NU 311 Clinical Nursing Skills Final Exam
(NEW) questions with correct answers
Infusion |Nursing |Society |(INS) |standards |for |reducing |infection |related |to |IV |Therapy |- |VERIFIED |
ANSWER✔✔-• |Assess |the |VAD |catheter-skin |junction |site |and |surrounding |area |for |redness, |
tenderness, |swelling, |and |drainage |by |visual |inspection |and |palpation |through |the |intact |dressing. |
Assess |short-peripheral |catheters |minimally |at |least |every |4 |hours |or |more |if |clinically |indicated |and |
daily |for |outpatient |or |home |care |patients. |CVADs |should |be |assessed |at |least |daily.
• |Change |the |dressing |immediately |to |assess, |clean, |and |disinfect |the |site |in |the |event |of |drainage, |
tenderness, |other |signs |of |infection |or |if |dressing |becomes |loose |or |dislodged.
• |Perform |hand |hygiene |before |placing |and |providing |any |VAD-associated |interventions.
• |Perform |dressing |changes |at |a |frequency |based |on |the |type |of |catheter |and |dressing. |Short-
peripheral |catheter |dressings |are |changed |if |the |dressing |becomes |damp, |loosened, |and/or |visibly |
soiled; |if |there |is |blood |or |drainage |under |the |dressing; |and |at |least |every |5-7 |days. |Change |CVAD |
dressings |at |least |every |5-7 |days |for |TSM |dressings |and |at |least |every |2 |days |for |gauze |dressings |that |
cover |a |catheter |site |or |are |under |a |TSM.
• |Use |approved |antiseptic |agents |before |venipuncture |and |when |performing |skin |antisepsis. |The |
preferred |skin |antiseptic |is |>0.5% |chlorhexidine |gluconate |(CHG) |in |alcohol |solution. |Tincture |of |
iodine, |an |iodophor |(povidone-iodine), |or |70% |alcohol |may |be |used |if |CHG |solution |is |
contraindicated.
• |Allow |skin |antiseptic |to |dry |fully |before |dressing |placement; |alcoholic |chlorhexidine |solutions, |for |at
|least |30 |seconds; |iodophors, |for |at |least |1.5-2 |minutes.
• |Use |catheter |stabilization |device |that |allows |visual |inspection |of |access |site.
• |Use |vigorous |mechanical |scrubbing |methods |when |disinfecting |needleless |connectors |before |each |
access |using |70% |isopropyl |alcohol, |iodophors, |or |>0.5% |chlorhexidine |alcoholic |solution. |Disinfect |
before |each |access |when |multiple |accesses |are |req
The |Needle |Safety |and |Prevention |Act |of |2001 |- |VERIFIED |ANSWER✔✔--Mandates |that |health |care |
agencies |use |safe |needle |devices |and |manufactured |needleless |systems |to |reduce |needlestick |injury. |
Systems |with |catheter |ports |or |Y-connector |sites |are |designed |to |contain |a |needle |housed |in |a |
protective |covering. |Needleless |infusion |lines |allow |a |direct |connection |with |the |IV |line |via |a |recessed
|connection |port, |a |blunt-ended |cannula, |or |shielded-needle |device, |eliminating |the |risk |for |exposure |
to |an |IV |needle.
,Recommendations |for |the |Prevention |of |Needlestick |Injuries |- |VERIFIED |ANSWER✔✔-• |Avoid |using |
needles |when |effective |needleless |systems |or |sharps |with |engineered |sharps |injury |protection |(SESIP) |
safety |devices |are |available.
• |Do |not |recap |any |needle |after |medication |administration.
• |Plan |safe |handling |and |disposal |of |needles |before |beginning |a |procedure.
• |Immediately |dispose |of |needles, |needleless |systems, |and |SESIP |into |puncture-proof |and |leak-proof |
sharps |disposal |containers.
• |Maintain |a |sharps |injury |log |that |reports |the |following: |type |and |brand |of |device |involved |in |the |
incident; |location |of |the |incident |(e.g., |department |or |work |area); |description |of |the |incident; |and |
privacy |of |the |employees |who |have |had |sharps |injuries.
• |Attend |education |offerings |on |bloodborne |pathogens |and |follow |recommendations |for |infection |
prevention, |including |receiving |the |hepatitis |B |vaccine.
• |Participate |in |the |selection |and |evaluation |of |SESIP |devices |with |safety |features |within |your |agency |
whenever |possible.
Isotonic |solutions |- |VERIFIED |ANSWER✔✔-•Dextrose |5% |in |water
|-Dextrose |is |quickly |metabolized, |leaving |free |water |to |be |distributed |evenly |in |all |fluid |
compartments |so |it |acts |like |a |hypotonic |solution
•0.9% |sodium |chloride† |(NS)
•Lactated |Ringer's‡
| -Has |multiple |electrolytes
Hypotonic |solutions |- |VERIFIED |ANSWER✔✔-•0.45% |sodium |chloride |(half |NS) |
•0.33% |sodium |chloride |(one-third |NS)
Hypertonic |solutions |- |VERIFIED |ANSWER✔✔-•Dextrose |10% |in |water |
•Dextrose |50% |in |water
•3%-5% |sodium |chloride |
•Dextrose |5% |in |0.9% |sodium |chloride |
•Dextrose |5% |in |0.45% |NaCl |sodium |chloride
•Dextrose |5% |in |Lactated |Ringer's
,Prepare |IV |tubing |and |solution |for |continuous |infusion. |- |VERIFIED |ANSWER✔✔-a. |Check |IV |solution |
using |six |rights |of |medication |administration |and |review |label |for |name |and |concentration |of |solution,
|type |and |concentration |of |any |additives, |volume, |beyond-use |and |expiration |dates, |and |sterility |
state. |If |using |bar |code, |scan |code |on |patient's |wristband |and |then |on |IV |fluid |container. |Be |sure |that
|prescribed |additives |such |as |potassium |and |vitamins |have |been |added. |Check |solution |for |color |and |
clarity. |Check |bag |for |leaks.
b. |Open |IV |infusion |set, |maintaining |sterility. |NOTE: |EIDs |sometimes |have |a |dedicated |administration |
set; |follow |manufacturer's |instructions.
c. |Place |roller |clamp |about |2 |to |5 |cm |(1 |to |2 |inches) |below |drip |chamber |and |move |roller |clamp |to
|"off" |position.
d. |Remove |protective |sheath |over |IV |tubing |port |on |plastic |IV |solution |bag |or |top |of |IV |solution |bottle
|while |maintaining |sterility.
e. |Remove |protective |cover |from |IV |tubing |spike |while |maintaining |sterility |of |spike. |Insert |spike |into |
port |of |IV |bag |using |a |twisting |motion. |If |solution |container |is |glass |bottle, |clean |rubber |stopper |on |
glass-bottled |solution |with |antiseptic |swab |and |insert |spike |into |rubber |stopper |of |IV |bottle. |Bottles |
require |vented |tubing.
f. |Compress |drip |chamber |and |release, |allowing |it |to |fill |one-third |to |one-half |full |
g. |Prime |air |out |of |IV |tubing |by |filling |with |IV |solution: |Remove |protective |cover |on |end |of |IV |tubing |
(some |tubing |can |be |primed |without |removing |protective |cover) |and |slowly |open |roller |clamp |to |
allow |fluid |to |flow |from |drip |chamber |to |distal |end |of |IV |tubing. |If |tubing |has |a |Y |connector, |invert |Y |
connector |when |fluid |reaches |it |to |displace |air. |Return |roller |clamp |to |"off" |position |after |priming |
tubing |(filled |with |IV |fluid). |Replace |protective |cover |on |distal |end |of |tubing. |Label |IV |tubing |with |
date |according |to |agency |policy |and |procedure.
h. |Be |certain |that |IV |tubing |is
Starting |and |IV |Implementation |- |VERIFIED |ANSWER✔✔-1. |Swabs |injection |cap |and |primes |saline |lock
|leaving |syringe |attached. |Loosens |protector |cap |(maintain |sterility). |Removes |over |needle |catheter |
(ONC) |and |transparent |dressing |from |wrappers.
, 2. |Applies |tourniquet |4 |- |6 |inches |above |selected |site |(check |radial |pulse) |and |assesses |vein |for |
appropriateness. |If |need |additional |prep |time |may |release |tourniquet |temporarily.
3. |Applies |clean |gloves
| 4. |Moves |saline |lock |nearby, |on |over-the-bed |table, |maintaining |in |sterile |package.
|5. |Cleanses |site |with |Chlorhexidine |- |using |friction |horizontal, |vertical, |and |circular. |Cleanse |for |at |
least |30 |seconds |and |allow |site |to |completely |dry. |Do |not |touch |site!
|6. |Performs |venipuncture: |Anchors |vein |1.5-2 |inches |below |insertion |site |by |gently |stretching |the |
skin |against |the |direction |of |insertion |site. |Be |sure |not |to |touch |the |cleansed |site |or |allow |the |ONC |to
|touch |the |anchoring |thumb; |advises |patient |to |remain |still |and |that |there |will |be |a |quick |stick; |
inserts |ONC |with |bevel |up |at |10-30 |° |angle |in |the |direction |parallel |to |the |vein.
7. |Observes |for |blood |return. |Lowers |needle |and |advances |1/4 |inch.
8. |Continues |to |hold |skin |and |advances |catheter |all |the |way |to |hub |without |advancing |the
|stylet/needle. |Stabilizes |catheter |with |one |hand |and |releases |tourniquet |with |the |other |hand. |(Push |
and |pop)
9. |Apply |gentle/firm |pressure |1 |1⁄4 |inch |above |insertion |site |and |removes |stylet/needle |of |ONC. |
Disposes |of |stylet |in |sharps |container |if |close |or |temporarily |places |on |bedside |table |away |from |
patient.
10. |Removes |cap |and |maintains |sterility; |quickly |connects |end |of |saline |lock |to |catheter. |Secures |
temporarily |with |tape.
11. |Reassesses |for |blood |return |with |gentle |aspiration |and |flushes |the |vein |with |remaining |saline, |
observing |site |for |swelling. |Removes |flush |syringe |and |places |in |sharps |container.
12. |Applies |a |sterile |transparent |dressing
Principles |for |Vein |selection |- |VERIFIED |ANSWER✔✔--Veins |on |dorsal |and |ventral |surfaces |of |arms |
(e.g., |metacarpal, |cephalic, |basilic, |or |median) |are |preferred |in |adults.
image
- |Use |most |distal |site |in |nondominant |arm |if |possible.
Patients |with |VAD |placement |in |their |dominant |hand |have |decreased |ability |to |perform |self-care.
- |With |your |fingertip, |palpate |vein |at |intended |insertion |site |by |pressing |downward. |Note |resilient, |
soft, |bouncy |feeling |while |releasing |pressure |
- |Select |well-dilated |vein
Methods |to |improve |vascular |distention |- |VERIFIED |ANSWER✔✔--Increased |volume |of |blood |in |vein |
at |venipuncture |site |makes |vein |more |visible.
(NEW) questions with correct answers
Infusion |Nursing |Society |(INS) |standards |for |reducing |infection |related |to |IV |Therapy |- |VERIFIED |
ANSWER✔✔-• |Assess |the |VAD |catheter-skin |junction |site |and |surrounding |area |for |redness, |
tenderness, |swelling, |and |drainage |by |visual |inspection |and |palpation |through |the |intact |dressing. |
Assess |short-peripheral |catheters |minimally |at |least |every |4 |hours |or |more |if |clinically |indicated |and |
daily |for |outpatient |or |home |care |patients. |CVADs |should |be |assessed |at |least |daily.
• |Change |the |dressing |immediately |to |assess, |clean, |and |disinfect |the |site |in |the |event |of |drainage, |
tenderness, |other |signs |of |infection |or |if |dressing |becomes |loose |or |dislodged.
• |Perform |hand |hygiene |before |placing |and |providing |any |VAD-associated |interventions.
• |Perform |dressing |changes |at |a |frequency |based |on |the |type |of |catheter |and |dressing. |Short-
peripheral |catheter |dressings |are |changed |if |the |dressing |becomes |damp, |loosened, |and/or |visibly |
soiled; |if |there |is |blood |or |drainage |under |the |dressing; |and |at |least |every |5-7 |days. |Change |CVAD |
dressings |at |least |every |5-7 |days |for |TSM |dressings |and |at |least |every |2 |days |for |gauze |dressings |that |
cover |a |catheter |site |or |are |under |a |TSM.
• |Use |approved |antiseptic |agents |before |venipuncture |and |when |performing |skin |antisepsis. |The |
preferred |skin |antiseptic |is |>0.5% |chlorhexidine |gluconate |(CHG) |in |alcohol |solution. |Tincture |of |
iodine, |an |iodophor |(povidone-iodine), |or |70% |alcohol |may |be |used |if |CHG |solution |is |
contraindicated.
• |Allow |skin |antiseptic |to |dry |fully |before |dressing |placement; |alcoholic |chlorhexidine |solutions, |for |at
|least |30 |seconds; |iodophors, |for |at |least |1.5-2 |minutes.
• |Use |catheter |stabilization |device |that |allows |visual |inspection |of |access |site.
• |Use |vigorous |mechanical |scrubbing |methods |when |disinfecting |needleless |connectors |before |each |
access |using |70% |isopropyl |alcohol, |iodophors, |or |>0.5% |chlorhexidine |alcoholic |solution. |Disinfect |
before |each |access |when |multiple |accesses |are |req
The |Needle |Safety |and |Prevention |Act |of |2001 |- |VERIFIED |ANSWER✔✔--Mandates |that |health |care |
agencies |use |safe |needle |devices |and |manufactured |needleless |systems |to |reduce |needlestick |injury. |
Systems |with |catheter |ports |or |Y-connector |sites |are |designed |to |contain |a |needle |housed |in |a |
protective |covering. |Needleless |infusion |lines |allow |a |direct |connection |with |the |IV |line |via |a |recessed
|connection |port, |a |blunt-ended |cannula, |or |shielded-needle |device, |eliminating |the |risk |for |exposure |
to |an |IV |needle.
,Recommendations |for |the |Prevention |of |Needlestick |Injuries |- |VERIFIED |ANSWER✔✔-• |Avoid |using |
needles |when |effective |needleless |systems |or |sharps |with |engineered |sharps |injury |protection |(SESIP) |
safety |devices |are |available.
• |Do |not |recap |any |needle |after |medication |administration.
• |Plan |safe |handling |and |disposal |of |needles |before |beginning |a |procedure.
• |Immediately |dispose |of |needles, |needleless |systems, |and |SESIP |into |puncture-proof |and |leak-proof |
sharps |disposal |containers.
• |Maintain |a |sharps |injury |log |that |reports |the |following: |type |and |brand |of |device |involved |in |the |
incident; |location |of |the |incident |(e.g., |department |or |work |area); |description |of |the |incident; |and |
privacy |of |the |employees |who |have |had |sharps |injuries.
• |Attend |education |offerings |on |bloodborne |pathogens |and |follow |recommendations |for |infection |
prevention, |including |receiving |the |hepatitis |B |vaccine.
• |Participate |in |the |selection |and |evaluation |of |SESIP |devices |with |safety |features |within |your |agency |
whenever |possible.
Isotonic |solutions |- |VERIFIED |ANSWER✔✔-•Dextrose |5% |in |water
|-Dextrose |is |quickly |metabolized, |leaving |free |water |to |be |distributed |evenly |in |all |fluid |
compartments |so |it |acts |like |a |hypotonic |solution
•0.9% |sodium |chloride† |(NS)
•Lactated |Ringer's‡
| -Has |multiple |electrolytes
Hypotonic |solutions |- |VERIFIED |ANSWER✔✔-•0.45% |sodium |chloride |(half |NS) |
•0.33% |sodium |chloride |(one-third |NS)
Hypertonic |solutions |- |VERIFIED |ANSWER✔✔-•Dextrose |10% |in |water |
•Dextrose |50% |in |water
•3%-5% |sodium |chloride |
•Dextrose |5% |in |0.9% |sodium |chloride |
•Dextrose |5% |in |0.45% |NaCl |sodium |chloride
•Dextrose |5% |in |Lactated |Ringer's
,Prepare |IV |tubing |and |solution |for |continuous |infusion. |- |VERIFIED |ANSWER✔✔-a. |Check |IV |solution |
using |six |rights |of |medication |administration |and |review |label |for |name |and |concentration |of |solution,
|type |and |concentration |of |any |additives, |volume, |beyond-use |and |expiration |dates, |and |sterility |
state. |If |using |bar |code, |scan |code |on |patient's |wristband |and |then |on |IV |fluid |container. |Be |sure |that
|prescribed |additives |such |as |potassium |and |vitamins |have |been |added. |Check |solution |for |color |and |
clarity. |Check |bag |for |leaks.
b. |Open |IV |infusion |set, |maintaining |sterility. |NOTE: |EIDs |sometimes |have |a |dedicated |administration |
set; |follow |manufacturer's |instructions.
c. |Place |roller |clamp |about |2 |to |5 |cm |(1 |to |2 |inches) |below |drip |chamber |and |move |roller |clamp |to
|"off" |position.
d. |Remove |protective |sheath |over |IV |tubing |port |on |plastic |IV |solution |bag |or |top |of |IV |solution |bottle
|while |maintaining |sterility.
e. |Remove |protective |cover |from |IV |tubing |spike |while |maintaining |sterility |of |spike. |Insert |spike |into |
port |of |IV |bag |using |a |twisting |motion. |If |solution |container |is |glass |bottle, |clean |rubber |stopper |on |
glass-bottled |solution |with |antiseptic |swab |and |insert |spike |into |rubber |stopper |of |IV |bottle. |Bottles |
require |vented |tubing.
f. |Compress |drip |chamber |and |release, |allowing |it |to |fill |one-third |to |one-half |full |
g. |Prime |air |out |of |IV |tubing |by |filling |with |IV |solution: |Remove |protective |cover |on |end |of |IV |tubing |
(some |tubing |can |be |primed |without |removing |protective |cover) |and |slowly |open |roller |clamp |to |
allow |fluid |to |flow |from |drip |chamber |to |distal |end |of |IV |tubing. |If |tubing |has |a |Y |connector, |invert |Y |
connector |when |fluid |reaches |it |to |displace |air. |Return |roller |clamp |to |"off" |position |after |priming |
tubing |(filled |with |IV |fluid). |Replace |protective |cover |on |distal |end |of |tubing. |Label |IV |tubing |with |
date |according |to |agency |policy |and |procedure.
h. |Be |certain |that |IV |tubing |is
Starting |and |IV |Implementation |- |VERIFIED |ANSWER✔✔-1. |Swabs |injection |cap |and |primes |saline |lock
|leaving |syringe |attached. |Loosens |protector |cap |(maintain |sterility). |Removes |over |needle |catheter |
(ONC) |and |transparent |dressing |from |wrappers.
, 2. |Applies |tourniquet |4 |- |6 |inches |above |selected |site |(check |radial |pulse) |and |assesses |vein |for |
appropriateness. |If |need |additional |prep |time |may |release |tourniquet |temporarily.
3. |Applies |clean |gloves
| 4. |Moves |saline |lock |nearby, |on |over-the-bed |table, |maintaining |in |sterile |package.
|5. |Cleanses |site |with |Chlorhexidine |- |using |friction |horizontal, |vertical, |and |circular. |Cleanse |for |at |
least |30 |seconds |and |allow |site |to |completely |dry. |Do |not |touch |site!
|6. |Performs |venipuncture: |Anchors |vein |1.5-2 |inches |below |insertion |site |by |gently |stretching |the |
skin |against |the |direction |of |insertion |site. |Be |sure |not |to |touch |the |cleansed |site |or |allow |the |ONC |to
|touch |the |anchoring |thumb; |advises |patient |to |remain |still |and |that |there |will |be |a |quick |stick; |
inserts |ONC |with |bevel |up |at |10-30 |° |angle |in |the |direction |parallel |to |the |vein.
7. |Observes |for |blood |return. |Lowers |needle |and |advances |1/4 |inch.
8. |Continues |to |hold |skin |and |advances |catheter |all |the |way |to |hub |without |advancing |the
|stylet/needle. |Stabilizes |catheter |with |one |hand |and |releases |tourniquet |with |the |other |hand. |(Push |
and |pop)
9. |Apply |gentle/firm |pressure |1 |1⁄4 |inch |above |insertion |site |and |removes |stylet/needle |of |ONC. |
Disposes |of |stylet |in |sharps |container |if |close |or |temporarily |places |on |bedside |table |away |from |
patient.
10. |Removes |cap |and |maintains |sterility; |quickly |connects |end |of |saline |lock |to |catheter. |Secures |
temporarily |with |tape.
11. |Reassesses |for |blood |return |with |gentle |aspiration |and |flushes |the |vein |with |remaining |saline, |
observing |site |for |swelling. |Removes |flush |syringe |and |places |in |sharps |container.
12. |Applies |a |sterile |transparent |dressing
Principles |for |Vein |selection |- |VERIFIED |ANSWER✔✔--Veins |on |dorsal |and |ventral |surfaces |of |arms |
(e.g., |metacarpal, |cephalic, |basilic, |or |median) |are |preferred |in |adults.
image
- |Use |most |distal |site |in |nondominant |arm |if |possible.
Patients |with |VAD |placement |in |their |dominant |hand |have |decreased |ability |to |perform |self-care.
- |With |your |fingertip, |palpate |vein |at |intended |insertion |site |by |pressing |downward. |Note |resilient, |
soft, |bouncy |feeling |while |releasing |pressure |
- |Select |well-dilated |vein
Methods |to |improve |vascular |distention |- |VERIFIED |ANSWER✔✔--Increased |volume |of |blood |in |vein |
at |venipuncture |site |makes |vein |more |visible.
