postsurgical incision with staples
.
d A wound with a moderate amount of
. drainage
ANS: D
Hydrocolloids are occlusive, adhesive dressings composed of gelling agents and
carboxymethylcellulose. They absorb a small to moderate amount of drainage over a 3- to 7-day
period, forming a gel as drainage is absorbed. A wound with a large amount of drainage would
require a foam or alginate dressing, a postsurgical incision with staples could use Steri-Strips or
gauze, and a wound that is tunneling may require packing.
10)The nurse knows that mechanical debridement involves all of the following except:
a wet to dry
. dressings.
b damp to dry
. dressing.
c enzymatic
. dressing.
d whirlpool baths.
.
ANS: C
Enzymatic debridement is achieved through the application of topical agents containing enzymes
that work by breaking down the fibrin, collagen, or elastin present in devitalized tissue, thus
allowing for its removal. Mechanical debridement is a nonselective form of debridement because
it not only removes the necrotic tissue, but also can remove or disturb exposed viable tissue that
may be in the wound. The main forms of mechanical debridement are wet/damp-to-dry dressings
and
Prep Quiz #2
1)The nurse has placed her sterile gloved hands below her waist. Her hands are now considered:
a sterile.
.
b non-sterile.
.
c free of disease-causing
.
organisms.
d aseptic.
.
ANS: B
Once the hands have been placed below the waist, they can longer be considered sterile or free
from organisms. Asepsis refers to freedom from disease-causing contamination.
2)The nurse is educating the patient about the signs and symptoms of a wound infection.
Which statement indicates a need for further education?
a “The wound will be red.”
.
b “The wound will be warm.”
.
c “The wound will have pus.”
.
d “The wound will need to be
. treated.”
ANS: C
An infected wound shows clinical signs of infection, including redness, warmth, and increased
drainage that may or may not be purulent (contain pus), and has a bacterial count in the tissue of
at least 105 per gram of tissue sampled when cultured. The wound will need to be treated for the
infection.
3)A home care nurse prepares to administer intravenous medication to a client. The nurse
assesses the site and reviews the client’s chart prior to administering the medication:
Client: Thomas Jackson
DOB: 5/3/1936
Gender: Male
January 23 (Today): Right upper extremity PICC is intact, patent, and has a good
blood return. Site clean and free from manifestations of infiltration, irritation, and
infection. –Sue Franks, RN
January 20: Purulent drainage from sacral wound. Wound cleansed and dressing
changed. Dr. Smith notified and updated on client status. New orders received for
intravenous antibiotics. –Sue Franks, RN
January 13: Client alert and oriented. Sacral wound dressing changed. –Sue Franks,
RN
January 6: Right upper extremity PICC inserted. No complications. Discharged with
home health care. –Dr. Smith
Based on the information provided, which action should the nurse take?
a Switch the medication to the oral
,. route.
b Discontinue the PICC.
.
c Administer the prescribed
.
medication.
d Notify the health care provider.
.
ANS: C
A PICC that is functioning well without inflammation or infection may remain in place for months
or even years. Because the line shows no signs of complications, it is permissible to administer
the IV antibiotic. There is no need to call the physician to have the IV route changed to an oral
route.
4)A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action
should the nurse take to protect the client’s skin during this procedure?
a Place a washcloth between the skin and
.
tourniquet.
b Apply warm compresses to the extremity.
.
c Lower the extremity below the level of the
.
heart.
d Tap the skin lightly and avoid slapping.
.
ANS: A
To protect the client's skin, the nurse should place a washcloth or the client's gown between the
skin and tourniquet. The other interventions are methods to distend the vein but will not protect
the client's skin.
5)A nurse assesses a client’s peripheral IV site, and notices edema and tenderness above the site.
Which action should the nurse take next?
a Elevate the extremity on a
.
pillow.
b Stop the infusion of intravenous
.
fluids.
c Flush the catheter with normal
.
saline.
d Apply cold compresses to the IV
.
site.
ANS: B
Infiltration occurs when the needle dislodges partially or completely from the vein. Signs of
infiltration include edema and tenderness above the site. The nurse should stop the infusion and
remove the catheter. Cold compresses and elevation of the extremity can be done after the
catheter is discontinued to increase client comfort. Alternatively, warm compresses may be
prescribed per institutional policy and may help speed circulation to the area.
,6)The nurse is caring for a client 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 Document the date, time, and nurse’s initials after each dose is
.
administered.
c Use sterile gloves when drawing up and administering the
.
medication.
d Use a new IV tubing set each time the medication is
.
administered.
ANS: A
Phenytoin (Dilantin) can cause significant irritation to blood vessels and tissues when
administered via IV. For this reason, the nurse must ensure that the IV catheter is located
correctly in the vein by checking for a blood return prior to administration. Dilantin may not be
given with IV fluids that contain dextrose as precipitation and crystallization, so the nurse must
also check compatibility with the patient's prescribed IV fluids.
7)A nurse responds to an IV pump alarm related to increased pressure. Which action should the
nurse take first?
a Flush the catheter with a thrombolytic
.
enzyme.
b Check for kinking of the catheter.
.
c Remove the IV catheter.
.
d Get a new infusion pump.
.
ANS: B
Fluid flow through the infusion system requires that pressure on the external side be greater than
pressure at the catheter tip. Fluid flow can be slowed for many reasons. A common reason, and
one that is easy to correct, is a kinked catheter. If this is not the cause of the pressure alarm, the
nurse may have to ascertain whether a clot has formed inside the catheter lumen, or if the pump
is no longer functional. Removal of the IV catheter and placement of a new IV catheter should be
completed when no other option has
8)The nurse knows the layer that delivers the blood supply to the dermis, provides
insulation, and has a cushioning effect is:
a stratum
. germinativum.
b epidermis.
.
c subcutaneous
. layer.
d stratum corneum.
.
, ANS: C
The subcutaneous layer delivers the blood supply to the dermis, provides insulation, and has a
cushioning effect. The stratum germinativum constantly produces new cells that are pushed
upward through the other layers of the epidermis toward the stratum corneum, where they
flatten, die, and are eventually sloughed off and replaced by new cells. The epidermis is the
outermost layer of the skin and the thinnest of the layers. The stratum corneum is made up of
flattened dead cells.
9)The nurse knows that a hydrocolloid dressing is appropriate for the following type of
wound:
a A wound with a large amount of
. drainage
b A wound that is tunneling
.
c A postsurgical incision with staples
.
d A wound with a moderate amount of
. drainage
ANS: D
Hydrocolloids are occlusive, adhesive dressings composed of gelling agents and
carboxymethylcellulose. They absorb a small to moderate amount of drainage over a 3- to 7-day
period, forming a gel as drainage is absorbed. A wound with a large amount of drainage would
require a foam or alginate dressing, a postsurgical incision with staples could use Steri-Strips or
gauze, and a wound that is tunneling may require packing.
10)The nurse knows that mechanical debridement involves all of the following except:
a wet to dry
. dressings.
b damp to dry
. dressing.
c enzymatic
. dressing.
d whirlpool baths.
.
ANS: C
Enzymatic debridement is achieved through the application of topical agents containing enzymes
that work by breaking down the fibrin, collagen, or elastin present in devitalized tissue, thus
allowing for its removal. Mechanical debridement is a nonselective form of debridement because
it not only removes the necrotic tissue, but also can remove or disturb exposed viable tissue that
may be in the wound. The main forms of mechanical debridement are wet/damp-to-dry dressings
and
Prep Quiz #2
